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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395634
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
03/20/2025
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395634
If continuation sheet
Page 2 of 3
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
03/20/2025
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395634
If continuation sheet
Page 3 of 3
