Accura Healthcare of Shenandoah

Inspectors wroteBased on resident council meetings, Electronic Health Record review, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #1, #2, #12 and #28). The facility reported a census of 40 residents.

Inspectors wroteBased on document review, staff interview and policy review the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 6 of 90 days reviewed (April 1 - June 30, 2025). The facility reported a census of 40 residents.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by serving incorrect portion sizes for meals. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to store food in accordance with professional standards. The facility reported a census of 30 residents.

Inspectors wroteBased on document review, staff interviews, and facility policy review the facility failed to demonstrate evidence of systematic identification of reporting, investigation, analysis, and prevention of adverse events. The facility failed to demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility reported a census of 40 residents.

Inspectors wroteBased on Medication Administration Record - Treatment Administration Record (MAR-TAR) review, Electronic Health Record (EHR) review, resident interviews, staff interviews and policy review the facility failed to provide dignity and respect during interactions with a resident and failed to provide medication when a resident requested for 1 of 16 residents reviewed (Resident #1). The facility reported a census of 40 residents.

Inspectors wroteBased on resident interview, staff interviews and document review the facility failed to ensure 1 of 1 resident's personal property was protected from loss or theft when Resident #32 reported a missing ring and necklace and no personal inventory sheet was completed upon entry to the facility or updated throughout time living at the facility. The facility reported a census of 40 residents.

Inspectors wroteBased on Medication Administration Record (MAR) - Treatment Administration record (TAR), Electronic Health Records (EHR) review, resident interviews, staff interviews and policy review the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing the use of insulin for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, document review and staff interviews, the facility failed to refer a resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who had an identified mental disorder, intellectual disability, or other related condition that was not addressed on PASRR completed prior to admission to the facility, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 resident (Resident #2) reviewed for PASRR requirements. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #35) requiring the use of oxygen. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, Medication Administration Record / Treatment Administration Record (MAR/TAR) review, Electronic Health Record (EHR) review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when blood glucose sample was obtained and when providing care to a residents on Enhanced Barrier Precautions (EBP) for 2 of 4 residents reviewed (Resident #4 and #8). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to develop care plans to address COVID-19, oxygen therapy and medications in 4 out of 14 sampled residents reviewed for comprehensive care plans (Resident #16, 22, 29 and 35). The facility reported a census of 41 residents.

Inspectors wroteBased on facility document review and staff interview the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 7 of 33 days reviewed. The facility reported a census of 19 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food, and failed to keep utensils on a sanitary surface during meal service. The facility identified a census of 41 residents.

Inspectors wroteBased on observations, facility policy review, procedure review and staff interviews, the facility failed to perform proper transmission based precaution techniques, perform appropriate hand hygiene during wound care, and failed to effectively sanitize a glucometer for 2 of 14 residents reviewed (Resident #16, #25). The facility reported a total census of 41 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to obtain physical signatures or record attempts to obtain physical signatures on notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 and CMS form CMS-10055 for 1 of 3 sampled residents (Residents #38). The facility reported a census of 41 residents. Findings Include: Record review for Resident #38 revealed form CMS 10123-NOMNC with a services end date of 9/24/24. Resident #38's representative gave verbal consent for signature on 9/20/24 however lacked a signature of resident or resident representative. CMS-10055 form lacked a services ending date and reason Medicare may not pay. Resident #38's representative gave verbal consent for signature on 9/20/24 however lacked a signature of resident or resident representative. [...]

Inspectors wroteBased on clinical record review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of a diuretic for 1 of 5 residents reviewed (Resident #22). The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to provide professional standards of care by not obtaining daily weights per physician orders, and allowing a resident to self administer medications without a physician's order for 2 of 14 residents reviewed (Resident #6 and #29). The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, hospital record review, staff interviews, and facility provided document review the facility failed to follow facility guidance by transferring without a full body lift after a fall for 3 of 3 residents (Resident #1, Resident #2, Resident #3) reviewed. The facility reported a census of 42 residents.

