Inspection Reports for Mennonite Friendship Communities Inc
600 W BLANCHARD AVE, KS, 67505-1526
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 20, 2018, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed a pattern of deficiencies related mainly to resident dignity and privacy, medication labeling and storage, communication and assessment for residents with intellectual disabilities, and food safety and sanitation. Complaint investigations over time included substantiated issues such as inadequate supervision leading to resident elopement, failure to prevent and treat pressure ulcers, and lapses in abuse reporting and investigation. Enforcement actions included denial of payment for new Medicare and Medicaid admissions due to repeated noncompliance, and immediate jeopardy findings related to resident safety during transport. The facility demonstrated improvement by correcting cited deficiencies promptly, with the most recent inspection showing full compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
34.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
478% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
102 residents
Based on a August 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 20, 2018
Visit Reason
An offsite revisit survey was conducted on 09/20/2018 for all previous deficiencies cited on 08/16/2018.
Findings
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.
Inspection Report
Annual Inspection
Census: 102
Deficiencies: 4
Date: Aug 16, 2018
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failure to ensure catheter bags were covered to maintain resident dignity for two residents.
Failure to ensure professional staff with expertise in developmental disabilities were available to assess and develop interventions for expressive communication needs for two residents.
Failure to properly label and date insulin vials, nasal sprays, inhalers, and failure to dispose of expired medical supplies and properly label insulin pens.
Failure to store, prepare, and serve food under sanitary conditions including uncovered food containers, open and unlabeled drink containers, dirty ice and water dispensers, and lack of temperature logs for steam table.
Report Facts
Survey Census: 102
Sample Size: 22
Supplemental Residents: 26
Expired medical supplies: 10
Unlabeled drink containers: 6
Unlabeled food containers: 4
Ice and water dispensing units: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Aide/Social Services Director | Social Services Director | Provided information about residents R38 and R49 and communication devices |
| Consultant Speech and Language Therapist | Speech and Language Therapist | Interviewed regarding speech assessments for residents R38 and R49 |
| Lead Charge Nurse | Lead Charge Nurse | Interviewed about insulin vial dating practices |
| Licensed Practical Nurse 2 | LPN | Interviewed about checking expiration dates on medical supplies |
| Licensed Practical Nurse 3 | LPN | Found insulin pen mislabeled and discussed medication administration |
| Unit Manager 1 | Unit Manager | Investigated mislabeled insulin pen and pharmacy error |
| Charge Certified Medication Aide 1 | CCMA | Interviewed about medication bottle labeling |
| Cook 1 | Cook | Confirmed improper sealing of food containers and unlabeled drinks and pies |
| Director of Food Services | Director of Food Services | Confirmed dirt and grime on water and ice dispensers |
| Dietary Aide 1 | Dietary Aide | Confirmed lack of temperature logs for steam table |
| Cook 2 | Cook | Confirmed lack of temperature logs for steam table |
| Dietary Supervisor | Dietary Supervisor | Unaware of missing temperature logs for steam table |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Aug 16, 2018
Visit Reason
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.
Findings
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.
Deficiencies (4)
Privacy covers for residents with catheters were not consistently used.
Residents with intellectual disabilities required reassessment and updated care plans for communication.
Medication labels and open dates were not consistently checked or accurate.
Food and drinks were found without dates; containers with warped lids were in use; ice machine cleaning procedures were inadequate.
Report Facts
Residents identified for catheter privacy review: 2
Residents identified for communication reassessment: 2
Frequency of audits: 3
Completion dates for substantial compliance: Sep 15, 2018
Completion date for food safety compliance: Sep 18, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 16, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance |
Inspection Report
Re-Inspection
Census: 12
Deficiencies: 6
Date: Jul 2, 2018
Visit Reason
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.
Findings
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.
Deficiencies (6)
Negotiated service agreements were not signed by all parties involved.
Failure to ensure licensed nurse provided or coordinated necessary health care services meeting resident needs related to falls and skin conditions.
Failure to provide ongoing nurse assessment and monitoring of impaired skin integrity.
Failure to ensure licensed nurse oriented and instructed certified medication aides in blood sugar testing and document competency.
Failure to place full resident names on over-the-counter medication packages or containers.
Failure to provide quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 12
Residents affected by OTC medication labeling: 7
Number of residents sampled: 3
Number of unsigned negotiated service agreements in sample: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Interviewed and confirmed deficiencies related to negotiated service agreements, health care services, wound assessments, and medication aide training | |
| Licensed Nurse E | Documented fall incident for resident #701 | |
| Licensed Nurse F | Documented fall incident for resident #701 | |
| Direct Care Staff G | Documented fall incident for resident #703 | |
| Administrator D | Administrator | Confirmed lack of quarterly emergency preparedness training |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 9, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to involuntary discharge and transfer practices of a resident at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to allow a resident to remain in the facility without proper documentation meeting involuntary discharge requirements.
