Inspection Reports for Souderton Mennonite Homes
207 W Summit St, Souderton, PA 18964, United States, PA, 18964
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Inspection Report
Renewal
Census: 99
Capacity: 154
Deficiencies: 10
Mar 24, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with a full, unannounced inspection on 03/24/2025 and 03/25/2025.
Findings
The inspection identified multiple deficiencies including treatment of residents with dignity, locking poisonous materials, posting emergency telephone numbers, furniture and equipment hazards, exterior hazards, incomplete fire drill records, incomplete medical evaluations, medication storage procedures, preadmission screening, and additional resident assessments. Plans of correction were accepted and implemented with follow-up audits scheduled.
Deficiencies (10)
| Description |
|---|
| Resident reported feeling intimidated by staff member's attitude when assistance was needed to lift legs onto bed. |
| Poisonous materials such as hand cleanser and bleach wipes were unlocked and accessible to residents in the secured dementia care unit. |
| Emergency telephone numbers for nearest hospital and fire department were not posted by the telephone in resident bedroom 3515. |
| Tool cart with hazardous tools was unattended, unlocked, and accessible to residents in the secured dementia care unit. |
| Outdoor courtyards had mulch areas with drops to storm drains that were only roped off with sticks and rope, posing tripping hazards. |
| Fire drill records did not include specific exit routes used, only general descriptions such as 'hallways to safe zones' or 'hallways to stair towers or exits'. |
| Resident medical evaluation did not include medication regimen, contraindicated medications, or medication side effects. |
| Medication administration record and narcotic control log for Resident #3 did not match in dates and times of administration. |
| Resident's preadmission screening form was not completed within 30 days prior to admission as required. |
| Resident assessment did not include need for assistance getting in and out of bed despite resident reporting need for assistance. |
Report Facts
License Capacity: 154
Residents Served: 99
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 3
Total Daily Staff: 122
Waking Staff: 92
Residents Age 60 or Older: 99
Residents with Mobility Need: 23
Inspection Report
Follow-Up
Census: 94
Capacity: 154
Deficiencies: 3
Feb 10, 2025
Visit Reason
The visit was a follow-up inspection to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Several deficiencies related to posting of current license, emergency telephone numbers, and fire safety inspection were noted and corrected.
Deficiencies (3)
| Description |
|---|
| The home's current violation report and a copy of 55 Pa.Code Chapter 2600 were not posted in a conspicuous and public place in the home. |
| No emergency telephone numbers including nearest hospital, police, fire department, poison control, local emergency management, and complaint hotline were posted on or by the telephone in the Serenata activity area and kitchen. |
| The last fire safety inspection observed by a fire safety expert did not include the newly built Serenata neighborhood. |
Report Facts
License Capacity: 154
Residents Served: 94
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 1
Residents Age 60 or Older: 94
Residents with Mobility Need: 18
Total Daily Staff: 112
Waking Staff: 84
Inspection Report
Monitoring
Census: 97
Capacity: 154
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection was a monitoring visit conducted on 04/02/2024 to review the facility's compliance status and plan of correction implementation.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Continued compliance is required to be maintained by the facility.
Deficiencies (1)
| Description |
|---|
| Failure to properly document blood sugar readings on the Medication Administration Record as required by storage procedures. |
Report Facts
License Capacity: 154
Residents Served: 97
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 19
Resident Support Staff Daily Hours: 120
Waking Staff Daily Hours: 90
Inspection Report
Follow-Up
Census: 95
Capacity: 154
Deficiencies: 2
Jan 3, 2024
Visit Reason
The inspection visit was a follow-up to review the submitted plan of correction related to medication administration deficiencies identified previously.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up inspection. The report details medication administration violations including missing staff initials on medication records and failure to administer prescribed medications, with corrective actions and training completed.
Deficiencies (2)
| Description |
|---|
| Medication administration record did not include the initials of the staff person who administered medication. |
| Resident was not administered prescribed medications as ordered, including missed doses due to medication unavailability. |
Report Facts
License Capacity: 154
Residents Served: 95
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Total Daily Staff: 111
Waking Staff: 83
Medication Pass Observations: 5
Medication Administration Audits: 3
Inspection Report
Enforcement
Census: 92
Capacity: 154
Deficiencies: 6
Oct 2, 2023
Visit Reason
The inspection was conducted as part of ongoing monitoring and enforcement activities following multiple prior inspections and plan of correction submissions. The facility was issued a second provisional license due to violations found in previous inspections.
Findings
Multiple violations were found including abuse between residents, improper medication storage, incomplete staff training, failure to evacuate all residents during fire drills, and medication administration errors. Several plans of correction were submitted but many were not fully implemented by the deadlines.
