Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shenandoah Center during CMS and state inspections, most recent first.
Improper freezer food storage was observed when an opened box of frozen ground beef and an opened box of fish filets were found with the inner plastic unsealed and left open to air. The CDM acknowledged the condition, and the Kitchen Mgr stated staff were supposed to tie the plastic to reseal it after opening. Facility policy required foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination.
Delayed Response to Resident Call Lights: Survey observations and resident interviews found repeated long waits for call lights to be answered, with residents reporting delays of 30 to 45 minutes. One resident was observed waiting for staff assistance while his call light remained on, and staff later acknowledged the wait was too long and unacceptable. Multiple residents and the Resident Council President reported similar delays, often being told staff were busy.
Accident Hazards Found in Resident Room Storage and Shared Bathroom: Surveyors found razors, shaving cream, and other personal care items stored in accessible vanity drawers in a resident room, and a resident reported another resident had been getting into his drawers. In a shared bathroom, surveyors observed a broken baseboard heater with jagged edges and a damaged wall night light exposing the bulb and wiring; the EAM and ADM were aware of the hazards.
A resident’s private areas and brief were exposed with the room door wide open while the resident’s son was changing her. Three staff members in the hall had a clear view into the room and did not provide privacy until surveyor staff pointed it out; an Employee then pulled the curtain, and the DON acknowledged the lapse.
A resident remained in the facility after the last covered Medicare Part A day, but there was no evidence that the required SNF-ABN was reviewed with the resident. During interview, the BOM stated that the SNF-ABN had not been issued.
A resident was transferred to the hospital, and the EMR contained no evidence that a written bed hold notice was provided to the resident or the resident’s representative. The Administrator acknowledged the facility could not produce evidence that the notice had been given.
A resident with PTSD from severe domestic violence reported that loud voices, closed doors, and rough handling were triggers for re-traumatization. Although Social Services documented the PTSD diagnosis and yelling as a trigger, the care plan did not address the diagnosis or any triggers, and the SW confirmed the omission could lead to re-traumatization and unnecessary mental anguish.
Infection prevention and control was not maintained when an employee handled a resident's hamburger buns without gloves, and multiple residents' wheelchairs were observed with torn armrests and exposed inner padding. The DON and Administrator acknowledged that the damaged arm pads could not be properly sanitized to prevent infection.
A resident exhibited repeated behavioral issues, including entering other residents' rooms, consuming their food and drinks, and public urination, which were observed and documented by staff. Despite these ongoing behaviors and the need for frequent redirection, the care plan was not updated to reflect or address these concerns.
A facility failed to provide safe dialysis care for a resident by repeatedly taking blood pressure in the arm with an AV fistula, contrary to medical orders. The facility also neglected to perform post-dialysis assessments, as required. Observations showed a lack of signage to alert staff about the restricted limb, and staff interviews confirmed non-compliance with care plans, leading to immediate jeopardy.
Two incidents of abuse and neglect occurred in a LTC facility. An LPN physically abused a resident during a combative episode, while a NA neglected another resident by leaving them in a soiled state. Both incidents were substantiated, and the staff involved were terminated. However, there was no evidence of preventive measures taken for the neglect incident.
A resident in a long-term care facility was mistakenly given 25 units of insulin despite not being diabetic or having an insulin order. The error occurred after a room change, and the nurse failed to verify the resident's identity. The resident's blood sugar was monitored following the incident, but the facility did not document any investigation or corrective measures to prevent future errors. Interviews revealed that the LPN involved was unaware of the room change and did not verify the resident's identity.
The facility failed to provide showers and timely transfers according to residents' preferences and care plans. Several residents reported not receiving showers for over thirty days, despite being scheduled for them. A resident experienced psychosocial harm due to a delay in being transferred from her chair to her bed, causing distress. Records showed inconsistencies in bathing schedules, highlighting a systemic issue in meeting residents' needs.
The facility failed to maintain proper infection control practices, including improper disposal of soiled linen and gloves, inadequate use of PPE in EBP rooms, and improper handling of meal trays and bedpans. These deficiencies were observed by surveyors and confirmed through staff interviews, indicating a potential risk to the facility's residents.
