Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Souderton Mennonite Homes during CMS and state inspections, most recent first.
Incomplete Weekly Skin Evaluation Documentation: The facility failed to document required weekly skin evaluations for three residents. One resident had diabetes with a foot ulcer and pressure-induced deep tissue damage, another had hemiplegia and skin cancer, and a third had thalassemia, anxiety, and HTN; the record also showed a deep tissue injury on the left heel for one resident, but the weekly skin evaluation task was not documented as completed after the injury was identified. The DON confirmed there was no documented evidence the evaluations were completed per policy.
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.
Incomplete Weekly Skin Evaluation Documentation
Penalty
Summary
The facility failed to maintain complete clinical records for three sampled residents by not documenting required weekly skin evaluations in accordance with facility policy and physician orders. The facility policy, Pressure Ulcer Prevention Program, required a weekly Skin Analysis Evaluation or Pressure Ulcer Potential Assessment using the Point of Care Skin Evaluation task, with nursing staff completing a visual inspection of the resident’s body and documenting the findings in the medical record. Resident 4 had diagnoses including diabetes with foot ulcer and pressure induced deep tissue damage, and a physician ordered weekly skin evaluations with a new evaluation documented in the evaluations tab weekly; however, no completed weekly skin evaluations were documented after March 14, 2026. Resident 5 had diagnoses including hemiplegia, squamous cell carcinoma of the skin, and a trigeminal nerve disorder, and the record lacked documentation that weekly skin evaluations were completed on January 14, 2026, February 25, 2026, and March 11, 2026. Resident 43 had diagnoses including thalassemia, anxiety, and hypertension, and the record lacked documentation that weekly skin evaluations were completed on March 12 and 19, 2026; after a nurse’s note on March 23, 2026 documented a deep tissue injury on the left heel, the Weekly Skin Evaluation/Skin Problem Task still lacked documentation that the evaluation was completed after that injury was identified. The DON confirmed on April 1, 2026, that there was no documented evidence the weekly skin evaluations were completed per facility policy.
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.
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Illustrative
What surveyors actually found near you
We read the 1,394 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Souderton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Community At Telford | 1.3 mi | ★★★★★ | 1 | 0 |
| Community At Rockhill, The | 2.6 mi | ★★★★★ | 1 | 0 |
| Dock Terrace | 3.8 mi | ★★★★★ | 4 | 0 |
| Peter Becker Community | 4.1 mi | ★★★★★ | 3 | 0 |
| Elm Terrace Gardens | 5.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.