Inspection Reports for Shenandoah Senior Living

VA

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Inspection Report Monitoring Census: 44 Deficiencies: 0 Oct 29, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-10-24 regarding allegations in the areas of resident care and protection of adults and reporting.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector toured the facility, reviewed resident records, and conducted interviews with residents and staff.
Report Facts
Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4
Inspection Report Monitoring Census: 44 Deficiencies: 0 Oct 29, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 10/24/2025 regarding allegations in the areas of resident care and protection of adults and reporting.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector toured the facility, reviewed one resident record, and conducted interviews with one resident and two staff members.
Report Facts
Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2
Inspection Report Complaint Investigation Census: 43 Deficiencies: 8 Sep 9, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-09-08 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance in admission, retention and discharge of residents, and resident care and related services. Multiple violations were found including failure to retain written acknowledgments, incomplete service plans, delayed staff response to resident needs, missing documentation, and unsafe storage of hazardous materials.
Complaint Details
The complaint was substantiated in part. The regional licensing office received an APS referral alleging that resident 1's call bell was broken and staff were taking more than thirty minutes to respond. The investigation found multiple issues related to resident care and safety.
Deficiencies (8)
Description
Facility failed to ensure a written acknowledgment of receipt of the disclosure by the resident or legal representative was retained in the resident's record.
Facility failed to ascertain and document whether a potential resident was a registered sex offender prior to admission.
Facility failed to complete the individualized service plan prior to the person participating in respite care.
Facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances.
Facility failed to ensure procedures for documentation and recordkeeping to ensure resident records were accurate, clear, and well-organized.
Facility failed to ensure the resident's record contained signed physician's or prescriber's orders or dated notation of oral orders with orders organized chronologically.
Facility failed to store cleaning supplies and other hazardous materials in a locked area.
Facility failed to ensure a signaling device was present and easily accessible to the resident in his bedroom and connecting bathroom.
Report Facts
Number of residents present: 43 Number of resident records reviewed: 1 Number of staff interviews conducted: 6 Call bell response delays: 61 Missing end of shift reports: 34
Employees Mentioned
NameTitleContext
Angela N ViaLicensing InspectorCurrent inspector conducting the complaint investigation and inspection.
Staff 6Staff member interviewed who confirmed missing documentation and acknowledged issues with call bell response times and recordkeeping.
Staff 7Staff member who acknowledged and reminded staff about locking cleaning carts and was present during observation of unlocked cleaning supplies.
Staff 4Staff member interviewed regarding resident cognitive status and medication awareness.
Staff 3Staff member who assisted licensing inspector during tour and secured chemicals in locked area.
Staff 1Staff member interviewed about resident medication awareness.
Inspection Report Renewal Census: 44 Deficiencies: 24 Aug 11, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to resident record documentation, staff training and records, medication administration, emergency preparedness, and facility safety. Plans of correction were provided for each deficiency to address compliance.
Deficiencies (24)
Description
Failed to obtain written approval from a guardian or legal representative prior to placing a resident with serious cognitive impairment in a safe, secure environment.
Failed to determine and justify in writing the appropriateness of placement in the special care unit for a resident with serious cognitive impairment.
Failed to ensure protective devices on bedroom windows to prevent windows from opening wide enough for a resident to crawl through.
Failed to retain written acknowledgment of receipt of disclosure by resident or legal representative in resident record.
Failed to ensure required orientation and training occurred within first seven working days of employment for staff.
Failed to ensure all direct care staff attended at least 18 hours of annual training.
Failed to maintain personal and social data in staff records.
Failed to ensure documented absence of tuberculosis in communicable form for staff.
Failed to provide written assurance of appropriate license to resident at admission with signed copy retained in record.
Failed to obtain physical examination including tuberculosis risk assessment within 30 days preceding admission.
Failed to ascertain and document registered sex offender status prior to admission.
Failed to ensure Uniform Assessment Instrument was signed by qualified assessor.
Failed to complete comprehensive individualized service plan within 30 days after admission.
Failed to ensure individualized service plan was signed and dated by resident or legal representative.
Failed to keep all resident records in a locked area.
Failed to ensure medications and supplements were filled and refilled timely to avoid missed dosages.
Failed to administer medications in accordance with physician's instructions, including documentation of vital signs and physician notification.
Failed to store cleaning supplies and hazardous materials in a locked area.
Failed to ensure the building was free from foul odors.
Failed to ensure at least an annual fire inspection by appropriate official.
