Shenandoah Senior Living Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jan 7, 2026

  Based on a review of clinical records, select facility investigative documentation, facility policies, American Heart Association (AHA) guidelines, facility-provided witness statements, and staff interviews, it was determined that the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated for a resident in accordance with the resident's advance directives and nationally recognized standards of practice. This failure placed one of 10 residents sampled (Resident CR1) and 47 other residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, and 47) who desired CPR, out of the facility's 101 resident census, in Immediate Jeopardy to… […]

• Actual harm, isolatedF658Jan 7, 2026

  Based on a review of clinical records, select facility policies, applicable state professional nursing standards, and staff interviews, it was determined the facility failed to provide nursing services in accordance with professional standards of practice, resulting in actual harm. Specifically, the facility failed to initiate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure consisting of chest compressions and rescue breathing used when an individual is found unresponsive and not breathing normally) for one out of 10 residents reviewed (Resident CR1) who had documented wishes for Full Code status (meaning the resident wanted all possible life-saving measures, including CPR, if their heart or breathing stopped). […]

• Actual harm, isolatedF600Feb 16, 2024

  Based on review of the facility's abuse prohibition policy and procedures, clinical records, and select investigative reports and staff interview it was determined that the facility neglected to provide care and services necessary to avoid physical harm, a fractured hip and a fractured ankle, and maintain physical health of two residents out of eight residents sampled (Residents CR1 and 2). Findings include: A review of the facility's policy entitled Abuse Policy states the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. […]

• Actual harm, isolatedF760May 31, 2022

  Based on review of resident clinical records, select facility policy and reports and interview with facility staff it was revealed that the facility failed to assure that two out of five residents sampled were free of significant medication errors resulting in one resident requiring hospitalization in intensive care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of a facility policy for administering medications, dated as reviewed April 2022, revealed that, medications are administered in a safe and timely manor and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. […]

• No harm, potential for more than minimal, patternF807Jun 11, 2026

  Based on a review of select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for four residents of 24 residents observed for the presence of drinking water. (Residents 1,2,3,4).Findings include: A review of the facility policy titled Serving Drinking Water last reviewed by the facility on June 2025, indicated the facility will provide a fresh supply of drinking water and provide adequate fluids for the residents. […]