Inspection Reports for The Meadows at Shannondell

6000 SHANNONDELL DRIVE,, PA, 19403

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Deficiencies per Year

36 27 18 9 0
2021
2022
2023
2024
2025
Unclassified

Census Over Time

90 120 150 180 210 Feb '21 Jul '21 Jun '23 Apr '24 Jul '25
Census Capacity
Inspection Report Plan of Correction Census: 143 Capacity: 171 Deficiencies: 4 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.
Deficiencies (4)
Description
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
License Capacity: 171 Residents Served: 143 Secured Dementia Care Unit Capacity: 34 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 Monitoring Census: 141 Capacity: 171 Deficiencies: 5 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.
Deficiencies (5)
Description
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 License capacity: 171 Secured Dementia Care Unit capacity: 34 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 Monitoring Census: 149 Capacity: 184 Deficiencies: 3 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.
Deficiencies (3)
Description
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
License Capacity: 184 Residents Served: 149 Secured Dementia Care Unit Capacity: 34 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 Renewal Census: 161 Capacity: 184 Deficiencies: 36 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.
Deficiencies (36)
Description
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
License Capacity: 184 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 Complaint Investigation Census: 160 Capacity: 184 Deficiencies: 3 Aug 24, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE MEADOWS AT SHANNONDELL.
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.
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.
Deficiencies (3)
Description
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
License Capacity: 184 Residents Served: 160 Secured Dementia Care Unit Capacity: 134 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 Complaint Investigation Census: 156 Capacity: 184 Deficiencies: 0 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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 184 Residents Served: 156 Secured Dementia Care Unit Capacity: 34 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 Complaint Investigation Census: 154 Capacity: 184 Deficiencies: 5 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.
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.
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.
Deficiencies (5)
Description
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
License Capacity: 184 Residents Served: 154 Secured Dementia Care Unit Capacity: 34 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
NameTitleContext
Staff Member ANamed in findings related to neglect and failure to report incidents; terminated following investigation.
Staff Member BNamed in findings related to improper use of restraints and prohibited procedures; suspended and monitored following investigation.
Inspection Report Monitoring Census: 145 Capacity: 184 Deficiencies: 4 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.
Deficiencies (4)
Description
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
License Capacity: 184 Residents Served: 145 Secured Dementia Care Unit Capacity: 34 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 Plan of Correction Deficiencies: 0 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
Inspection Report Follow-Up Census: 138 Capacity: 184 Deficiencies: 2 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.
Deficiencies (2)
Description
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
License Capacity: 184 Residents Served: 138 Secured Dementia Care Unit Capacity: 34 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 Capacity: 184 Deficiencies: 0 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
Maximum capacity: 184 Secure Dementia Care Unit capacity: 34
Inspection Report Complaint Investigation Census: 111 Capacity: 184 Deficiencies: 1 Jul 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements at THE MEADOWS AT SHANNONDELL.
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.
Complaint Details
The visit was complaint-related. The plan of correction was accepted and fully implemented by 09/03/2021.
Deficiencies (1)
Description
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
License Capacity: 184 Residents Served: 111 Secured Dementia Care Unit Capacity: 34 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 Renewal Deficiencies: 0 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 Renewal Census: 113 Capacity: 184 Deficiencies: 10 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.
Deficiencies (10)
Description
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
License Capacity: 184 Residents Served: 113 Residents Served in Secured Dementia Care Unit: 26 Capacity of Secured Dementia Care Unit: 34 Hospice Residents: 9 Total Daily Staff: 167 Waking Staff: 125 Number of resident toiletry baskets found in unlocked closet: 13
Inspection Report Complaint Investigation Census: 122 Capacity: 184 Deficiencies: 0 May 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the follow-up type was noted as not required. No substantiation status was explicitly stated.
Report Facts
Residents Served: 122 License Capacity: 184 Secured Dementia Care Unit Capacity: 34 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 Follow-Up Census: 122 Capacity: 184 Deficiencies: 2 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.
Deficiencies (2)
Description
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
License Capacity: 184 Residents Served: 122 Secured Dementia Care Unit Capacity: 34 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

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