The facility failed to honor the bathing preferences of several residents, with some not receiving showers for over a month despite being scheduled for twice-weekly showers. Residents expressed dissatisfaction, and records confirmed significant gaps in bathing schedules. The DON acknowledged the issue and stated efforts were underway to address it.
A facility failed to keep residents' medical information confidential when an LPN left a computer unattended on a medication cart with resident information visible. The LPN later acknowledged the oversight, and the DON confirmed that the computer should have been locked.
The facility failed to maintain a homelike environment, with multiple resident doors showing visible cracks and rough edges, and a PTAC unit in a resident's room covered in moldlike substance. The resident expressed concerns about allergies, potentially linked to the mold, which was confirmed by the Maintenance Supervisor.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and personal care needs. A resident's care plan did not include a diagnosis of Dementia, while another's lacked interventions for anxiety disorder. Additionally, several residents reported not receiving showers as per their preferences, and a resident's care plan intervention to avoid taking blood pressure in a specific arm was not followed.
The facility failed to maintain a safe environment by leaving a treatment cart unlocked and unattended in a resident TV room, and unsecured medication at a resident's bedside. An RN confirmed these items should not have been left accessible to residents, unauthorized persons, or visitors.
The facility did not conduct yearly performance evaluations for three Nurse Aides, as identified during a survey. A review of records showed missing evaluations for these aides, and the Administrator confirmed the oversight, acknowledging the need to address the issue.
A facility failed to monitor behavior and side effects for a resident prescribed Lorazepam for anxiety. The resident's MAR showed no monitoring from December 2023 to May 2024, despite instructions to observe for sedation, morning hangover, ataxia, and nausea. The DON confirmed the lack of monitoring during an interview.
A survey found that a facility failed to maintain complete temperature logs for its medication refrigerator from March to July 2024. The facility's policy requires twice-daily temperature checks, but numerous dates were missing records. The Administrator confirmed the logs were incomplete, potentially affecting the care of residents.
The facility failed to discard expired food items, including scalloped potatoes and moldy onions, found in the kitchen's walk-in refrigerator. The Dietary Manager in Training acknowledged the oversight and stated they would dispose of the items. This deficiency had the potential to affect more than a limited number of residents.
The facility failed to maintain a functioning resident call system, as observed during a tour of the 200 and 300 halls where the call light system was turned off and the volume was too low. The Maintenance Assistant confirmed the system was turned off by staff, and the Maintenance Director noted that all call systems had been turned down since his employment began.
The facility failed to notify the State ombudsman of a discharge for a resident. A record review revealed that the resident had been discharged to another facility, but there was no evidence of the required notification being sent. The Administrator confirmed the absence of the notification.
The facility failed to accurately complete MDS assessments for two residents regarding their discharge destinations. One resident was discharged to another LTC facility, but the MDS listed home as the destination. Another resident was discharged to home, but the MDS recorded a short-term general hospital as the destination. These errors were confirmed by the Administrator.
A facility failed to update a resident's care plan when the status of her pressure ulcer changed. The care plan inaccurately listed the ulcer as a Stage 2, despite a skin and wound evaluation indicating it was unstageable. The DON acknowledged ongoing issues with care plan revisions.
A facility failed to provide an adequate activity program for a resident, as observations showed the resident spent long periods in the TV Lounge without engaging in meaningful activities. The resident's care plan required one-to-one visits three times a week, which were not consistently provided. The Activity Director confirmed the visits were not conducted as scheduled.
A resident experienced a decline in range of motion in both knees due to the facility's failure to provide necessary care. Initially, the resident had normal range of motion, but by July, contractures were observed. Staff interviews revealed that staffing shortages, particularly among aides, prevented them from completing assignments and providing essential care, such as range of motion exercises. The facility had previously discontinued a restorative program due to these staffing issues.
A facility failed to provide adequate staffing, affecting resident care. A resident with knee contractures did not receive necessary range of motion exercises, as confirmed by medical records and staff interviews. Staff reported consistent understaffing, particularly with aides, leading to incomplete care and the removal of the restorative aide position. Despite requests for agency staff, the facility operated below required staffing levels, impacting the quality of care provided.
