Inspection Reports for
Mennonite Friendship Communities Inc

The complaint investigation focused on the involuntary discharge of Resident 1 for non-payment of services. The investigation found the discharge notice lacked required appeal rights and contact information, and the discharge documentation was incomplete. The resident was denied Medicaid services due to failure to submit required paperwork.

The facility failed to ensure the involuntary discharge notice contained required appeal rights, discharge location, and state agency contact information. Additionally, the facility did not document the reason for discharge in the medical record and failed to provide a written discharge summary, recapitulation of stay, or medication reconciliation to the resident or their representative.

The facility had multiple deficiencies including failure to notify physicians of out-of-parameter blood sugars, failure to verify CMS receipt of MDS transmissions, environmental safety hazards, improper feeding tube care, inadequate pharmacist medication reviews, medication errors, and lack of hospice care coordination.

The facility had multiple deficiencies including failure to notify physicians of out-of-parameter blood sugars, inadequate environment safety measures, failure to verify MDS transmissions, improper feeding tube care, medication errors including psychotropic drug management, and lack of coordination with hospice services.

The facility failed to follow physician's orders for insulin administration for one resident, delayed pharmacist recommendation follow-up causing unnecessary medication use, failed to store and handle food safely, and failed to properly handle and process linen and biohazard waste to prevent infection spread.

The facility had multiple deficiencies including failure to maintain resident dignity with catheter care, failure to notify ombudsman and residents about hospital transfers and bed hold policies, untimely transmission of Minimum Data Set (MDS) assessments, incomplete care plans for oxygen use, improper catheter care increasing UTI risk, failure to change and store oxygen tubing properly, unsafe food handling and storage practices, and inadequate infection control practices related to glove use and hand hygiene.

The survey found the most serious deficiencies to be a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm and 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 facility was found not in substantial compliance with multiple regulatory requirements including resident dignity, accuracy of assessments, medication labeling and storage, and food safety and sanitation.

The facility failed to ensure negotiated service agreements were signed by all parties, licensed nurses provided or coordinated necessary health care services including fall risk interventions and wound care, certified medication aides were properly trained and documented for delegated tasks, over-the-counter medications were properly labeled, and emergency preparedness training was conducted quarterly for staff and residents.

The facility identified issues with involuntary discharge procedures, including lack of proper documentation, notification, and resident rights information. Corrective actions include policy development, care team meetings, and monitoring compliance.

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.

The complaint investigation #126186 and #126172 focused on the facility's handling of involuntary discharge of a resident exhibiting violent and inappropriate behaviors. The investigation found multiple regulatory violations related to discharge documentation, notice requirements, bed hold policy, and resident return rights.

The facility failed to meet regulatory requirements for involuntary discharge, including proper documentation, notice content, timely notification to the ombudsman, provision of bed hold policy, and permitting the resident to return after hospitalization.

All deficiencies have been corrected as of the compliance date 2017-11-23, and no new noncompliance was found.

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

The plan addresses a pressure ulcer on a resident's right heel and outlines measures for skin assessments, pressure injury prevention, staff education, and ongoing monitoring to prevent ulcer development.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed due to noncompliance.

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

The facility failed to develop and implement timely and effective interventions to prevent avoidable pressure ulcers in two residents, resulting in 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 implement a repositioning schedule for at-risk residents.

The report confirms that the previously cited deficiency under regulation 26-40-305 (i)(1)(2)(3) was corrected as of 05/26/2017. No other deficiencies or uncorrected issues are noted.

The revisit confirmed that the previously cited deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of the revisit date. No uncorrected deficiencies were noted.

The survey found a 'D' level deficiency indicating no actual harm but 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 May 26, 2017.

Complaint investigation #114573 involved a resident with dementia and other mental health diagnoses who exited the facility on 4/9/17 at 1:02 AM and was locked out until 6:09 AM. Staff did not document the event timely or assess the resident for injuries. The resident was found outside wearing night clothes and complained of being cold. The doorbell at the exit door was nonfunctional, and staff failed to respond to the resident's attempts to re-enter.

The facility failed to ensure the environment was free from accident hazards when a resident exited the facility and could not re-enter due to a locked door. Staff failed to routinely verify the resident's whereabouts and assess the resident for injuries after being outside for five hours and complaining of cold.

