Inspection Reports for Mennonite Friendship Communities Inc

An offsite revisit survey was conducted on 09/20/2018 for all previous deficiencies cited on 08/16/2018.

All deficiencies have been corrected as of the compliance date of 09/18/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department of Aging and Disability Services (KDADS) to assess compliance with 42 CFR 483 subpart B.

The facility was found not in substantial compliance with multiple deficiencies including failure to maintain resident dignity, inaccurate assessments for residents with intellectual disabilities, improper labeling and storage of drugs, and unsanitary food storage and preparation conditions.

This document is a Plan of Correction submitted in response to deficiencies cited in the inspection report dated August 16, 2018, for Mennonite Friendship Communities Inc.

The Plan of Correction addresses multiple deficiencies including catheter care and privacy, communication for residents with intellectual disabilities, medication labeling and storage, and food safety and sanitation practices. Corrective actions include root cause analyses, staff education, audits, and policy updates to ensure substantial compliance by mid-September 2018.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-09-18.

The visit was a resurvey conducted on 6/26/18 and 7/2/18 to assess compliance with previously cited deficiencies at Mennonite Friendship Communities Inc.

The facility was found deficient in multiple areas including failure to ensure negotiated service agreements were signed, failure to provide or coordinate necessary health care services especially related to fall risk and skin integrity, failure to provide ongoing nurse assessment of wounds, failure to properly train certified medication aides for delegated tasks, failure to label over-the-counter medications with resident names, and failure to conduct quarterly emergency preparedness reviews with staff and residents.

The inspection was conducted as a complaint investigation related to involuntary discharge and transfer practices of a resident at the facility.

The facility failed to meet regulatory requirements regarding involuntary discharge, including lack of proper documentation, failure to provide complete and timely notices with required information to the resident and representatives, failure to provide the bed hold policy at the time of transfer, and failure to allow the resident to return to the facility after hospitalization due to safety concerns.

The complaint investigation (#126186 and #126172) focused on the involuntary discharge of resident #1, including failure to meet transfer and discharge requirements, notice requirements, bed hold policy notification, and permitting return to the facility.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective February 23, 2018.

An off-site survey was conducted for the deficiencies cited on February 9, 2018.

The deficiencies cited during the survey were corrected as of the compliance date of February 23, 2018.

This document is a Plan of Correction submitted to address deficiencies identified in a prior inspection, indicating that all deficiencies have been corrected as of the compliance date 11/23/17.

All deficiencies identified in the prior inspection have been corrected by the compliance date, and no new noncompliance was found.

A revisit survey was conducted on 12/21/17 to verify correction of all previous deficiencies cited on 10/24/17.

All deficiencies cited in the prior inspection have been corrected as of 11/23/17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Mennonite Friendship Communities Inc.

The plan addresses deficiencies related to pressure ulcer prevention and management, including skin assessments, wound measurement, staff education, and ongoing monitoring by nursing and quality assurance staff.

The plan of correction is in response to a complaint investigation at the facility.

The inspection was conducted as a complaint investigation (#120207) focusing on pressure ulcer prevention and treatment at the facility.

The facility failed to develop and implement timely and effective interventions to prevent the development and worsening of avoidable pressure ulcers, including a stage 4 heel pressure ulcer for resident #1 and a stage 3 pressure ulcer for resident #2. The facility did not adequately offload heels or develop a repositioning schedule, resulting in pressure ulcers that affected residents' mobility and overall health.

Complaint investigation #120207 focused on pressure ulcer prevention and treatment failures.

An abbreviated survey was conducted on October 24, 2017, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given, resulting in enforcement actions including denial of payment for new Medicare and Medicaid admissions.

This report documents a revisit conducted by a State surveyor to verify that previously reported deficiencies have been corrected and to record the dates when corrective actions were accomplished.

The revisit confirmed that the previously identified deficiency with ID Prefix S1372 related to regulation 26-40-305 (i)(1)(2)(3) was corrected as of 05/26/2017. No other deficiencies or uncorrected issues were noted.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit report indicates that the deficiencies previously cited have been corrected as of the revisit date.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a "D" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective May 26, 2017.

The inspection was conducted as a complaint investigation (#114573) regarding a resident who exited the facility and was locked out overnight, raising concerns about supervision and accident hazards.