A facility failed to accurately document a resident's dental condition during the admission assessment. The resident reported having only four teeth and difficulty chewing, but the clinical admission evaluation incorrectly marked 'own teeth' and left the dental section incomplete. The administrator confirmed the assessment's incompleteness.
Improper Freezer Food Storage
Penalty
Summary
The facility failed to properly store food in accordance with professional standards after surveyors observed issues in the kitchen freezer during a second kitchen visit. The Corporate Dietary Manager acknowledged that there was 1 opened box of frozen ground beef with the inner plastic unsealed and left open to air, and 1 opened box of fish filets with the inner plastic unsealed and left open to air. The Kitchen Manager stated that the frozen ground beef and frozen fish filets were left open to air and that staff were supposed to tie the plastic to reseal it once the items had been opened. A review of the facility policy on food storage stated that all foods are to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Survey observations, staff interviews, and resident interviews identified repeated delays in staff response to call lights, with residents reporting waits of 30 to 45 minutes and staff acknowledging that some response times were too long and unacceptable. Resident #11 was observed with his call light on while trying to get staff assistance. He waited from 2:50 PM until 3:17 PM before two nurse aides entered his room, then waited until 3:25 PM for another nurse aide to assist him with a bed pan. During the delay, he requested a glass of water and help with the bed pan. A nurse aide later acknowledged the 30-minute wait for the help and care he needed, and the DON stated she was aware of the amount of time he had waited and said it was too long and not acceptable. Other residents, including Resident #4, Resident #61, Resident #3, Resident #9, Resident #71, and Resident #29, reported similar delays in having call lights answered, including waits up to 45 minutes and instances where staff said they were busy or did not return.
Accident Hazards Found in Resident Room Storage and Shared Bathroom
Penalty
Summary
The facility failed to ensure resident rooms and shared areas remained free of accident hazards as much as possible. During a facility walk-through and resident interviews, surveyors found 4 cans of shaving cream and 2 opened packages of razors, along with other bathing products such as body lotions, shampoo, and mouthwash, in the top two drawers of a shared sink/vanity area in one resident room. These drawers were easily accessible to any resident who might wander into the room. Resident #3 stated the top two drawers were not his and belonged to his roommate, and he also stated he had made complaints that Resident #50 gets into his bedside drawers and all other drawers in the room. In the shared bathroom between rooms #301 and #303, surveyors observed the top of the metal baseboard heater was broken with protruding jagged edges. They also found a broken encased wall night light with the glass cover out of place, exposing the glass bulb and electrical wiring. The Environmental Account Manager acknowledged the hazards and stated she would report them to maintenance for immediate repair. The Facility Administrator later stated she had been made aware of the hazards in the shared bathroom and that maintenance was actively repairing them.
Failure to Provide Privacy During Resident Care
Penalty
Summary
The facility failed to ensure Resident #16 had a dignified existence inside the facility when the resident’s private areas and brief were exposed with the room door wide open during a walk-through on the 100 hall. Three staff members were observed in the hall with clear visibility into the room, and they did not provide privacy for the resident before surveyor staff brought the situation to Employee #36’s attention. Employee #36 then entered the room and pulled the curtain for privacy. In an interview, the DON acknowledged that the door was open while Resident #16’s son was changing her, and that staff members in the hall did not provide privacy until the surveyor intervened.
Failure to Provide SNF-ABN for Medicare Coverage End
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form to one resident reviewed during the annual survey. Resident #31 remained in the facility after the last covered Medicare Part A day on 11/11/25, and there was no evidence that the SNF-ABN was ever reviewed with the resident. During an interview, the Business Office Manager stated that a SNF-ABN had not been issued.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written Bed Hold Notice for Resident #45, who was transferred to an acute care setting. An electronic medical record review completed on 03/10/2026 at 9:56 PM found no evidence in the resident’s medical record that a bed hold notice had been provided to the resident or the resident’s representative. During an interview on 03/11/26 at 8:30 AM, the Administrator acknowledged that the facility could not provide evidence that a written bed hold notice had been given.
