Shenandoah Center

F-F0400 daily preferences were not assessed.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Further review of the resident's MDS dated [DATE REDACTED] at 4:10 PM revealed, he had responded to the question:

Level of Harm - Actual harm How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?

Residents Affected - Few His response was - Very Important

Record review of Resident #3's shower logs reveal:

For the month of January 2024, the resident received three (3) bed/sponge baths, and no showers.

For the month of February 2024, the resident received three (3) bed/sponge baths, and no showers.

For the month of March 2024, the resident received three (3) bed/sponge baths, and one (1) shower. It was also noted the resident had received no bed/sponge baths, or showers for 17 days, from 2/29/24 to 3/18/24.

For the month of April 2024, the resident received one (1) bed/sponge baths, and no showers. A record

review revealed the resident had received no bed/sponge baths or showers for 19 days, from 03/27/24 to 04/16/24.

For the month of May 2024, the resident received one (1) shower.

For the month of June 2024, the resident received four (4) bed/sponge baths, and one (1) shower. The resident's last shower in May was on 05/22/24, and his next shower was twenty (20) days later, on 06/11/24.

For the month of July 2024, the resident received eight (8) bed/sponge baths and no showers, as of 07/24/24.

e) Resident #51

On 07/24/24 at 1:28 PM a record review revealed, Resident #51 was admitted on [DATE REDACTED] and has only received 1 shower.

On 07/24/24 at 1:36 PMm during an interview Resident #51 stated they don't give much showers here even if I ask.

Further review of the record on 07/24/24 revealed Resident #51 is care planned to have showers per preference.

During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working on getting those issues resolved.

f) Resident #65

On 07/22/24 at 3:36 PM, during an interview Resident #65 stated I don't get showers when I want one, it's been weeks since I have had a shower.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 On 07/24/24 at 1:41 PM, a record review revealed Resident #65 has had two (2) showers and 13 bed baths from 04/01/24 through 06/31/24. Level of Harm - Actual harm

On 07/22/24 at 3:36 PM resident stated, I don't get showers when i want one, its been weeks since i have Residents Affected - Few had a shower.

During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working on getting those issues resolved.

g) Resident #22

On 07/22/24 at 2:07 PM, during an interview Resident #22 stated I have not had a shower in two (2) weeks.

On 07/24/24 at 12:03 PM, a record review revealed Resident #22 has had one (1) shower on 07/03/24 in the past month from 06/24/24 to 07/24/24.

Further record review on 07/24/24 revealed Resident #22 had received four (4) showers from 04/01/24 through 06/31/24 and only seven (7) bed baths in this time frame.

On 07/24/24 at 1:20 PM, a review of Resident #22's care plan revealed the following care plan intervention, showers per preference and requires extensive assistance with showers/bathing.

During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working getting those issues resolved

g) Resident #60

During the initial interview on 07/22/24 at 1:22 PM, Resident #60 stated, 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. I have asked for showers and they say they will get to me as soon as they can and then end up doing a bed bath or not a bath at all.

A record review on 07/24/24 at 12:10 PM, revealed the following care plan:

Focus:

I need assistance with my ADL's due to

my physical limitations and history of

electrolyte imbalance and weakness

Intervention:

- Shower/bed bath scheduled per my preference. Monitor and document refusals.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Further record review showed, Resident #60 is scheduled to have a shower on Wednesday's and Saturday's. Resident #60 received the following showers and/or bed baths from 05/02/24 to present: Level of Harm - Actual harm None noted for the month of May. No refusals noted from 05/02/24 to present. Residents Affected - Few 06/11/24-Shower

06/19/24-Shower

06/22/24-Bed bath

06/23/24-Bed bath

06/25/24-Bed bath

06/26/24-Bed bath

06/27/24-Bed bath

06/29/24-Bed bath

06/30/24-Bed bath

07/04/24-Bed bath

07/11/24-Bed bath

07/18/24-Bed bath

07/21/21-Bed bath

During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed, Resident #60 had not had a shower since 06/19/24, and had not been bathed according to schedule.

h) Resident #63

During the initial interview on 07/22/24 at 1:46 PM, Resident #63 stated, The most recent shower I have had I believe was the fourth of July. They haven't offered. Well now that I think about it, I think the fourth of July was a bed bath. I have not had a shower since I have been in this room for about a month and a half.

A record review on 07/24/24 at 12:10 PM, revealed the following care plan:

Focus:

Resident/Patient is at risk for decreased

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 ability to perform ADL(s) in bathing,

Level of Harm - Actual harm grooming, personal hygiene, dressing, bed

Residents Affected - Few mobility, transfer, locomotion, toileting

related to: left AKA with complications of, history of cerebral infarction,

spina bifida

Intervention:

-Provide resident/patient with substantial/maximal assist of staff for bathing. He

refuses at times.

Further record review showed that Resident #63 is scheduled to have a shower on Wednesday's and Saturday's. Resident #63 received the following showers and/ or bed bath from 05/02/24 to present:

No refusals are noted.

