Inspection Reports for The Meadows at Shannondell
6000 SHANNONDELL DRIVE,, AUDUBON, PA, 19403
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
219% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
84% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 143
Capacity: 171
Deficiencies: 4
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.
Deficiencies (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
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
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.
Deficiencies (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
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
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.
Deficiencies (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
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
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.
Deficiencies (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
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
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.
Deficiencies (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
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
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
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
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.
Deficiencies (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
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
| 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
Monitoring
Census: 145
Capacity: 184
Deficiencies: 4
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.
Deficiencies (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
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
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
Inspection Report
Follow-Up
Census: 138
Capacity: 184
Deficiencies: 2
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.
Deficiencies (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
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
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
Maximum capacity: 184
Secure Dementia Care Unit capacity: 34
Inspection Report
Complaint Investigation
Census: 111
Capacity: 184
Deficiencies: 1
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.
Deficiencies (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
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
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
Renewal
Census: 113
Capacity: 184
Deficiencies: 10
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.
Deficiencies (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
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
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
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
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.
Deficiencies (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
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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