Failure to Address PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to ensure Resident #62 received trauma-informed care that accounted for her experiences and preferences to help mitigate triggers that could cause re-traumatization. During interview, the resident stated she had PTSD related to a marriage involving severe domestic violence and identified loud voices directed toward her, closed doors, and rough handling as potential triggers. Record review showed a Social Services Assessment documented the PTSD diagnosis and the trigger of yelling, but the resident’s care plan did not address the PTSD diagnosis or her potential triggers in any way. The Social Worker confirmed the care plan did not address the resident’s PTSD diagnosis and acknowledged that lack of proper care planning could potentially lead to re-traumatization and unnecessary mental anguish.
Infection Control Deficiencies with Improper Food Handling and Damaged Wheelchairs
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation, Employee #7 handled Resident #94's hamburger buns without gloves, and then acknowledged the incident and stated she returned the plate to the kitchen for a replacement. In a separate observation, the wheelchairs used by Resident #9 and Resident #55 in one room had rips and tears on both armrests with exposed inner padding, and Resident #12's wheelchair was also observed to have holes and tears in the right armrest with exposed inner padding. The DON and Administrator acknowledged the damaged wheelchairs and stated that the arm pads could not be properly sanitized to prevent infection.
Failure to Update Care Plan for Resident Behavioral Issues
Penalty
Summary
The facility failed to ensure that the care plan for Resident #48 was accurate and up to date, as required by regulations. Record review and staff interviews revealed that Resident #48 exhibited behaviors such as wandering into other residents' rooms, drinking from their cups, eating their food, and retrieving ice with bare hands, as well as public urination and using other residents' items. These behaviors were observed and documented by staff, but were not reflected in the resident's care plan. Staff interviews confirmed that the resident required ongoing re-queuing and redirection, and had difficulty adjusting to the facility, yet the care plan did not address these specific behavioral issues.
Failure to Provide Safe Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, as evidenced by multiple instances of blood pressure being taken in the resident's left arm, where an arteriovenous (AV) fistula was located. This practice is against professional standards as it can lead to serious complications such as clots, loss of use of the fistula, and potentially a stroke. The resident's medical records showed several documented instances where blood pressure was taken in the left arm, despite clear orders and care plans indicating that this should not occur. Additionally, the facility did not complete post-dialysis assessments for the resident upon their return from dialysis sessions. The dialysis communication book lacked documentation of these assessments, which are crucial for monitoring the resident's condition and ensuring any complications are promptly addressed. The care plan for the resident included instructions to monitor for signs of infection, edema, and bleeding upon return from dialysis, but these were not consistently followed. Observations revealed that there was no signage in the resident's room or on their person to alert staff about the restricted limb for blood pressure measurements. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the orders and care plan were not adhered to, leading to the deficiency. This oversight placed the resident at immediate risk of serious injury, prompting the state agency to determine the situation as an immediate jeopardy.
Removal Plan
- Resident #9 will be evaluated by the licensed nurse upon return to the facility.
- All dialysis residents have the potential to be affected.
- The Unit Managers/designee conducted an audit for all residents on dialysis with specific B/P orders to be taken and POST dialysis assessment is completed upon return to the facility with any corrective action immediately upon discovery.
- The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the Medication Administration Record in all Capital letters and will be added to the care plan and kardex in capital letters.
- The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to validate understanding regarding hemodialysis graft, fistula care, communication, and documentation.
- Verify orders and instructions from hemodialysis facility or hospital, if patient is a new Admission.
- Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.
- Inspect fistula site for decrease or absence of vein dilation.
- Palpate for distal thrill.
- Auscultate for bruit.
- Palpate skin around graft/fistula for warmth.
- Evaluate skin around vascular access noting redness, swelling, local warmth, exudate, tenderness.
- Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for complications.
- Protect access site from getting wet for several hours after HD or HHD treatment.
- Avoid trauma or treatment procedures in the accessed extremity, such as limiting activity of extremity, blood pressure measurement, venipuncture, injection of any type, use of creams or lotions on the access site.
