Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Shenandoah during CMS and state inspections, most recent first.
Delayed call light response and inadequate nursing staffing: Multiple residents with BIMS scores of 15 reported that call lights were often answered after more than 15 minutes, sometimes up to 45 minutes, especially when needing toileting assistance. Resident council notes, grievance forms, and staff interviews described CNAs turning off call lights without returning, residents calling the nurses station with phones, and staff acknowledging there did not appear to be enough CNA coverage to answer lights in a timely manner.
A Dietary Cook/Aide served altered diet meals without measuring the total volume after pureeing, leaving extra food in the container and using visual estimates instead of the facility's volume chart. The cook reported serving pureed and mechanical soft diets for several residents, while the Dietary Mgr stated staff were not using a food volume chart for altered foods despite the facility policy requiring accurate portion control and specific portion sizes.
Improper Food Storage in Kitchen Dry Storage Area: Surveyors observed multiple dry food items stored improperly in the kitchen dry storage area, including an open box of rice, expired jelly, expired dressing packets, expired wraps, tortillas without a use-by date, and cocoa powder stored open to air. The Dietary Manager stated she was unaware the items were expired or that the dry storage area needed regular checks for expired food items. The facility policy required food to be stored in a clean, dry area and opened or bulk items to be kept in tight-fitting or sealable containers with accurate labels and dates.
QAPI/QAA Process Not Demonstrated: The facility failed to show evidence of a systematic process for identifying, reporting, investigating, analyzing, and preventing adverse events, and also failed to show development, implementation, and evaluation of corrective actions or PI activities. CMS survey history showed repeated deficient practices, and the Administrator acknowledged the repeat deficiencies during interview while stating progress was reviewed in monthly and quarterly QAPI/QAA meetings.
Failure to maintain required RN coverage: PBJ staffing data showed no RN hours on multiple days during the review period, and the Administrator confirmed the facility only had one RN at the time. The Administrator stated the expectation was for 8 hours of RN coverage per day, and the facility assessment referenced federal minimum staffing standards for RN staffing.
A resident with no cognitive impairment reported that an LPN was rude during a respiratory treatment interaction, threw down the nebulizer mask, and told her not to call for help with shortness of breath. The resident also reported the LPN refused to apply Voltaren gel when requested for pain. Staff interviews and the DON’s statements confirmed concerns that the resident was not treated with dignity and respect and that requested medication was not provided as expected.
A resident with moderate cognitive impairment reported a missing diamond necklace and engagement ring that she said were brought to the facility with her. Her daughter/POA confirmed the items were present on admission and said they were family heirlooms, but staff searches did not locate them. The facility acknowledged the admission inventory sheet was not completed appropriately and was later updated by the family, while staff and the DON described inconsistent responsibility for checking and updating the inventory. Staff also noted a jewelry box was found in a trash can, and the missing items were not documented on the original inventory sheet.
A resident’s MDS inaccurately recorded insulin use during the assessment period even though the resident stated she had not been on insulin, the EHR showed no current insulin order, and the MAR/TAR contained no insulin orders. Staff stated the resident had been on Ozempic until it was discontinued, and the Nurse Consultant acknowledged Ozempic is not insulin and should not be identified as such on the MDS.
A resident admitted with bipolar disorder had a PASRR Level I screen that did not list the mental health diagnosis, and the facility did not refer the resident for a Level II PASRR evaluation. The MDS showed a BIMS score of 15 and documented bipolar disorder on admission, while the MDS Coordinator and Nurse Consultant acknowledged the diagnosis should have been included on the PASRR. The DON stated the facility did not have a policy on PASRR completion.
A resident who required O2 did not receive respiratory equipment care in accordance with the facility’s schedule. The resident’s care plan and MAR directed weekly changes of O2 tubing, humidifier, and concentrator cleaning, but observations showed dated tubing and a humidifier bottle that had not been changed as expected. An LPN and the IP confirmed that Sunday night staff were responsible for changing and dating all O2 therapy components, and facility policy required weekly replacement or cleaning of the equipment.