Failed to provide complete and accurate notices of involuntary discharge including required contact information, appeal rights, and sending copies to the ombudsman.
Failed to provide the resident's durable power of attorney a copy of the bed hold policy at the time of transfer to a geriatric psychiatric hospital.
Failed to allow the resident to return to the facility after hospitalization.
Report Facts
Days bed hold exceeded: 10
Notice period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Interviewed regarding discharge process and documentation; provided explanations about notice and bed hold policy. | |
| Physician B | Contacted by facility regarding resident discharge and placement. | |
| Physician C | Provided medical opinion agreeing with need for resident discharge. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 9, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 9, 2018
Visit Reason
An off-site survey was conducted for the deficiencies cited on February 9, 2018.
Findings
The deficiencies cited during the survey were corrected as of the compliance date of February 23, 2018.
Report Facts
Compliance date: Feb 23, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 21, 2017
Visit Reason
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.
Findings
All deficiencies identified in the prior inspection have been corrected by the compliance date, and no new noncompliance was found.
Deficiencies (1)
All deficiencies have been corrected as of the compliance date 11/23/17.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 21, 2017
Visit Reason
A revisit survey was conducted on 12/21/17 to verify correction of all previous deficiencies cited on 10/24/17.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 3, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Mennonite Friendship Communities Inc.
Complaint Details
The plan of correction is in response to a complaint investigation at the facility.
Findings
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.
Deficiencies (1)
Pressure ulcer on right heel requiring complete skin assessment, measurement, and prevention measures.
Report Facts
Complete Date for Correction: Nov 23, 2017
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Date: Oct 24, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#120207) focusing on pressure ulcer prevention and treatment at the facility.
Complaint Details
Complaint investigation #120207 focused on pressure ulcer prevention and treatment failures.
Findings
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.
Deficiencies (1)
Failure to develop and implement timely and effective interventions to prevent avoidable stage 3 and stage 4 pressure ulcers.
Report Facts
Census: 99
Braden Risk Assessment Score: 16
Braden Risk Assessment Score: 15
Pressure ulcer size: 3.5
Pressure ulcer size: 6.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse D | Licensed Nurse | Interviewed regarding resident wound care and treatment |
| licensed nurse C | Licensed Nurse | Interviewed regarding resident pressure ulcer status |
| administrative licensed nurse B | Administrative Licensed Nurse | Interviewed regarding resident admission and pressure ulcer development |
| licensed nursing staff G | Licensed Nursing Staff | Interviewed regarding resident pressure ulcer and treatment compliance |
| physician H | Physician | Interviewed regarding pressure ulcer etiology and treatment |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 24, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers, indicating avoidable pressure ulcers and inadequate care and services to prevent worsening conditions.
Report Facts
Denial of payment effective date: Nov 20, 2017
Previous survey date: Mar 30, 2017
Compliance deadline: Apr 24, 2018
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to complaint coordination and instructions for dispute resolution |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 26, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency previously reported under regulation 26-40-305 (i)(1)(2)(3) was corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 26, 2017
Visit Reason
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.
Findings
The revisit report indicates that the deficiencies previously cited have been corrected as of the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 28, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and coordinator related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Date: Apr 9, 2017
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to ensure the environment remained free from accident hazards when a resident exited and was locked out overnight.
Failed to ensure staff conducted routine verification of resident's whereabouts and assessed resident for injuries after being outside for 5 hours.
Report Facts
Resident census: 104
Resident absence duration: 5
Resident sign-outs: 9
Resident sign-outs: 5
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Date: Mar 30, 2017
Visit Reason
The inspection was a partial extended survey conducted for investigation of complaint KS00113628 regarding resident safety during transport.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to complete routine preventative maintenance checks of a platform lift used to raise/lower residents in a facility bus, resulting in a resident fall and serious injury.
Failure to ensure completion of routine preventative maintenance checks for safety related to ramps used to load/unload residents into facility vans.
Failure to have a system in place to ensure routine mechanical/safety/preventive maintenance checks of lifts/equipment/facility owned vehicles used to transport residents.
Report Facts
Resident census: 107
Height of fall: 3
Date of incident: Mar 22, 2017
Date of inspection: Mar 30, 2017
Date of lift repair invoice: Jan 26, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Reported details of the fall incident and removal of bus/lift from service | |
| Transportation Staff C | Demonstrated platform lift operation and confirmed no prior mechanical issues | |
| Transportation Staff D | Driver who transported resident on day of fall and described incident | |
| Administrative Nurse B | Assisted with demonstration of platform lift |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 30, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a corrected complaint inspection conducted at Mennonite Friendship.