- Instruct patient to avoid excessive pressure on the extremity or strain and in strengthening exercises to enhance blood flow if permitted by physician/APP and dialysis facility.
- Document location of access site on admission assessment, status of access site in Nurses' notes, status of pulses distal to access area, color and temperature of extremity, presence or absence of pain or numbness, status of bruit and thrill, notification and response of physician/APP and dialysis facility, patient education and family involvement, nursing intervention.
- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility.
- Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit.
- Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.
- Upon return of the patient to the Center, a licensed nurse will review the certified dialysis facility communication, evaluate/observe the patient, and complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form.
- Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.
- Document notification of certified dialysis facility regarding return of form or other communication.
- Maintain the Hemodialysis Communication Record or state required form in the patient's medical record.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The DON/designee will complete medication pass competencies quarterly to ensure physician orders are followed including ensuring B/P's are not taken in restricted arm.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are taking B/P and the licensed nurse is completing the dialysis communication sheets POST dialysis daily across all shifts.
- Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Abuse and Neglect Incidents in LTC Facility
Penalty
Summary
The facility failed to provide an environment free from abuse and neglect, as evidenced by two separate incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) physically abused a resident during an episode of combative behavior. The resident, who had a complex medical history including dementia and chronic kidney disease, became combative during incontinence care. The LPN, in an attempt to administer medication, was spat on by the resident and reacted by striking the resident in the face. This incident was witnessed by multiple staff members and was reported to the facility's administration. In the second incident, a Nurse Aide (NA) neglected a resident by leaving them in a soiled state. The resident was found with vomit on their clothing and dried feces on their legs, and their bed was soiled with urine and feces. The NA responsible for the resident's care admitted to not changing the resident, citing a concern about the resident becoming combative if awakened. This neglect was reported by another NA and confirmed by the LPN assigned to the resident that night. Both incidents were substantiated by the facility, with the staff members involved being terminated. However, the report notes that there was no evidence of education or other actions taken to prevent recurrence of the neglect incident, highlighting a gap in the facility's response to such deficiencies.
Medication Error: Insulin Administered to Non-Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident #65. On April 19, 2024, Resident #65, who was not diabetic and had no insulin order, was mistakenly administered 25 units of insulin. This error occurred after a room change, where the resident was moved from room 401A to 107. The resident reported that the nurse did not verify the identity of the person receiving the insulin shot, leading to the administration of the wrong medication. The progress notes from the incident indicated that the resident's blood sugar was 135 before the insulin was administered, and after the error was discovered, the resident was understandably upset. The on-call doctor was notified, and initial orders were given to monitor the resident's blood sugar every 15 minutes. However, the resident initially refused to have his blood sugar checked, only consenting after speaking with his wife. Subsequent checks showed a blood sugar level of 118. Despite the seriousness of the error, the facility did not provide documentation of any investigation or process implementation to prevent such errors in the future. Interviews conducted during the investigation revealed that the LPN responsible for the error did not verify the resident's identity because they were unaware of the room change. The facility administrator confirmed that a one-to-one education session was conducted with the LPN involved, but this occurred two months after the incident. The LPN was noted to be a part-time or as-needed employee, which may have contributed to the oversight. The lack of immediate corrective action and investigation highlights a systemic issue within the facility's medication administration process.
Failure to Provide Showers and Timely Transfers
Penalty
Summary
The facility failed to provide showers and/or bed baths in accordance with the residents' preferences and/or their care plans. Several residents reported that staff preferred to give bed or sponge baths instead of showers, as it required less effort. This issue was identified for multiple residents, including those who had not received a shower for over thirty days, despite being scheduled for showers multiple times a week. The records showed inconsistencies in the provision of showers and bed baths, with significant gaps between bathing sessions. Resident #42 experienced psychosocial harm due to a delay in being transferred from her chair to her bed. During a night observation, the resident was found crying and repeatedly calling for help. Despite the presence of staff, the resident was not attended to promptly, leading to distress. The LPN on duty acknowledged the resident's agitation due to the delay and the need for assistance with a mechanical lift, which was not immediately available. Other residents, such as Resident #48, #40, and #3, expressed dissatisfaction with the lack of showers, which were important to them as per their Minimum Data Set (MDS) preferences. The facility's records corroborated these claims, showing a pattern of missed showers and infrequent bed baths. Interviews with residents and staff highlighted a systemic issue with the facility's ability to meet the residents' bathing preferences and schedules, contributing to the deficiency identified during the survey.
