Inspection Reports for
The Meadows at Shannondell
6000 SHANNONDELL DRIVE,, AUDUBON, PA, 19403
Back to Facility Profile36 Reports
Inspection Report — Dec 18, 2025
Monitoring
Date: Dec 18, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit to review compliance and verify the submitted plan of correction for the facility.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, breaches in record confidentiality, unsanitary conditions, safety hazards such as obstructed egress and presence of prohibited portable heaters, and medication management issues including unlocked medications and failure to follow prescriber's orders. Plans of correction were accepted and some were implemented by early 2026.
Citations (11)
16c - The home failed to report two incidents, including a choking and a fall with injury, to the Department within 24 hours as required.
17 - Resident records were left unlocked and unattended on medication carts and nursing office desks, violating confidentiality requirements.
85a - A resident's toilet was found with feces smeared and dust and dirt accumulated in the shower corner, indicating unsanitary conditions.
88a - An active leak was observed in a hallway with water running down walls and wet carpet, and a large brown stain was found above a kitchen area.
100b - Snow and ice accumulations were observed on exterior walkways and patios, obstructing safe egress.
121a - An emergency exit door required significant force to open, though it functioned as designed with a push bar.
127a - A prohibited portable space heater was found on a desk in the salon area and was removed.
183b - Medication carts and resident rooms contained unlocked, unattended medications accessible to unauthorized persons.
183e - Loose pills and punctured blister packs were observed in medication carts, indicating improper medication storage.
185a - The home failed to have available prescribed medications for a resident, violating safe storage and availability procedures.
187d - The home did not administer a prescribed medication on two days due to unavailability, but the delay was approved by the medical team and family.
Report Facts
Residents Served: 155
Residents Served in Dementia Unit: 33
Hospice Current Residents: 18
Residents Age 60 or Older: 154
Residents with Mobility Need: 76
Inspection Report — Dec 13, 2025
Monitoring
Date: Dec 13, 2025
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted over multiple dates to review compliance and verify the implementation of a submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to record confidentiality, contact list maintenance, sanitary conditions, bed linens, walls and floors, fire drill evacuation procedures, and medication storage and administration. Plans of correction were accepted and implemented with ongoing audits scheduled.
Citations (9)
Record confidentiality was violated when a laptop containing resident medication administration records was left unlocked and unattended on a medication cart in a hallway.
The administrator did not maintain a current list of staff persons working in the personal care units of the home.
Sanitary conditions were not maintained as evidenced by urine in a resident's bathroom sink, a chair stained with a dark brown substance, and a strong odor of feces in a resident's bedroom.
A resident's bed linens and blankets were stained with what appeared to be urine.
The floor in a resident's bedroom was stained with a red substance reported as dried Jello.
Residents did not evacuate to a designated fire-safe area during fire drills when the drill was not near their room.
Prescription and topical medications were found unlocked, unattended, and accessible in resident rooms and bathrooms.
Medication storage was disorganized with a loose pill observed in a medication cart and a torn blister pack remaining in the cart.
A resident's medication label was inconsistent with the medication administration record, showing conflicting dosage instructions.
Report Facts
Residents Served: 141
Secured Dementia Care Unit Residents Served: 27
Residents Age 60 or Older: 139
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 65
Inspection Report — Sep 17, 2025
Complaint Investigation
Date: Sep 17, 2025
Visit Reason
The inspection was an unannounced partial inspection conducted due to a complaint and incident involving resident care and safety concerns.
Complaint Details
The visit was complaint-related and substantiation is implied by the detailed violations and deficiencies documented.
Findings
The facility failed to timely report incidents to the Department, maintain resident confidentiality, provide adequate assistance with activities of daily living, prevent neglect and abuse, maintain sanitary conditions, keep living spaces in good repair, properly document medication refusals, and follow prescriber's orders.
Citations (8)
16c - Written Incident Report: The home failed to submit initial incident reports to the Department for multiple resident incidents involving falls and hospitalizations.
17 - Record Confidentiality: Resident assignment sheets with personal care information were left unlocked and accessible on a medication cart.
23a - Activities of Daily Living Assistance: Resident did not receive required assistance with toileting and was found on the floor with injuries and wet clothing after an unwitnessed fall.
42b - Abuse: Resident was neglected overnight, found with injuries and confusion, and staff failed to obtain ordered urine culture; resident later expired due to complications.