Severity Breakdown
Class 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident #1 physically abused resident #2 resulting in scratches; failure to implement adequate safety measures. | Class 2 |
| Medications stored without proper open/discard after dates as per manufacturer instructions. | Class 2 |
| Direct care staff did not receive required annual training on medication self-administration, infection control, personal care needs, fire safety, and accident prevention. | Class 2 |
| Residents did not evacuate to designated meeting places during fire drills; only those directly affected evacuated. | Class 2 |
| Medication administration records showed medication not given at prescribed times but staff initials were present indicating otherwise. | Class 2 |
| Failure to follow prescriber's orders for medication administration. | Class 2 |
Report Facts
License Capacity: 154
Residents Served: 92
Fine Amount: 460
Number of Violations: 4
Inspection Report
Monitoring
Census: 92
Capacity: 154
Deficiencies: 6
Oct 2, 2023
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted to review ongoing compliance and follow-up on previous deficiencies at Souderton Mennonite Homes.
Findings
Multiple deficiencies were identified including abuse between residents, improper medication storage, incomplete staff training, failure to evacuate all residents during fire drills, and medication administration errors. Plans of correction were submitted but many were not fully implemented by the time of the last follow-up.
Severity Breakdown
Class 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident #1 physically abused resident #2 resulting in scratches; inadequate assessment and support plan for aggression. | Class 2 |
| Opened bottles of eye drops in medication carts lacked open/discard after dates as required. | Class 2 |
| Direct care staff persons A and B did not receive required annual training on medication self-administration, resident needs, infection control, fire safety, and falls prevention. | Class 2 |
| During fire drills, not all residents evacuated to designated meeting places; only those directly affected evacuated. | Class 2 |
| Resident #1 was not administered prescribed Lorazepam at 8:00 PM on 08/03/2023, but staff initials were present on the medication administration record. | Class 2 |
| Failure to follow prescriber's orders for medication administration for resident #1 on 08/03/2023. | Class 2 |
Report Facts
License Capacity: 154
Residents Served: 92
Secure Dementia Care Unit Capacity: 22
Residents in Secure Dementia Care Unit: 17
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 460
Number of Residents with Mobility Need: 17
Inspection Report
Enforcement
Census: 92
Capacity: 154
Deficiencies: 5
Oct 2, 2023
Visit Reason
The inspection was conducted as part of ongoing enforcement actions following multiple licensing inspections and plan of correction submissions due to violations of 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple violations including resident abuse, improper medication storage and administration, inadequate staff training, and failure to evacuate all residents to designated meeting places during fire drills. Several plans of correction were submitted but many were not fully implemented by the dates specified.
Severity Breakdown
Class 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident abuse involving physical aggression between residents without adequate assessment or intervention. | Class 2 |
| Medications stored without proper open/discard after dates as per manufacturer instructions. | Class 2 |
| Direct care staff did not receive required annual training on medication administration, resident needs, infection control, fire safety, and accident prevention. | Class 2 |
| Residents did not evacuate to designated meeting places during fire drills; only those directly affected evacuated. | Class 2 |
| Medication administration records showed medications not administered as prescribed and improper documentation. | Class 2 |
Report Facts
License Capacity: 154
Residents Served: 92
Fine Amount: 460
Fine Violations Count: 4
Residents Served in Dementia Unit: 17
Capacity of Dementia Unit: 22
Inspection Report
Enforcement
Census: 92
Capacity: 154
Deficiencies: 6
Apr 13, 2023
Visit Reason
The inspection visits were conducted on April 13, 2023, June 8, 2023, August 14, 2023, and October 2, 2023, due to incidents, monitoring, and renewal/provisional license review, including enforcement actions related to violations of 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including abuse between residents, improper medication storage, incomplete staff training, failure to follow medication administration orders, and inadequate fire drill evacuation procedures. Enforcement actions included fines, issuance of a second provisional license, and directed plans of correction with deadlines.
Severity Breakdown
Class 2: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident #1 attacked resident #2 resulting in physical injury; inadequate assessment and management of aggressive behavior. | Class 2 |
| Opened eye drop medications in medication carts lacked open/discard after dates as required. | Class 2 |
| Direct care staff persons A and B did not receive required annual training on medication self-administration, resident needs, infection control, fire safety, and accident prevention. | — |
| Residents did not evacuate to designated meeting places during fire drills; only those directly affected evacuated. | — |
| Resident #1 was not administered prescribed Lorazepam at the scheduled time, but staff initials were recorded on the medication administration record. | — |
| Failure to follow prescriber's orders for medication administration for resident #1. | — |
Report Facts
Fine Per Resident Per Day: 5
Number of Violations with Fines: 4
License Capacity: 154
Residents Served: 92
Secure Dementia Care Unit Capacity: 22
Residents in Secure Dementia Care Unit: 17
Total Daily Staff: 109
Waking Staff: 82
Inspection Report
Monitoring
Census: 88
Capacity: 154
Deficiencies: 4
Dec 14, 2022
Visit Reason
The inspection was an unannounced partial visit conducted for monitoring purposes.
