Pennsylvania Department of Health
SHENANDOAH SENIOR LIVING COMMUNITY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SHENANDOAH SENIOR LIVING COMMUNITY
Inspection Results For:

There are 110 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SHENANDOAH SENIOR LIVING COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a state revisit and abbreviated complaint survey completed on February 9, 2025, at Shenandoah Senior Living Community it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of nursing time schedules, resident census and staff interviews, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for six shifts out of 21 reviewed.

Findings included:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse aide staff of 1:11 on the evening shift and 1:15 on the night shift, based on the facility's census:

April 2, 2025- 8.00 NAs on the evening shift, versus the required 9.36 for a census of 103.
April 5, 2025- 7.00 NAs on the evening shift, versus the required 9.00 for a census of 99.
April 6, 2025- 8.00 NAs on the evening shift, versus the required 9.00 for a census of 99.
April 6, 2025- 6.00 NAs on the night shift, versus the required 6.60 for a census of 99.
April 7, 2025 - 8.50 NAs on the evening shift, versus the required 8.91 for a census of 98.
April 8, 2025 - 8.50 NAs on the evening shift, versus the required 9.00 for a census of 99.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator (NHA) on April 9, 2025, at 12:15 PM, confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.

Plan of Correction - To be completed: 05/23/2025

P5520 CNA Staffing Ratios
1. The facility is unable to correct CNA staffing ratios for April 2, 2025, April 5,2025, April 6, 2025, April 7, 2025, and April 8, 2025.
2. No other dates were identified during the survey.
3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and scheduler to ensure the CNA staffing ratios are adequate for the census. Staffing will be based on current census and supervisors or scheduler will contact other staff to cover call offs.
NHA,DON, HR and/or Scheduler will meet daily during the week to review staffing needs, call offs ,ppd & ratios.
Facility is using Nurse Aide Training program to recruit and train new Nursing Assistants.
4. To monitor or maintain ongoing compliance, the DON/designee will audit the schedule weekly x 4 weeks and biweekly x 4 to ensure the CNA staffing ratio has been met. Results will be reviewed at the QAPI meeting.
5. 5/23/2025

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for seven shifts out of 21 reviewed from April 2, 2025, through April 8, 2025..

Findings included:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift and 1:40 on the night shift based on the facility's census.

April 2, 2025 - 4..00 LPNs on the day shift, versus the required 4.12 for a census of 103
April 2, 2025 - 2.00 LPNs on the night shift, versus the required 2.60 for a census of 104.
April 3, 2025 - 2.00 LPNs on the night shift, versus the required 2.55 for a census of 102.
April 5, 2025 - 2.00 LPNs on the night shift, versus the required 2.48 for a census of 99.
April 6, 2025 - 2.00 LPNs on the night shift, versus the required 2.48 for a census of 99.
April 7, 2025 - 2.00 LPNs on the night shift, versus the required 2.45 for a census of 98.
April 8, 2025 - 2.00 LPNs on the night shift, versus the required 2.45 for a census of 98.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator (NHA) on April 9, 2025, at 12:03 PM, confirmed confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 05/23/2025

P5530 Nursing Services
1. The facility is unable to correct LPN staffing ratio on April 2, 2025, April 3, 2025, April 5,2025, April 6, 2025, April 7, 2025 and April 8, 2025.
2. No other dates were identified during the survey.
3. To prevent this from reoccurring, the DON/designee completed education with the
Nursing supervisors and the scheduler to maintain LPN ratio with current census. If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift.
NHA, DON, HR and/or Scheduler will meet daily during the week to review staffing needs, call offs ,ppd & ratios.
4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4 , biweekly x 4 and monthly x 2 to ensure the LPN ratio has been met. Results will be reviewed at the QAPI meeting.
5. 5/23 / 2025

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily on five out of the 7 days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.20 hours of general nursing care to each resident:

April 2, 2025 - 2.88 direct care nursing hours per resident.
April 5, 2025 - 2.89 direct care nursing hours per resident.
April 6, 2025 - 2.80 direct care nursing hours per resident.
April 7, 2025 - 3.08 direct care nursing hours per resident.
April 8, 2025 - 3.14 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the above dates.

An interview with the Nursing Home Administrator (NHA) on April 9, 2025, at 12:05 PM, confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 05/23/2025

P5640 Nursing Services
1. The facility is unable to correct PPDs for April 2, 2025, April 5,2025, April 6, 2025, April 7, 2025 and April 8, 2025.
2. No other dates were identified during the survey.
3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and the scheduler to maintain a PPD of 3.2 . If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift.
NHA, DON, HR and/or Scheduler will meet daily during the week to review staffing needs, call offs ,ppd & ratios.
Facility is using Nurse Aide Training program to recruit and train new Nursing Assistants.
4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4, biweekly x 4 and monthly x 2 to ensure the PPD has been met. Results will be reviewed at the QAPI meeting.
5. 5/23/2025

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