Souderton Mennonite Homes.

“Resident 1's bedside mobility device had openings between bars measuring 9 inches by 14 inches, posing an entrapment risk. The device was covered with a loose pillowcase and rubber band, which does not allow for safe gripping and presents a risk to the resident.”

“There was an approximate 1/4 inch accumulation of lint and debris in the lint trap of the Serenata laundry area dryer, creating a fire hazard.”

“Resident 2's medical evaluation did not include documentation regarding the ability to self-administer medications, which is a required component of the medical evaluation form.”

“Resident 3 had multiple unlocked, unattended medications including Protonix, Amlodipine, Aspirin, Metoprolol, Multivitamin, Atorvastatin, Nitrostat, Systane, Triamcinolone, Antacid, and Lidocaine patches in their bedroom. Resident 4 had unlocked, unattended medications in their bathroom medicine cabinet. Medications must be kept locked in a safe and secure location.”

“Resident 3's record did not include a current list of medications. The medication list was missing Nitrostat sublingual 0.4mg, Systane eye drops, Triamcinolone cream, Antacid tablets, and Lidocaine patches, and incorrectly included Acetaminophen which was not present in the home.”

“Staff person A administered topical prescription medications (Nystop powder and Eucerin healing cream) to residents without having completed the required medication administration training for topical medications. Only qualified personnel may administer prescription medications.”

“Three medications were found in the home that were no longer current: Nystop powder prescribed for Resident 2 was discontinued on 4/17/2026, Triamcinolone cream prescribed for Resident 7 was discontinued on 1/13/2026, and Preservision Areds2 and Systane eyedrops prescribed for Resident 8 were for a resident discharged on 4/7/2026. Only current medications may be kept in the home.”

“Two expired medications were found in the medication room: Puritan's Pride C-1000 mg with rose hips expired 10/2024, and Puritan's Pride Ultra Woman's 50 Plus expired 3/2026. Medications must be stored under proper conditions and in accordance with manufacturer's instructions.”

“The home failed to report an unexpected death to the Department within 24 hours, reporting at 10:00 am instead of within the required timeframe. Additionally, the home delayed reporting an incident involving a resident sent to the emergency room due to a change in condition.”

“A resident in the secure dementia care unit with cognitive impairment and documented supervision requirements was left unattended during an off-unit event and subsequently eloped, leaving the home unseen and traveling approximately 1 mile away while crossing multiple streets and train tracks. The home failed to complete an updated assessment of the resident's needs related to wandering or supervision following this incident.”

“Direct care staff person A did not receive required training in medication self-administration during the training year of September 2024 to August 2025.”

“A resident in the secure dementia care unit with cognitive impairment eloped from the home after attending an off-unit event. The home did not complete an updated assessment following this significant change in condition to prevent future elopements, despite the resident's wander guard device and documented supervision requirements.”

“Direct care staff person A did not receive training in medication self-administration during the training year September 2024 to August 2025.”

“Two residents participated in the development of their support plans but did not sign the support plans as required.”

“The fire extinguisher in the home's Secured Dementia Care Unit has not been inspected by a fire safety expert since August 2024.”

“A resident reported feeling intimidated by a staff member who displayed an attitude while providing care, particularly when the resident required assistance with activities the resident could not perform independently due to their medical condition.”

“Poisonous materials including Gojo Green certified foam hand cleanser and Micro kill bleach germicidal bleach wipes were unlocked, unattended, and accessible to residents in the secured dementia care unit. Not all residents have been assessed as capable of recognizing and using poisons safely. This is a repeat violation.”

“Emergency telephone numbers including the nearest hospital and fire department were not posted on or by the telephone in resident bedroom 3515. This is a repeat violation.”

“An unattended, unlocked tool cart was accessible to residents in the secured dementia care unit. The cart contained hazardous items including a box cutter, hammer, and pliers that presented a safety hazard to residents.”

“The secured dementia care unit's outdoor courtyards contain multiple storm drain drop-offs (up to 3 feet) that are only roped off with sticks and rope, presenting potential tripping hazards to residents.”