05/07/24-Shower

05/19/24-Bed bath

05/20/24-Bed bath

06/12/24-Bed bath

06/23/24-Bed bath

06/25/24-Bed bath

06/26/24-Bed bath

06/27/24-Bed bath

07/04/24-Bed bath

07/06/24-Bed bath

07/11/24-Bed bath

07/16/24-Bed bath

07/21/24-Bed bath

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed that Resident #60 had not had a shower since 06/19/24 Level of Harm - Actual harm and had not been bathed according to schedule.

Residents Affected - Few 49751

50795

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or 49465 potential for actual harm Based on observation, record review, and staff interview the facility failed to provide an activity program to Residents Affected - Few meet the needs and interest of the residents and failed to provide scheduled one-to-one visits for residents.

This failed practice was found true for (1) one of (6) six residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #27. Facility Census 71.

Findings include:

a) Resident #27

During the initial observation on 07/22/24 at 1:30 PM, Resident #27 was sitting in the Television Lounge in front of the TV.

Further observation at 3:45PM, showed Resident #27 sitting in the Television Lounge in front of the TV.

Further observation at 5:40PM , showed Resident #27 sitting in the Television Lounge in front of the TV.

A record review on 07/24/24 at 1:00 PM of Resident #27's Activity care plan read as follows:

Focus:

While in the facility, I state that it is

important that I have the opportunity to

engage in daily routines that are

meaningful relative to my preferences.

GOAL:

I receive one-to-one visits

three times/week as tolerated

through the next review.

INTERVENTIONS:

During one-to-one visits staff reads to her and provides hand massages.

I am of the Protestant religion. Please offer me bible readings during one-to-one

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 visits.

Level of Harm - Minimal harm or I receive visits from family and friends every few months. This is very important to potential for actual harm me. Residents Affected - Few

It is important for me to choose what clothing to wear.

It is important for you to know which of my personal belongings I prefer to take care of

myself.

It is important for me to choose a shower.

I like to snack between meals and prefer ice cream.

It is important for me to choose my bedtime and I prefer to go to bed between 7-

9pm.

Further record review of Resident #27's Recreation Quarterly Progress Note and Care Plan Evaluation, under 2c. List Individual engagement opportunities reads as follows:

1:1, Sensory, morning visits.

Further record review of Resident #27's activity participation record for the months of 05/2024, 06/2024, and 07/2024 read as follows:

05/01/24 to 05/07/24- Two one-to-one visits were completed. No group activity.

05/08/24 to 05/15/24- Three one-to-one visits were completed. No group activity.

05/16/24 to 05/22/24- Two one-to-one visits were completed. No group activity.

05/23/24 to 05/31/24- Three one-to-one visits were completed. No group activity.

06/01/24 to 06/07/24- No one-to-one visits were completed. No group activity.

06/08/24 to 06/15/24- No one-to-one visits were completed. No group activity.

06/16/24 to 06/22/24- Two one-to-one visits were completed. No group activity.

06/23/24 to 06/30/24- One, one to one visit was completed. No group activity.

07/01/24 to 07/07/24- One, one-to-one visit was completed. No group activity.

07/08/24 to 07/15/24- One, one-to-one visit was completed. No group activity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 07/16/24 to 07/22/24- Five one-to-one visits were completed. No group activity.

Level of Harm - Minimal harm or 07/26/24 at 12:31 PM, The Activity Director (AD), confirmed the one-to-one visits were not being done as potential for actual harm scheduled.

Residents Affected - Few

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49467

Residents Affected - Few Based on observation, record review, and resident and staff interviews, the facility failed to provide services and/or treatment to Resident #64 to prevent reduction in range of motion. This was true for one (1) of four (4) residents reviewed for limited range of motion during the survey process. Resident identifier: 64. Facility census: 71.

Findings include:

A) Resident #64

At approximately 9:16 AM on 07/23/24, an interview was conducted with Resident #64. During the interview,

it was noted the resident seemed to have contractures in both knees, with his left knee being worse than the right. During the interview, Resident #64 states I don't remember much about when I came in, so I don't really remember when my knees got this way, I know they weren't like this when I came in, but I just don't remember when they got this way. Resident #64 stated no staff member helped him work on range of motion

during times when care is being provided.

At approximately 10:30 AM on 07/23/24, during a review of Resident #64's medical record, it was noted that

the Minimum Data Set (MDS), dated [DATE REDACTED] indicated Resident #64's range of motion in his lower extremities was within normal limits.

Review of physical therapy evaluation and notes (dates of service 03/21/24-04/05/2024) and occupational therapy evaluation and notes (dates of service 03/22/24-04/08/24) indicated Resident #64's range of motion

in lower extremities was within normal limits.

A review of the MDS for Resident #64 dated 06/26/24 indicated the resident has impairment on both lower extremities.