The facility failed to follow infection prevention practices during blood glucose monitoring for one resident and during wound care for another resident on EBP. An RN used a shared glucometer during a medication pass, placed it on the bedside table without a barrier, and returned it to the cart without cleaning it per the wipe’s required wet time. During a dressing change for a resident with skin tears, an LPN and CNA performed the care without wearing a gown even though EBP supplies were outside the room and staff stated gowns were required for wound care.
The facility failed to develop comprehensive care plans for four residents, addressing critical health needs such as COVID-19 management, oxygen therapy, and medication administration. A resident with COVID-19 and heart failure lacked a care plan for oxygen therapy, while another resident with COVID-19 had no care plan for virus management or oxygen therapy. A resident on diuretic therapy and another with COVID-19 also lacked appropriate care plans. The DON and MDS Coordinator acknowledged these deficiencies.
The facility did not have a Registered Nurse (RN) present for eight consecutive hours on seven days within a 33-day period, despite having a census of 19 residents. This deficiency was confirmed through staffing data and nursing schedule reviews, with the Administrator acknowledging the lack of RN coverage on the specified dates.
The facility failed to maintain sanitary conditions in the kitchen, with observations of grease and food debris accumulation, unsanitary utensil handling during meal service, and inadequate deep cleaning due to time constraints. The Dietary Manager acknowledged the inability to complete necessary cleaning tasks despite having the required help.
The facility failed to follow proper infection control practices, including hand hygiene and equipment sanitation, during care for two residents. An LPN did not perform hand hygiene during wound care for a resident with COVID-19 and improperly sanitized a blood glucose machine for another resident. Additionally, PPE was not correctly donned and doffed, and another staff member also failed to sanitize equipment according to protocol.
A facility failed to obtain physical signatures or document attempts to obtain them on NOMNC forms for a resident. The resident's representative gave verbal consent, but the forms lacked signatures and necessary details. CMS guidelines require documentation of contact and attempts to obtain signatures when in-person delivery is not possible. The DON was unaware of the requirement for physical signatures, and the facility lacked a policy for advance beneficiary notices.
A facility failed to document a resident's use of a diuretic in the MDS assessment. The resident, with moderate cognitive impairment and hypertension, was prescribed furosemide starting in early August. The MDS coordinator and DON acknowledged the oversight, while the Administrator claimed adherence to care standards.
The facility failed to obtain daily weights for a resident with CHF and allowed another resident to self-administer medications without a physician's order. The facility did not clarify the weight order during a COVID-19 infection, and medication was left for self-administration without assessment, contrary to policy.
The facility failed to use mechanical lifts for transferring residents after falls, affecting three residents with varying degrees of cognitive impairment and fall risk. Despite documented protocols, staff manually assisted residents off the floor, leading to injuries and hospitalizations. The facility lacked specific fall-related policies, contributing to repeated deficiencies.
Delayed Call Light Response and Inadequate Nursing Staffing
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by repeated delays in answering call lights for 4 of 18 residents reviewed. Resident interviews, resident council discussions, grievance forms, EHR review, and staff interviews all described call light response times that frequently exceeded 15 minutes, with some residents reporting waits of up to 45 minutes, especially when needing assistance on the toilet or during evening and overnight hours. Resident #1, who had a BIMS score of 15 indicating no cognitive impairment, stated staff took longer than 15 minutes to answer her call light at least twice a week and that staff told her it took a while because there was not enough staff. Resident #2, also with a BIMS score of 15, stated staff had taken longer than 15 minutes to answer her light a couple of times in the prior 2 weeks. Resident #12, with a BIMS score of 15, stated call lights in the evening took forever to be answered, especially when she was on the toilet, and said waits could be up to 45 minutes and occurred longer than 15 minutes almost nightly. During a resident council meeting, Resident #28 stated it would be nice if it only took 15 minutes to have a call light answered and said waits could be up to 45 minutes. Other residents reported CNA staff would enter rooms, turn off call lights, and not return, forcing residents to call the nurses station with their phones. Grievance forms and resident council documentation reflected ongoing concerns about call light delays. Staff interviews supported the concern, with an RN stating there did not seem to be enough staff, an LPN stating there was not enough staff to provide adequate care, and the DON and Administrator acknowledging resident complaints and call light wait times, while the DON stated she had not reviewed the actual resident council minutes and had not documented the call light audit on a form.
