Shenandoah Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812May 30, 2024

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store and prepare food in accordance with professional standards for food service safety in one of one kitchen. The findings included: 1. The facility staff failed to store foods in a manner to prevent contamination and failed to label and date items in the freezer and refrigerators. On 5/28/24 at 11:10 a.m., an initial tour of the kitchen was conducted with the dietary manger. This observation revealed that in the refrigerators there was a Ziplock bag that contained hard boiled eggs with a watery liquid in the bag. The bag had no dates to indicate when they were opened or to be used by. […]

• No harm, potential for more than minimal, isolatedF638May 30, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct a quarterly assessment timely for one resident (Resident #46 - R46), in a survey sample of 22 residents. The findings included: For R46, the facility staff failed to conduct a quarterly MDS (minimum data set - an assessment tool) in a timely manner. On 5/29/24, during a clinical record review, according to the MDS tab, R46 had a quarterly MDS assessment scheduled with an ARD (assessment reference date) of 5/11/24. The MDS assessment was noted to be incomplete and in-process. On 5/29/24 at 1:07 p.m., an interview was conducted with registered nurse #1 (RN #1), who was the MDS coordinator. […]

• No harm, potential for more than minimal, isolatedF656May 30, 2024

  Based on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty-two residents in the survey sample (Resident #30). The findings include: Resident #30 had no plan of care developed regarding use of a remote pacemaker monitoring device. Resident #30 (R30) was admitted to the facility with diagnoses that included anxiety, seizure disorder, diabetes, respiratory failure, cerebral infarction with hemiplegia, atrial fibrillation with cardiac pacemaker, heart failure, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R30 with severely impaired cognitive skills. R30's clinical record documented a cardiology consult dated 8/21/23. […]

• No harm, potential for more than minimal, isolatedF657May 30, 2024

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for one resident (Resident #46 - R46), in a survey sample of 22 residents. The findings included: For R46, the facility staff failed to review and revise the care plan to address a stage III pressure ulcer to R46's left heel. On 05/28/24 at 12:10 p.m., an interview was conducted with R46. During the interview, it was observed that R46 had a bandage to the left foot. When asked, R46 reported he had a sore on the heel and said, They removed the dead skin from it, and it hurt. […]

• No harm, potential for more than minimal, isolatedF658May 30, 2024

  Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of practice to one resident (Resident #31- R31), during medication observations conducted on one of two nursing units. The findings included: On 5/28/24 at 4:03 p.m., an observation was conducted of resident medication administration being conducted by LPN #1 (licensed practical nurse). LPN #1 prepared medications to administer to R31. The medications included coumadin and potassium chloride 20 meq ER [extended release]. LPN #1 stated that R31 took medications crushed and LPN #1 proceeded to crush the medications. LPN #1 then entered R31's room and administered the medications. […]