Souderton Mennonite Homes
Inspection history, citations, penalties and survey trends for this long-term care facility in Souderton, Pennsylvania.
- Location
- 207 West Summit Avenue, Souderton, Pennsylvania 18964
- CMS Provider Number
- 395634
- Inspections on file
- 15
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Souderton Mennonite Homes during CMS and state inspections, most recent first.
A resident with a history of falls, muscle weakness, and use of a motorized wheelchair required supervision outdoors but was non-compliant with requesting staff assistance. Despite staff awareness of the resident's daily departures from the unit, the facility did not develop or implement an individualized care plan or interventions to address the resident's ongoing non-compliance with notifying staff when leaving the building.
A facility failed to follow physician's orders for a resident with congestive heart failure and hypertension. The resident experienced significant weight gains without cardiology being notified, as required. Additionally, carvedilol was administered despite the resident's systolic blood pressure being below the ordered parameters. The DON confirmed these deficiencies.
A facility failed to provide necessary adaptive eating equipment to a resident with Parkinson's disease, dementia, and dysphagia. The resident's care plan required a partitioned scoop dish on blue Dycem and weighted utensils for meals, but observations showed these were not provided. The deficiency was confirmed by the DON.
A facility failed to conduct required pre-employment screenings for a newly hired RN, including reference checks and license verification, as per their policies. These checks were completed only after the RN had already started working, which was confirmed by the DON.
The facility failed to follow the bowel management protocol for a resident with muscle weakness and dysphagia, resulting in multiple instances of unaddressed constipation. Despite physician's orders and facility policy, staff did not administer the required laxatives, suppositories, or enemas over several shifts in March and April 2024. The DON confirmed the lapse in protocol adherence.
The facility failed to ensure consistent catheter care and timely urologist follow-up for a resident with an indwelling urinary catheter. Documentation revealed multiple instances of missed or incomplete catheter care and a lack of timely medical follow-up, as confirmed by the resident and the Director of Nursing.
A resident with Alzheimer's, depression, and anxiety experienced significant weight losses of 6.3% and 6.6% over two periods. The facility failed to have a dietitian assess or address these losses in a timely manner, with delays until December 1, 2023, and February 19, 2024. This deficiency was confirmed by a dietitian.
The facility failed to post pertinent Ombudsman contact information in an accessible area. Residents were aware of the Ombudsman Program but did not know where to find the contact details, and one resident had outdated information.
Failure to Develop and Implement Individualized Care Plan for Resident Needing Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed the specific needs of a resident with a history of falls, muscle weakness, and lack of coordination, who used a motorized wheelchair. Clinical records showed that the resident required distant supervision when using the wheelchair outdoors and regularly left the nursing unit to visit his wife in another part of the building, with staff awareness. The care plan noted the resident's non-compliance with requesting staff supervision for outdoor wheelchair use, but there was no documented evidence of an individualized care plan or interventions to address his ongoing non-compliance with notifying staff when leaving the building. The Director of Nursing confirmed the lack of compliance and absence of appropriate care planning for this issue.