Investigation of complaint KS00113628 found the facility failed to maintain safe transport equipment, resulting in a resident fall with serious injuries. The complaint was substantiated and the deficient practice was corrected on 3/22/17.

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 lacked documentation of safety checks and preventive maintenance for the lift and ramps used for resident transport.

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

The plan addresses past noncompliance issues identified under tags F0000 and F323-J, both of which required no plan of correction as they were past noncompliance.

All previously reported deficiencies were corrected as of the revisit date. Each deficiency listed shows completion of corrective action.

The report confirms that the previously cited deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.

The plan addresses multiple deficiencies including injury reporting, bathing preferences, maintenance repairs, care plan updates, catheter management, fall incident analyses, medication labeling, infection control, and safety audits. Corrective actions include staff education, audits, repairs, and ongoing monitoring through Quality Assurance and Risk Committees.

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 based on credible allegation of compliance and evidence of correction.

The inspection was triggered by multiple complaints including allegations of abuse, neglect, falls, infection control issues, and medication management concerns. Several complaint investigations (#8328, #9184, 7925) were included in the survey.

The facility had multiple deficiencies 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, failure to follow physician orders for catheter care, inadequate fall prevention and investigation, improper medication management, unsanitary food preparation and serving practices, and infection control lapses.

The report confirms that the previously cited deficiency under regulation 26-41-101 (f)(1) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.

The survey found the most serious deficiencies to be 'E' level, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.

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

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.

Complaint KS00106400 triggered the investigation. The complaint involved concerns about resident elopement and inadequate supervision. The investigation substantiated that resident #1 eloped and that the facility failed to assess and manage elopement risks for residents #1, #2, and #3.

The facility failed to provide adequate supervision and elopement risk assessments for residents with cognitive impairment, resulting in resident #1 eloping from the assisted living house and other residents being at risk of elopement or unsupervised exit. The facility's policies and staff practices were inadequate to prevent these incidents.

The inspection was triggered by complaint investigations KS00097424, KS00097414, and KS00105652. The complaints involved issues such as medication administration without resident consent, failure to update care plans, inadequate supervision leading to elopement, and medication administration failures.

The facility was found deficient in multiple areas including failure to ensure a resident's right to refuse treatment, failure to review and revise care plans for residents with changing needs, inadequate supervision leading to an elopement incident, and failure to administer prescribed medications due to pharmaceutical system issues.

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

The plan addresses multiple deficiencies including medication administration errors, care plan updates, wanderguard bracelet placement and door code security, and medication availability for residents on Hospice.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required, and enforcement remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This Plan of Correction is related to a complaint investigation identified by event ID EUB811 and complaint date 03/02/2016.

The plan addresses deficiencies related to resident supervision during meals and when out of room, timely reporting of suspected abuse, and proper assessment and documentation for residents with diminished cognitive skills who self-toilet.

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 required supervision and timely reporting of abuse, and failed to adequately monitor and treat a resident's bowel condition.

The facility failed to ensure one resident was free from sexual/physical abuse due to lack of 1:1 supervision as directed by the care plan. The facility also failed to immediately report the abuse incident to the administrator and state agency. Additionally, the facility 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, resulting in hospitalization and death.

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

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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The visit was triggered by complaint investigations #KS00093218, KS00093160, and KS00093286 involving allegations of abuse and mistreatment of residents.

The facility failed to ensure residents were free from physical abuse by other residents, failed to thoroughly investigate and report allegations of abuse, and failed to timely revise care plans and provide necessary interventions to manage resident behaviors. Multiple incidents of inappropriate physical and verbal behaviors by resident #1 towards other residents and staff were documented, with inadequate monitoring and follow-up.

The report confirms that all previously identified deficiencies were corrected by 07/17/2015 as documented by the correction completion dates for each cited regulation.

The facility identified multiple deficiencies related to posting information, medication administration, resident assessments, hospice care documentation, fall interventions, expired medications, disinfectant use, and QA meeting attendance. Corrective actions and staff education plans were implemented to address these issues.

The facility had multiple deficiencies including failure to post required hotline information legibly, failure to notify physicians of significant changes in residents' conditions, failure to promote resident dignity regarding clothing protectors, failure to complete significant change MDS assessments timely, inaccurate MDS assessments, failure to coordinate hospice care, inadequate fall prevention interventions, medication errors including missed doses and failure to notify physicians of abnormal blood sugars, expired medications not removed, and improper disinfectant use by housekeeping.