At approximately 12:40 PM on 07/23/24, an interview was conducted with Nurse Aide (NA) #58. During the interview, NA #58 states 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. NA #58 stated the facility used to have restorative aides which would work with residents on such things, but the restorative aide position was removed from the building due to the facility not having enough staff to provide care.

At approximately 1:00 PM on 07/23/24, an interview was conducted with Registered Nurse (RN) #21, RN #20, and RN #31. During the interview, RN #21 stated staffing had not been an issue for nurses, but it had been a serious problem with the aides, knowing the aides were struggling getting assignments completed due to being short staffed, and not having enough time to spend with the residents. RN #31 stated the facility used to have a restorative program and has not used it in quite some time because they don't have enough staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 At approximately 11:30 PM on 07/23/24, an interview was conducted with NA #39, who stated the aides are not able to work with residents like we should due to not having enough staff in the facility and not being able Level of Harm - Minimal harm or to spend the time we need to spend with the residents. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 42120

Residents Affected - Some Based on observation, policy review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 71.

Findings Include:

a) Treatment Cart

On 07/22/24 at 12:50 PM, an observation found an unlocked, unattended treatment cart in the resident tv room. The cart was in a place which was easily accessible allowing access to these medication/treatment supplies by residents, unauthorized persons, or visitors.

On 07/22/24 at 1:42 PM, during an interview with Registered Nurse (RN) #21, it was confirmand the Treatment cart was unlocked. RN #21 verified the treatment cart should not be unlocked when unattended.

She closed and locked the cart at this time.

b) Resident #57

An observation on 07/22/24 at 1:23 PM found nystatin powder generic myconustatin 60 gm, at Resident #57's bed side, unsecured and unattended and allowing access to this medication by residents, unauthorized staff, or visitors.

During an interview on 07/22/24 at 1:28 PM, RN #21 confirmed, the nystatin powder generic myconustatin 60 gm, at Resident #57's bed side should not be left out in the room. RN #21 removed the nystatin powder at

this time.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Immediate 49751 jeopardy to resident health or safety Based on record review, observation and staff interview the facility failed to ensure Resident #9 who requires dialysis received such services, in accordance with professional standards of practice. Resident #9 had an Residents Affected - Some arteriovenous (AV) fistula in their left arm. The facility on multiple occurrences documented they were obtaining the residents blood pressure in their left arm.

Obtaining blood pressure in the arm where the AV fistula is located may result in clots, clots that can dislodge, loss of use of the fistula and could cause a stroke. All of these things put the resident in an immediate risk of serious injury and/or death.

The state agency (SA) determined this failure to be an immediate jeopardy (IJ) situation. The facility was notified of the IJ on 07/25/24 at 11:09 am. The SA accepted the facility's plan of correction (POC) on 07/25/24 at 1:15 PM.

After observation of implementation of the POC the IJ was abated at 3:30 PM on 07/26/24. After the immediacy was removed a deficient practice remained for Resident #9 in regard to the completion of Post dialysis assessments at which time the Scope and severity was decreased form a K to an E.

These failed practices were true for one (1) of one (1) residents reviewed for the care area of dialysis during

the long term care survey process. Resident Identifier: #9. Facility Census: #71.

Findings include:

a) Resident #9

A review of Resident #9's medical record on 07/25/24 at approximately 10:00 am found the following physician order:

A review of Resident #9's electronic medical record on 07/25/24 found under the blood pressure vital signs tab the following dates and times when facility staff documented they had taken Resident #9's blood pressure in his left arm:

-- 12/16/23 at 2:25 PM

-- 12/18/23 at 11:53 AM

-- 01/10/24 at 9:30 AM

-- 05/14/24 at :48 PM

-- 05/26/24 at 2:41 AM

-- 05/28/24 at 6:36 PM

-- 05/29/24 at 6:25 PM

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 -- 06/08/24 at 11:53 AM

Level of Harm - Immediate -- 06/09/24 at 5:40 PM jeopardy to resident health or safety -- 06/20/24 at 11:26 AM

Residents Affected - Some -- 06/21/24 at 1:27 PM

-- 06/22/24 at 11:57 PM

-- 06/23/24 at 10:42 PM and

-- 06/25/24 11:50 PM.

Continued record review on 07/25/24 found an order stating, Monitor AV fistula.graft site to left arm for S/S infection, edema, bleeding and upon return from dialysis, notify primary care physician and dialysis if AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician if bleeding does not stop.

Record review of the Dialysis communication book revealed the facility was not completing POST dialysis assessments on Resident #9 after returning from dialysis.

Record review of Residents # 9's care plan revealed the following:

- Do not take B/P in my left arm due to my AV

- Monitor for s/s of infection, edema, bleeding upon return from dialysis

An observation on 07/25/24 at approximately 10:30 AM, revealed Resident #9 had no signage in room stating not to take BP in left arm

Further observation of Resident #9 found his room and person was void of any signage and/or bracelet which would have brought awareness to the staff that Resident #9 had a restricted limb.

During an interview on 07/25/24 with LPN #68, stated they take blood pressure in the opposite arm of the AV fistula, Record review had previously revealed LPN #68 had documented having taken blood pressure in Resident #9's left arm.

