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40/100SHENANDOAH SENIOR LIVING COMMUNITY Inspection Report, Violations & Safety Grade (SHENANDOAH, Pennsylvania)
101 E. WASHINGTON ST, SHENANDOAH, Pennsylvania 17976
Phone: 5704621908
CMS Overall:1/5
Overview & Bed Count
Certified Beds
119
Avg Residents/Day
104.4
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Schuylkill
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing2/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Pennsylvania Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.44 | 0.78 | -0.33 |
| Total Nurse Hours per Resident per Day | 3.21 | 3.90 | -0.68 |
| CMS Staffing Rating | 2/5 | 3.1/5 | - |
| Nursing Staff Turnover | 47.7% | 44.6% | - |
Health Citation History
40 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-11 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | E – Moderate Harm Potential |
| 2026-05-01 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2026-05-01 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | E – Moderate Harm Potential |
| 2026-05-01 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2026-05-01 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2026-05-01 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-05-01 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2026-05-01 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2026-05-01 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | C – Minimal Harm Potential |
| 2026-01-07 | Quality of Life and Care Deficiencies | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J – Immediate Jeopardy |
| 2026-01-07 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | G – Actual Harm |
| 2026-01-07 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | E – Moderate Harm Potential |
| 2025-07-02 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E – Moderate Harm Potential |
| 2025-07-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-07-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-07-02 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-07-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | D – Moderate Harm Potential |
| 2024-09-13 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2024-09-13 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2024-09-13 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-09-13 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-09-13 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-09-13 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-09-13 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2024-09-13 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-09-13 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-09-13 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-09-13 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | D – Moderate Harm Potential |
| 2024-05-15 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2024-05-15 | Resident Rights Deficiencies | Honor the resident's right to organize and participate in resident/family groups in the facility. | E – Moderate Harm Potential |
| 2024-05-15 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-05-15 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2024-05-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-03-27 | Quality of Life and Care Deficiencies | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | E – Moderate Harm Potential |
| 2024-03-27 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-03-27 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-03-27 | Administration Deficiencies | Provide timely, quality laboratory services/tests to meet the needs of residents. | D – Moderate Harm Potential |
| 2024-02-16 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2023-10-04 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | E – Moderate Harm Potential |
| 2023-10-04 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
Fire Safety Citation History
19 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-01 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2026-05-01 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2026-05-01 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2026-05-01 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | C – Minimal Harm Potential |
| 2025-07-02 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-07-02 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-07-02 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2025-07-02 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2025-07-02 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | C – Minimal Harm Potential |
| 2024-09-13 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2024-09-13 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-09-13 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-09-13 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2024-09-13 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2024-09-13 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2024-09-13 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2024-09-13 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2024-09-13 | Smoke Deficiencies | Provide properly protected cooking facilities. | C – Minimal Harm Potential |
| 2024-09-13 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | C – Minimal Harm Potential |
Total Penalties & Fines
$76,285
Total Fine Amount (CMS)
2
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-01-07 | Fine | $12,650 | - |
| 2024-02-16 | Fine | $63,635 | - |
| 2024-02-16 | Payment Denial | - | 20 days starting 2024-05-16 |
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SHENANDOAH area at no cost.
Find Safe, Vetted Facilities Near SHENANDOAH
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.