Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shalom Gardens Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of stroke and dysphagia experienced a choking incident during a meal, but the facility failed to provide immediate emergency care. The LPN on duty, unfamiliar with the unit, attempted ineffective abdominal thrusts, and the emergency cart was not used. The resident became unresponsive and later expired, with staff citing the resident's DNR status as a reason for not continuing treatment. The facility's policy for choking incidents was not followed, and documentation did not support the actions taken.
The facility staff failed to follow physician orders for three residents, resulting in deficiencies in care. A resident with cellulitis did not have a wound dressing changed as ordered, another resident with severe cognitive impairment missed multiple medication doses, and a third resident with leg ulcers did not receive prescribed Lidocaine patches for pain management. These failures highlight a lack of adherence to the six rights of medication administration.
A resident with Multiple Sclerosis and other conditions did not receive scheduled showers during a three-week stay in an LTC facility. Despite being alert and requiring extensive assistance with ADLs, the resident reported not receiving any showers, except for one offer which was declined. The facility's policy required showers twice a week, but records showed missing documentation for nine shifts. Interviews with staff confirmed the expectation for regular hygiene care, yet the necessary services were not provided or documented.
A resident with a Traumatic Brain Injury had an ingrown hair follicle causing irritation on the groin area, which was not reported to the physician in a timely manner. The resident's RP informed an LPN about the issue, but it was not communicated to the physician until a week later, leading to a delay in treatment. The deficiency was noted during a survey and discussed with facility leadership.
A resident with bilateral leg ulcers and leg pain did not receive Lidocaine patches as prescribed, due to a transcription error in the MAR. The patches were scheduled only once daily instead of twice, and were often omitted, leaving the resident without adequate pain relief. LPNs acknowledged the error and noted the resident's frequent pain complaints. The facility's administration was informed of the issue.
Two residents in an LTC facility did not receive their prescribed medications due to failures in the medication management process. One resident, with severe cognitive impairment, missed doses of Protonix, Boost, and Mucinex, while another resident did not receive her OTC supplements for nine days. Interviews revealed a lack of communication and adherence to procedures among the nursing staff and pharmacy, leading to these deficiencies.
Failure to Provide Emergency Care During Choking Incident
Penalty
Summary
The facility failed to provide emergency treatment and care in accordance with professional standards for a resident who experienced a choking incident. The resident, who had a history of diabetes, stroke, and dysphagia, was observed choking during a meal. Despite the presence of staff, the resident was not immediately assisted in the dining room, and emergency procedures were not properly executed. The resident was removed from the dining room and taken to the nurse's station, where a large amount of food was removed from their mouth, but the resident became unresponsive and later expired. The Licensed Practical Nurse (LPN) on duty, who was unfamiliar with the residents and working on the unit for the first time, attempted to perform abdominal thrusts while pushing the resident's wheelchair but admitted that the effort was ineffective. The emergency cart, which contained necessary equipment such as a suction machine and oxygen, was not retrieved during the incident. The facility's policy for handling choking incidents was not followed, as no immediate treatment was provided in the dining room, and the resident's condition was not promptly addressed. Interviews with staff revealed a lack of coordination and adherence to emergency procedures. The Director of Nursing (DON) and other staff members acknowledged the failure to provide timely emergency care, citing the resident's Do Not Resuscitate (DNR) status as a reason for not continuing treatment after the resident became unconscious. However, the facility's documentation did not support the actions taken during the incident, and there was no evidence of proper emergency care being administered according to the facility's policy.
Failure to Follow Physician Orders for Three Residents
Penalty
Summary
The facility staff failed to follow physician orders for three residents, leading to deficiencies in care. For one resident with cellulitis, the staff did not change a wound dressing on the right lower extremity as ordered by the physician. The dressing, which was supposed to be changed daily, was observed to have not been changed for two days. This oversight was brought to the attention of the staff by the resident's family member, prompting a revision of the wound care orders. Another resident, who had severe cognitive impairment and required extensive assistance with daily activities, did not receive medications and treatments as prescribed by the physician. The Medication and Treatment Administration Record revealed multiple instances where medications were not administered on the specified dates. The facility's nursing standards, which emphasize adherence to the six rights of medication administration, were not followed, resulting in the omission of necessary medications. A third resident, suffering from bilateral leg ulcers and pain, did not receive Lidocaine pain patches as ordered. The patches were intended to be applied twice daily but were only scheduled once per day and were often omitted entirely. The resident reported persistent leg pain and inadequate pain management. Interviews with LPNs confirmed a transcription error in the medication administration record, leading to the resident being without the prescribed pain relief. The facility's adherence to nursing standards was again called into question, as the six rights of medication administration were not consistently followed.
