Cycle 1
Health 2025-05-01 · Fire 2025-05-01
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Audubon, PA
Rehab At Shannondell
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
5000 Shannondell Drive, Audubon, PA
(610) 728-5400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-01-31
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.41
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,607
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9965
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.36% · Performance 22.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.26
Baseline 5.35% · Performance 5.66% · Measure score 7.26 · Achievement 7.26 · Improvement 0
Total nurse turnover
7.09
Baseline 36.89% · Performance 34.69% · Measure score 7.09 · Achievement 7.09 · Improvement 1.33
Adjusted total nurse staffing
3.06
Baseline 3.71 hours · Performance 3.95 hours · Measure score 3.06 · Achievement 3.06 · Improvement 0.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 1716 · Observed rate 9.09% · Lower 95% interval 8.82% |
| Discharge to community | 69.81% |
50.57%
19.2 pts better
|
Better than the National Rate · Eligible stays 1913 · Observed rate 68.01% · Lower 95% interval 67.39% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 1026 · Denominator 1026 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 7 · Denominator 1026 |
| Discharge self-care score | 51.53% |
53.69%
2.2 pts worse
|
Numerator 420 · Denominator 815 |
| Discharge mobility score | 58.4% |
50.94%
7.5 pts better
|
Numerator 476 · Denominator 815 |
| Pressure ulcers or injuries, new or worsened | 0.39% |
2.29%
1.9 pts better
|
Numerator 4 · Denominator 1026 · Adjusted rate 0.53% |
| Healthcare-associated infections requiring hospitalization | 5.66% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 1082 · Observed rate 4.44% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 15.03% |
8.2%
6.8 pts better
|
Numerator 58 · Denominator 386 |
| Staff flu vaccination coverage | 97.41% |
42%
55.4 pts better
|
Numerator 488 · Denominator 501 |
| Discharge function score | 55.46% |
56.45%
1 pts worse
|
Numerator 452 · Denominator 815 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 855 · Denominator 855 |
| Transfer of health information to patient | 99.34% |
96.28%
3.1 pts better
|
Numerator 151 · Denominator 152 |
| Resident COVID-19 vaccinations up to date | 34.72% |
25.2%
9.5 pts better
|
Numerator 184 · Denominator 530 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.2% |
68.9%
12.7 pts worse
|
81.7%
25.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.8% · Q2 63.9% · Q3 53.8% · Q4 46.0% · 4Q avg 56.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
9.8%
0.6 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 7.7% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.2% · Q3 0.3% · Q4 0.2% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.5% |
68.7%
3.8 pts better
|
79.7%
7.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
23.1%
4.3 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 22.0% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-09-08 · Fire 2023-09-08
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-30
C · Minimal harm
2025-05-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-30
F · Potential for more than minimal harm
2024-07-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-07-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-15
C · Minimal harm
2024-07-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-15
C · Minimal harm
2024-07-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-15
C · Minimal harm
2024-07-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-15
C · Minimal harm
2024-07-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-15
F · Potential for more than minimal harm
2023-09-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-08
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-01
C · Minimal harm
2023-09-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-06-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-26
D · Potential for more than minimal harm
2024-12-04
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-07-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-27
D · Potential for more than minimal harm
2023-09-08
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-08
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-03-23
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-05-03
Penalties and ownership
What sits behind the stars
Ownership
Builders Acceptance Corp
5% Or Greater Direct Ownership Interest · Organization
Darrenkamp, Scott
Operational/Managerial Control · Individual
Frank, Ronald
Operational/Managerial Control · Individual
Freed, Daniel
Operational/Managerial Control · Individual
Handler Haley, Payce
Operational/Managerial Control · Individual
Joyce, Jenn
Operational/Managerial Control · Individual
Kim, Wendy
Operational/Managerial Control · Individual
Moore, Kelly
Operational/Managerial Control · Individual
Rittenhouse, David
5% Or Greater Direct Ownership Interest · Individual
Rittenhouse, David
Corporate Officer · Individual
Scott, Dorothy
Operational/Managerial Control · Individual
Sorom, Jim
Operational/Managerial Control · Individual
Sorom, Jim
Corporate Officer · Individual
Wethey, Gregory
Operational/Managerial Control · Individual
Williamson, Victoria
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
King Of Prussia Skilled Nursing And Rehabilitation
King Of Prussia, PA
2-star overall rating with 2-star inspections with $3,145 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Norriton Square Nursing And Rehabilitation Center
Norristown, PA
2-star overall rating with 2-star inspections with abuse icon flag with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Markley Rehabilitation And Healthcare Center
Norristown, PA
3-star overall rating with 2-star inspections with $9,311 in total fines with 18 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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