Failure to Implement Physician's Orders for Resident Care
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with congestive heart failure and hypertension. A physician's order required the resident to be weighed daily, with cardiology to be notified of a three-pound weight gain in one day or a five-pound weight gain in one week. However, the resident experienced significant weight gains on multiple occasions in February and March 2025, without documented evidence of cardiology being notified. Additionally, the resident was prescribed carvedilol for hypertension, with specific parameters to withhold the medication if the systolic blood pressure (SBP) was less than 110 mm/Hg or the heart rate was less than 60. Despite this, the medication was administered on several occasions when the resident's SBP was below the ordered parameters. The Director of Nursing confirmed the lack of documentation regarding cardiology notification and the administration of medication outside the ordered parameters.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment to a resident with specific medical conditions. Resident 6, who has diagnoses including Parkinson's disease, dementia, and dysphagia, was identified as needing adaptive equipment to assist with meals. The care plan for this resident included the provision of a partitioned scoop dish on blue Dycem and weighted utensils for all meals. However, observations on March 18 and March 19, 2025, revealed that the resident was not provided with these items during meal times. This deficiency was confirmed in an interview with the Director of Nursing on March 20, 2025.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the hiring process, specifically in conducting necessary screenings for new employees. The facility's policy, titled 'Resident Abuse or Suspected Abuse,' required screenings for all potential hires, including license and registration verification. Additionally, the 'Employment Procedures 2.07' policy mandated reference checks for all potential hires. However, for one newly hired employee, a Registered Nurse, these procedures were not followed. The employee began working at the facility without a completed reference check, which was only conducted over a month later, and without verification of their professional license, which was not completed until nearly two months after their start date. This oversight was confirmed by the Director of Nursing, who acknowledged the lack of documented evidence for these checks prior to the employee's start of employment.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement physician's orders and follow the bowel protocol for one of the sampled residents, identified as Resident 44. The facility's policy on bowel management required staff to monitor bowel movements and take action to prevent complications of constipation and/or fecal impaction. This included administering an oral laxative for no bowel movement in nine shifts, followed by a suppository if the laxative was ineffective, and an enema if the suppository was ineffective. However, clinical record reviews revealed that Resident 44, who had diagnoses including muscle weakness and dysphagia and was cognitively impaired, did not have documented bowel movements on multiple occasions in March and April 2024. Specifically, there were no bowel movements recorded from March 5 through 8, March 10 through 13, March 21 through 25, and March 28 through April 2, totaling up to 18 shifts without a bowel movement. Despite the lack of bowel movements, there was no evidence that the physician's orders or the facility's bowel management policy were followed to address Resident 44's constipation. The Director of Nursing confirmed in an interview that the staff did not implement the physician's orders or follow the bowel protocol as required. This failure to adhere to the prescribed bowel management protocol resulted in a deficiency in the care provided to Resident 44.
Failure to Provide Consistent Catheter Care and Timely Urologist Follow-Up
Penalty
Summary
The facility failed to ensure that catheter care and services were consistently provided for Resident 47, who had an indwelling urinary catheter. The resident was admitted with diagnoses including benign prostatic hyperplasia, urinary tract infection, and retention of urine. Despite the care plan indicating the need for follow-up with a urologist and staff assistance with catheter care every shift, documentation revealed multiple instances of missed or incomplete catheter care. Specifically, from March 5, 2025, through April 3, 2024, there were three shifts with missing documentation, 18 shifts marked as not applicable, and one shift documented as not completed. Additionally, there was no evidence that the resident had been seen by a urologist in a timely manner as recommended by the nurse practitioner on multiple occasions. In an interview, Resident 47 confirmed that staff did not consistently assist him with catheter care. The Director of Nursing also confirmed the lack of consistent documentation and timely urologist follow-up. This deficiency highlights a failure in providing necessary catheter care and ensuring timely medical follow-up, as required by the resident's care plan and medical recommendations.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess significant weight loss for a resident diagnosed with Alzheimer's disease, depression, and anxiety. The resident experienced a significant weight loss of 6.3% between October 5, 2023, and November 6, 2023, and another significant weight loss of 6.6% between January 8, 2024, and February 5, 2024. Despite these significant weight losses, there was no evidence that a dietitian assessed or addressed the issue in a timely manner, with delays until December 1, 2023, and February 19, 2024, respectively. This deficiency was confirmed by Dietitian 1 during an interview on April 4, 2024.
Failure to Post Accessible Ombudsman Contact Information
Penalty
Summary
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 accessible to all residents and resident representatives. On April 2, 2024, it was observed that the information was posted on the upper part of a bulletin board on the way to the main dining room, which was not at eye level for residents, especially those in wheelchairs. During a group interview on April 3, 2024, five alert and oriented residents stated they were aware of the Ombudsman Program but did not know where to find the contact information. One resident mentioned having outdated information about the Ombudsman and not knowing the current contact details.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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