Health inspection·April 4, 2024

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Some Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation and interview, it was determined that the facility failed to post pertinent names, addresses, and phone numbers of the Office of the State/County Long-Term Care Ombudsman Program in an area that was accessible to all residents and resident representatives. Findings include: Observation on the first day of the survey, April 2, 2024, revealed that the information to contact the Ombudsman was posted on the upper/top part of a bulletin board on the way to the main dining room on the nursing unit. The information was not at eye level nor was it accessible at eye level for someone who utilized a wheelchair. During a group interview on April 3, 2024, at 11:05 a.m., five of five alert and oriented residents, R3, R14, R40, R46 and R47, stated that they were aware that there was an Ombudsman Program: however, they did not know where the information was regarding how to contact the Ombudsman if they needed assistance from that particular advocacy agency. In addition, Resident 14 stated that she had outdated information about the Ombudsman and did not know who the current Ombudsman was for the facility. 28 Pa. Code 201.18(b)(d) Management. Page 1 of 4 395634 395634 04/04/2024 Souderton Mennonite Homes 207 West Summit Avenue Souderton, PA 18964

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. 395634 Page 2 of 4 395634 04/04/2024 Souderton Mennonite Homes 207 West Summit Avenue Souderton, PA 18964

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. 395634 Page 3 of 4 395634 04/04/2024 Souderton Mennonite Homes 207 West Summit Avenue Souderton, PA 18964

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. 395634 Page 4 of 4