Infection Control Deficiencies in PPE Use and Waste Disposal
Penalty
Summary
The facility failed to maintain an appropriate infection control program, as evidenced by several observations and staff interviews. Soiled linen was found improperly disposed of, with linen observed on the PPE cart and on the floor in a resident's room. Staff, including a registered nurse and nurse aides, were observed not wearing proper personal protective equipment (PPE) while transferring and providing care to a resident in an Enhanced Barrier Precaution (EBP) room, despite signage indicating the required PPE for specific activities. Additionally, a meal tray that was refused by a resident was placed back onto a cart with clean trays, and uncovered bedpans were found on the floor in a restroom. Further observations revealed soiled gloves discarded on the floor of a hallway, which was confirmed by a licensed practical nurse as an infection control issue. Staff interviews indicated a lack of adherence to proper disposal protocols for soiled gloves and dressings, which should have been discarded in the appropriate receptacles within residents' rooms. These deficiencies in infection control practices had the potential to affect more than an isolated number of residents, given the facility's census of 71.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor residents' preferences for bed baths and showers, affecting five out of seven residents reviewed during the Long-Term Care Survey Process. Resident #60 expressed dissatisfaction with the infrequency of showers, having received only two showers between May and July 2024, despite being scheduled for twice-weekly showers. The Director of Nursing confirmed the lack of showers for Resident #60 since June 19, 2024. Similarly, Resident #63 reported not having a shower since early May 2024, although scheduled for twice-weekly showers, and the Director of Nursing acknowledged this issue. Resident #48 also reported that his requests for showers were not honored, with records showing he received no showers in January, February, and May 2024, and only two showers in June 2024. Despite expressing that choosing between different types of baths was very important to him, his preferences were not met. Resident #40, who indicated that choosing between bath types was somewhat important, received no showers from January to July 2024, with significant gaps between bed/sponge baths. Resident #3, who considered choosing between bath types very important, received only one shower in March and May 2024, and none in July 2024. The records revealed long periods without any form of bathing, such as a 17-day gap in March 2024. The Director of Nursing acknowledged the problem of not honoring residents' bathing preferences and stated that the facility was working on addressing the issue.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information. On July 23, 2024, at 11:04 PM, a Licensed Practical Nurse (LPN) was observed at the nurses' station using a computer. Shortly after, at 11:08 PM, a computer was found unattended on top of the medication cart with resident identifiable information visible on the screen. This situation presented a random opportunity for unauthorized access to sensitive information, potentially affecting more than a minimal number of residents in the facility, which had a census of 71 at the time. During an interview conducted at 11:12 PM, the LPN returned to the medication cart and locked the computer screen, acknowledging awareness that it had been left unlocked. The following day, the Director of Nursing (DON) confirmed in an interview that the computer and medication cart should have been secured to prevent such breaches of confidentiality.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for residents in several rooms, as observed during a facility tour. The tour revealed that multiple resident doors had visible cracks and rough edges with putty applied, indicating inadequate maintenance. Additionally, in one resident's room, the slats of the Packaged Terminal Air Conditioner (PTAC) unit were covered in a moldlike substance. The resident expressed concerns about allergies, which could be related to the mold. The Maintenance Supervisor confirmed the presence of mold and acknowledged the need for cleaning.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and personal care needs. Resident #54's care plan did not include a diagnosis of Dementia, despite it being documented in their medical record. Similarly, Resident #61's care plan lacked interventions for their diagnosed anxiety disorder, even though the resident had been seen for psychological telemedicine visits. Resident #71's care plan was incomplete, missing focus areas such as activities of daily living, suspected infections, and risk for skin breakdown. These omissions were confirmed by the facility's Director of Nursing and Administrator during interviews. Additionally, the facility did not adequately address the personal hygiene preferences of several residents. Resident #51, #65, and #22 reported not receiving showers as per their preferences, with their care plans either lacking specific interventions or not being followed. Resident #9's care plan included an intervention to avoid taking blood pressure in the left arm due to an AV fistula, yet records showed this was not adhered to on multiple occasions. These failures were acknowledged by the facility's administration, indicating a systemic issue in care plan development and implementation.
