Shenandoah Valley Health and Rehab

In the surveyor’s words

From the most serious findings on record at Shenandoah Valley Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF657Jan 31, 2024

  Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct timely revisions of the comprehensive care plan for two residents (Resident #1 and Resident #5) in a survey sample of 14 residents. For Resident #1 (R1) the failure to revise the care plan and implement interventions that ensured R1 received the required dialysis treatments as ordered, resulted in R1 missing 3 dialysis sessions and 3 partial treatments, which resulted in four hospitalization s. This constituted four occurrences of harm. The findings included: 1. […]

• Actual harm, isolatedF698Jan 31, 2024

  Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure a Resident who required dialysis received scheduled dialysis treatments as ordered by the physician for 1 Resident (Resident #1) in a survey sample of 3 dialysis Residents reviewed. Resident #1 (R1) was hospitalized 4 times during a 3-month period due to missed dialysis treatments, requiring hospitalization for urgent dialysis due to being symptomatic of fluid overload, this constituted harm. The findings included: According to the clinical record R1, was initially admitted to the facility on [DATE]. Diagnoses for R1 included but were not limited to end stage renal disease and legal blindness. On [DATE] and [DATE], a closed record review was conducted of R1's chart. […]

• Actual harm, isolatedF689May 31, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision/support to ensure safety during a transfer, resulting in serious adverse outcome (harm) for one of six residents in the survey sample (Resident #1). The findings include: Assessed as requiring two-person assistance, Resident #1 fell forward, hitting head against the wall, while being provided one-person assistance with toileting/transferring. […]

• Actual harm, isolatedF686May 27, 2021

  Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly assess, implement interventions, and provide immediate care for the prevention and/or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50 developed two pressure ulcers on the inside of both knees initially identified at an unstageable status with thick, necrotic tissue over the wounds. There was no prior assessment of impaired skin in those areas, and after treatment, were assessed as stage 4 pressure ulcers. Staff failed to follow physician orders and infection control practices during dressing changes to Resident #50's pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF730Jan 31, 2024

  Based on staff interview and facility documentation review, the facility staff failed to complete performance reviews of nurse aides and therefore failed to provide in-service education based on the outcome of the performance reviews, affecting all 40 nurse aides employed by the facility. The findings included: On 1/30/24 at 10 a.m., the survey team met with the human resources manager (HRM) and requested to review the employee files for three sampled CNAs (certified nursing assistants). The HRM asked what documents were requesting to be reviewed and the surveyor let her know that the performance reviews needed to be reviewed. The HRM said OK and stepped out of the room. […]