Inspection Reports for
Souderton Mennonite Homes

The waiver is granted under specific conditions including documentation of education equivalency and annual review during inspections to ensure compliance. Failure to comply may result in termination of the waiver or other licensing actions.

Multiple deficiencies were identified related to resident personal equipment safety, lint removal in laundry, incomplete medical evaluations, improper medication storage and administration, and medication record inaccuracies. All deficiencies had plans of correction accepted and were implemented by June 10, 2026.

The facility was found to have delayed reporting of an unexpected resident death and an emergency room visit beyond the required 24 hours. A resident eloped from the secure dementia care unit without updated assessments or supervision plans. Additionally, a direct care staff member did not receive required medication self-administration training during the annual training year.

The facility failed to develop and implement a complete care plan for one of five sampled residents, who required supervision when using a motorized wheelchair outdoors but was non-compliant with requesting staff supervision. There was no documented evidence of individualized care planning or interventions to address this non-compliance.

The waiver allows a specific employee to serve as direct care staff based on a credential evaluation of education obtained outside the United States, subject to conditions and annual review during inspections.

The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to staff training, fire extinguisher inspection, and support plan signatures were addressed and corrected.

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.

The facility failed to complete reference checks and license verification prior to employment for one new hire, failed to implement physician's orders for one resident including notification of weight gain and medication administration outside ordered parameters, and failed to provide adaptive eating equipment to a resident requiring it.

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.

The waiver allows a specified employee to serve as direct care staff despite education received outside the United States, contingent on documentation and annual review during inspections.

The facility was found to be in compliance overall, with a submitted plan of correction fully implemented. Several deficiencies were identified related to staff training, medication storage and records, furniture repair, annual medical evaluations, use of chemical restraints, and support plan documentation, all with corrective actions accepted and implemented.

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.

The visit was complaint-related, triggered by concerns about Ombudsman information accessibility, bowel management, catheter care, and weight loss monitoring. Substantiation status is not explicitly stated.

The facility failed to post Ombudsman contact information accessibly for residents, did not implement bowel management orders for one resident, inconsistently provided catheter care and follow-up for another resident, and failed to timely assess significant weight loss for a resident at risk.

The waiver allows staff educated outside the United States to serve as direct care staff if their education is deemed equivalent to one year of undergraduate study. Documentation must be maintained and made available upon request, with annual reviews during inspections to ensure compliance.

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.

The waiver is granted with conditions including documentation of equivalency and annual review during inspections to ensure compliance. Failure to comply may result in termination of the waiver or other licensing actions.

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.

The facility failed to ensure that the environment remained free of accident hazards in the shower room, where an unlocked cabinet contained potentially hazardous items and there was no locking mechanism on the shower room door to prevent resident access.

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.

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.

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.

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.

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.

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.

The submitted plan of correction was determined to be fully implemented. Deficiencies involved failure to immediately suspend a staff member after an allegation of abuse, lack of dignity and respect toward a resident, incomplete and inconsistent resident assessments, and unsigned support plans.

No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.

The Department of Human Services has approved the renewal application and issued a regular license. An onsite inspection is required at least once every twelve months as part of the annual inspection process.

No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.

The inspection identified multiple violations related to resident care, safety, medication storage and administration, fire safety training, evacuation procedures, and equipment calibration. Plans of correction were submitted with partial implementation and adequate progress noted as of February 11, 2020.

No regulatory citations or deficiencies were identified as a result of this inspection.

No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.

The inspection found violations related to medication administration records and following prescriber directions. A plan of correction was developed to address these issues and ensure compliance.

The complaint was substantiated based on observed staff behavior on 03-10-18. Staff person A was suspended and later terminated. Residents were followed up with and staff received education on resident rights and abuse prevention.

The investigation found that staff raised their voices at residents and made inappropriate comments, violating residents' rights to dignity, respect, and to freely associate. A plan of correction was implemented including staff suspension and education on resident rights.

No inspection findings are reported in this document. It is a licensing and renewal notification letter with an enclosed certificate of compliance.

The complaint investigation was substantiated with findings of abuse by staff person A against residents. Staff person A was suspended and terminated due to substandard work performance and abuse allegations.

The inspection found violations related to abuse allegations, dignity and respect issues, and failure to complete annual medical evaluations. Plans of correction were partially implemented with adequate progress noted.

The visit was complaint-related due to an incident involving neglect of Resident #1. The complaint was substantiated as violations were found.

A violation was found involving neglect and inadequate care related to a resident's painful sore on the lower right leg. Staff failed to provide proper care and assessment, resulting in corrective actions including termination of a staff member and education for direct care staff.

Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report an incident timely, disrespectful treatment of a resident, unsanitary conditions, improper trash handling, and an outdated support plan for a resident. Plans of correction were submitted with partial implementation noted.

The inspection was complaint-related due to an incident. The violation involved medication administration errors by staff member A. No substantiation status was explicitly stated.

A violation was found where a staff member did not follow the prescriber's medication orders for a resident, resulting in medication being administered at incorrect times. A plan of correction was developed including staff education and re-education on medication administration procedures.

No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license.

Violations were found related to staff training on fire safety and emergency procedures, and incomplete initial resident assessments. Plans of correction were submitted to address these issues with timelines for completion.

No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.