Souderton Mennonite Homes

In the surveyor’s words

From the most serious findings on record at Souderton Mennonite Homes, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF842Apr 1, 2026

  Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to maintain clinical records that were complete for three of six sampled residents. (Resident 4, 5, 43)Findings include:Review of the facility policy entitled, Pressure Ulcer Prevention Program, last reviewed January 2, 2026, revealed that a Skin Analysis Evaluation or Pressure Ulcer Potential Assessment would be completed weekly using the Point of Care Skin Evaluation task. Once weekly nursing staff were to complete a visual inspection of the resident's body and document the findings on the medical record.Clinical record review revealed that Resident 4 had diagnoses that included diabetes with foot ulcer and pressure induced deep tissue damage. […]

• No harm, potential for more than minimal, isolatedF656Dec 2, 2025

  Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included a history of falls, muscle weakness, and lack of coordination. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident used a motorized wheelchair. Review of a therapy Discharge summary dated [DATE], revealed that the resident required distant supervision when using his motorized wheelchair outdoors. […]

• No harm, potential for more than minimal, isolatedF684Mar 20, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 18 sampled residents. (Resident 24) Findings include: Clinical record review revealed that Resident 24 had diagnoses that included congestive heart failure and hypertension. A physician's order dated May 6, 2024, directed staff to weigh the resident daily and to call cardiology with a three pound weight gain in one day or a five pound weight gain in one week. Review of Resident 24's Medication Administration Record (MAR) for February and March 2025, revealed that Resident 24 had more than a three pound weight gain on February 2, 18, 24, and 26, 2025, and March 3 and 16, 2025. […]

• No harm, potential for more than minimal, isolatedF810Mar 20, 2025

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of two sampled residents who required adaptive equipment with meals. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included Parkinson's disease, dementia, and dysphagia. Review of the care plan revealed that the resident was at risk for nutrition problems with an intervention for adaptive equipment. The intervention was for staff to provide a partitioned scoop dish on blue Dycem (non-slip material that prevents objects from slipping), and weighted utensils for all meals. On March 18, 2025, from 12:15 p.m. through 12:30 p.m., and on March 19, 2025, from 12:10 p.m. […]

• No harm, potential for more than minimal, isolatedF684Apr 4, 2024

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to implement physician's orders and follow bowel protocol for one of 18 sampled residents. (Resident 44) Findings include: Review of the facility policy entitled, Bowel Management, last reviewed January 8, 2024, revealed that staff on all shifts were to monitor a resident's bowel movements and take action to prevent complications of constipation and/or fecal impaction. The resident's bowel movements were to be charted daily in the clinical record. Staff were to administer an oral laxative for no bowel movement in nine shifts. If ineffective, staff were to administer a suppository the following shift. […]