Incorrect Portion Sizes for Altered Diet Meals
Penalty
Summary
The facility failed to provide a well balanced diet that met nutritional and special dietary needs by serving incorrect portion sizes for meals. During continuous observation of the lunch meal, a Dietary Cook/Aide placed 3 hot dogs into a blender to be pureed and transferred the pureed food to a holding steel container without measuring the total volume to divide it into 3 serving portions. The cook also pureed 3 servings of hot vegetables with 3 buns and, before transferring the food into a steel container, visually estimated the amount using the blender measurement marks and stated it was about 12 oz. The cook completed serving lunch and stated all pureed diet servings had been served, but there was still food left in the container. She also had mechanical soft diets for 3 residents and had leftover hot dogs in the container. She stated she did not know why extra food remained even though she used 8 oz portion scoops, and she did not use the facility's volume chart. In interview, the Dietary Manager stated the cooks did not use a food volume chart to measure altered food items, and she then provided a pureed diet portion sizes/scoops chart for use in measuring the total volume after pureeing and dividing it by the original number of portions. The facility policy required accurate portion control, standardized recipes, specific portion sizes on menus, and use of proper measuring tools for food service.
Improper Food Storage in Kitchen Dry Storage Area
Penalty
Summary
The facility failed to store food in accordance with professional standards in the kitchen dry storage area. During an initial kitchen tour, surveyors observed a half-full 25 lb box of white rice lined with blue plastic that was not sealed and was open to the air, 5 bottles of grape jelly and strawberry jelly that were expired, a box of Pan Asian sesame seed dressing packets that was expired, a box of 12-inch Garden Wraps with 2 packs expired, a box of Catallia Premium Tortillas with an opened date but no use-by date, and a box of baking cocoa powder with a clear liner unsecured and open to the air that had been labeled opened on 11/20/23. During interview, the Dietary Manager stated she was not aware the food items were expired or that the dry food storage area had to be checked regularly for expired items. She then discarded the expired food items and those that were not stored properly. The facility policy titled Policy & Procedure Manual, Food Storage, dated 2021, stated that food must be stored in a clean, dry area free from contaminants, stored by methods designed to prevent contamination or crosscontamination, and that plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages; all containers or storage bags must be legible and accurately labeled and dated.
QAPI/QAA Process Not Demonstrated
Penalty
Summary
The facility failed to demonstrate evidence of a systematic process for identifying, reporting, investigating, analyzing, and preventing adverse events, and also failed to demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities. Review of the facility's CMS report showed repeated deficient practices identified during the annual surveys completed 10/17/2024, 06/29/2023, and the current survey, including F658, F812, and F880. During an interview on 09/18/2025 at 1:16 pm, the Administrator acknowledged the repeat deficiencies and stated that progress was reviewed during monthly and quarterly QAPI and QAA meetings, with recent improvement noted in several areas. Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA), dated 5/23/23, stated that the purpose was to ensure facilities develop a plan describing the process for conducting QAPI/QAA activities, including identifying and correcting quality deficiencies and opportunities for improvement.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was in the facility for eight consecutive hours on 6 of 90 days reviewed during the quarter from April 1 through June 30, 2025. Review of the Payroll Based Journal staffing data showed no RN hours on 04/20, 04/26, 05/11, 05/18, 05/31, and 06/21/2025. During an entrance interview on 9/15/2025, the Administrator confirmed that the facility did not have RN coverage listed on the PBJ for those dates and stated that the facility only had one RN during this time. The Administrator also stated that the expectation was for 8 hours of RN coverage per day. Review of the facility assessment dated 7/27/2024 showed the facility’s staffing document referenced federal minimum staffing standards, including RN hours per resident day.