85a - Sanitary Conditions: Resident room had a strong odor of old urine, dried blood splatter in bathroom, and brown stains on walls.
101o - Walls, Floors, Ceilings: Resident room walls were in extreme disrepair with large gashes and exposed metal corners.
187c - Refusal of Medication: Resident refused prescribed nebulization medication multiple times and the home failed to report refusals to the prescriber.
187d - Follow Prescriber's Orders: The home failed to obtain a prescribed urine specimen and missed administering a medication due to unavailability.
Report Facts
Residents Served: 141
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 7
Staff Total Daily Staff: 206
Staff Waking Staff: 155
Residents Age 60 or Older: 141
Residents with Mental Illness: 4
Residents with Intellectual Disability: 1
Residents with Mobility Need: 65
Inspection Report — Jul 24, 2025
Plan of Correction
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with a follow-up plan of correction submission to verify compliance.
Findings
The facility had deficiencies related to incomplete medical evaluations missing medication regimen details, discontinued medications not discarded, improper medication storage and security procedures, and incomplete resident incident report documentation. Plans of correction were submitted and implemented to address these issues.
Citations (4)
Resident medical evaluation did not include the medication regimen, contraindicated medications, or medication side effects.
Discontinued medication was found in the home's narcotics locked box.
Keys to medication cart and narcotics box were left unattended during a shift; controlled substances were counted by only one licensed nurse instead of two.
Resident records did not include a record of incident reports for individual residents.
Report Facts
Residents Served: 143
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 11
Residents Age 60 or Older: 142
Residents with Mobility Need: 61
Total Daily Staff: 204
Waking Staff: 153
Inspection Report — Jun 30, 2025
Monitoring
Date: Jun 30, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted to review compliance and verify the submitted plan of correction.
Findings
The inspection found multiple deficiencies including insufficient staff certified in first aid/CPR during certain shifts, unlocked medication carts unattended and accessible, incomplete narcotic medication logs, and incomplete medication administration records. Plans of correction were submitted and accepted with completion dates in early August 2025.
Citations (5)
Insufficient number of staff certified in first aid, obstructed airway techniques, and CPR present during shifts with 141 residents.
Medication carts were found unlocked, unattended, and accessible in hallways and in front of resident bedrooms.
Narcotic inventory log did not include the time medication was removed, violating the home's narcotic policy.
Medication administration record (MAR) lacked documentation of units given for insulin for a resident.
Medication administration record did not include initials of staff administering medication at specified times for a resident.
Report Facts
Residents present: 141
Secured Dementia Care Unit residents served: 32
Hospice current residents: 9
Residents age 60 or older: 140
Residents with mobility need: 64
Residents diagnosed with mental illness: 3
Inspection Report — Aug 12, 2024
Monitoring
Date: Aug 12, 2024
Visit Reason
The visit was a monitoring review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The inspection found deficiencies related to medication storage, documentation accuracy, and following prescriber's orders. Loose pills were found in medication carts, punctured blister packs were noted, medication documentation errors occurred, and some prescribed glucose checks were not performed due to unavailable equipment. Plans of correction were accepted with training and auditing measures to ensure compliance.
Citations (3)
Loose pills found in medication carts and punctured blister packs with medication still present.
Inaccurate documentation of resident glucose readings and missing medications in the home.
Failure to follow prescriber's orders for glucose checks due to unavailable glucometer.
Report Facts
Residents Served: 149
Secured Dementia Care Unit Residents Served: 31
Current Hospice Residents: 13
Residents Age 60 or Older: 148
Residents with Mental Illness: 2
Residents with Mobility Need: 55
Inspection Report — Apr 15, 2024
Renewal
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons over multiple days from 04/15/2024 to 04/18/2024.
Findings
The inspection identified multiple deficiencies including failure to post current license conspicuously, denial of access to department agents, confidentiality breaches, inadequate assistance with activities of daily living, abuse and neglect issues, improper storage and labeling of medications, sanitary and maintenance concerns, and lack of proper emergency communication systems. Plans of correction were accepted and implemented by 10/22/2024.
Citations (36)
Current license was not posted in a conspicuous and public place on the 4th floor of the 5000 building.
Staff person refused immediate access to the lower level Secured Dementia Care Unit to department agents.