Failed to ensure semiannual review of emergency preparedness plan included all required elements.
Failed to ensure availability of a 96-hour supply of emergency drinking water with at least 48-hour supply on site.
Failed to obtain sworn statement or affirmation for all applicants for employment.
Failed to obtain original criminal history record report for each employee within 30 days of employment.
Report Facts
Number of residents present: 44 Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of staff interviews conducted: 4 Days supplements not administered: 8 Days supplements not administered: 9 Days supplements not administered: 9 Days supplements not administered: 8 Blood sugar readings above 300: 4 Date of last fire inspection before survey: Jan 16, 2024
Employees Mentioned
NameTitleContext
Angela N ViaLicensing InspectorConducted the inspection and is the contact for questions
Staff 1Confirmed supplements were not administered and provided medication administration record
Staff 2Acknowledged missing documentation for orientation, training, tuberculosis risk assessments, job descriptions, and other records
Staff 5Confirmed missing approvals and documentation in resident records
Staff 7Confirmed missing documentation and unlocked storage room
Memory Care DirectorResponsible for completing audits and corrective actions related to Memory Care Unit
Business Office Manager/Human ResourcesResponsible for audits and ensuring employee records compliance
Resident Service DirectorLicensed NurseResponsible for tuberculosis risk assessments and medication compliance
Dietary DirectorResponsible for maintaining emergency drinking water supply
Maintenance DirectorResponsible for window safety devices and emergency preparedness plan updates
Executive DirectorSubmitted fire inspection report
Inspection Report Complaint Investigation Census: 43 Deficiencies: 0 Jul 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-09 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2025-04-09 regarding allegations in Resident Care and Related Services. The investigation did not substantiate the complaint.
Report Facts
Number of residents present: 43 Number of resident records reviewed: 1 Number of staff interviews conducted: 1
Inspection Report Complaint Investigation Census: 43 Deficiencies: 0 Jul 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-24 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint received on 2025-04-24 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 43 Number of resident records reviewed: 1 Number of staff interviews conducted: 1
Inspection Report Monitoring Census: 43 Deficiencies: 1 Jul 29, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards following a self-reported incident regarding resident care and related services.
Findings
The inspection found non-compliance with applicable standards related to the facility's failure to assume general responsibility for the health, safety, and well-being of residents, specifically involving a resident leaving the secured Memory Care unit through an unsecured door.
Deficiencies (1)
Description
Facility failed to assume general responsibility for the health, safety, and well-being of residents, evidenced by a resident leaving the Memory Care unit through an unsecured door.
Report Facts
Number of residents present: 43 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1
Inspection Report Complaint Investigation Census: 43 Deficiencies: 1 Jul 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-31 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations being issued. The licensee was given the opportunity to submit a plan of correction to address the cited violations and maintain compliance.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards or law.
Deficiencies (1)
Description
A late entry of the incident was documented on 2025-08-19 by the Memory Care Director. Staff failed to document within the resident record the incident that occurred on 2025-03-26 involving Resident 1 and another resident trying to assist her off the couch.
Report Facts
Residents present: 43 Resident records reviewed: 1 Staff records reviewed: 0 Resident interviews conducted: 0 Staff interviews conducted: 1
Employees Mentioned
NameTitleContext
Angela N ViaLicensing InspectorCurrent inspector conducting the complaint investigation
Sarah PearsonLicensing InspectorContact person for questions regarding the inspection
Inspection Report Complaint Investigation Census: 43 Deficiencies: 1 Jul 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-24 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance with standards or law. However, a violation unrelated to the complaint was identified regarding failure to document changes in a resident's condition and corresponding actions in the resident's record.
Complaint Details
Complaint was related to Resident Care and Related Services and was not substantiated based on the evidence gathered during the investigation.
Deficiencies (1)
Description
Facility failed to note changes in a resident's condition or functioning, including illness, injury or altered behavior, and any corresponding action taken was not documented in the resident's record.
Report Facts
Number of residents present: 43 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1
Inspection Report Complaint Investigation Census: 38 Deficiencies: 1 Mar 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to Resident Care and Related Services at Shenandoah Senior Living.
Findings
The investigation supported some, but not all, of the allegations. A violation was found related to the failure to ensure the Individualized Service Plan (ISP) included the Do Not Resuscitate (DNR) order for a resident.
Complaint Details
The complaint was substantiated in part; evidence showed Resident 1 had a DNR order dated 10/9/2024, but the ISP updated on the same date incorrectly stated the resident's Code Status as Full Code.