Complaint Details
This plan of correction relates to a corrected complaint dated 03/30/2017.
Findings
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.
Deficiencies (2)
Past non compliance: no plan of correction required.
Past non compliance: no plan of correction required.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 30, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Facility conditions constituted Immediate Jeopardy, Past Non-compliance to resident health or safety F323, "J", CFR 483.25(d)(1)(2)(n)(1)-3.
Report Facts
Days to request Informal Dispute Resolution: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact for questions and signatory of the letter |
| Leigh Peck | Administrator | Facility administrator named in the report |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Mar 22, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
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.
Deficiencies (12)
Injury of cited resident was called into the hotline and will be investigated; nursing staff educated on reporting injuries of unknown origin.
Administration staff discussed bath options and preferences with cited residents; policy updated for bathing options.
All cited areas on the 400 hall will be repaired by maintenance; staff re-educated on reporting repair needs.
Care plans for cited residents reviewed and updated to reflect interventions and causal factors related to falls.
Care plan for cited resident with pressure ulcers reviewed and updated; nurses educated on interventions.
Cited resident's catheter changed to match physician's order; audits and nurse in-service planned.
Root Cause Analysis with interventions completed on all cited residents with falls; care plans updated.
Director of Nursing held in-service for nurses on PRN medication assessments and documentation.
Hot water booster for dishwasher repaired; dining services staff in-serviced on infection control and dishwasher use.
Cited medications labeled or removed; weekly audits by Certified Medication Aides planned.
Nursing staff in-serviced on appropriate glove use and infection control; spot checks planned.
Current cords replaced by water resistant cords in bathing areas; weekly audits by housekeeping.
Report Facts
Correction completion date: Mar 22, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Leigh Peck | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 11
Date: Mar 22, 2017
Visit Reason
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.
Findings
All previously reported deficiencies were corrected as of the revisit date, with each correction documented and completed on 03/22/2017.
Deficiencies (11)
483.13(c)(1)(ii)-(iii), (c)(2) - (4)
483.15(b)
483.15(h)(2)
483.20(d)(3), 483.10(k)(2)
483.25(c)
483.25(d)
483.25(h)
483.25(l)
483.35(i)
483.60(b), (d), (e)
483.65
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 22, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) previously reported
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 11
Date: Feb 20, 2017
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations related to allegations of abuse, neglect, falls, and infection control.
Complaint Details
The inspection included complaint investigations related to allegations of abuse, neglect, falls, and infection control violations.
Findings
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.
Deficiencies (11)
Failure to investigate and report an injury of unknown source for resident #125.
Failure to assess bathing preferences for resident #31.
Failure to maintain sanitary, orderly, and comfortable interior due to unrepaired damage in hallways and bathrooms.
Failure to revise care plans after falls and pressure ulcers for multiple residents (#125, #55, #37, #157, #28, #51).
Failure to follow physician orders for suprapubic catheter replacement for resident #114.
Failure to provide adequate supervision, ensure assistive devices were in place, and thoroughly investigate falls for residents (#55, #112, #125, #51, #157).
Failure to document reason and effectiveness of PRN medications administered to resident #88.
Failure to ensure sanitization of dishware and proper cleaning of food preparation utensils for residents receiving pureed diets.
Failure to ensure staff wore gloves when feeding residents finger foods.
Failure to properly label and store medications and medication pens, including expired nasal spray and unlocked treatment cart.
Failure to ensure infection control practices including isolation of residents with active airborne illness and proper glove use during incontinent care.