Failure to Provide Dignity, Respect, and Requested Medication
Penalty
Summary
The facility failed to provide dignity and respect during interactions with a resident and failed to provide medication when requested for Resident #1, who had a BIMS score of 15 and no cognitive impairment. Resident #1 reported that Staff A, an LPN, became rude when questioned about the frequency of a respiratory treatment, threw the nebulizer mask down, and told her not to call if she was short of breath because she would not help. Resident #1 also reported that Staff A refused to apply diclofenac sodium (Voltaren gel) when requested for pain. Resident #1’s EHR and MAR-TAR showed orders for DuoNeb solution twice daily for shortness of breath and diclofenac sodium topically twice daily for pain. Staff interviews reflected that Resident #1 had complained about Staff A not providing the breathing treatment and not applying the Voltaren gel when requested. One CNA stated she had observed staff being short, unkind, and not providing dignity or respect to residents, and another CNA stated she saw Staff A not give the Voltaren gel until she repeatedly asked the nurse to apply it. An RN also stated she did not think there was enough staff to provide adequate care to residents. The DON and MDS Coordinator both acknowledged Resident #1 had reported that Staff A told her if she did not take the breathing treatment at that time, she would not want to hear about breathing trouble later, and that Staff A refused to apply the Voltaren gel when requested. The Administrator acknowledged reports of staff being short with residents and stated corrective action was being drafted, while the DON stated she did not feel Resident #1 was provided the dignity and respect she deserved in those incidents. The facility policy stated residents are to be treated with respect and dignity and requests for assistance are to be responded to in a timely manner.
Missing Resident Jewelry Not Protected by Inventory Controls
Penalty
Summary
The facility failed to protect one resident’s personal property from loss or theft when Resident #32 reported that a diamond necklace and engagement ring were missing. Resident #32 had a BIMS score of 12, indicating moderate cognitive impairment, and stated the jewelry had been brought to the facility when she moved in. Her daughter and POA also stated the resident had the ring and necklace when she entered the facility and that the items were family heirlooms. The resident said she had spoken with the Administrator about the missing jewelry, and staff searched drawers and the room with the resident’s permission, but the items were not found. Document review and staff interviews showed the facility did not have a completed or consistently updated personal inventory sheet for the resident’s belongings. The Administrator acknowledged the initial inventory sheet from admission was either not filled out or not completed appropriately, and stated the only sheet found was one later updated by the daughter. The DON stated the inventory sheet was part of the admission packet and was placed on the back of the door to be updated, while the Administrator stated staff were supposed to check the family’s entries against the inventory sheet. However, the Administrator also stated there was no expectation for staff to ensure the inventory sheet was filled out. The resident’s daughter and POA stated the jewelry had been worn at the facility on several occasions and that she did not take the items home. Staff D stated the missing ring had been discussed in care conference and that she thought a grievance had been filed, but she acknowledged she did not fill out a grievance form. Staff A later stated a jewelry box had been found in the trash can and that an agency CNA found the box. The investigation documented that the daughter was told the missing jewelry was not listed on the inventory sheet and was advised that items brought into the facility needed to be added to the sheet.
Inaccurate MDS Documentation of Insulin Use
Penalty
Summary
The facility failed to ensure an accurate resident assessment by incorrectly documenting insulin use for one resident during the MDS observation period. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment, and also recorded that 1 day of insulin injections had been received during the last 7 days, even though the resident stated she had not been on insulin since being at the facility and said she had previously been on Ozempic. Review of the resident’s EHR showed no current order for insulin, and the Ozempic order had been discontinued on 7/17/25. Review of the MAR/TAR for June, July, August, and September showed no orders for insulin. During interviews, the MDS Coordinator/RN stated the resident had been on Ozempic until it was discontinued and that staff had believed Ozempic was insulin; the Nurse Consultant later acknowledged that Ozempic is not a type of insulin and would not be identified as insulin on the MDS. The facility policy stated that residents are to receive an accurate assessment reflective of their status and that the RN is responsible for coordinating and certifying completion of the assessment.