The facility failed to ensure the environment was free from accident hazards when a resident exited the building and was locked out for approximately 5 hours overnight. Staff did not routinely verify the resident's whereabouts or assess the resident for injuries after the incident. The doorbell at the exit door was nonfunctional, and staff failed to respond to the resident's attempts to re-enter the building.

Complaint investigation #114573 focused on a resident who exited the facility on 4/9/17 at 1:02 AM and was locked out until 6:09 AM. The resident was outside overnight in inadequate clothing and complained of feeling cold. Staff failed to document or respond appropriately to the incident.

The inspection was a partial extended survey conducted for investigation of complaint KS00113628 regarding resident safety during transport.

The facility failed to ensure the resident environment was free from accident hazards during transport by not completing routine preventative maintenance checks on a platform lift used in a facility bus. Resident #1 fell approximately 3 feet from the lift, sustaining serious injuries including brain bleed and fractured leg. The facility also lacked documentation of safety checks for ramps and smaller vans used for resident transport.

The visit was triggered by complaint KS00113628. The complaint involved a resident falling from a platform lift during transport, resulting in serious injuries. The complaint was substantiated with findings of immediate jeopardy due to failure in maintenance and safety checks.

This document is a Plan of Correction submitted in response to a corrected complaint inspection conducted at Mennonite Friendship.

The plan of correction addresses past non-compliance issues identified under tags F0000 and F323-J, with no new plan of correction required as these were past non-compliance findings.

This plan of correction relates to a corrected complaint dated 03/30/2017.

An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The facility was found not to be in substantial compliance with participation requirements, with conditions constituting Immediate Jeopardy and Past Non-compliance to resident health or safety.

This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.

The plan outlines corrective actions for multiple deficiencies including injury reporting, bathing preferences, maintenance repairs, care plan updates, catheter management, fall incident root cause analysis, medication labeling, infection control, and equipment safety. All corrections are scheduled to be completed by March 22, 2017.

This post-certification revisit was conducted to verify that previously cited deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

All previously reported deficiencies were corrected as of the revisit date, with each correction documented and completed on 03/22/2017.

This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.

The revisit report confirms that the previously identified deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of 03/22/2017. No other deficiencies or findings are noted.

The inspection was conducted as a health resurvey and complaint investigations related to allegations of abuse, neglect, falls, and infection control.

The facility was found deficient in multiple areas including failure to investigate and report injuries of unknown source, failure to assess resident preferences, inadequate housekeeping and maintenance, failure to revise care plans after falls and pressure ulcers, improper medication management, inadequate infection control practices, and failure to ensure safe environment and supervision to prevent falls.

The inspection included complaint investigations related to allegations of abuse, neglect, falls, and infection control violations.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 22, 2017.

The document is an assisted living resurvey of the facility to verify compliance and check for deficiencies.

The resurvey resulted in a finding of no deficiency citations.

This document is a Plan of Correction submitted in response to a prior inspection report for Mennonite Friendship ALF.

No deficiencies were cited in the related inspection report.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that the previously cited deficiency with ID Prefix S3026 and regulation 26-41-101 (f)(1) was corrected as of 11/09/2016. No other deficiencies or uncorrected issues are noted.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'E' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

All previously cited deficiencies identified by regulation numbers 483.10(b)(4), 483.20(d)(3), 483.10(k)(2), 483.25(h), and 483.60(a),(b) were corrected as of the revisit date.

This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Mennonite Assisted Living.

Deficiencies included issues related to elopement risk assessments and missing resident policies. Corrective actions involved completing risk assessments for cited residents, placing wanderguards, auditing all assisted living residents, and updating policies and training for new employees.

This Plan of Correction is related to a complaint investigation identified as Mennonite AL complaint 10122016.

The inspection was a partial extended survey conducted for investigation of complaint KS00106400 regarding resident safety and supervision in an assisted living facility.

The facility failed to provide adequate supervision and elopement risk assessments for residents with cognitive impairment, resulting in resident #1 eloping from the facility and other residents being at risk of leaving unsupervised. The facility's failures placed resident #1 in immediate jeopardy. Corrective actions were implemented to address these issues.

The complaint investigation revealed failures in supervision and risk assessment that led to resident #1 eloping from the assisted living facility and other residents being at risk of unsupervised exit.