On 07/25/24 at 11:30 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm and complete the POST dialysis assessment in the resident's dialysis book.

b) Facility plan of correction (typed as written):

Resident #9 will be evaluated by the licensed nurse upon return to the facility.

All dialysis residents have the potential to be affected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 The Unit Managers/designee conducted an audit on 07/25/2024 for all residents on

Level of Harm - Immediate dialysis with specific B/P orders to be taken and POST dialysis assessment is jeopardy to resident health or safety completed upon return to the facility with any corrective action immediately upon discovery.

Residents Affected - Some 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 (as follows):

Procedure: 1. Verify orders and instructions from hemodialysis facility or hospital, if

patient is a new Admission.

2. Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.

2.1 Inspect fistula site for decrease or absence of vein dilation.

2.2 Palpate for distal thrill.

2.3 Auscultate for bruit.

2.4 Palpate skin around graft/fistula for warmth.

2.5 Evaluate skin around vascular access noting redness, swelling, local

warmth, exudate, tenderness.

3. Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for.

3.1 Pain, numbness, swelling, redness, odor, bleeding or drainage at site;

3.2 Extreme warmth or coolness of extremity; 3.3 Blebs (ballooning or bulging) of the vascular access site;

3.4 Absence of pulses distal to access site;

3.5 Absence of bruit or thrill.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 4. Protect access site from getting wet for several hours after HD or HHD treatment.

Level of Harm - Immediate 5. Avoid trauma or treatment procedures in the accessed extremity, such as: jeopardy to resident health or safety 5.1 Limit activity of extremity,

Residents Affected - Some 5.2 Blood pressure measurement,

5.3 Venipuncture, injection of any type,

5.4 Use of creams or lotions on the access site.

6. Instruct patient:

6.1 To avoid excessive pressure on the extremity or strain (e.g., laying on it or lifting heavy object with it).

6.2 In strengthening exercises to enhance blood flow such as squeezing

small rubber ball, if permitted by physician/APP and dialysis facility. 6.3 In proper care of fistula/graft.

7. Document:

7.1 Location of access site on admission assessment;

7.2 Status of access site in Nurses'

7.3 Status of pulses distal to access area;

7.4 Color and temperature of extremity;

7.5 Presence or absence of pain or numbness;

7.6 Status of bruit and thrill;

7.7 Notification and response of physician/APP and dialysis

facility, if indicated;

7.8 Patient education and family involvement; 7.9 Nursing

intervention.

Policy: Center staff will communicate with the certified dialysis facility regarding the

ongoing assessment of the patient's condition by monitoring for complications before

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 and after hemodialysis (HD) treatments received at a certified dialysis facility.

Level of Harm - Immediate PURPOSE: To ensure ongoing communication and collaboration with the certified jeopardy to resident health or safety dialysis facility regarding hemodialysis (HD) patient care and services.

Residents Affected - Some 1. 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.

2. 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.

3. Upon return of the patient to the Center, a licensed nurse will:

3.1 Review the certified dialysis facility communication;

3.2 Evaluate/observe the patient; and

3.3 Complete the post-hemodialysis treatment section on the Hemodialysis

Communication Record or state required form.

4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.

4.1 Document notification of certified dialysis facility regarding return of form or other

Communication.

5. 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 x 2 quarters

to ensure physician orders are followed including ensuring B/P ' s are not taken in

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 restricted arm.

Level of Harm - Immediate The Unit Managers (UM)/Designee will conduct observations starting on 7/25/2024 to jeopardy to resident health or safety ensure all licensed nurses are taking B/P and the licensed nurse is completing the

Residents Affected - Some dialysis communication sheets POST dialysis daily across all shifts for 2 weeks

including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a

week for 4 weeks, then randomly thereafter.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49467

Residents Affected - Few Based on observation, record review, and resident and staff interview, the facility failed to have sufficient staff to provide care for residents at the facility. This has the potential to affect all residents currently residing at the facility. Resident identifier: #64. Facility census: 71.

Findings include:

A) Resident #64

At approximately 9:16 AM on 07/23/24, an interview was conducted with Resident #64. During the interview,

it was noted the resident seemed to have contractures in both knees, with his left knee being worse than the right. During the interview, Resident #64 states, I don't remember much about when I came in, so I don't really remember when my knees got this way, I know they weren't like this when I came in, but I just don't remember when they got this way. Resident #64 stated no staff member helped him work on range of motion

during times when care is being provided.

At approximately 10:30 AM on 07/23/24 during a review of Resident #64's medical record, it was noted that

the Minimum Data Set (MDS), dated [DATE REDACTED] indicated Resident #64's range of motion in his lower extremities was within normal limits.

Review of physical therapy evaluation and notes (dates of service 03/21/24-04/05/24) and occupational therapy evaluation and notes (dates of service 03/22/24-04/08/24) indicated Resident #64's range of motion

in lower extremities were within normal limits.