Deficiencies (1)
Description
Facility failed to ensure the ISP included the Do Not Resuscitate order for Resident 1.
Report Facts
Number of residents present: 38 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3
Employees Mentioned
NameTitleContext
Angela N ViaLicensing InspectorCurrent inspector conducting the complaint investigation
Sarah PearsonLicensing InspectorContact person for questions regarding the inspection findings
Inspection Report Complaint Investigation Census: 38 Deficiencies: 0 Mar 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to resident care and related services at Shenandoah Senior Living.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered during the investigation.
Report Facts
Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1
Inspection Report Complaint Investigation Census: 38 Deficiencies: 0 Mar 7, 2025
Visit Reason
The inspection was conducted as a complaint-related investigation to review allegations of non-compliance with standards or law at Shenandoah Senior Living.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance. An exit meeting was planned to review the inspection findings, and the summary will be posted publicly.
Complaint Details
The inspection was complaint-related, but the investigation did not substantiate the allegations of non-compliance with standards or law.
Report Facts
Number of residents present: 38 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1
Inspection Report Complaint Investigation Census: 38 Deficiencies: 0 Feb 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations of non-compliance with standards or law at the assisted living facility.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting will be conducted to review the findings.
Complaint Details
The visit was complaint-related, but the investigation did not substantiate the allegations of non-compliance.
Report Facts
Number of resident records reviewed: 22 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2
Inspection Report Complaint Investigation Census: 38 Deficiencies: 2 Feb 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to staffing, resident care, and facility conditions at Shenandoah Senior Living.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Building and Grounds and Resident Care and Related Services. Violations included failure to have staff lead scheduled activities and failure to maintain furnishings and equipment in clean and good repair.
Complaint Details
The complaint investigation found some allegations substantiated, specifically regarding staffing for activities and cleanliness and maintenance of furnishings and equipment.
Deficiencies (2)
Description
Facility failed to ensure that a staff person was available to lead the scheduled activity at 10:00am due to lack of an Activities Director.
Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair, including stained mattress, used catheter bag left in bathroom, and stained sink.
Report Facts
Number of residents present: 38 Number of resident records reviewed: 3 Number of staff interviews conducted: 4 Number of resident interviews conducted: 2
Inspection Report Monitoring Census: 38 Deficiencies: 1 Feb 27, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws, specifically a failure to report a major incident within 24 hours to the regional licensing office. A violation notice was issued and a plan of correction was submitted.
Deficiencies (1)
Description
Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of residents.
Report Facts
Number of residents present: 38 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of staff interviews conducted: 2
Employees Mentioned
NameTitleContext
Sarah PearsonLicensing InspectorContact person for questions regarding the inspection
Angela N ViaLicensing InspectorCurrent inspector conducting the inspection
Inspection Report Complaint Investigation Census: 45 Deficiencies: 2 Sep 27, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to Administration and Administrative Services and Resident Care and Related Services at Shenandoah Senior Living.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance in Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
The complaint investigation found that some allegations were substantiated related to Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued. The licensee has the opportunity to submit a plan of correction.
Deficiencies (2)
Description
The facility failed to ensure that the health care service needs of residents are met, including notifying the resident's legal representative of medication changes.
The facility failed to implement interventions as soon as a nutritional problem was suspected, including failure to notify the attending physician of significant weight loss and lack of documented interventions.
Report Facts
Number of residents present: 45 Number of resident records reviewed: 1 Number of staff interviews conducted: 2 Weight loss percentage: 6.32 Weight loss in pounds: 6
Inspection Report Renewal Census: 47 Deficiencies: 3 Aug 7, 2024
Visit Reason
The inspection was a renewal visit conducted on August 7 and 8, 2024, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found non-compliance with several standards including failure to develop a coordinated Individualized Service Plan (ISP) including hospice services, failure to maintain a 96-hour supply of emergency food and drinking water, and failure to meet background check requirements for staff.
Deficiencies (3)
Description
Facility failed to develop a coordinated Individualized Service Plan (ISP) to include hospice services.
Facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water.
Facility failed to meet the requirements for Background Checks for Assisted Living Facilities and Adult Day Care Centers.
Report Facts
Number of residents present: 47 Number of resident records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Number of staff with late background checks: 3
Inspection Report Complaint Investigation Census: 46 Deficiencies: 0 Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations of non-compliance with standards or law at Shenandoah Senior Living.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered.