The inspection was conducted as a result of complaint investigations KS00097424, KS00097414, and KS00105652.

The facility was found deficient in multiple areas including failure to ensure a resident's right to refuse treatment when medications were mixed with Dr. Pepper without informing the resident, failure to review and revise care plans for residents with changing needs, inadequate supervision leading to resident elopement, and failure to administer prescribed antipsychotic medication for six days due to lack of availability.

The inspection findings represent the results of complaint investigations KS00097424, KS00097414, and KS00105652.

A Life Safety Code survey was conducted on June 13, 2016, by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be at 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that all cited deficiencies, including those related to regulations 483.13(b), 483.13(c)(1)(i), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.25, were corrected as of 04/01/2016.

The inspection was conducted as a complaint investigation based on allegations of resident-to-resident sexual/physical abuse and failure to provide necessary care and services.

The facility failed to ensure one resident was free from sexual/physical abuse when staff did not provide required 1:1 supervision, resulting in inappropriate touching. Additionally, the facility failed to immediately report the abuse incident to the administrator and state agency. The facility also failed to provide necessary care to a resident at risk for constipation, including monitoring bowel movements, implementing bowel management protocols, monitoring fluid intake, and conducting timely nursing assessments, which contributed to a resident's hospitalization and death.

The complaint investigations #KS00097287, KS00097354, and KS00097406 involved allegations of resident-to-resident sexual/physical abuse and failure to provide necessary care and services. The facility failed to provide 1:1 supervision as directed, resulting in inappropriate touching. The abuse incident was not reported immediately to the administrator or state agency, with a 4-day delay in notification.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be D level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

This is a post-certification revisit to verify correction of previously cited deficiencies as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously cited deficiencies identified by regulation numbers F0223, F0225, F0280, and F0309 were corrected as of the revisit date 11/12/2015.

The inspection was conducted as a complaint investigation based on allegations of abuse involving residents #1, #2, #3, and #5.

The facility failed to ensure residents were free from physical abuse, failed to thoroughly investigate and report allegations of abuse, and failed to provide timely evaluation and interventions to manage resident #1's repeated inappropriate behavioral symptoms. Multiple incidents of inappropriate touching and behaviors were documented involving resident #1 and other residents. The facility also failed to revise care plans timely and adequately supervise residents as care planned.

The complaint investigations involved allegations of physical abuse and inappropriate behaviors by resident #1 towards residents #2, #3, and #5. The facility failed to adequately monitor resident #1, failed to thoroughly investigate and report abuse allegations, and failed to revise care plans and provide interventions to manage behaviors.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be an 'E' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective November 12, 2015.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The report shows that all previously cited deficiencies were corrected by 07/17/2015, with no uncorrected deficiencies remaining as of the revisit date.

The inspection was a health resurvey of Mennonite Friendship Communities Inc nursing facility to assess compliance with federal regulations.

The facility had multiple deficiencies including failure to post required hotline information legibly, failure to notify physicians of significant resident changes, failure to promote resident dignity regarding clothing protectors, failure to complete significant change MDS assessments timely, inaccurate MDS assessments, failure to coordinate hospice care, failure to prevent falls by identifying root causes and implementing interventions, medication errors including missed medications and failure to notify physicians of abnormal blood sugars, expired medications not removed, and improper disinfectant use by housekeeping.

The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs.

The survey found the most serious deficiencies in the facility to be at 'F' level, indicating significant noncompliance. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.

This document is a Plan of Correction submitted by Mennonite Friendship Communities in response to deficiencies cited during a prior survey inspection.

The facility identified multiple deficiencies related to posting information, medication administration, resident assessments, care planning, fall interventions, medication management, housekeeping practices, and QA meeting attendance. Corrective actions include staff education, process changes, monitoring, and ongoing compliance measures.

This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that the deficiencies previously cited under regulations 483.25 and 483.25(h) were corrected by 04/06/2015. No uncorrected deficiencies remain as of the revisit date.

An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to prior noncompliance on a previous abbreviated survey, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for all new Medicare admissions effective April 12, 2015.

Complaint Investigation #KS00084476 was conducted due to concerns about the care and supervision related to a resident who sustained a 2nd degree burn from an overheated Bed Buddy (heated rice pack).