A review of the MDS for Resident #64 dated 06/26/24 indicates the resident has impairment on both lower extremities.

At approximately 12:40 PM on 07/23/24, an interview was conducted with Nurse Aide (NA) #58. During the interview, NA #58 states 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. NA #58 stated the facility used to have restorative aides that would work with residents on such things, but the restorative aide position was removed from the building due to the facility not having enough staff to provide care.

At approximately 1:00 PM on 07/23/24, an interview was conducted with Registered Nurse (RN) #21, RN #20, and RN #31. During the interview, RN #21 stated staffing had not been an issue for nurses, but it had been a serious problem with the aides, knowing the aides were struggling getting assignments completed due to being short staffed, and not having enough time to spend with the residents.

RN #31 stated the facility used to have a restorative program and has not used it in quite some time because

they don't have enough staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 At approximately 11:30 PM on 07/23/24, an interview was conducted with NA #39, who stated the aides are not able to work with residents like we should due to not having enough staff in the facility and not being able Level of Harm - Minimal harm or to spend the time we need to spend with the residents. potential for actual harm b) Staff interviews Residents Affected - Few At approximately 12:40 PM on 07/23/24, an interview was conducted with NA #58. NA #58 stated the facility runs 4 aides during day shift pretty regularly. Very rarely do we have more than that. NA #58 stated weekends are worse than weekdays, although not every weekend has staffing issues. NA #58 stated they were asked to stay late almost all the time due to staffing issues at the facility. NA #58 states, I feel like I have to rush through providing care because we don't have enough staff, and the residents suffer because of it.

At approximately 1:00 PM on 07/23/24, an interview was conducted with RN #21, RN #20, and RN #31.

During the interview, all three stated they were aware the staffing situation with the Nurse Aides was not good, as they were asked to pick up shifts as an aide regularly because they don't have enough. RN #21 stated I know they have asked for agency multiple times to get help with the situation, but they won't bring them in here.

At approximately 11:30 PM on 07/23/24, an interview was conducted with NA #39. During the interview, NA #39 stated, Very rarely do we have time to care for the residents the way we should because we don't have enough staff. 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.

NA #39 states, We bring staffing concerns to management all the time, but they turn it around on us and make it out to be our fault, saying we call in too much. We have asked for agency, and we don't get it. People here don't get showers on day shift or evening shift because no one has time to do them.

NA #39 stated, I get three (3) to four (4) days off every week and every single one of those days I get a call from this place asking me to come in and work on my days off because we don't have enough people. When I am scheduled to work, I am constantly asked to come in early and stay late because of the staffing.

At approximately 11:45 AM on 07/25/24 an interview was conducted with the Administrator regarding staffing levels at the facility. The administrator stated the facility needs to have five (5) aides, at least, during day shift, but averages four (4) most days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 49467 potential for actual harm Based on record review and staff interview, the facility failed to conduct yearly performance evaluations for Residents Affected - Some each Nurse Aide. This was true for three (3) out of five (5) Nurse Aides reviewed during the survey process. Staff identifiers: NA #34, NA #63, NA# 61. Facility census: 71.

Findings included:

A) Record review

At approximately 2:45 PM on 07/23/24 a review of yearly performance evaluations and educations were conducted for randomly selected Nurse Aides (NA). During review, it was discovered the facility was missing yearly performance evaluations for NA #34, NA #63, and NA #61.

B) Staff interviews

At approximately 3:30 PM on 07/23/24 an interview was conducted with the Administrator. During the interview, the administrator confirmed the absence of performance evaluations for the three (3) NAs. The administrator stated We knew there were some missing and we are aware of it. We are trying to get caught up on them.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 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 Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm 49465 Residents Affected - Some Based on record review and staff interview the facility failed to do behavior and side effect monitoring for psychotropic medications. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #54. Facility Census 71.

Findings include:

a) Resident #54

Record review, on 07/24/24 at 4:00 PM, of Resident #54's orders revealed Resident #54 was ordered Lorazepam Oral Tablet 0.5 Milligrams (MG) on 12/22/23. It further read, (1) one tablet by mouth at bedtime for Anxiety. Monitor for Sedation, morning hangover, ataxia, nausea and report side effects to physician.

Further record review of Resident #54's Medication Administration Record (MAR) for behavior and side effect monitoring showed no monitoring for 12/2023, 01/2024, 02/2024, 03/2024, 04/2024, and 05/2024.

During an interview on 07/25/24 at 10:00 AM, The Director of Nursing (DON) stated, We did identify a problem and are now working on it. She later confirmed the behavior and side effect monitoring was not being done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Immediate 49751 jeopardy to resident health or safety Based on resident interview and record review the facility failed to ensure Resident #65 was free from significant medication errors. Resident #65 was administered an injection of 25 units of insulin on 04/19/24 Residents Affected - Few when the resident was not ordered any insulin nor was he a diabetic.