PASRR screening failed to identify bipolar disorder
Penalty
Summary
The facility failed to refer Resident #2 for a Level II PASRR evaluation and determination after the resident was admitted with a diagnosis of bipolar disorder that was not identified on the PASRR Level I screen completed prior to admission. The MDS documented that Resident #2 had a BIMS score of 15, indicating no cognitive impairment, and also showed a diagnosis of bipolar disorder upon admission to the facility on 7/10/25. However, the Notice of PASRR Level 1 Screen Outcome dated 7/1/25 did not list bipolar disorder under the mental health diagnoses portion of the screening. During interviews, the MDS Coordinator stated bipolar disorder should have been identified on the PASRR for Resident #2 upon admission and acknowledged that the diagnosis was not included on the 7/1/25 PASRR. The Nurse Consultant stated it was her expectation that the diagnosis of bipolar disorder would have been documented on the PASRR and that the missed diagnosis should have been noticed and submitted upon admission. The DON documented in an email that the facility did not have a policy on PASRR completion.
Failure to Maintain Oxygen Equipment per Schedule
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident who required oxygen. The resident’s MDS documented that oxygen was needed in the last 14 days, and the care plan included interventions for respiratory abnormalities related to oxygen dependence, including changing the oxygen tubing and humidifier bottle on Sunday night shift. The MAR for September 2025 also documented an order to change the oxygen tubing, humidifier, and clean the concentrator every Sunday on night shift, with completion documented on 9/7 and 9/14. During an observation on 9/15/25, the resident’s oxygen concentrator was set to 1 L/min, and the humidifier bottle contained sterile water at about one-quarter full. The humidifier bottle and the tubing connecting it to the concentrator were dated 9/8/25, while the tubing from the humidifier bottle to the nasal cannula was dated 9/15/25. A later observation on 9/17/25 showed the same dates still in place. An LPN stated the tubing was scheduled to be changed every Sunday night and that all oxygen therapy components needed to be changed and labeled with a date and staff initials. The Infection Preventionist confirmed that Sunday overnight staff were supposed to change the oxygen tubing and humidifier sterile water and date it. Facility policy stated that O2 tubing and nasal cannula/mask are to be changed weekly, the tubing is also to be changed when the nasal prong area is noted lying on the floor, and the pre-filled humidifier bottle is to be replaced weekly and as needed, with the refillable humidifier receptacle cleaned weekly.
Infection Prevention Practices Not Followed During Glucose Monitoring and Wound Care
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during blood glucose monitoring for Resident #4, who had a BIMS score of 15 and an order for NovoLog insulin with sliding scale coverage four times daily. During observation, Staff C completed medication administration and obtained a blood glucose sample while using the same blood glucose machine for residents. Staff C handled the glucometer during the medication pass, placed it on the resident’s bedside table without a barrier, later returned it to the medication cart without cleaning it, and moved on to the next resident. Staff interviews confirmed that the same blood glucose machine was used for all residents and that the sanitizing wipes required the meter to remain wet for 2 minutes to be effective, while the DON stated a barrier should have been used and the machine should have been cleaned and left moist for the required time. The facility also failed to follow Enhanced Barrier Precautions for Resident #8, who had a BIMS score of 7 and skin tears requiring daily dressing changes to the left upper thigh and right posterior mid-thigh. During observation of the dressing change, Staff J and Staff K performed hand hygiene and glove changes multiple times while removing and applying dressings, but no gown was worn during the wound care. EBP supplies were observed outside the resident’s room, and Staff K later acknowledged that a gown should have been worn into the room during the dressing change. Facility policy titled Enhanced Barrier Precautions stated that EBP would be used during wound care with any skin opening requiring a dressing change. The nursing consultant stated the facility’s expectation was that EBP would have been followed with gowns worn during the dressing change. Policy titled Competency for Cleaning of Glucometers stated staff would wear gloves to disinfect the glucometer and follow the manufacturer’s recommended cleansing and drying time, which staff acknowledged was 2 minutes for the wipes being used.