Resident records and communication logs were unlocked, unattended, and accessible in multiple locations.
Residents did not receive required assistance with hearing aids, feeding, catheter management, dressing, and personal hygiene.
Resident was neglected and left without hearing aids; catheter bags not properly managed; residents confined without access to call bells or repositioning; wheelchair broken; residents not changed timely.
Residents 4 and 5 lacked access to clean, seasonal clothing and were observed in hospital gowns.
Residents not able to freely leave the home due to key fob system restricting elevator and exit door access.
Resident was observed with foam wedges on both sides of hospital bed restricting movement (restraint).
Surveillance cameras lacked signage; resident privacy violated during bathing and care procedures.
Direct care staffing hours were below minimum required hours on multiple days.
Direct care staffing hours during waking hours were below required 75% minimum on multiple days.
Resident did not receive assistance with incontinence care; catheter bags not changed due to lack of staff.
Direct care staff observed serving food instead of performing direct care duties.
Direct care staff persons A, F, and G did not receive required training in medication self-administration and dementia care.
Resident 5's wheelchair had a broken seat; bedside mobility device not secured to bed frame.
Poisonous materials were unlocked and accessible to residents.
Sanitary conditions not maintained: dirty kitchen equipment, strong odors, spoiled food, uncovered trash cans.
Gnats present in kitchenettes and pantry areas.
Floors, walls, ceilings, and surfaces were stained, damaged, or had hazards such as electric razors in resident rooms.
Hot water temperature exceeded 120°F in multiple resident bathrooms.
Home lacked a system for staff communication across different parts of the home in emergencies.
Broken toilet paper holder in resident room.
Residents lacked operable bedside lamps within reach.
Carpet in resident room was stained and dirty.
Food was not protected from contamination; uncovered food and ice bins observed.
Freezer temperature was above required level; no thermometer in refrigerated salad prep station.
Food stored in opened and unsealed containers.
Outdated and improperly stored medications found on medication carts and counters.
Medications and syringes were unlocked, unattended, and accessible.
Discontinued medications were not destroyed properly.
Prescription medications were not properly labeled with pharmacy labels.
OTC medications and CAM were not labeled with resident names.
Glucometer not calibrated correctly; medications not available as prescribed.
Medication administration records were not properly dated and initialed.
Residents' support plans did not document use or need for bedside mobility devices.
Resident records did not include a complete inventory sheet of personal property.
Report Facts
Residents Served: 161
Residents Age 60 or Older: 152
Residents with Mobility Need: 59
Total Daily Staff: 220
Waking Staff: 165
Direct Care Staffing Hours Provided: 186
Direct Care Staffing Hours Provided: 182
Direct Care Staffing Hours Provided: 176
Direct Care Staffing Hours During Waking Hours: 136
Direct Care Staffing Hours During Waking Hours: 126
Direct Care Staffing Hours During Waking Hours: 129
Housekeeping Hours: 470.25
Housekeeping Hours: 442.5
Housekeeping Hours: 468
Temperature: 95.3
Temperature: 124.3
Temperature: 127.7
Temperature: 122.5
Freezer Temperature: 10
Number of Residents: 153
Number of Residents: 141
Number of Residents: 141
Inspection Report — Aug 24, 2023
Complaint Investigation
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE MEADOWS AT SHANNONDELL.
Complaint Details
The visit was complaint-related, investigating incidents including improper medical evaluations and prohibited restraint use. The plan of correction was accepted and fully implemented.
Findings
The inspection identified deficiencies related to incomplete and inaccurate medical evaluations, prohibited use of restraints, and missing signatures on support plans. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (3)
Resident #1's medical evaluation was inaccurate regarding safety around poisonous materials.
Staff placed physical restraints behind resident #1's wheelchair to prevent movement, which is prohibited.
Resident #2's support plan lacked the required assessor's signature.
Report Facts
Residents Served: 160
Residents Served in SDCU: 33
Hospice Residents: 15
Residents Age 60 or Older: 159
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 53
Inspection Report — Aug 7, 2023
Complaint Investigation
Date: Aug 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE MEADOWS AT SHANNONDELL facility on 08/07/2023.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 156
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 12
Residents Age 60 or Older: 155
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 59
Inspection Report — Jun 21, 2023
Complaint Investigation
Date: Jun 21, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at The Meadows at Shannondell facility on 06/21/2023.
