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Deficiency Records for Shenandoah Senior Living Community
A list of the most recent deficiencies for Shenandoah Senior Living Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Shenandoah Senior Living Community. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-15 | 2024-06-05 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-05-15 | 2024-06-05 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-05-15 | 2024-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-15 | 2024-06-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-15 | 2024-06-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-27 | 2024-05-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-27 | 2024-05-15 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-03-27 | 2024-05-15 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-03-27 | 2024-05-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-16 | 2024-03-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-10-04 | 2023-11-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-04 | 2023-11-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-04 | 2023-11-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-04 | 2023-11-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-04 | 2023-11-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-04 | 2023-11-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-04 | 2023-11-21 | 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 | 2023-10-04 | 2023-11-21 | 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 | 2023-10-04 | 2023-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-04 | 2023-11-21 | N |
| Have policies on smoking. | Health | 2023-10-04 | 2023-11-21 | 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 | 2023-10-04 | 2023-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-11 | 2023-11-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-28 | 2022-12-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-28 | 2022-12-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-28 | 2022-12-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-28 | 2022-12-13 | 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 | 2022-10-28 | 2022-12-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-28 | 2022-12-13 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-10-28 | 2022-12-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-08 | 2022-09-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-08 | 2022-09-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-31 | 2022-07-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-31 | 2022-07-05 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-05-31 | 2022-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-04 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-10 | 2022-02-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-10 | 2022-02-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-10 | 2022-02-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-10 | 2022-02-10 | 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 | 2021-12-21 | 2022-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-21 | 2022-01-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-21 | 2022-01-25 | N |
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