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, addressing critical health needs such as COVID-19 management, oxygen therapy, and medication administration. Resident #16, who returned from a hospital with diagnoses including COVID-19 and heart failure, was observed receiving oxygen therapy, yet lacked a care plan for this treatment. Similarly, Resident #29, diagnosed with COVID-19, did not have a care plan for managing the virus or for oxygen therapy, despite the presence of a sign indicating PPE requirements and a positive COVID-19 test result. The Director of Nursing acknowledged the absence of a care plan for COVID-19 and oxygen therapy for this resident. Resident #22, with moderate cognitive impairment and a prescription for furosemide, a diuretic, also lacked a care plan addressing diuretic therapy. Additionally, Resident #35, diagnosed with COVID-19, did not have a care plan for managing the virus. The MDS Coordinator and the Director of Nursing both acknowledged the absence of necessary care plans for these residents, indicating a failure to meet the facility's expectations for care plan development. The facility reported a census of 41 residents, with these deficiencies identified in 4 out of 14 sampled residents.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for eight consecutive hours on seven specific days within a 33-day review period. The facility, which had a census of 19 residents, did not have RN coverage on the dates of 5/11, 5/26, 9/14, 9/15, 9/28, 9/29, and 10/12/24. This deficiency was identified through a review of the PBJ Staffing Data Report and the nursing schedules for the last 30 days. The Administrator confirmed the absence of RN coverage on these dates and acknowledged that the facility's expectation was to have RN coverage for eight consecutive hours each day.
Sanitation Deficiencies in Kitchen Area
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen area, as observed during a walkthrough and meal service. During the initial kitchen walkthrough, surveyors noted significant cleanliness issues, including a thick layer of grease and food debris on the stove top and backsplash, food splatter in the oven, and visible grease buildup on the hood. Additionally, a clean dish cart was found with scattered food debris, and the floor had an accumulation of food debris and dried liquid. The stand-up freezer units contained debris at the bottom, and the dishwasher had thick, crusty layers of lime, with lime buildup also noted on the floor beneath it. The Dietary Manager was unable to join the tour due to filling in as the cook, indicating potential staffing issues. During the lunch service observation, Staff B was seen using unsanitary practices, such as placing a knife on top of a meal ticket after cutting a sandwich and later using it again, placing a rubber spatula on an unsanitized counter before using it to scoop butter, and placing a food scoop on an unsanitized area of the steam table before using it to plate food. The facility's Food Safety and Sanitation policy, dated 2021, requires adherence to regulations outlined by official health agencies and organizations, and mandates that food should be protected from contamination. However, the Dietary Manager admitted that deep cleaning was not being completed due to insufficient time, despite having the required help.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care for Resident #16, who had returned from a critical access hospital with diagnoses including COVID-19, heart failure, atrial fibrillation, and dementia. During an observation, a Licensed Practical Nurse (LPN) did not perform hand hygiene before and after glove changes while attending to the resident's wound. The LPN also failed to place a barrier under the resident's heel, allowing it to rest directly on the bed linens. The Infection Preventionist (IP) noted these lapses in hand hygiene and infection control during the observation. In another incident involving Resident #25, who had moderate cognitive impairment, the same LPN did not follow proper procedures for donning and doffing personal protective equipment (PPE) and failed to perform hand hygiene between glove changes. The LPN also improperly sanitized a blood glucose machine by using an alcohol wipe instead of following the facility's protocol, which required the use of sanitizing wipes and a specific procedure for disinfection. The IP and Director of Nursing (DON) confirmed these deficiencies and acknowledged the improper handling of PPE and the blood glucose machine. Additionally, another staff member, Staff E, was observed improperly sanitizing a blood glucose machine by using an alcohol wipe instead of the required sanitizing wipe procedure. This further highlighted the facility's failure to ensure proper infection control practices were consistently followed by staff, as outlined in their policies and procedures for hand hygiene, PPE use, and equipment sanitation.