Note: The nursing home is Giving a resident an insulin injection when they are not ordered the medication, nor a diabetic can cause disputing this citation. serious consequences including serious harm and or death. The state agency (SA) determined this to be an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 07/22/24 at 6:49 PM. The SA accepted the facility's Plan of Correction (POC) on 07/22/24 at 7:40 PM. After completing observations,

record reviews, and staff interviews regarding the implementation of the POC the IJ was abated at 07/23/24 at 2:30 pm.

This failed practice was a random discovery and was true for Resident #65, but due to the systemic failures

the failed practice had the potential to affect more than a limited number of residents. Resident identifier: 65. Facility Census: 71.

Findings include:

a) Resident #65

During an interview on 07/22/24 at approximately 3:45 PM, Resident #65 stated back in April 2024 a male nurse who he was unable to recall their name gave him an insulin shot and he was not a diabetic. The resident continued to state, the nurse did not verify who they were giving the insulin shot to.

Record review revealed a progress note dated 04/19/24 which read as follows: Resident was administered with 25 units of Lantus at 9pm by error. Residents had a room change from this shift from 401A to 107. Resident BS before the insulin was administered was 135. Resident was notified and he was upset because

he was given the wrong medication. He said he never took any medications till he was admitted to the facility. On- call Dr called and initial orders were given to monitor resident BS Q for 15 minutes. Resident refused to have his blood sugar checked. At 10:30 after speaking to his wife he allowed a BS check and it was 118. On- Call (Dr Name) was notified and gave orders to check Blood Sugar (BS) at 5AM and Q shift for tomorrow.

The facility was unable to provide any documentation to prove they investigated and or implemented any process to ensure this failure never occurred again.

Further record review revealed the following change in condition Situation:

At the time of evaluation resident/patient vital signs, weight and blood sugar were:

- Blood Pressure: BP 112/75 - 4/19/2024 21:08 Position: Lying l/arm

- Pulse: P 78 - 4/19/2024 21:08 Pulse Type: Regular

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 - RR (respirations): R 18 - 4/19/2024 21:10

Level of Harm - Immediate - Temp (Temperature): T 97.7 - 4/19/2024 21:10 Route: Forehead (non-contact) jeopardy to resident health or safety - Weight: W 198.6 lb. - 4/10/2024 08:23 Scale: Wheelchair

Residents Affected - Few - Pulse Oximetry: O2 97.0 % - 4/18/2024 22:59 Method: Room Air

Note: The nursing home is - Blood Glucose: BS 118 - 4/19/2024 22:30 disputing this citation. Nursing observations, evaluation, and recommendations were :No changes noted to resident at this time, will continue to monitor for changes.

Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recheck Blood Sugar at 5:00 AM and every shift tomorrow. Continue to monitor all shifts.

During an interview with LPN#66 the LPN at approximately 4:30 PM stated, they had gotten report on a different resident and when he went to give the meds he didn't verify because he didn't know the residents had switched rooms.

An interview on 07/22/24 at approximately 6:00 PM with the facility Administrator revealed at the time of the error a one-to-one education/competency was completed with LPN#66 on 06/19/24, the error occurred on 04/19/24, at this time the DON stated LPN#66 is not full time and works part time or as needed.

b) Facility Plan of Correction

The facilities Plan of Correction (POC) read as follows.

The licensed nurse conducted a change in condition on 04/19/24 with notification to the medical provider for Resident#65.

All residents of the facility have the potential to be affected.

The Nurse Educator conducted an audit on 07/22/2024 of all licensed nurse's medication administration competencies to ensure all licensed nurses are competent with medication administration within the last 12 months with any corrective action immediately upon discovery.

The Administrator/Designee conducted an audit on 07/22/2024 for all residents to ensure they had a photo identification on the eMar with any corrective action immediately upon discovery. No residents were identified.

Re-education as provided by the DON/Designee to all licensed nurses starting on 7/22/24 on safe medication administration practices including verification of correct: Patient, drug, route, dose, time, special considerations, and expiration date with a POST test to validate understanding. Any licensed nurse 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 New licensed nurses will be provided education, including post-test during orientation by DON/Designee. Annual in-servicing will be provided to licensed nurses regarding medication administration. Level of Harm - Immediate jeopardy to resident health or The unit managers(UM)/Designee will conduct observations starting on 7/22/24 to ensure all licensed nurses safety are passing medications with verification of right person, drug, route, dose, time, special considerations, and expiration dates across all shifts for two weeks, including holidays, then five times a week for four weeks, Residents Affected - Few then three times a week for four weeks, then randomly thereafter.

Note: The nursing home is Results of observations will be reported by the UM/designee monthly to the Quality Improvement disputing this citation. Committee(QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter determined by the QIC committee.

A review of the facility POST test was reviewed on 07/23/24 at 11:00 AM:

The following Licenses nurses were interviewed and confirmed they had got the training and took the posttest and understood what was being educated to them.

~Registered Nurse(RN)#31

~RN#20

~RN#13

~RN#21

~LPN#35

~LPN#48

~LPN#50

~LPN#52

IJ was abated 07/23/24 at 2:30 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 45173 Residents Affected - Some Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71.