Complaint Details
The visit was complaint-related involving allegations of neglect and abuse. The home was aware of the neglect allegation but failed to report it to the department. The complaint was substantiated with findings of neglect and abuse.
Findings
The investigation found multiple deficiencies including failure to report incidents timely, neglect in responding to call bells for assistance, improper use of restraints, and failure to implement positive interventions to manage resident behavior. Staff members involved were terminated or suspended, and corrective actions including staff training and monitoring were implemented.
Citations (5)
Failure to report an incident or condition to the Department within 24 hours as required.
Neglect of residents by not responding to call bells for assistance in a timely manner.
Use of restraints by placing a cloth in the mouth of a resident to prevent biting.
Failure to implement positive interventions to modify or eliminate resident behavior that endangers self or others.
Use of prohibited procedures including placing a cloth in the mouth of a resident.
Report Facts
Residents Served: 154
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 14
Residents Age 60 or Older: 153
Residents with Mental Illness: 5
Residents with Mobility Need: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to neglect and failure to report incidents; terminated following investigation. | |
| Staff Member B | Named in findings related to improper use of restraints and prohibited procedures; suspended and monitored following investigation. |
Inspection Report — Dec 5, 2022
Monitoring
Date: Dec 5, 2022
Visit Reason
The visit was a monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to review compliance with licensing requirements at THE MEADOWS AT SHANNONDELL.
Findings
The inspection identified several medication-related deficiencies including improper labeling of an insulin pen, an uncalibrated glucometer, missing initials on medication administration records, and illegible record entries. The facility submitted a plan of correction which was accepted and fully implemented by March 15, 2023.
Citations (4)
Insulin pen was in the medication cart without an open/discard after date as required by manufacturer instructions.
Resident's glucometer was not calibrated to the correct time.
Medication administration records (MAR) missing initials of staff who administered medication on multiple occasions.
Entries in resident's record were crossed out without proper notations and overwritten, violating legibility and documentation standards.
Report Facts
Residents Served: 145
Secured Dementia Care Unit Residents Served: 34
Residents Age 60 or Older: 145
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 56
Inspection Report — Sep 15, 2022
Plan of Correction
Date: Sep 15, 2022
Visit Reason
The document reports on the Pennsylvania Department of Human Services, Bureau of Human Service Licensing review conducted on 09/15/2022, 09/16/2022, and 09/22/2022 to determine the implementation status of a submitted plan of correction for the facility.
Findings
The submitted plan of correction was found to be fully implemented, and continued compliance must be maintained.
Report Facts
Inspection dates: 3
Notice — Aug 16, 2022
Date: Aug 16, 2022
Visit Reason
This letter responds to Shannondell Inc.'s request to remove the existing waiver of 55 Pa. Code Chapter 2600 provisions related to unobstructed egress and emergency evacuation at The Meadows at Shannondell.
Findings
The letter outlines the required modifications to door access systems to comply with regulations §2600.121(b) and §2600.123(a), including keypad-operated devices and automatic door opening systems with emergency release buttons. It states that the waiver granted in 2009 will be rescinded 90 days from the letter date and that compliance will be reviewed during annual inspections.
Report Facts
Days until waiver rescinded: 90
Date of architectural plan submission: Mar 25, 2022
Inspection Report — Nov 19, 2021
Follow-Up
Date: Nov 19, 2021
Visit Reason
The inspection was conducted as a partial, unannounced incident review following an incident at the facility.
Findings
The facility was found to have not fully implemented the submitted plan of correction related to incident reporting and support plan documentation for residents. Specific violations included failure to report an incident within 24 hours and incomplete documentation of a resident's support plan for fall risk management.
Citations (2)
Failure to report an incident involving Resident #1 to the department within 24 hours as required.
Resident #2's support plan did not document how the need for fall risk management would be met.
Report Facts
Residents Served: 138
Secured Dementia Care Unit Residents Served: 33
Current Hospice Residents: 13
Residents Age 60 or Older: 138
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 61
Notice — Aug 12, 2021
Date: Aug 12, 2021
Visit Reason
The document serves as a response to the renewal application submitted on August 12, 2021, for The Meadows at Shannondell Personal Care Home, and notifies that a regular license is being issued. It also advises that an onsite annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a licensing and renewal notice confirming the issuance of a regular license and the facility's capacity.
