8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Shenandoah, PA
1-star overall rating with 1-star inspections with $63,635 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
101 E. Washington St, Shenandoah, PA
(570) 462-1908
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
119
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gabriel Sebbag & The Samara Family
Operator or chain grouping
Approved since
1982-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 1 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.50
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
9,533
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.08% · Performance 22.09% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.47
Baseline 7.17% · Performance 5.60% · Measure score 7.47 · Achievement 7.47 · Improvement 6.71
Total nurse turnover
1.88
Baseline 32.61% · Performance 56.00% · Measure score 1.88 · Achievement 1.88 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.88 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 10.8% · Lower 95% interval 7.78% |
| Discharge to community | 47.62% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 40.99% · Lower 95% interval 39.18% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 1.15% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 87 |
| Discharge self-care score | 46.48% |
53.69%
7.2 pts worse
|
Numerator 33 · Denominator 71 |
| Discharge mobility score | 59.15% |
50.94%
8.2 pts better
|
Numerator 42 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.15% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 87 · Adjusted rate 0.86% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 3.6% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 44.86% |
42%
2.9 pts better
|
Numerator 48 · Denominator 107 |
| Discharge function score | 49.3% |
56.45%
7.2 pts worse
|
Numerator 35 · Denominator 71 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 2 · Denominator 44 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.7% |
86.9%
5.2 pts worse
|
93.4%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 84.3% · Q3 82.8% · Q4 77.2% · 4Q avg 81.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
93.5%
2 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.1% · Q3 2.3% · Q4 4.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
6.5%
2.8 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 3.8% · Q4 4.5% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.5%
0.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 7.4% · Q3 7.6% · Q4 5.8% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
19.9%
0.5 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 19.0% · Q3 19.5% · Q4 21.6% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
18.7%
6.3 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 18.5% · Q3 11.1% · Q4 4.3% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.1% |
0.2%
0.9 pts worse
|
0.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.0% |
19.6%
1.4 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 21.2% · Q3 20.9% · Q4 17.6% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
18.3%
5.1 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 11.2% · Q3 15.4% · Q4 13.3% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
26.4%
1.2 pts better
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 27.8% · Q3 21.2% · Q4 24.3% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.3%
3.1 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.3% · Q3 0.0% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.3% |
68.9%
40.6 pts worse
|
81.7%
53.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 26.4% · Q3 29.2% · Q4 26.5% · 4Q avg 28.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.8%
2.8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 7.4% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.3% |
68.7%
45.4 pts worse
|
79.7%
56.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
23.1%
3.5 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 19.8% · Expected 24.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
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 2025-08-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-12
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-12
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-21
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 2024-10-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-21
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-21
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-21
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-07
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-07
Inspection history
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-01-25
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-25
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-01-25
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 2025-08-26
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-26
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-09-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-22
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-22
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-22
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-22
Health
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.
Corrected 2024-10-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-22
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-22
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-10-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-05
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-06-05
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-05
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 2024-06-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-05
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-05-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-15
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-15
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-05-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-27
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 2023-11-21
Health
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.
Corrected 2023-11-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-21
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-21
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-21
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-11-21
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-21
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-21
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-21
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 2023-11-21
Health
Have policies on smoking.
Corrected 2023-11-21
Penalties and ownership
Fine · fine $63,635
Fine
Payment Denial · denial start 2024-05-16 · 20 days
20 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Nearby options
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0-star overall rating with 0-star inspections with Special Focus status with $346,725 in total fines with 15 recent health deficiencies
Frackville, PA
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Pottsville, PA
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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