Failure to Obtain Physical Signatures on Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to obtain physical signatures or document attempts to obtain physical signatures on the Notice of Medicare Non-Coverage (NOMNC) forms CMS-10123 and CMS-10055 for a resident. The resident's representative provided verbal consent for the signature, but the forms lacked the necessary physical signatures. Additionally, the CMS-10055 form did not include a services ending date or a reason why Medicare may not pay. The resident's progress notes did not document the verbal consent given by the representative or any attempts to obtain the physical signatures. The Centers for Medicare & Medicaid Services (CMS) guidelines require that notifications of changes in coverage be made to a representative if the resident is not competent. The guidelines also specify that if in-person delivery of the notice is not possible, other methods such as telephone, mail, secure fax, or email should be used, and the notifier must document the contact and attempts to obtain a signature. The Director of Nursing was unaware of the requirement for physical signatures if verbal consent was obtained, and the facility did not have a policy for advance beneficiary notices, although they claimed to follow standard regulations.
Failure to Document Diuretic Use in MDS Assessment
Penalty
Summary
The facility failed to accurately assess and document the use of a diuretic for a resident during the observation period of the Minimum Data Set (MDS). The resident, identified as having moderate cognitive impairment and a diagnosis of essential hypertension, was prescribed furosemide, a diuretic, starting on August 2, 2024. However, the MDS assessment did not reflect the use of this medication. Staff A, the MDS coordinator, acknowledged the oversight, confirming that the resident had been on furosemide since the specified date. The Director of Nursing (DON) also confirmed the expectation that the MDS should have documented the diuretic use. Despite this, the Administrator stated that the facility adhered to standards of care and regulations for MDS assessments.
Failure to Follow Physician Orders and Medication Management
Penalty
Summary
The facility failed to adhere to professional standards of care by not obtaining daily weights for a resident with congestive heart failure, fluid overload, and pulmonary hypertension, as per physician orders. Despite the resident being COVID-19 positive, the facility did not clarify the daily weight order with the physician, resulting in a lack of weight monitoring for ten consecutive days. The Director of Nursing (DON) acknowledged that staff should have sought clarification from the physician or the DON regarding the daily weight order during the resident's COVID-19 infection. The facility lacked a policy on professional standards or following physician orders, which contributed to this oversight. Additionally, the facility allowed a resident to self-administer medications without a physician's order or a self-administration assessment. A Registered Nurse (RN) left medication in the resident's nebulizer and a tablet of gabapentin on the bedside table for the resident to self-administer. The DON admitted that the resident had been self-administering nebulizer treatments since entering the facility, assuming it was the practice at the previous facility. The facility's policy on medication management required staff to explain the medication to the resident and document its administration, which was not followed in this case.
Failure to Use Mechanical Lifts for Resident Transfers After Falls
Penalty
Summary
The facility failed to adhere to its guidance on using a full body lift for transferring residents after a fall, affecting three residents. Resident #1, with moderate cognitive impairment and a history of falls, was found on the floor complaining of leg pain. Despite the resident's complaints and visible discomfort, staff assisted the resident back to bed manually without using a mechanical lift, contrary to the facility's protocol. The resident was later diagnosed with a displaced fracture, indicating the severity of the fall and the need for proper handling. Resident #2, who had severe cognitive impairment and was at moderate risk for falls, experienced an unwitnessed fall resulting in abrasions and a head injury. The resident was manually assisted off the floor and later sent to the hospital for evaluation. The facility's failure to use a mechanical lift as per their guidance was evident in this incident as well, highlighting a pattern of non-compliance with established safety protocols. Resident #3, with moderate cognitive impairment and a history of falls, was found on the floor multiple times. On one occasion, the resident sustained a laceration requiring hospital treatment. Despite the facility's documentation indicating the use of a mechanical lift for such situations, staff continued to manually assist the resident off the floor. The facility lacked specific policies related to falls, relying instead on general guidelines, which contributed to the repeated deficiencies in handling fall incidents appropriately.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Shenandoah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden View Care Center | 0.4 mi | — | 45 | 2 |
| The Ambassador Sidney Inc | 14.3 mi | ★★★★★ | 6 | 0 |
| Azria Health Clarinda | 17.3 mi | ★★★★★ | 0 | 0 |
| Tabor Manor Care Center | 18.4 mi | ★★★★★ | 22 | 0 |
| Red Oak Rehab And Care Center | 19.9 mi | ★★★★★ | 8 | 0 |
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