Rehab At Shannondell
Inspection history, citations, penalties and survey trends for this long-term care facility in Audubon, Pennsylvania.
- Location
- 5000 Shannondell Drive, Audubon, Pennsylvania 19403
- CMS Provider Number
- 396101
- Inspections on file
- 20
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rehab At Shannondell during CMS and state inspections, most recent first.
A resident experienced a fall during the overnight shift and was assisted by a nurse aide, who failed to report the incident to nursing staff. The fall was only discovered when the resident self-reported it to an LPN during the next shift, resulting in delayed physician notification and assessment. The resident sustained pain and a skin tear, and the DON confirmed the reporting failure.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A facility failed to inform a resident and her family of their right to formulate an advanced directive upon admission and did not verify her code status, leading to confusion during a medical emergency. The resident, admitted after a hospital stay for serious conditions, was considered Full Code by default, despite hospital documentation indicating a DNR/DNI status. This oversight resulted in CPR being administered without confirmation of the resident's wishes, highlighting a significant deficiency in the facility's admission process.
The facility failed to maintain accurate records for controlled drugs on two medication carts, with missing and pre-signed entries in the narcotic book. Staff interviews revealed that nurses sometimes pre-signed or failed to sign the narcotic book, leading to incomplete records and a lack of accountability for controlled substances.
The facility had a medication error rate of eight percent due to incorrect administration of Cyanocobalamin to two residents. Both residents were prescribed the medication sublingually, but it was administered orally by a registered nurse and an LPN. This error was confirmed by the DON.
The facility failed to store and label medications according to professional standards. An expired Glucagon injection was found in a medication cart, and an open vial of Tuberculin PPD lacked a date opened label in the medication room. These issues were confirmed by the respective licensed nurses.
Failure to Immediately Notify Physician of Resident Fall and Injury
Penalty
Summary
The facility failed to immediately notify the attending physician of an accident resulting in injury for one resident. According to the facility's policy, the charge nurse is responsible for promptly informing the physician of any changes in a resident's condition, including accidents or incidents, and for documenting the details and any instructions received. In this case, a resident experienced a fall at 5:00 a.m. while ambulating to the bathroom. The nurse aide on duty at the time assisted the resident after the fall but did not report the incident to the nursing staff or document it. The fall was only discovered when the resident self-reported the incident to a licensed nurse during the following shift. Subsequent review of the clinical and hospital records indicated that the resident sustained pain in the left elbow, hip, and knee, as well as a left shin skin tear, and reported hitting her head. The physician was eventually notified and ordered x-rays and pain medication, along with treatment for the skin tear. Interviews confirmed that the nurse aide failed to report the fall as required, resulting in a delay in physician notification and assessment. The Director of Nursing verified that the incident was not reported until the resident disclosed it during the next shift.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Verify Code Status and Inform of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident and/or her responsible party of their right to formulate an advanced directive upon admission, and did not clarify the resident's code status to ensure her end-of-life care wishes would be honored. The facility's policy required social services to verify a patient's code status within one business day of admission, but this was not done for the resident in question. The resident was admitted to the facility after a hospital stay for serious medical conditions, including a fall and multiple types of brain hemorrhages, and was assessed as alert and oriented to person and time but not to place or situation. Upon admission, the facility did not attempt to determine if the resident had an advanced directive or wanted to create one. The resident's hospital discharge summary indicated a DNR/DNI status, but this information was not verified or documented by the facility. When the resident experienced a medical emergency, CPR was initiated without confirmation of her code status, leading to a situation where emergency medical technicians had to contact the resident's son to confirm whether CPR should continue. Interviews with facility staff revealed that the resident was considered Full Code by default upon admission, as the social services assessment to confirm code status had not yet been completed. The facility's failure to verify the resident's code status and inform her of her rights regarding advanced directives resulted in a lack of clarity during a critical medical event, ultimately leading to the continuation of CPR against the resident's documented wishes.
Plan Of Correction
1. R1 is no longer in our facility. 2. A baseline audit will be completed to verify that all patients have an opportunity to formulate an advanced directive, including code status. 3. The Advanced Directive P&P will be updated. 4. The DON or designee will create an Advanced Directive assessment. 5. The Advanced Directive assessment will be completed by the admitting nurse when each patient arrives. 6. The licensed nurses will be in-serviced on the newly created AD Assessment. 7. For the next sixty (60) days, the DON or designee will complete random audits to ensure that the Advanced Directive Assessment is being completed correctly. 8. The DON or designee will report patterns and trends from these audits to the facility QA Committee. 9. The DON or designee will monitor for compliance.
Inadequate Record-Keeping for Controlled Drugs
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs between shifts, leading to discrepancies in the narcotic book for two medication carts on the 3rd Floor B. During an observation on July 10, 2024, it was found that the narcotic book for Medication Cart 3rd Floor B Front had a pre-signed entry by a nurse who was going off duty, which was confirmed by the nurse himself. Additionally, several entries in the narcotic book for both Medication Cart 3rd Floor B Front and Back were missing signatures from either the nurse going off duty or the nurse coming on duty on various dates in June and July 2024. Interviews with the involved staff revealed that the outgoing and incoming nurses are supposed to count the narcotics together and sign the narcotic book accordingly. However, it was discovered that some nurses pre-signed the narcotic book, and others failed to sign it altogether, resulting in incomplete records. This lack of proper documentation and accountability for controlled substances was observed during medication administration on the 3rd floor unit, indicating a systemic issue in the facility's management of pharmaceutical services.
Medication Administration Error: Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of eight percent based on 25 medication opportunities with two errors. The errors involved the administration of Cyanocobalamin (Vitamin B-12) to two residents, R9 and R244. According to the physician's orders, both residents were to receive Cyanocobalamin 1,000 mcg via the sublingual route once daily. However, during a medication administration pass, Registered Nurse Employee E3 and Licensed Practical Nurse Employee E4 administered the medication orally instead of sublingually to Residents R9 and R244, respectively. This deviation from the prescribed route of administration was confirmed by the Director of Nursing during an interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to professional standards. During an observation of the medication cart on the 3rd floor unit, a Glucagon injection with an expired date was found in the top drawer. This was confirmed by Licensed Nurse, Employee E6, who acknowledged the presence of the expired medication. Additionally, in the third-floor medication room, an open vial of Tuberculin PPD 5TU/0.1ml was found in the refrigerator without a date opened affixed to the vial or the box. This was confirmed by Licensed Nurse, Employee E7, who acknowledged the lack of proper labeling. These findings indicate a failure to adhere to the facility's policy for medication administration, which requires checking expiration dates and labeling multi-dose vials with the date they were opened.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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