Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Accura Healthcare Of Shenandoah during CMS and state inspections, most recent first.
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.
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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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 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 | — | 20 | 0 |
| Red Oak Rehab And Care Center | 19.9 mi | — | 8 | 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.