The insulin error occurred April 19 when a licensed practical nurse gave the injection to the wrong resident after patients switched rooms. The resident's blood sugar dropped from 135 to 118, requiring emergency monitoring every 15 minutes. "Resident was notified and he was upset because he was given the wrong medication," staff documented. "He said he never took any medications till he was admitted to the facility."
The nurse, identified as LPN #66, told inspectors he "didn't verify because he didn't know the residents had switched rooms." The facility provided no documentation showing they investigated the error or implemented safeguards to prevent recurrence.
Federal inspectors declared immediate jeopardy on July 25 after discovering staff had taken blood pressure readings in the left arm of a dialysis patient with an arteriovenous fistula. Taking blood pressure in the arm containing the fistula can cause clots, stroke, or loss of the dialysis access — putting the resident at immediate risk of serious injury or death.
Records showed staff documented blood pressure readings in the restricted arm on at least 13 occasions between December 2023 and June 2024. The resident's care plan specifically stated "Do not take B/P in my left arm due to my AV" and physicians had ordered monitoring of the fistula site for signs of infection or bleeding.
The dialysis patient had no signage in his room warning against blood pressure readings in the left arm, and wore no identification bracelet alerting staff to the restriction. When interviewed, LPN #68 claimed they take blood pressure "in the opposite arm of the AV fistula," despite records showing this nurse had documented taking blood pressure in the restricted left arm.
Multiple residents complained about inadequate bathing. Resident #51, admitted in early 2024, told inspectors "they don't give much showers here even if I ask" and had received only one shower since admission. Resident #65 said "I don't get showers when I want one, it's been weeks since I have had a shower." Records showed this resident received just two showers and 13 bed baths between April and June.
Resident #22 reported not having a shower in two weeks. Records confirmed one shower in July and only four showers between April and June. Resident #60 expressed frustration: "I don't get showers often. Heck, I would be happy with at least a bed bath once a week. I was in an actual shower probably over a month ago."
One resident who specifically requested showers received extensive periods without any bathing. Resident #3's assessment showed he considered choosing between shower types "Very Important," yet he went 17 days without bathing in March and 19 days in April. His last shower in May was followed by a 20-day gap before his next shower in June.
The Director of Nursing acknowledged the bathing problems during interviews, stating "We have identified this problem and are working on it."
Staffing shortages contributed to deteriorating care quality. Nurse Aide #58 explained: "We don't have time to finish assignments with residents due to not having enough staff. We just don't have enough time with them and aren't able to do the things we should be doing, like working on range of motion with them while we are providing care."
The facility eliminated its restorative aide program due to insufficient staffing. Registered Nurse #31 confirmed "the facility used to have a restorative program and has not used it in quite some time because they don't have enough staff."
Aide #39 described chaotic conditions: "When we come in we come bed strips, overflowing trash, trays left in the rooms, trash in the floor. People hanging their feet off the side of the bed because the last shift didn't do their rounds or didn't have time to do their rounds."
The administrator admitted the facility needs at least five aides during day shift but averages only four most days.
Staff shortages affected one resident's mobility. Resident #64 developed contractures in both knees after admission, telling inspectors his knees "weren't like this when I came in." His initial assessment showed normal range of motion in March, but by June he had impairment in both lower extremities. No staff helped him with range of motion exercises during care.
Safety violations included an unlocked treatment cart left unattended in the resident television room, allowing access to medications and supplies. Inspectors found nystatin powder unsecured at a resident's bedside. A registered nurse confirmed both violations and immediately corrected them.
The facility failed to monitor medication refrigerator temperatures consistently from March through July, missing dozens of required readings. Their own policy required checking temperatures twice daily, but extensive gaps appeared in documentation.
Infection control breakdowns were widespread. Staff failed to wear required personal protective equipment when caring for residents in enhanced barrier precaution rooms, despite door signs specifying when PPE must be worn for activities like bathing, transferring, and wound care. Soiled linen was found on floors and equipment carts.
During meal service, a nurse aide took a dinner tray to a resident who refused it, then placed the rejected tray back on the cart with clean trays. Three used bedpans sat uncovered on a bathroom floor for hours. Soiled gloves were discarded in hallways instead of proper receptacles.
The call light system was turned off at the end of two hallways, making it impossible for residents to summon help audibly. The maintenance director confirmed all call systems in the building had been turned down and "it had been that way since he started."
Activity programs fell short of care plan requirements. Resident #27's plan called for one-to-one visits three times weekly, but records showed multiple weeks with no visits at all. The activity director confirmed scheduled visits weren't being completed.
Performance evaluations were missing for three of five nurse aides reviewed. The administrator acknowledged the deficiency, stating "We knew there were some missing and we are aware of it."
One resident's admission assessment was incomplete, marking that he had "own teeth" without documenting that he actually had only four teeth and difficulty chewing food.
Expired food remained in the kitchen, including scalloped potatoes with a July 11 discard date found July 22, and onions covered in mold-like substance. The dietary manager confirmed the violations and disposed of the items.
Psychotropic medication monitoring failed for one resident prescribed lorazepam for anxiety. Despite physician orders to monitor for sedation and other side effects, no monitoring occurred for six months.
The immediate jeopardy designation was lifted July 26 after the facility implemented corrective measures, but deficient practices remained across multiple areas of resident care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shenandoah Center from 2024-07-26 including all violations, facility responses, and corrective action plans.