Report Facts
Inspection Report — Jul 8, 2021
Complaint Investigation
Date: Jul 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements at THE MEADOWS AT SHANNONDELL.
Complaint Details
The visit was complaint-related. The plan of correction was accepted and fully implemented by 09/03/2021.
Findings
The facility was found to have deficiencies related to resident assessments, specifically that Resident #1's initial assessment did not include frequent changes in blood sugar readings or signs and symptoms to monitor. The submitted plan of correction was fully implemented.
Citations (1)
Resident #1’s assessment did not include the frequent changes in blood sugar readings and signs and symptoms to monitor for additional blood sugar readings.
Report Facts
Residents Served: 111
Secured Dementia Care Unit Residents Served: 26
Hospice Residents: 10
Residents Age 60 or Older: 111
Residents with Mental Illness: 2
Residents with Mobility Need: 57
Total Daily Staff: 168
Waking Staff: 126
Inspection Report — Jul 1, 2021
Renewal
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 07/01/2021 for the facility.
Findings
No regulatory citations were identified as a result of this licensing inspection.
Inspection Report — Jun 14, 2021
Renewal
Date: Jun 14, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with unannounced full inspections on 06/14/2021, 06/15/2021, and 06/17/2021.
Findings
The inspection identified multiple deficiencies including lack of a carbon monoxide detector near the kitchen, unsigned resident contracts and rights acknowledgments, unsecured poisonous materials and treatment carts, lack of bedside lighting in one resident room, medication administration delays, and missing signage for key-locking devices. Plans of correction were accepted or directed, and subsequent document submissions confirmed implementation.
Citations (10)
No Carbon Monoxide detector near the facility's kitchen which uses natural gas to fuel equipment.
Resident #1's contract was not signed by the resident.
Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
A closet marked 'CLEAN LINEN' on the secured dementia unit was unlocked and accessible to residents, containing poisonous materials.
Resident room #123 did not have access to a source of light that can be turned on/off at bedside.
A treatment cart containing medical equipment and treatment items was unlocked and accessible on the 4th floor of the rehab building.
Resident #2's prescribed medication was not available at the time of administration; delivery was delayed.
Resident #3 was administered medication at times different from the original prescriber's order.
Resident #1 was not educated on the right to refuse medication and no signed documentation was provided.
Directions for operating the home's locking mechanism were not conspicuously posted near the doors to the Secure Dementia Care Unit.
Report Facts
Residents Served: 113
Residents Served in Secured Dementia Care Unit: 26
Hospice Residents: 9
Total Daily Staff: 167
Waking Staff: 125
Number of resident toiletry baskets found in unlocked closet: 13
Inspection Report — May 25, 2021
Complaint Investigation
Date: May 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection.
Complaint Details
The inspection was complaint-related and the follow-up type was noted as not required. No substantiation status was explicitly stated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 122
Secured Dementia Care Unit Residents Served: 27
Residents Age 60 or Older: 122
Residents with Mental Illness: 1
Residents with Physical Disability: 51
Residents with Mobility Need: 51
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report — Feb 3, 2021
Follow-Up
Date: Feb 3, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, specifically a follow-up to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to prior deficiencies, including failure to timely report suspected resident abuse and incomplete documentation in a resident's support plan regarding hallucinations.
Citations (2)
Failure to file an Act 13 report timely for suspected staff to resident abuse.
Resident support plan did not document how hallucination needs would be met or what services would be provided.
Report Facts
Residents Served: 122
Secured Dementia Care Unit Residents Served: 27
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 51
Residents 60 Years or Older: 122
Residents with Physical Disability: 51
Inspection Report — Oct 2, 2020
Complaint Investigation
Date: Oct 2, 2020
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site inspection dates and an unannounced partial inspection on 10/02/2020.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 144
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 22
Residents Age 60 or Older: 144
Residents with Mobility Need: 42
Residents with Physical Disability: 1
Inspection Report — Aug 27, 2020
Follow-Up
Date: Aug 27, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to staff supervision during abuse allegations and direct care staff qualifications and training. Continued compliance is required.
Citations (3)
15b - Supervisor Plan: The facility reinstated a staff person accused of resident abuse before the Department completed its investigation, violating the requirement to suspend alleged perpetrators until approval.
