Accura Healthcare of Shenandoah

In the surveyor’s words

From the most serious findings on record at Accura Healthcare of Shenandoah, in the surveyor’s own words.

• Immediate jeopardy, patternF609Dec 6, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF600Dec 6, 2023

  Based 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. […]

• Actual harm, isolatedF684Jun 29, 2023

  Based 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. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (intact cognitive ability). […]

• No harm, potential for more than minimal, patternF725Sep 18, 2025

  Based 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.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/16/25 at 9:33 AM Resident #1 stated it took the staff longer than 15 minutes at least twice a week to answer her call light. Resident #1 stated the staff have told her it took a while to answer the call lights because there just wasn't enough staff. […]

• No harm, potential for more than minimal, patternF727Sep 18, 2025

  Based 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.Findings include:Review of the Payroll Based Journal (PBJ) staffing data report for the fiscal year quarter three (April 1st through June 30th, 2025) revealed there was no Registered Nurse (RN) hours for 04/20, 04/26, 05/11, 05/18, 05/31, and 06/21/2025.In an interview on entrance date 9/15/2025 the Administrator confirmed that the facility did not have RN coverage listed on the PBJ. The Administrator confirmed these dates, and revealed that the facility only had one RN at the facility during this time. […]