A list of the most recent deficiencies for Shenandoah Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-14 | 2023-07-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-01 | 2023-03-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-01 | 2023-03-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-27 | 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 | 2022-09-27 | 2022-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-27 | 2022-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-27 | 2022-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-27 | 2022-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-27 | 2022-11-14 | 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 |
| Ensure each resident receives an accurate assessment. | 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 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 safe, appropriate dialysis care/services for a resident who requires such services. | 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 |
| 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 |
| Post nurse staffing information every day. | 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 |
| 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 |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-30 | 2022-11-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-30 | 2022-11-01 | Y |
| 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 | Y |
| 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 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-30 | 2022-11-01 | Y |
| 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 | Y |
| Report COVID19 data to residents and families. | Health | 2022-09-30 | 2022-11-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-20 | 2020-01-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-20 | 2020-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-20 | 2020-01-02 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-20 | 2020-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-20 | 2020-01-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-20 | 2020-01-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-20 | 2020-01-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-20 | 2020-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-20 | 2020-01-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-20 | 2020-01-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-11-20 | 2020-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-20 | 2020-01-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-20 | 2020-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-11 | 2018-12-19 | 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 | 2018-10-10 | 2018-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-10 | 2018-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-10 | 2018-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-10 | 2018-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-10 | 2018-11-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-11 | 2018-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-11 | 2018-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-11 | 2018-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-11 | 2018-11-13 | 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 | 2018-10-11 | 2018-11-13 | N |