Complaint Investigation #KS00084476 focused on the care and supervision related to resident #1 who sustained a 2nd degree burn from a hot rice pack applied by staff. The complaint was substantiated based on findings of inadequate nursing assessments and supervision.

The facility failed to provide timely and thorough nursing assessments of a 2nd degree burn sustained by resident #1 over a 12-day period. Additionally, the facility failed to provide adequate supervision when non-licensed staff applied an overheated Bed Buddy, resulting in the resident sustaining burns.

The survey found widespread 'F' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.

All previously cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii),(c)(2)-(4), 483.25(c), 483.25(h), 483.25(i), and 483.25(k) were corrected by 08/15/2014 as confirmed during this revisit.

The complaint investigations focused on allegations of failure to report and investigate elopement, pressure ulcer prevention, accident hazards related to elopement risk, nutrition management, and oxygen therapy implementation.

The facility failed to immediately report and investigate an elopement incident, failed to prevent development of pressure ulcers for one resident, failed to accurately assess elopement risk for another resident, failed to provide planned nutritional snacks contributing to weight loss, and failed to implement continuous oxygen therapy as ordered for two residents.

This Plan of Correction responds to deficiencies cited during a complaint investigation survey conducted on 07/23/2014.

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

The facility identified deficiencies related to pressure sore care, fall risk management, and quality assurance monitoring. The plan outlines corrective actions including care plan revisions, staff education, audits, and committee oversight to ensure compliance and improve resident care.

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

The inspection was triggered by a complaint investigation #65316 and a non-compliance revisit.

The facility failed to revise care plans adequately to prevent pressure ulcer redevelopment and promote healing, failed to provide necessary treatment and positioning for pressure ulcers, failed to prevent accidents by ensuring adequate supervision and use of assistive devices, and lacked an effective quality assurance program to monitor and correct these deficiencies.

The plan addresses multiple deficiencies including incident reporting, resident dignity during dining, equipment cleaning, skin integrity monitoring, fall prevention, food sanitation, medication management, toileting assistance, and ventilation system maintenance. Corrective actions and staff education are planned to ensure substantial compliance by 03/28/2014.

The facility was found deficient in multiple areas including failure to report alleged verbal abuse, failure to assist residents with dignity during meals, inadequate housekeeping and maintenance, failure to monitor skin conditions and pressure ulcers, inadequate fall prevention interventions, improper food handling and sanitation, improper medication storage and disposal, and infection control practices.

The plan outlines corrective actions for catheter management, security improvements in the South Hall utility room, and staff communication enhancements in the dementia unit. The facility aims to achieve substantial compliance by December 7, 2012.

The inspection included a complaint investigation related to 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 report confirms that deficiencies previously cited under regulations 483.20(b)(2)(ii) and 483.25(h) were corrected by the revisit date of 09/05/2012.

The plan addresses significant change assessments for residents with falls resulting in fractures and the review of care plans for fall interventions. Staff education on alarm protocols and weekly audits for residents at fall risk are included.

The complaint investigation was triggered by complaint #KS00056898. The complaint was substantiated as the facility failed to complete required assessments and ensure fall prevention measures for resident #2.

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

Complaint investigation related to alleged abuse was conducted. The investigation results were negative for resident impact.

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 abuse, neglect, and exploitation reporting protocols and to review and update related policies.

The revisit confirmed that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.

The complaint investigation involved four allegations of mistreatment, neglect, or abuse. One allegation involved a direct care staff shoving a resident into a chair. The facility failed to immediately report this allegation and prevent further abuse. The allegation was substantiated by the investigation.

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. The investigation revealed delays in reporting and suspension of the alleged staff involved in shoving a resident.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey.

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.

The plan addresses deficiencies including a resident requiring a wanderguard bracelet and increased monitoring every 2 hours at night, and maintenance issues with doorbells that were corrected by replacing batteries and direct wiring.

The Plan of Correction outlines corrective actions including root cause analyses, staff education, audits, and policy updates to address issues related to catheter privacy covers, communication for residents with intellectual disabilities, medication labeling, and food storage and sanitation.

The plan addresses deficiencies related to resident psych evaluation and medication monitoring, abuse investigations, care plan reviews and updates, and staff orientation for residents with inappropriate behaviors.