The facility failed to provide timely and thorough nursing assessments of a 2nd degree burn sustained by resident #1 on the upper left shoulder/scapula over a 12-day period. Additionally, the facility failed to provide adequate supervision when unlicensed staff applied an overheated Bed Buddy, resulting in the burn injury.

The complaint investigation found substantiated evidence that resident #1 sustained a 2nd degree burn from an overheated Bed Buddy applied by unlicensed staff. The facility failed to monitor the hot pack after placement and did not perform timely nursing assessments of the injury.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.

This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.

The revisit report confirms that all previously cited deficiencies related to regulations 483.13(c)(1)(ii)-(iii),(c)(2)-(4), 483.25(c), 483.25(h), 483.25(i), and 483.25(k) were corrected as of 08/15/2014.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation survey conducted on 07/23/2014.

The plan addresses multiple deficiencies including elopement risk, skin breakdown prevention, safety awareness for cognitively impaired residents, nutritional status monitoring, and oxygen equipment competency. The facility outlines corrective actions and monitoring plans to ensure compliance and resident safety.

This plan of correction is in response to a complaint investigation survey conducted on 07/23/2014 regarding multiple deficiencies at the facility.

An abbreviated survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found a serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to prior noncompliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare admissions effective August 22, 2014.

The inspection was conducted as a complaint investigation related to allegations of elopement, pressure ulcers, accident hazards, nutrition, and oxygen therapy.

The facility failed to immediately report an elopement incident and conduct a timely investigation, failed to prevent development of pressure ulcers for one resident, inadequately assessed elopement risk leading to an elopement with fall, failed to provide planned nutritional snacks contributing to weight loss, and failed to implement continuous oxygen therapy as ordered for two residents.

The complaint investigations #77122 and #77135 focused on allegations of abuse, neglect, mistreatment, elopement, pressure ulcers, accident hazards, nutrition, and oxygen therapy.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report documents that multiple deficiencies previously cited under various regulations were corrected by the revisit date of 06/05/2014.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to ensure compliance with regulations.

The plan addresses deficiencies related to pressure sore care, fall risk management, and quality assurance monitoring. The facility describes specific interventions, audits, education, and committee oversight to achieve and maintain compliance.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.

The report confirms that the deficiency identified under regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 04/07/2014.

This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-02-28.

The report shows that all previously cited deficiencies identified by regulation numbers were corrected as of the revisit date 2014-04-07.

The inspection was a non-compliance revisit and complaint investigation focusing on care plan revisions, pressure ulcer treatment and prevention, fall risk management, and quality assurance program effectiveness.

The facility failed to revise care plans adequately to prevent pressure ulcer redevelopment, failed to provide necessary treatment and positioning to promote healing of pressure ulcers, failed to implement effective fall prevention interventions, and lacked an effective quality assurance program to monitor and ensure corrective actions were implemented.

The revisit and complaint investigation #65316 focused on care plan revisions, pressure ulcer treatment and prevention, fall risk management, and quality assurance program effectiveness.

This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey. It outlines corrective actions to ensure compliance with regulations and prevent recurrence of identified issues.

The plan addresses multiple deficiencies including incident reporting of abuse, dining assistance, equipment cleaning and maintenance, skin care and bruising documentation, fall prevention, food sanitation, medication management, toileting assistance, and ventilation system maintenance. Corrective actions include staff education, policy review, audits, and monitoring to ensure substantial compliance by 03/28/2014.

The inspection was conducted as a health resurvey including review of allegations of abuse, resident care, housekeeping, medication management, infection control, and safety.

The facility was found deficient in multiple areas including failure to immediately report verbal abuse, failure to assist residents with dignity during meals, inadequate housekeeping and maintenance, failure to monitor bruising and pressure ulcers, inadequate fall prevention interventions, improper food handling and sanitation, expired medications not properly disposed, and improper infection control practices related to glove use.

This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The revisit confirmed that the deficiencies previously reported under regulations 483.25(d), 483.25(h), and 483.70(f) were corrected as of 12/07/2012.

This document is a Plan of Correction submitted by Mennonite Friendship Communities addressing deficiencies cited in a prior inspection report.

The plan outlines corrective actions for deficiencies related to catheter management, security of the South Hall utility room, and provision of pagers for staff in the dementia unit, with education and monitoring plans to ensure compliance.

The inspection was conducted as a health resurvey and complaint investigation into complaint #56631.