Findings
The inspection identified multiple deficiencies including lack of operable bedside lighting for a resident, incomplete medical evaluation documentation, delayed recording of medication administration, and missing preadmission screening form completion date. Plans of correction were accepted with proposed completion dates ranging from January to April 2023.
Deficiencies (4)
| Description |
|---|
| Resident #1 does not have access to a source of light that can be turned on/off at bedside. |
| Resident #2's medical evaluation did not include special health or dietary needs of the resident. |
| Staff did not record the date and time of medication administration at the time it was given for Resident #3. |
| Resident #2's preadmission screening form was missing the completion date. |
Report Facts
License Capacity: 154
Residents Served: 88
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 3
Residents Age 60 or Older: 88
Residents with Mobility Need: 17
Inspection Report
Renewal
Census: 89
Capacity: 154
Deficiencies: 9
Oct 12, 2022
Visit Reason
The inspection visit was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including failure to post resident rights poster conspicuously, clogged bathroom sink drain, lack of operable bedside lighting for a resident, presence of outdated food, incomplete emergency procedures for inoperable smoke detectors, incomplete medical evaluations, improper medication storage, incorrect blood glucose documentation, and incomplete resident support plans.
Deficiencies (9)
| Description |
|---|
| The Department's resident's rights poster is not posted in a conspicuous and public place in the home. |
| Resident 1's bathroom sink drain is clogged. |
| Resident 2 does not have access to a source of light that can be turned on/off at bedside. |
| There was an unlabeled, undated bag of cookie dough, a bag of bread, and a bag of onion rings in the main kitchen freezer. |
| The home's emergency procedures do not indicate what procedures will be implemented when a smoke detector or fire alarm is inoperable. |
| Resident 3's medical evaluation did not include special health or dietary needs of the resident. |
| Lorazepam Tab 0.5 mg belonging to resident 4 was in a blister card with ripped foil and tape applied. |
| An incorrect blood glucose level was recorded on resident 3's MAR; glucometer registered 306 but MAR documented 305. |
| Resident 5's support plan does not document how the need for a special diet, no sodium added, will be met. |
Report Facts
License Capacity: 154
Residents Served: 89
Memory Care Capacity: 22
Memory Care Residents Served: 17
Current Hospice Residents: 1
Residents with Mobility Need: 17
Inspection Report
Complaint Investigation
Census: 68
Capacity: 154
Deficiencies: 6
Sep 15, 2022
Visit Reason
The inspection was conducted due to a complaint and incident involving suspected resident abuse and other regulatory concerns.
Findings
The inspection found multiple violations related to failure to report suspected resident abuse, incomplete incident reporting, physical abuse of residents by staff, improper restraint use, and inadequate staff orientation and training on abuse reporting and emergency procedures.
Complaint Details
The visit was complaint-related involving allegations of resident abuse by staff persons A and D, including physical injury and improper restraint. The allegations were substantiated by observations and incident reports.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of residents to the local area agency on aging. |
| Failure to include all details of an incident on the Incident Reporting Form submitted to the Department. |
| Physical abuse of resident 1 by staff person A causing fractured hip, shoulder, and elbow. |
| Physical abuse and improper restraint of resident 2 by staff persons A and D causing skin tears and bruising. |
| Staff person E did not complete required orientation training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of reportable incidents. |
| Use of prohibited manual restraint by staff person A holding resident 2's arms down during care. |
Report Facts
License Capacity: 154
Residents Served: 68
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 18
Staff Total Daily: 86
Waking Staff: 65
Deficiencies Cited: 6
Inspection Report
Follow-Up
Census: 71
Capacity: 154
Deficiencies: 6
May 19, 2022
Visit Reason
The visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Deficiencies related to fire safety orientation and multiple medication administration errors were addressed with education, policy revisions, and audits.
Deficiencies (6)
| Description |
|---|
| Staff person did not receive orientation on fire safety and emergency procedures on first day of work. |
| The home did not identify the correct resident when administering morning medications, resulting in resident #1 receiving resident #2's medications. |
| The home failed in safe distribution of medications by administering resident #2's morning medications to resident #1. |
| Resident #1 was administered medications prescribed for resident #2. |
| The home did not follow the directions of the prescriber; resident #1 was administered medications prescribed for resident #2 in error (repeat violation). |
| Resident #2's preadmission screening form was completed after admission date. |
Report Facts
License Capacity: 154
Residents Served: 71
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 1
Staffing Hours - Total Daily Staff: 91
Staffing Hours - Waking Staff: 68
Residents Age 60 or Older: 71
Residents with Mobility Need: 20
Notice
Capacity: 154
Deficiencies: 0
May 18, 2021
Visit Reason
The document serves as a renewal license approval and certificate of compliance for Souderton Mennonite Homes, a Personal Care Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection requirement.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 154
Secure Dementia Care Unit capacity: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
| Monique Cole | Executive Director | Facility Executive Director addressed in the renewal letter |
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