Findings Include:

On 07/25/24 at 9:25 AM, the medication room was observed. The observation found the medication refrigerator temperatures were not completed for March 2024 through July 2024. The following dates were not completed:

--03/16/24 PM

--03/17/24 PM

--03/18/24 PM

--03/19/24 PM

--03/20/24 PM

--03/21/24 PM

--03/22/24 PM

--03/23/24 AM

--03/25/24 PM

--03/26/24 PM

--03/28/24 PM

--03/29/24 AM

--03/29/24 PM

--03/30/24 PM

--03/31/24 AM

--04/01/24 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 --04/02/24 PM

Level of Harm - Minimal harm or --04/04/24 PM potential for actual harm --04/05/24 PM Residents Affected - Some --04/06/24 PM

--04/08/24 PM

--04/09/24 PM

--04/10/24 PM

--04/11/24 PM

--04/12/24 AM

--04/13/24 PM

--04/14/24 PM

--04/15/24 AM

--04/15/24 PM

--04/16/24 PM

--04/17/24 PM

--04/18/24 PM

--04/19/24 PM

--04/21/24 PM

--04/22/24 PM

--04/23/24 AM

--04/23/24 PM

--04/24/24 PM

--04/25/24 AM

--04/25/24 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 --04/26/24 PM

Level of Harm - Minimal harm or --04/27/24 PM potential for actual harm --04/28/24 PM Residents Affected - Some --04/29/24 PM

--04/30/24 PM

--05/01/24 PM

--05/02/24 PM

--05/03/24 PM

--05/04/24 AM

--05/05/24 AM

--05/06/24 PM

--05/07/24 PM

--05/08/24 AM

--05/09/24 PM

--05/10/24 AM

--05/10/24 PM

--05/11/24 AM

--05/11/24 PM

--05/12/24 AM

--05/13/24 PM

--05/14/24 PM

--05/15/24 PM

--05/16/24 PM

--05/17/24 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 --05/20/24 PM

Level of Harm - Minimal harm or --05/21/24 PM potential for actual harm --05/22/24 AM Residents Affected - Some --05/22/24 PM

--05/23/24 AM

--05/23/24 PM

--05/24/24 AM

--05/24/24 PM

--05/25/24 PM

--05/26/24 PM

--05/27/24 PM

--05/28/24 PM

--05/29/24 PM

--05/30/24 PM

--05/31/24 PM

--06/01/24 AM

--06/01/24 PM

--06/04/24 AM

--06/04/24 PM

--06/05/24 AM

--06/05/24 PM

--06/07/24 AM

--06/07/24 PM

--06/11/24 AM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 --06/11/24 PM

Level of Harm - Minimal harm or --06/12/24 AM potential for actual harm --06/13/24 PM Residents Affected - Some --06/15/24 AM

--06/15/24 PM

--06/16/24 AM

--06/17/24 PM

--06/18/24 PM

--06/19/24 AM

--06/19/24 PM

--06/20/24 AM

--06/21/24 PM

--06/24/24 AM

--06/25/24 PM

--06/26/24 AM

--06/27/24 PM

--06/29/24 PM

--06/30/24 PM

--07/01/24 AM

--07/02/24 AM

--07/03/24 AM

--07/05/24 PM

--07/06/24 PM

--07/07/24 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 --07/08/24 PM

Level of Harm - Minimal harm or --07/09/24 PM potential for actual harm --07/10/24 PM Residents Affected - Some --07/11/24 PM

--07/13/24 PM

--07/15/24 PM

On 07/25/24 at 9:45 AM, the Administrator and the Director of Nursing (DON) were notified. The Administrator confirmed the medication refrigerator temperature logs were incomplete.

b) Policy

On 07/25/24 at 2:00 PM, the facility policy entitled, Medication and Vaccine Refrigerator/Freezer Temperatures was reviewed. Under the heading of Policy, the following was listed:

Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49465

Residents Affected - Some Based on observation and staff interview the facility failed to ensure food was discarded after the expiration date. This failed practice had the potential to affect more than a limited number of residents currently residing

in the facility. Facility Census 71.

Findings included:

a) Kitchen

During the initial observation on 07/22/24 at 1:30 PM, the following items were found to be out of date and/or covered in an mold like substance in the kitchen:

1. Scalloped potatoes were wrapped in plastic wrap in the walk-in refrigerator with a discard date of 07/11/24.

2. There was a box of onions in the walk-in refrigerator with 8 onions in it, 4 of the onions were covered in what appeared to be mold.

During an interview on 07/22/24 at 1:40 PM, The Dietary manager in training (DMT) stated, Yes, those potatoes are out of date. I will get the potatoes and onions thrown out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 49467

Residents Affected - Few Based on record review and resident and staff interviews, the facility failed to accurately document the dental condition of Resident #227 on the admission assessment. This was a random opportunity for discovery. Resident identifier: #227. Facility census: 71.