54a - Direct Care Staff: A direct care staff person lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
65d - Initial Direct Care Training: A direct care staff person provided unsupervised ADL services before completing and passing the Department-approved training and competency test.
Report Facts
Residents Served: 124
Secured Dementia Care Unit Residents Served: 24
Direct Care Staff Person Hire Date: Jul 6, 2020
Direct Care Staff Person Training Completion Date: Aug 28, 2020
Notice — Jan 3, 2020
Date: Jan 3, 2020
Visit Reason
The document serves as a notification of approval for a revised license capacity increase for The Meadows at Shannondell Personal Care Home.
Findings
The Department of Human Services approved an increase in the facility's licensed capacity from 144 to 184 residents. The expiration date of the license remains unchanged.
Report Facts
Notice — Dec 18, 2019
Date: Dec 18, 2019
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of The Meadows at Shannondell, confirming receipt of the renewal application and informing about the upcoming annual inspection.
Findings
No inspection findings are reported in this document. It only confirms the license renewal and states that an annual inspection will be conducted within the next twelve months.
Report Facts
Inspection Report — Jun 17, 2019
Annual Inspection
Date: Jun 17, 2019
Visit Reason
The inspection was conducted as an annual licensing inspection to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Findings
Violations of the Personal Care Homes regulations were found during the inspection. Deficiencies included privacy violations during medication administration and inadequate posting of key-locking device instructions.
Citations (2)
42s. A resident has the right to privacy of self and possessions. A staff person administered medication to a resident in the dining room with other residents present, violating privacy.
233c. Directions for operating the home's locking mechanism were not conspicuously posted near the door to the Secure Dementia Care Unit.
Report Facts
Residents Served: 124
Memory Care Unit Residents Served: 31
Hospice Current Residents: 21
Residents Age 60 or Older: 124
Residents with Mobility Need: 55
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruthella Stubblebine | Administrator | Named as Administrator in facility information and signatory on plan of correction |
Inspection Report — Apr 10, 2019
Complaint Investigation
Date: Apr 10, 2019
Visit Reason
The inspection was conducted as a complaint investigation at The Meadows at Shannondell to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The findings included missing prescribed medications for residents. The complaint was substantiated by the violations found.
Findings
Violations were found related to medication availability and administration procedures. Plans of correction were developed to address missing medications and ensure ongoing audits and staff training.
Citations (2)
2600.185a: Resident #1 was prescribed Dulcolax 10 MG Rectal Suppository as needed, but the medication was not available in the home on 04/10/19.
2600.187d: Resident #2 was prescribed Miralax 17 grams dissolved in liquid every other day, but the medication was not available on 04/10/19.
Report Facts
Residents Served: 112
Residents Served: 22
Current Residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruthis Stubblebine | Legal Entity Representative | Signed plan of correction documents related to medication administration violations |
Notice — Dec 18, 2018
Date: Dec 18, 2018
Visit Reason
This document serves as a renewal notice for the Personal Care Home license of The Meadows at Shannondell, confirming the issuance of a regular license and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notification and certificate of compliance.
Report Facts
Inspection Report — Jun 11, 2018
Renewal
Date: Jun 11, 2018
Visit Reason
The inspection was an annual licensing renewal inspection conducted on June 11 and 12, 2018, to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found related to criminal background checks, menu posting, medication storage and administration, medication record accuracy, resident assessments, and documentation for secured dementia care unit admissions. Plans of correction were submitted with partial implementation progress noted.
Citations (7)
55 Pa.Code §2600.51: Staff member had a criminal background check completed two days after hire date, which is noncompliant with hiring policies.
55 Pa.Code §2600.162(c): The home's menu for Chatham C Wing was not posted in a conspicuous and public place in the home.
55 Pa.Code §2600.185(a): Glucometers for residents #1 and #2 were not calibrated with the correct date and time on June 12, 2018.
55 Pa.Code §2600.187(a): Medication administration record for resident #3 showed an outdated order for Acetaminophen, reflecting incorrect timing instructions.
55 Pa.Code §2600.225(c): Resident #4's most recent assessment was completed but not placed in the resident file, and the home failed to complete an annual assessment due in November 2017.
55 Pa.Code §2600.231(b): Resident #3 had a medical evaluation that did not document diagnosis of dementia or need for secured dementia care unit.