“Fire drill records for multiple drills conducted between May 2024 and March 2025 do not include the different exit routes used; instead, only generic descriptions such as 'hallways to safe zones' or 'hallways to stair towers or exits' are listed.”

“The home's current license inspection summary and a copy of 55 Pa Code Chapter 2600 were not posted in a conspicuous and public place in the personal care home.”

“Emergency telephone numbers including the nearest hospital, police department, fire department, poison control, local emergency management and personal care home complaint hotline were not posted on or by the telephone in the Serenata activity area and Serenata kitchen.”

“The last fire safety inspection conducted by a fire safety expert did not include the newly built Serenata neighborhood.”

“Medication documentation error: A resident's blood glucose reading was not accurately documented on the Medication Administration Record, indicating a failure to properly implement safe storage, access, security, distribution and use procedures for medications and medical equipment.”

“Medication administration record for a resident's daily oral medication does not include the initials of the staff person who administered the medication on the date and time specified.”

“Facility failed to follow prescriber's orders for multiple residents: one resident prescribed medication twice daily was not administered on specified date/time; another resident prescribed medication every 12 hours was not administered on two specified dates/times; and a third resident's prescribed medication was not administered because it was not available in the home.”

“Civil money penalty assessed. Fine of $5 per day per 92 residents at time of inspection = $460 per day, with correction date of 5 calendar days from mailing date of December 13, 2023.”

“Resident #1 attacked resident #2 while resident #2 was resting in bed, resulting in scratches to resident #2's right arm. Resident #1 had displayed escalating aggressive behaviors including paranoid behavior, yelling, cursing, and threatening behaviors toward resident #2 over several days prior to the physical attack. Despite resident #1's assessment documenting aggression as a service need, a new assessment was not completed when the aggression escalated to physical violence, and both residents remained in the same apartment despite resident #2 lacking cognitive capacity to safely respond to resident #1's behaviors.”

“Civil money penalty assessed. Fine of $5 per day per 92 residents at time of inspection = $460 per day, with correction date of 5 calendar days from mailing date of December 13, 2023.”

“Civil money penalty assessed. Fine of $5 per day per 92 residents at time of inspection = $460 per day, with correction date of 5 calendar days from mailing date of December 13, 2023.”

“Facility issued a SECOND PROVISIONAL license due to violations of 55 Pa Code Chapter 2600. License is valid from December 13, 2023 to June 13, 2024.”

“Facility issued a SECOND PROVISIONAL license due to violations of 55 Pa Code Chapter 2600. License is valid from December 13, 2023 to June 13, 2024.”

“Civil money penalty assessed. Fine of $5 per day per 92 residents at time of inspection = $460 per day, with correction date of 5 calendar days from mailing date of December 13, 2023.”

“Facility issued a SECOND PROVISIONAL license due to violations of 55 Pa Code Chapter 2600. License is valid from December 13, 2023 to June 13, 2024.”

“Facility issued a SECOND PROVISIONAL license due to violations of 55 Pa Code Chapter 2600. License is valid from December 13, 2023 to June 13, 2024.”

“Resident #1 attacked resident #2 while resident #2 was resting in bed, resulting in scratches to resident #2's right arm. Resident #1 had displayed escalating aggressive behaviors including paranoid behavior, yelling, cursing, and threatening behaviors toward resident #2 over several days prior to the physical attack. Despite resident #1's assessment documenting aggression as a service need, a new assessment was not completed when the aggression escalated to physical violence, and both residents remained in the same apartment despite resident #2 lacking cognitive capacity to safely respond to resident #1's behaviors.”

“Civil money penalty assessed. Fine of $5 per day per 92 residents at time of inspection = $460 per day, with correction date of 5 calendar days from mailing date of December 13, 2023.”

“Civil money penalty assessed. Fine of $5 per day per 92 residents at time of inspection = $460 per day, with correction date of 5 calendar days from mailing date of December 13, 2023.”