Pennsylvania Department of Health
SHENANDOAH SENIOR LIVING COMMUNITY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 21, 2026, at Shenandoah Senior Living Community, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 190102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, it was determined that Shenandoah Senior Living Community was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices in one location, affecting one of one floor.

Findings include:

1. Observation on May 21, 2026, at 10:51 am, revealed the Blue Hall med room door was being held open by an unauthorized means. (cabinet placed in front of the door).

Exit interview with the Facilities Manager on May 21, 2026, at 11:30 am, confirmed the door being held open.

Plan of Correction - To be completed: 06/11/2026

0223
1. Medication room door will not be held open
2. 6/11/2026
3. Licensed Nursing Staff will be educated on not propping open medication room doors.
4. The maintenance director/designee will do 2 random audits to ensure that medication room doors are not propped open. Audits will be weekly for 1
month, biweekly for 2months. Results to QAPI.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of one floor.

Findings include:

1. Documentation Review on May 21, 2026, between 9:15 am, and 10:30 am, revealed the facility lacked documentation for a 1st quarter sprinkler inspection for 2026.

Exit interview with the Facilities Manager on May 21, 2026, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 06/11/2026

0353
1. First quarter inspection was completed 2 days late.
2. 6/11/2026
3. The maintenance staff were educated on ensuring Sprinkler inspections are completed timely & within the quarter.
4. The maintenance director will add sprinkler inspections to TELS & report to NHA when completed. Results to QAPI for 3 months.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor openings, affecting one of one floor.

Findings include:

1. Observation on May 21, 2026, at 10:44 am, Dining room doors near the kitchen had the latching mechanism on the top of the door frame removed. (Right Leaf).

Exit interview with the Facilities Manager on May 21, 2026, at 11:30 am, confirmed the latching mechanism removed.

Plan of Correction - To be completed: 06/11/2026

0363
l. Dining room door latch mechanism was replaced.
2. 6/11/2026
3. The maintenance staff were educated on ensuring all doors have latching mechanism & are fully latching.
4. The maintenance director/designee will do 2 random audits to ensure that doors have all latching mechanism & are fully latching. Audits will be weekly for 1 month, biweekly for 2months. Results to QAPI.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain ventilation systems in two locations, affecting one of one floor.

Findings include:

1. Observation on May 21, 2026, between 10:59 am, and 11:13 am, revealed the following:

a. At 10:59 am, Blue Hall, Soiled Linen room lacked a ceiling vent cover.
b. At 11:13 am, Yellow Hall, Kitchenette lacked a ceiling vent cover.

Exit interview with the Facilities Manager on May 21, 2026, at 11:30 am, confirmed the missing ceiling vent covers.

Plan of Correction - To be completed: 06/11/2026

K0521
1. Blue Hall soiled linen room & Yellow Hall kitchenette ceiling vent covers have been installed.
2. 6/11/2026
3. The maintenance staff were educated on ensuring all ceiling vent covers are in place.
4. The Maintenance director will do 2 random audits to ensure that vent covers are in place. Audits will be weekly for 1 month, biweekly for 2months. Results to QAPI.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 190102
Component 02
Therapy Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, at Shenandoah Senior Living Community, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy.

This is a one story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

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