55 Pa.Code §2600.231(e): Residents #3, #5, and #6 lacked documentation that the resident and designated person had not objected to admission to the secured dementia care unit.
Report Facts
Number of Residents Served: 94
Number of Residents Served: 84
Number of Residents Served in Secured Dementia Care Unit: 25
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 17
Inspection Report — May 23, 2018
Complaint Investigation
Date: May 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident.
Complaint Details
The visit was incident-driven and complaint-related. The violation involved staff disrespect towards a resident. No substantiation status was explicitly stated.
Findings
One violation was found related to resident dignity and respect involving staff response to a resident's request for assistance. A plan of correction was established focusing on staff training regarding resident rights.
Citations (1)
55 Pa.Code §2600.42(c) - A resident was not treated with dignity and respect when staff responded inappropriately to a call for assistance with repositioning in bed.
Report Facts
Number of Residents Served: 91
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 16
Number of Residents Served in Secured Dementia Care Unit: 20
Number of Residents Age 60 or Older: 91
Number of Residents with Mobility Need: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruthie Stubblebine | Administrator | Named as facility administrator on the violation report |
| Natasha Braswell | Department representative on-site during inspection |
Inspection Report — Apr 11, 2018
Complaint Investigation
Date: Apr 11, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving suspected abuse of residents at the facility.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect involving staff and residents. The home failed to report incidents timely and did not initially suspend the staff member involved.
Findings
The investigation found multiple violations related to suspected abuse and failure to timely report incidents. Staff were counseled, retrained, and corrective actions including suspensions were implemented. The facility submitted plans of correction addressing the violations.
Citations (5)
55 Pa.Code §2600.15(a) - The home failed to immediately report suspected abuse of residents involving staff persons as required by law.
55 Pa.Code §2600.15(b) - The home did not develop or implement a plan of supervision or suspend staff person involved in alleged abuse until investigation was complete.
55 Pa.Code §2600.16(c) - The home failed to report the incident to the Department within 24 hours as required.
55 Pa.Code §2600.42(b) - A resident was neglected, intimidated, verbally abused, and mistreated by staff person with threatening language.
55 Pa.Code §2600.42(c) - A resident reported staff was rough, brisk, and forceful during care, but there was no documentation or knowledge of this report by staff.
Report Facts
Number of Residents Served: 89
Number of Residents Served in Secured Dementia Care Unit: 18
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 12
Resident Support Staffing Hours: 89
Total Daily Staff: 211
Waking Staff: 158
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruthie Stubblebine | Administrator | Named as legal entity representative and involved in plan of correction approval |
Inspection Report — Jan 30, 2018
Date: Jan 30, 2018
Visit Reason
The inspection was a partial, announced visit conducted as a new inspection for licensing purposes at The Meadows at Shannondell.
Findings
The facility was found to have violations related to Personal Care Homes regulations, including a missing annual fire safety inspection. A plan of correction was submitted and approved to address the fire safety inspection deficiency.
Citations (1)
55 Pa.Code 2600.132(b) requires an annual fire safety inspection and fire drill by a fire safety expert. The home had not had a fire safety inspection completed by a fire safety expert for the new personal care location on the fourth floor.
Report Facts
Number of Residents Served: 83
Number of Residents Served in Secured Dementia Care Unit: 18
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 12
Residents Age 60 or Older: 83
Residents with Mobility Need: 33
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruthie Stubblebine | Administrator | Named as Administrator on violation report and signed plan of correction |
| Dean Gray | Department Representative conducting inspection on 01/30/2018 |
Inspection Report — Dec 11, 2017
Renewal
Date: Dec 11, 2017
Visit Reason
The document is a renewal application and license issuance for The Meadows at Shannondell Personal Care Home, with a notice that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming inspection requirements.
Report Facts
Notice — Feb 13, 2017
Date: Feb 13, 2017
Visit Reason
The document serves as a renewal notification and license issuance for The Meadows at Shannondell Personal Care Home following receipt of the renewal application.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an annual inspection will be conducted within the next twelve months.
Report Facts
Inspection Report — Dec 14, 2016
Annual Inspection
Date: Dec 14, 2016
Visit Reason
The inspection was an annual licensing inspection conducted on December 14 and 15, 2016, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Several violations related to medical evaluations, medication administration, transportation vehicle first aid kit, medication labeling, medication storage, blood glucose monitoring, and resident record keeping were identified. Plans of correction were submitted with partial or full implementation status.