Report Facts
Number of residents present: 46 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2
Inspection Report Complaint Investigation Census: 46 Deficiencies: 0 Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations of non-compliance with standards or law at Shenandoah Senior Living.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
The inspection was complaint-related, but the evidence did not substantiate the allegation of non-compliance.
Report Facts
Number of residents present: 46 Number of resident records reviewed: 1 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2
Inspection Report Monitoring Census: 46 Deficiencies: 1 May 29, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and regulations at Shenandoah Senior Living.
Findings
The inspection found violations related to the facility's failure to ensure cleaning supplies and other hazardous materials were kept in a locked area accessible to residents. Violations were issued based on self-report and investigation findings.
Deficiencies (1)
Description
Facility failed to ensure cleaning supplies and other hazardous materials are in a locked area.
Report Facts
Number of residents present: 46 Number of resident records reviewed: 1 Number of staff interviews conducted: 2 Volume of hand sanitizer found: 4
Inspection Report Complaint Investigation Deficiencies: 1 Jan 26, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 1/19/2024 regarding allegations in the areas of staffing and supervision and resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified concerning the facility's failure to ensure compliance with policies regarding private duty personnel who are not employees of a licensed home care organization.
Complaint Details
Complaint related to staffing and supervision and resident care; evidence did not support allegations of non-compliance with standards or law.
Deficiencies (1)
Description
Facility failed to ensure compliance with their own policies and procedures regarding private duty personnel who are not employees of a licensed home care organization.
Report Facts
Number of resident records reviewed: 5 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3
Inspection Report Monitoring Census: 48 Deficiencies: 1 Jan 17, 2024
Visit Reason
The inspection was a monitoring visit conducted on 1/17/2024 to review compliance with resident care and related services following a self-report regarding allegations in these areas.
Findings
The investigation supported the self-report of non-compliance related to medication management. A violation was issued due to failure to properly implement the medication management plan, including an incident where a staff member administered insulin from another resident's unopened insulin pen.
Deficiencies (1)
Description
Failure to ensure the medication management plan was implemented correctly, including improper use of another resident's insulin pen by staff.
Report Facts
Number of residents present: 48 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of staff interviews conducted: 2 Medication aide refresher course hours: 4
Inspection Report Complaint Investigation Deficiencies: 0 Dec 1, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-10-10 regarding allegations in the area(s) of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint investigation related to allegations in resident care and related services; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0
Inspection Report Renewal Census: 41 Deficiencies: 1 Sep 5, 2023
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing standards for Shenandoah Senior Living.
Findings
The facility was found to have a deficiency related to the failure to have a coordinated plan of care for residents receiving hospice services, specifically lacking documentation of coordination between the facility and hospice agency for certain residents.
Deficiencies (1)
Description
Failure to have a coordinated plan of care for residents receiving hospice services as required.
Report Facts
Records reviewed: 10 Interviews conducted: 8
Inspection Report Complaint Investigation Census: 39 Deficiencies: 4 Jun 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to personnel, resident care, buildings and grounds, and criminal history records compliance at Shenandoah Senior Living.
Findings
The investigation supported some, but not all, of the allegations. Violations were found in personnel records, confidentiality of resident records, documentation of hourly rounds, and obtaining criminal history reports for staff.
Complaint Details
The complaint investigation found some substantiated violations related to personnel, resident care, buildings and grounds, and criminal history records. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (4)
Description
Facility failed to ensure staff files included verification that staff received a copy of their current job description.
Facility failed to ensure all resident care records were treated confidentially and not left unattended.
Facility failed to ensure documentation of hourly rounds included date, time, and staff member initials.
Facility failed to ensure a criminal history report was obtained on or prior to the 30th day of employment for a staff member.
Report Facts
Residents present: 39 Resident records reviewed: 3 Staff records reviewed: 5 Resident interviews conducted: 2 Staff interviews conducted: 3
Inspection Report Original Licensing Census: 33 Deficiencies: 0 Dec 9, 2022
Visit Reason
The inspection was an initial licensing inspection conducted virtually due to COVID-19 presence in the building, to review the facility's compliance with regulations and readiness for licensing under new management.
Findings
The inspection included a virtual tour of the facility and review of prior inspection issues. The facility will be issued a conditional license valid for six months, with requirements to update employee background checks, admission agreements, and submit pending fire and health inspections.
Report Facts
Residents present: 33 Conditional license duration (months): 6

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