Shenandoah Valley Westminster Canterbury

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727May 1, 2026

  Based on staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage for one of 46 days reviewed for nurse staffing.The findings include:The facility staff failed to ensure eight consecutive hours of RN coverage on 9/13/2025.Review of the PBJ (payroll-based journal) Staffing Data Report for Quarter three and Quarter four 2025 revealed concerns related to the facility's requirement to have a Registered Nurse on duty for at least 8 consecutive hours a day. The report documented no RN hours on multiple dates including 9/13/2025. […]

• No harm, potential for more than minimal, widespreadF887May 1, 2026

  Based on staff interview, and facility document review, it was determined that the facility staff failed to maintain COVID-19 staff vaccination status. The findings include: During the facility task of Infection Prevention and review of facility documents, on 4/29/26, there was no evidence of maintenance of new hired staff COVID-19 vaccination status.On 4/30/26 at 11:00 AM an interview was conducted with the Infection Preventionist. Asked when she started in this role, she stated, two years ago in June of 2024. Asked to provide the evidence of maintenance of new hired staff COVID-19 vaccination status, the Infection Preventionist stated, Human Resources has been responsible for the screening of new hires, and they have not been screening them for the COVID-19 vaccination status. […]

• No harm, potential for more than minimal, widespreadF882Mar 23, 2023

  Based on staff interview and facility document review, it was determined that the failed to designate a qualified individual(s) onsite, who was responsible for implementing programs and activities to prevent and control infections. The findings include: The facility staff failed to ensure the acting infection preventionist had completed specialized training in infection prevention and control. On 3/20/23 during the entrance conference, ASM (administrative staff member) #1, the administrator, was asked to provide evidence of the infection preventionist's credentials. […]

• No harm, potential for more than minimal, patternF812May 1, 2026

  Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen and one of three nourishment areas in a sanitary manner. The findings include:On 4/29/26 at 8:35a.m., an observation was conducted in the kitchen with the following findings: in dry storage, one approximately 48oz bag of Sysco Fancy Pecan Pieces, inside a clear plastic bag without a label and date; one opened 5lb box of Pearl [NAME] Yellow Corn Meal, in the original box, without a label and date; one approximately 5lb box of Quaker Creamy Wheat labeled with the month and date but no year; one approximately 5lb box of Gold Medal Chocolate Fudge Cream Icing Mix opened and uncovered; and a food scooper left inside of a brown rice bin. […]

• No harm, potential for more than minimal, patternF656Mar 23, 2023

  Based on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for six of 17 residents in the survey sample, Residents #4, #36, #22, #6, #17 and #34. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan to provide non-pharmacological interventions prior to administration of as needed Tylenol with Codeine #3 (1). On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 1/4/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. […]