The facility failed to remove an indwelling catheter to prevent urinary tract infections for one resident, failed to secure hazardous chemicals posing accident hazards to cognitively impaired residents, and lacked an effective resident call system on the locked dementia unit.

The visit was triggered by complaint #56631 and included a health resurvey.

This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2012-08-06.

The report documents that the deficiencies previously cited under regulations 483.20(b)(2)(ii) and 483.25(h) were corrected as of 2012-09-05.

This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation for the Mennonite Friendship Communities facility.

The plan addresses deficiencies related to significant change assessments for resident #2 and evaluation of fall interventions, including staff education on alarm protocols and weekly audits for residents at fall risk.

The inspection was an abbreviated survey conducted in response to complaint #KS00056898 regarding the facility's compliance with resident care requirements.

The facility failed to conduct a comprehensive assessment within 14 days after a significant change in a resident's condition and failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident with recent falls.

The complaint investigation was triggered by complaint #KS00056898. The facility was found noncompliant in conducting timely comprehensive assessments and ensuring fall prevention measures for resident #2.

This document is a Plan of Correction submitted in response to a complaint investigation related to allegations of abuse, neglect, or exploitation at the facility.

The investigation found no negative impact on residents under the alleged perpetrator's care. The facility plans to provide training to all nursing staff on protocols for reporting abuse, neglect, and exploitation, and to review and update related policies as necessary.

Investigation was conducted due to a complaint alleging abuse. The results of the investigation were negative, indicating no impact on residents.

This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.

The report confirms that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) with ID prefix F0225 was corrected as of 07/05/2012.

The inspection was conducted as a complaint survey for complaint #57335, investigating allegations of mistreatment, neglect, or abuse at the facility.

The facility failed to immediately report one of four allegations of abuse to the administrator and failed to prevent further potential abuse by allowing the alleged perpetrator to complete his shift before suspension. The investigation revealed delays in reporting and suspension contrary to facility policy.

The complaint investigation involved four allegations of mistreatment, neglect, or abuse. One incident occurred on 5/16/12 at 11:10 p.m. involving a direct care staff shoving a resident into a chair. The facility failed to immediately report the allegation and failed to suspend the alleged perpetrator until the next day, allowing potential further abuse to 17 residents cared for by the staff.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at the facility.

The facility identified deficiencies related to wound assessment and the use of hot rice packs (Bed Buddies). Corrective actions include policy development, staff education, competency checks, and ongoing monitoring to ensure compliance and prevent recurrence.

This Plan of Correction is in response to a complaint investigation survey identified by the event ID OV9V11 and linked to the Mennonite 032315 Complaint.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.

The plan addresses deficiencies including a resident not wearing a wanderguard bracelet and doorbell maintenance issues. Corrective actions include increased resident monitoring, care plan updates, and maintenance checks on doorbells.

This Plan of Correction is related to deficiencies cited during a complaint investigation as referenced by the linked Mennonite 042817 Complaint Federal and State reports.

This document is a Plan of Correction submitted by Mennonite Friendship Communities in response to deficiencies cited during a prior inspection related to involuntary discharge policies and bed hold notices.

The Plan of Correction addresses deficiencies involving involuntary discharge procedures, including ensuring proper documentation, notification to residents and their representatives, and compliance with regulations. Policies will be updated and monitored to prevent improper discharge and ensure residents' rights to return.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.

The plan addresses deficiencies related to resident supervision during meals, reporting suspected abuse, and assessment protocols for residents with diminished cognitive skills who self-toilet.

This Plan of Correction is linked to a complaint investigation identified as 'mennonite friendship communities complaint 03022016'.

This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Mennonite Friendship facility.

The plan addresses deficiencies related to resident care, abuse investigations, care plan updates, and staff training, with corrective actions and responsible parties identified along with completion dates.

This Plan of Correction is related to a complaint investigation at Mennonite Friendship facility.

This document is a Plan of Correction submitted in response to deficiencies cited during the Mennonite Friendship complaint inspection dated 09/28/2016.

The plan addresses multiple deficiencies including medication administration errors, care plan updates, wanderguard security measures, and medication availability for hospice residents, with corrective actions and completion dates specified.

This Plan of Correction is related to the Mennonite Friendship complaint investigation dated 09/28/2016.