Findings included:

a) Resident #227

At approximately 9:00 AM on 07/24/24 an interview was conducted with Resident #227. During the interview,

the resident stated, I only have four (4) teeth and can't chew the food very well.

At approximately 9:30 AM on 07/24/24 a review of Resident #227's record was conducted. On the resident's clinical admission evaluation dated 07/19/24 at 4:24 PM, the box has own teeth was marked. However, the rest of the dental portion of the evaluation was incomplete.

At approximately 2:00 PM on 07/24/24 an interview was conducted with the Administrator regarding the incomplete assessment. The administrator reviewed the dental section of the assessment and confirmed it was incomplete.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45173 potential for actual harm Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection Residents Affected - Many control program for disposal of soiled linen, not wearing proper personal protective equipment (PPE) in enhanced barrier precaution (EBP) rooms, storage of used bedpans, placing a dirty dinner tray on the cart of clean trays and disposal of soiled gloves. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 71.

Findings included:

a) Soiled Linen

On 07/23/24 at 11:09 PM, an observation was made of linen laying on the PPE cart and soiled linen on the floor in room [ROOM NUMBER]. Registered Nurse (RN) #48 was notified and removed the soiled linen immediately.

On 07/24/24 at 9:55 AM, the Administrator was notified and confirmed soiled linen should be disposed of in

the appropriate container.

b) Enhanced Barrier Precautions

On 07/23/24 at 11:55 PM, an observation was made of RN #48 and Nurse Aide (NA) #39 transferring Resident #42, who was in an EBP room, without wearing the proper PPE.

On 07/24/24 at 12:05 AM, a continued observation of NA #39 and NA #65 revealed they were providing incontinence care for Resident #42 without wearing the proper PPE.

On 07/24/24 at 12:08 AM, NA #39 was interviewed regarding PPE. NA #39 stated, they have those signs hanging everywhere. NA #65 stated, it could have been from the resident who was in the room before.

On 07/24/24 at 12:10 AM, RN #48 was interviewed regarding wearing PPE in EBP rooms. RN #48 nodded his head in regards PPE should be worn in EBP rooms.

On 07/24/24 at 9:58 AM, the Administrator was notified. The Administrator confirmed PPE should be worn in EBP rooms.

c) Door Signage

On 07/25/24 at 10:05 AM, a copy of the door signage entitled Enhanced Barrier Precautions was received.

The door signage gives guidance of what PPE should be worn when caring for the residents. The following activities were listed:

--dressing

--bathing/showering

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 --transferring

Level of Harm - Minimal harm or --providing hygiene potential for actual harm --changing linens Residents Affected - Many --changing briefs or assisting with toileting

--device care or use of device

--wound care

On 07/25/24 at 10:06 AM, the Regional Nurse confirmed PPE should be worn in EBP rooms when providing

the activities described on the door signage.

d) Meal service

On 07/22/24 at approximately 5:18 PM, Nurse Aide (NA) #60 removed a tray from the tray delivery cart on

the 100 hall of the facility. NA #60 took the tray to a room and the resident refused the tray. NA #60 then proceeded to place the tray back onto the delivery cart. NA #60 acknowledged she placed the tray back onto

the cart stating, I don't know what else to do with it.

e) Bedpan in floor

On 07/22/24 at 1:15 PM, three (3) bedpans were observed laying uncovered in the restroom of room [ROOM NUMBER].

On 07/22/24 at 2:25 PM, three (3) bedpans were laying uncovered in the restroom of room [ROOM NUMBER]

On 07/22/24 at 4:43 PM, Nurse Aide(NA) #64 confirmed the three (3) bedpans should not be on the floor uncovered and picked them up to throw away.

50795

An observation, on 07/23/24 at 11:16 PM, revealed a pair of soiled, discarded, gloves on the floor of the 300 hallway.

LPN #48 confirmed this was an infection control issue, and the gloves should have been discarded in the appropriate receptacle.

During an interview on 07/25/24 at 10:31 AM , LPN #68 stated soiled gloves were to be discarded the in trash can in the resident's room.

On 07/23/34 at 12:18 PM, NA #58 stated soiled dressings and gloves were to be discarded in the appropriate receptacle, in resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 515167 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515167 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shenandoah Center 50 Mulberry Tree Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 42120 potential for actual harm Based on observation, and staff interview, the facility failed to ensure the resident call system was Residents Affected - Some functioning as designed. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 71.

Findings included:

a) Observation tour, on 07/22/24 at 2:30 PM, of the 200 and 300 halls, found the call light system turned off at the end of the halls. The volume was too low to be heard throughout the unit.

During an interview, on 07/23/24 at 12:26 PM, the Maintenance Assistant verified it was turned off at the end of the hall. At this time, he turned the audible switch back on. He stated the staff turned it off.

During an interview, on 07/23/24 at 12:33 PM, the Maintenance Director confirmed the call system was visual and audible. He stated all the call systems in the building were turned down and it had been that way since he started.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 515167