Citations (7)
Regulation 2600.141(a)(2): The medical evaluation for resident #1 dated 10-12-16 does not include the ability to self administer medications.
Regulation 2600.171(b)(5): The transportation vehicle does not have a thermometer in the first aid kit.
Regulation 2600.184(a): Medication labels for residents #2 and #3 do not match physician orders and have incorrect dosage instructions.
Regulation 2600.185(a): PRN medications for residents #2, #3, and #4 are not present in the medication cart.
Regulation 2600.187(d): Resident #4's blood glucose levels were not recorded as ordered, and resident #2 had no blood glucose levels recorded on specified dates.
Regulation 2600.188(b): A medication error occurred for resident #3 involving ferrous gluconate given twice daily instead of once daily and was not reported to the resident.
Regulation 2600.264(c): The narcotics book on the second floor was left unlocked and had incomplete medication information.
Report Facts
Number of Residents Served: 68
Number of Residents Served in Secured Dementia Care Unit: 18
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Galinkin | Legal Entity Representative | Signed multiple violation reports and plans of correction. |
| Lauren Kazimer | Inspector | Conducted the inspection on December 14 and 15, 2016. |
| Shawn Parker | Inspector | Conducted the inspection on December 14 and 15, 2016. |
Notice — Apr 7, 2016
Date: Apr 7, 2016
Visit Reason
The document serves as a notice of a revised license capacity for The Meadows at Shannondell following a recent adjustment of physical space.
Findings
The revised license indicates a new maximum capacity of 98 residents for the facility, with a secure dementia care unit capacity of 18. The license remains valid until March 31, 2016.
Report Facts
Inspection Report — Jan 22, 2016
Renewal
Date: Jan 22, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with contract signatures, hospice documentation, resident rights acknowledgments, staff qualifications, training, medication administration, and safety procedures. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (17)
55 Pa.Code §2600.25(b) - Contracts for Residents 1, 2, and 4 were not signed by the residents as required.
55 Pa.Code §2600.29(a) - The home lacked documentation that Holisticare Hospice is licensed to provide hospice services.
55 Pa.Code §2600.41(e) - Residents 1, 2, 3, and 4's records lacked statements signed by residents acknowledging receipt of resident rights.
55 Pa.Code §2600.52 - The home did not have completed criminal background checks for Holisticare Hospice staff providing services.
55 Pa.Code §2600.54(a) - Direct care staff member A lacked documentation of a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
55 Pa.Code §2600.55(d) - Direct care staff member B provided unsupervised ADL services without completing required training and competency testing.
55 Pa.Code §2600.55(f) - Staff members A and C did not receive training on medication self-administration and meeting resident needs during the 2015 training year.
55 Pa.Code §2600.65(g) - Staff member D did not receive training on falls and accident prevention during the 2015 training year.
55 Pa.Code §2600.101(j)(7) - Rooms #19 and #119 lacked operable lamps or other sources of lighting that can be turned on from the bedside.
55 Pa.Code §2600.132(g) - Fire drills were not routinely held at different days and times as required.
55 Pa.Code §2600.182(c) - Resident #5's blood sugar checks were not documented at the correct times and did not match the MAR.
55 Pa.Code §2600.187(a) - Resident #5's medication record lacked complete documentation of blood sugar checks including times and dates.
55 Pa.Code §2600.187(d) - Resident #5's blood sugar checks were not consistently documented at the time they were taken.
55 Pa.Code §2600.191 - Residents #1, #2, #3, and #4 were not educated on their right to refuse medication despite believing there was a medication error.
55 Pa.Code §2600.202 - Staff administered PRN psychotropic medications to Resident #3 without proper in-service training.
55 Pa.Code §2600.224(a) - Pre-admission screening for Resident #4 did not include a determination that the home can meet the resident's service needs.
55 Pa.Code §2600.231(e) - The home lacked documentation that residents #2 and #3 and their designated persons had not objected to admission or transfer to the secured dementia care unit.
Report Facts
Number of Residents Served: 46
Number of Deficiencies: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Galinkin | Executive Director | Named as legal entity representative signing the violation reports and plans of correction. |
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