Shenandoah Center

In the surveyor’s words

From the most serious findings on record at Shenandoah Center, in the surveyor’s own words.

• Immediate jeopardy, patternF698Jul 26, 2024

  Based on record review, observation and staff interview the facility failed to ensure Resident #9 who requires dialysis received such services, in accordance with professional standards of practice. Resident #9 had an arteriovenous (AV) fistula in their left arm. The facility on multiple occurrences documented they were obtaining the residents blood pressure in their left arm. Obtaining blood pressure in the arm where the AV fistula is located may result in clots, clots that can dislodge, loss of use of the fistula and could cause a stroke. All of these things put the resident in an immediate risk of serious injury and/or death. The state agency (SA) determined this failure to be an immediate jeopardy (IJ) situation. The facility was notified of the IJ on 07/25/24 at 11:09 am. […]

• Immediate jeopardy, isolatedF600Jul 26, 2024

  Based on record review and staff interview, the facility failed to provide an environment free from abuse and/or neglect from staff or other residents. Resident #123 was physically abused by Licensed Practical Nurse (LPN) #91. This created an immediate jeopardy situation. The LPN admitted to losing her temper and backhanding a combative resident. The facility took all appropriate steps after the situation including terminating the LPN. This issue is being cited as past noncompliance. Resident #23 was neglected by Nurse Aide (NA) #94. These were random opportunities for discovery. Resident identifiers: #123, and #23. […]

• Immediate jeopardy, isolatedF760Jul 26, 2024

  Based on resident interview and record review the facility failed to ensure Resident #65 was free from significant medication errors. Resident #65 was administered an injection of 25 units of insulin on 04/19/24 when the resident was not ordered any insulin nor was he a diabetic. Giving a resident an insulin injection when they are not ordered the medication, nor a diabetic can cause serious consequences including serious harm and or death. The state agency (SA) determined this to be an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 07/22/24 at 6:49 PM. The SA accepted the facility's Plan of Correction (POC) on 07/22/24 at 7:40 PM. […]

• Actual harm, isolatedF677Jul 26, 2024

  Based on resident and staff interview and record review, the facility failed to provide showers and/or bed baths in accordance with the residents' preference and/or plan of care. Residents stated the staff preferred to give them bed/sponge baths, rather than a shower, because it is less work. This was true for three (3) of six (6) residents reviewed for the care area of choices and for five (5) of seven (7) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process. For Resident #42 the facility failed to provide a timely transfer from her chair to her bed causing the resident to become agitated and cry out for a period of 30 minutes. This resulted in actual psychosocial harm for Resident #42. […]

• No harm, potential for more than minimal, widespreadF880Jul 26, 2024

  Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for disposal of soiled linen, not wearing proper personal protective equipment (PPE) in enhanced barrier precaution (EBP) rooms, storage of used bedpans, placing a dirty dinner tray on the cart of clean trays and disposal of soiled gloves. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 71. Findings included: a) Soiled Linen On 07/23/24 at 11:09 PM, an observation was made of linen laying on the PPE cart and soiled linen on the floor in room [ROOM NUMBER]. Registered Nurse (RN) #48 was notified and removed the soiled linen immediately. […]