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Deficiency Records for Shenandoah Center
View the most recent health deficiencies and inspection results for Shenandoah Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Shenandoah Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-03-11 | 2026-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-03-11 | 2026-04-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2026-03-11 | 2026-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2026-03-11 | 2026-04-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2026-03-11 | 2026-04-15 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-03-11 | 2026-04-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2026-03-11 | 2026-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-03-11 | 2026-04-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2026-03-11 | 2026-04-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-11-06 | 2025-12-11 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-07-26 | 2024-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-26 | 2024-09-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-07-26 | 2024-09-05 | N |
| Provide activities to meet all resident's needs. | Health | 2024-07-26 | 2024-09-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-26 | 2024-09-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-26 | 2024-09-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-26 | 2024-09-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-26 | 2024-09-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-26 | 2024-09-05 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-26 | 2024-09-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-26 | 2024-09-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-07-26 | 2024-09-05 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-07-26 | 2024-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-26 | 2024-09-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-26 | 2024-09-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-26 | 2024-09-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-26 | 2024-09-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-26 | 2024-09-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-07-26 | 2024-09-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-07-26 | 2024-09-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-26 | 2024-09-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-07-26 | 2024-08-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-26 | 2024-08-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-26 | 2024-08-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-26 | 2024-08-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-26 | 2024-08-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-26 | 2023-11-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-14 | 2023-07-22 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-30 | 2022-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-30 | 2022-11-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-30 | 2022-11-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-30 | 2022-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-30 | 2022-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-30 | 2022-11-14 | N |
| Report COVID19 data to residents and families. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-30 | 2022-11-01 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2022-09-30 | 2022-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-30 | 2022-11-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-09-30 | 2022-11-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-30 | 2022-11-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-30 | 2022-11-01 | N |
| Post nurse staffing information every day. | Health | 2022-09-30 | 2022-11-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-30 | 2022-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-30 | 2022-11-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-30 | 2022-11-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-30 | 2022-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-30 | 2022-11-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-30 | 2022-11-01 | N |