Unsecured Treatment Cart and Medication in Resident Areas
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible, which had the potential to affect more than a limited number of residents. During an observation, an unlocked and unattended treatment cart was found in the resident TV room, making medication and treatment supplies accessible to residents, unauthorized persons, or visitors. This was confirmed by RN #21, who acknowledged that the treatment cart should not be left unlocked when unattended. Additionally, nystatin powder was found unsecured and unattended at a resident's bedside, allowing access to the medication by residents, unauthorized staff, or visitors. RN #21 confirmed that the medication should not be left out in the room and removed it upon discovery.
Failure to Conduct Yearly Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct yearly performance evaluations for three out of five Nurse Aides reviewed during the survey process. This deficiency was identified through a record review conducted at approximately 2:45 PM on 07/23/24, which revealed missing yearly performance evaluations for Nurse Aides #34, #63, and #61. The facility census at the time was 71. During a staff interview at approximately 3:30 PM on the same day, the Administrator confirmed the absence of these evaluations. The Administrator acknowledged awareness of the missing evaluations and stated that efforts were being made to catch up on them.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to conduct behavior and side effect monitoring for psychotropic medications for one of the five residents reviewed during the Long-Term Care Survey Process. Specifically, Resident #54 was prescribed Lorazepam Oral Tablet 0.5 MG for anxiety, with instructions to monitor for sedation, morning hangover, ataxia, nausea, and to report any side effects to the physician. However, a review of the Medication Administration Record (MAR) revealed that there was no monitoring conducted for the months of December 2023 through May 2024. During an interview, the Director of Nursing confirmed that behavior and side effect monitoring was not being performed.
Incomplete Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain accurate temperature logs for the medication refrigerator, as observed during a survey on July 25, 2024. The survey revealed that the temperature recordings for the medication refrigerator were incomplete from March 2024 through July 2024. Specific dates were identified where the temperature checks were not documented, indicating a lapse in the facility's adherence to its policy of checking refrigerator temperatures twice daily. During the survey, the Administrator confirmed the incompleteness of the temperature logs. The facility's policy, titled 'Medication and Vaccine Refrigerator/Freezer Temperatures,' mandates that refrigerators and freezers used for storing medications and vaccines must operate within an acceptable temperature range and be checked twice daily. The failure to record these temperatures as per the policy could potentially affect more than a limited number of residents, given the facility's census of 71.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to ensure that food items were discarded after their expiration date, which had the potential to affect more than a limited number of residents. During an initial observation in the kitchen, scalloped potatoes were found wrapped in plastic wrap in the walk-in refrigerator with a discard date of 07/11/24, indicating they were out of date. Additionally, a box of onions in the walk-in refrigerator contained eight onions, four of which were covered in what appeared to be mold. During an interview, the Dietary Manager in Training (DMT) acknowledged that the potatoes were out of date and stated that they would dispose of the potatoes and onions. This deficiency was identified during a survey with a facility census of 71 residents.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that the resident call system was functioning as designed, which had the potential to affect more than a limited number of residents. During an observation tour of the 200 and 300 halls, it was found that the call light system was turned off at the end of the halls, and the volume was too low to be heard throughout the unit. The Maintenance Assistant verified that the system was turned off and stated that the staff had turned it off. The Maintenance Director confirmed that the call system was both visual and audible and noted that all the call systems in the building had been turned down since he started working there.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State ombudsman of a discharge for a resident, identified as Resident #71. This deficiency was identified during a record review conducted on 07/23/24, which revealed that the resident had been discharged to another facility on 05/09/24. However, there was no evidence that the required notification of discharge was sent to the State ombudsman. During an interview on the same day, the Administrator confirmed the absence of the notification to the Ombudsman regarding the discharge.
