Health inspection·March 20, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for one of five newly hired employees. (E2) Residents Affected - Some Findings include: A review of the facility policy entitled, Resident Abuse or Suspected Abuse, dated January 8, 2025, revealed that the facility was to conduct screenings for all potential hires. This included license/registration verification. A review of the facility policy entitled, Employment Procedures 2.07, dated January 8, 2025, revealed that the facility was to check references for all potential hires. Employee 2 (E2) had been working in the facility as a Registered Nurse since January 21, 2025, a reference check was not completed until March 3, 2025, and an inquiry to the state licensure board was not completed until March 19, 2025. In an interview on March 20, 2025, at 11:12 a.m., the Director of Nursing confirmed there was no documented evidence that a reference check and the license/registry verification were done prior to start of employment. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(3) Personnel policies and procedures. Page 1 of 3 395634 395634 03/20/2025 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 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) Residents Affected - Few 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. There was no documented evidence to support that the cardiologist was notified of the weight gain on the aforementioned dates. Further review of Resident 24's clinical record revealed on January 24, 2025, the physician ordered staff to administer a medication (carvedilol) twice a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters mercury (mm/Hg) or if the resident's heart rate was less than 60. Review of the MAR for February and March 2025 revealed that staff administered the medication on February 23 and 24, 2025, and March 17, 2025, when Resident 24's SBP was less than the ordered parameters. In an interview on March 20, 2025, at 9:37 a.m., the Director of Nursing confirmed that there was no documented evidence that the cardiologist was notified of the weight gain and the medication was administered outside of the ordered parameters. CFR(s) 483.25 Quality of Care Previously cited 4/4/24 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395634 Page 2 of 3 395634 03/20/2025 Souderton Mennonite Homes 207 West Summit Avenue Souderton, PA 18964

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm 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) Residents Affected - Few 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. through 12:20 p.m., Resident 6 was observed in the dining room without a partitioned scoop dish, blue Dycem, and weighted utensils. In an interview on March 20, 2025, at 9:27 a.m., the Director of Nursing confirmed that the resident should have received the partitioned scoop dish, blue Dycem, and weighted utensils. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395634 Page 3 of 3