Health inspection·April 4, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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) Residents Affected - Few 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. If the suppository was ineffective, staff were to administer an enema on the following shift. Clinical record review revealed that Resident 44 had diagnoses that included muscle weakness and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. Review of the care plan revealed the resident had a history of constipation and staff were to administer bowel protocol medications as needed. Review of physician's orders dated February 10, 2024, directed staff to administer magnesium hydroxide suspension (an oral laxative) as needed for no bowel movement in nine nursing shifts, a Dulcolax suppository as needed if an oral laxative was ineffective, and an enema as needed if the Dulcolax suppository was ineffective. An additional physician's order dated February 19, 2024, directed staff to administer a bisacodyl suppository as needed for constipation. Review of documentation and medication administration records for March and April 2024, revealed no evidence that the resident had a bowel movement March 5 through 8 (12 shifts), March 10 through 13 (12 shifts), March 21 through 25 (15 shifts), and March 28 through April 2 (18 shifts). There was no documentation to support that physician's orders and facility policy for bowel management were implemented to address Resident 44's constipation/lack of bowel movements on the identified dates/shifts. In an interview on April 4, 2024, at 11:07 a.m., the Director of Nursing confirmed that staff did not implement the physician's orders or follow bowel protocol per the facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395634 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Souderton Mennonite Homes 207 West Summit Avenue Souderton, PA 18964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that catheter care and services were consistently provided for one of one sampled residents with an indwelling urinary catheter. (Resident 47) Findings included: Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with diagnoses that included benign prostatic hyperplasia (enlarged prostate), urinary tract infection, and retention of urine. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment and had an indwelling urinary catheter. Review of Resident 47's current care plan revealed that the resident had an indwelling catheter with an intervention to follow up with the urologist. In an interview on April 2, 2024, at 12:01 p.m., Resident 47 stated staff did not assist him consistently with catheter care. On November 22 and 27, 2023, the nurse practitioner documented that the resident was to have follow-up with the urologist and that staff was to assist the resident with catheter care every shift. On February 14, 2024, the nurse practitioner again documented that the resident was to follow-up with the urologist for further evaluation. Review of the catheter care task documentation from March 5, 2025 through April 3, 2024, revealed three shifts with missing documentation, 18 shifts documented as not applicable, and one shift documented as not completed. There was also a lack of documentation to support that Resident 47 had been seen by the urologist in a timely manner as recommended by the nurse practitioner. In an interview on April 4, 2024, at 11:22 a.m., the Director of Nursing confirmed that there was no documentation to support the urinary catheter care had been consistently completed and that Resident 47 had not seen by a urologist in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395634 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Souderton Mennonite Homes 207 West Summit Avenue Souderton, PA 18964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess significant weight loss for one of two sampled residents at risk for weight loss. (Resident 2) Residents Affected - Few Findings include: Clinical record review revealed that Resident 2 had diagnoses that included Alzheimer's disease, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. Review of mini nutrition assessments dated December 28, 2023, and March 27, 2024, indicated that the resident was at risk for malnutrition. On October 5, 2023, the resident weighed 175.3 pounds (lbs.). On November 6, 2023, the resident weighed 164.2 lbs., which reflected a significant weight loss of 6.3%. There was no evidence that a dietitian assessed or addressed the significant weight loss until December 1, 2023. On January 8, 2024, the resident weighed 167.6 lbs. On February 5, 2024, the resident weighed 156.4 lbs., which reflected a significant weight loss of 6.6%. There was no evidence that a dietitian assessed or addressed the significant weight loss until February 19, 2024. In an interview on April 4, 2024, at 10:16 a.m., Dietitian 1 confirmed that the significant weight loss was not assessed or addressed in a timely manner. 28 Pa Code 211.12(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395634 If continuation sheet Page 4 of 4