Inaccurate MDS Discharge Destinations for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments regarding the discharge destinations for two residents. For Resident #71, the record review revealed that the resident was discharged to another long-term care facility, but the MDS inaccurately listed the discharge destination as home. This discrepancy was confirmed by the Administrator. Similarly, for Resident #72, the record review showed that the resident was discharged to home, yet the MDS incorrectly recorded the discharge destination as a short-term general hospital. The Administrator also confirmed this error. These inaccuracies were identified during a record review and staff interview process.
Failure to Revise Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident when the status of her pressure ulcer changed. A record review revealed an order for the resident's right heel, which was initially documented as a Stage IV pressure ulcer requiring specific wound care. However, the care plan inaccurately listed the ulcer as a Stage 2 pressure ulcer. A subsequent skin and wound evaluation indicated that the pressure ulcer was unstageable, yet the care plan was not updated to reflect this change. During an interview, the Director of Nursing acknowledged the issue, stating that there were ongoing problems with care plan revisions.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an activity program that met the needs and interests of its residents, specifically for one resident identified in the report. Observations revealed that the resident spent extended periods sitting in the Television Lounge without engaging in meaningful activities. The resident's care plan emphasized the importance of engaging in daily routines that were meaningful and included scheduled one-to-one visits three times a week, which were not consistently provided. A review of the resident's activity participation records for several months showed a lack of consistent one-to-one visits and no participation in group activities. The Activity Director confirmed that the scheduled one-to-one visits were not being conducted as planned. This deficiency highlights the facility's failure to adhere to the resident's care plan and provide the necessary engagement opportunities to meet the resident's preferences and needs.
Failure to Prevent Reduction in Range of Motion Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary services and treatment to a resident to prevent a reduction in range of motion. Resident #64, who initially had normal range of motion in the lower extremities as per evaluations and records from March and April 2024, was observed to have contractures in both knees by July 2024. The resident reported not receiving assistance with range of motion exercises during care, and the medical records indicated a decline in range of motion by June 2024. Interviews with staff, including nurse aides and registered nurses, revealed that the facility was experiencing staffing shortages, particularly among aides. This shortage resulted in insufficient time to complete assignments and provide necessary care, such as range of motion exercises. The facility previously had a restorative program to address such needs, but it was discontinued due to staffing issues, contributing to the deficiency in care for Resident #64.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the experiences of a resident and multiple staff members. A resident, identified as having contractures in both knees, reported not receiving assistance with range of motion exercises, which were previously within normal limits according to medical records. The resident's condition deteriorated without the necessary care, highlighting the facility's inability to maintain adequate staffing levels to ensure proper resident care. Interviews with nurse aides and registered nurses confirmed that the facility was consistently understaffed, particularly with aides, leading to incomplete care assignments and the removal of the restorative aide position. Staff interviews revealed that the facility typically operated with fewer aides than required, particularly during the day shift, and that weekends were often worse. Aides reported being asked to work extra hours frequently due to staffing shortages, which affected their ability to provide comprehensive care, such as assisting with range of motion exercises and ensuring residents received showers. Despite repeated requests for agency staff to alleviate the situation, these requests were not fulfilled, and management reportedly deflected responsibility onto the staff. The administrator acknowledged the need for more aides but confirmed that the facility often operated below the necessary staffing levels.
Incomplete Dental Assessment Documentation
Penalty
Summary
The facility failed to accurately document the dental condition of a resident during the admission assessment. During an interview, the resident stated that they only have four teeth and have difficulty chewing food. However, a review of the resident's clinical admission evaluation revealed that the section regarding dental condition was incomplete, with the box indicating 'own teeth' marked incorrectly. The administrator confirmed the incompleteness of the dental assessment upon review.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 220 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charles Town
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Tree Healthcare Center | 1 mi | ★★★★★ | 3 | 0 |
| Canterbury Center | 10.2 mi | ★★★★★ | 0 | 0 |
| Care Haven Center | 10.6 mi | ★★★★★ | 7 | 0 |
| Rose Hill Health And Rehab | 12.1 mi | ★★★★★ | 0 | 0 |
| Martinsburg Healthcare Center | 14.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.