Inspectors wroteBased on observations, record review, facility investigation file review, resident interview, staff interviews, and facility policy review the facility failed to report abuse concerns involving 3 of 6 residents (Resident #2, #4, and #5) reviewed for potential abuse. Staff reported Staff A would pick on Resident #2 to get a rise out of her. He would pick at her wig and annoy her, would hide her cell phone, move her shoes and she did not like it. If she wanted to go to bed before 8:00 PM, he would push her in her wheelchair to the opposite hall and make her self-propel to her room so she couldn't go to bed right when she wanted to. Staff A would run with Resident #2 in her wheelchair down the hall but backwards. Resident #4 stated Staff A had scared the poop out of her one time. [...]

Inspectors wroteBased on observations, record review, facility investigation file review, resident interview, staff interviews, and facility policy review the facility failed to ensure 4 of 6 residents (Resident #1, #2, #4, and #5) reviewed were free from abuse. Resident #1 stated Staff A crossed her arms and held them while doing something she did not want him doing and she told him to stop. Staff observed a bruise to her right outer forearm after the alleged incident. She indicated she would be frightened if she saw him again but if she does not see him she feels safe. Staff stated Resident #1 seemed really depressed about what happened and she could not understand why he would do that to her. Staff also reported Resident #1 indicated Staff A would pick on her, take her things, put them out of reach and was rough with her when he would change her brief. [...]

Inspectors wroteBased on observations, clinical record review, resident interview, staff interviews and facility policy review the facility failed to treat 1 of 6 residents (Resident #6) reviewed, in a dignified manner while assisting with her shower. The facility reported a census of 44 residents.

Inspectors wroteBased on observations, resident and staff interviews and clinical record review the facility failed to provide accurate and timely interventions to prevent hospitalization for 1 of 3 residents. Resident #29 had a diagnosis of Congestive Heart Failure (CHF) and required monitoring of Blood Pressures (BP), Heart Rate (HR) and weights. On 6/27/23 the resident was taken to the hospital for exacerbation of CHF with a BP of 181-126 (normal BP 120/80). A review of the chart revealed that her most recent complete set of vitals had been taken on 6/19/23. The facility reported a census of 37 residents.

Inspectors wroteBased on personnel record review, staff interview, and facility policy review the facility failed to complete an employee performance review at least once every 12 months. The facility reported a census of 37 residents.

Inspectors wroteBased on document review, policy review, and staff interview the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 37 residents.

Inspectors wroteBased on facility menu review, observations and staff interviews the facility failed to serve meals according to the menu. Staff failed to serve bread and butter to all of the residents during the lunch meal and provided rice instead of mashed potatoes to the 5 residents on mechanical soft diets. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, facility policy review and staff interviews the facility failed to store food in accordance with professional standards by not labeling foods that were open with open dates and not preventing physical contamination of food by wearing hair restraints improperly. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, staff interviews and facility policy review the facility failed to properly dispose of room trays with left-over food in a timely manner. In two separate observations it was discovered that the dinner trays from evening meals were on a rack in the hallway by resident rooms the following mornings. The facility reported a census of 37 residents.

Inspectors wroteBased on observations and staff interviews the facility failed to provide appropriate infection prevention practices by not providing separation between clean and dirty linen in the laundry department. The facility reported a census of 37 residents.

Inspectors wroteBased observation, clinical record review, resident and staff interviews the facility failed to follow grievance procedures to ensure that residents had a resolution to concerns for 1 of 12 residents. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews the facility failed to notify the physician of weight gain outside parameters per physician orders for 1 of 12 residents reviewed (Resident #6). The facility reported a census of 37 residents.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility failed to ensure the safety of the residents by failing to ensure the facility doors were properly alarmed. The facility reported 2 of 37 residents were at high risk for elopement (Resident #2 and #18). The facility reported a census of 37 residents.