Failure to Provide Scheduled Showers and Document Care
Penalty
Summary
The facility staff failed to provide necessary services to maintain personal hygiene for a resident who required extensive assistance with activities of daily living (ADLs). The resident, who was admitted with diagnoses including Multiple Sclerosis, Pulmonary Embolism, and Urinary Tract Infection, was coded as continent of bowel and bladder and had a BIMS score indicating no cognitive impairment. Despite the facility's policy requiring showers twice a week and bed baths on other days, the resident reported not receiving any showers during a three-week stay, except for one offer which was declined due to feeling unwell. The Unit Manager was unaware of the missed showers, and a review of records showed missing documentation for nine shifts since admission. Interviews with CNAs revealed that care was documented in the Point of Care system at the end of each shift, yet there was no documentation of showers being provided as scheduled. The Director of Nursing and Administrator confirmed the expectation for residents to receive showers twice a week and bed baths on other days, with all care documented. The facility's policy on ADLs emphasized providing appropriate care and assistance with hygiene, including bathing, at least twice weekly. Despite these policies, the facility failed to document or provide the necessary hygiene care for the resident, as confirmed by the lack of records and staff interviews.
Failure to Report and Assess Skin Condition
Penalty
Summary
The facility staff failed to ensure proper assessment and reporting of a skin condition on a resident's groin area. The resident, who has a diagnosis of Traumatic Brain Injury and intact cognitive abilities, was noted to have an ingrown hair follicle causing irritation. The resident's Responsible Party (RP) reported the issue to a Licensed Practical Nurse (LPN) a week prior, but the condition was not communicated to the physician until a later date. During an initial tour, the RP and a Certified Nursing Assistant (CNA) showed the area to another LPN, who then notified the Nurse Practitioner (NP). The NP assessed the area and prescribed an antibiotic. An interview with the LPN who initially saw the resident revealed that she did not report the condition, assuming the CNA would inform the resident's nurse. This lack of communication and failure to follow the facility's protocol for skin monitoring and reporting changes led to a delay in treatment. The deficiency was discussed with the facility's Administrator, Director of Nursing, and Corporate Consultant, but no further comments were made.
Inadequate Pain Management for Resident with Leg Ulcers
Penalty
Summary
The facility staff failed to provide adequate pain management for a resident with bilateral leg ulcers and leg pain, as prescribed by a physician. The resident, who was admitted with multiple diagnoses including end-stage renal disease, peripheral vascular disease, and heart failure, had a physician's order for Lidocaine patches to be applied twice daily for pain relief. However, the medication administration record (MAR) only scheduled the patches to be applied once daily at 9:00 AM, and they were not applied consistently. The patches were omitted entirely on several days, and the evening doses were never scheduled, leaving the resident without the prescribed pain relief. Interviews with LPNs revealed that the transcription of the physician's order was incorrect, leading to the resident not receiving the pain patches as ordered. The LPNs acknowledged the mistake and noted that the resident often complained of leg and back pain. They also mentioned that Tylenol was available for pain relief, but admitted it was not adequate for all types of pain. The facility's Administrator and Director of Nursing were informed of these findings but had no additional information to provide.
Medication Availability Deficiency in LTC Facility
Penalty
Summary
The facility staff failed to acquire and administer medications as ordered for two residents, leading to deficiencies in pharmaceutical services. For one resident, the facility did not ensure the availability of medications such as Protonix, Boost supplement, and Mucinex, despite having Pantaprazole available in bulk. The resident, who had severe cognitive impairment and required extensive assistance, did not receive the necessary medications due to a lack of communication and coordination between the nursing staff and the pharmacy. Interviews with the LPN, Unit Manager, and Director of Nursing revealed that the staff did not follow the proper procedures for obtaining medications from the on-site STAT box or notifying the physician for alternative orders. Another resident did not receive her over-the-counter medications, including Apple Cider Vinegar, Beet Root, and Biotin, for nine consecutive days. This resident, who had intact cognitive abilities, was informed by the staff that she needed to bring her vitamins from home as the facility did not have them available. Interviews with the RN and LPN indicated that the Director of Nursing was responsible for ordering OTC medications, but there was a lack of awareness and communication regarding the resident's needs. The deficiencies were identified through observations, clinical record reviews, staff interviews, and facility document reviews. The facility's failure to ensure the availability and administration of medications as ordered by physicians highlights a breakdown in the medication management process, affecting the residents' care and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury Rehabilitation And Healthcare Center | 0.8 mi | — | 20 | 2 |
| Lakewood Manor | 1 mi | — | 0 | 0 |
| Cedarfield Pinnacle Living | 2.3 mi | — | 0 | 0 |
| Our Lady Of Hope Health Center | 2.4 mi | — | 2 | 0 |
| The Laurels Of University Park | 2.9 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.