Report Facts
Residents sampled: 28
Residents with pureed diet: 13
Falls resident #125: 15
Falls resident #55: 8
Fall risk score resident #125: 15
Fall risk score resident #157: 15
Fall risk score resident #112: 15
Fall risk score resident #55: 15
Fall risk score resident #28: 15
Dishwasher log completion December 2016: 50
Dishwasher log completion January 2017: 25
Dishwasher log completion January 2017: 20
Dishwasher log completion January 2017: 6
Dishwasher log completion February 2017: 12
Dishwasher log completion February 2017: 11
Dishwasher log completion February 2017: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrator | Confirmed failure to investigate falls and update care plans |
| Licensed nurse CC | Licensed Nurse | Interviewed about resident fall history and care plan |
| Direct care staff W | Direct Care Staff | Interviewed about fall prevention interventions |
| Direct care staff HH | Direct Care Staff | Interviewed about fall prevention interventions |
| Licensed nurse M | Licensed Nurse | Interviewed about resident fall history and care plan |
| Licensed nurse O | Licensed Nurse | Interviewed about resident fall history and care plan |
| Direct care staff LL | Direct Care Staff | Observed and interviewed about glove use and incontinent care |
| Licensed nurse EE | Licensed Nurse | Observed and interviewed about glove use and incontinent care |
| Dietary staff JJ | Dietary Staff | Observed preparing pureed meals and cleaning utensils |
| Direct care staff FF | Direct Care Staff | Observed feeding resident without gloves |
| Licensed nurse J | Licensed Nurse | Interviewed about treatment cart locking |
| Direct care staff AA | Direct Care Staff | Interviewed about medication cart checks |
| Direct care staff Z | Direct Care Staff | Interviewed about medication cart checks |
| Licensed nurse L | Licensed Nurse | Interviewed about medication pen labeling |
| Licensed nurse K | Licensed Nurse | Interviewed about medication pen labeling |
| Physician TT | Physician | Interviewed about resident fall history |
| Licensed staff H | Licensed Nurse | Interviewed about PRN medication administration |
| Licensed nurse M | Licensed Nurse | Interviewed about PRN medication administration |
| Direct care staff Z | Direct Care Staff | Interviewed about PRN medication administration |
| Direct care staff RR | Direct Care Staff | Observed and interviewed about resident vomiting and infection control |
| Licensed nurse EE | Licensed Nurse | Interviewed about infection control and resident isolation |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 20, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
The document is an assisted living resurvey of the facility to verify compliance and check for deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Mennonite Friendship ALF.
Findings
No deficiencies were cited in the related inspection report.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 9, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
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.
Deficiencies (1)
Deficiency with ID Prefix S3026 related to regulation 26-41-101 (f)(1)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 28, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiencies cited at 'E' level that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 28, 2016
Visit Reason
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.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 12, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Mennonite Assisted Living.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Mennonite AL complaint 10122016.
Findings
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.
Deficiencies (1)
Elopement Risk Assessment was incomplete for cited residents and missing resident policies were not fully implemented.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Peck | Administrator | Submitted the Plan of Correction. |
| Dr. Janzen | Medical Director | To be reviewed with the QA team at the next QA meeting. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 2
Date: Oct 12, 2016
Visit Reason
The inspection was a partial extended survey conducted for investigation of complaint KS00106400 regarding resident safety and supervision in an assisted living facility.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to provide resident #1 with adequate supervision to prevent elopement, including failure to complete elopement risk assessment and failure to communicate resident's desire to leave.
Failure to assess elopement risk for resident #3 and failure to have systems in place to prevent resident #2 from exiting the facility and walking to a nearby pond without staff supervision.
Report Facts
Census: 15
Distance resident #1 eloped: 0.3
Distance to pond: 0.1
Mini-Mental score resident #1: 14
Mini-Mental score resident #2: 22
Mini-Mental score resident #2 prior: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff D | Let resident #1 out of assisted living house thinking resident was a visitor | |
| Direct Care Staff E | Found resident #1 outside near busy street and called family member | |
| Administrative Nurse B | Administrative Nurse | Responsible for admission assessments and elopement risk assessments; failed to complete proper assessments |
| Direct Care Staff C | Reported resident #1 was anxious and pacing prior to elopement | |
| Direct Care Staff F | Reported resident #2 knew door code and walked outside unsupervised | |
| Administrative Staff A | Administrator or Operator | Provided information about resident #1's admission and elopement incident |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 4
Date: Sep 28, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations KS00097424, KS00097414, and KS00105652.
Complaint Details
The inspection findings represent the results of complaint investigations KS00097424, KS00097414, and KS00105652.
Findings
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.
Deficiencies (4)
Failure to ensure resident's right to refuse treatment when medications were mixed with Dr. Pepper and administered without informing the resident.
Failure to review and revise care plans for residents related to transfer ability, fall prevention strategies, and pressure ulcer presence.
Failure to provide adequate supervision to prevent resident elopement and failure to implement timely interventions after elopement.
Failure to have pharmaceutical systems in place to ensure administration of medications as ordered; antipsychotic medication not administered for six days due to lack of availability.
Report Facts
Census: 102
Medication refusals: 26
Medication refusals: 28
Medication refusals: 18
Medication refusals: 3
Distance wandered: 800
Days medication not administered: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff B | Reported failure to inform resident #5 about medication mixed with Dr. Pepper. | |
| Direct Care Staff J | Observed mixing medications with Dr. Pepper and administering to resident #5 without informing. | |
| Direct Care Staff K | Reported mixing resident #5's medications with Dr. Pepper and uncertainty if resident knew. | |
| Administrative Staff A | Confirmed failures in care plan revisions and delayed Wanderguard placement after elopement. | |
| Administrative Nurse B | Confirmed resident #1 elopement details and failure to change door alarm codes promptly. | |
| Administrative Nurse I | Reported resident #6 expired and confirmed medication administration failure. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 13, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiencies cited at 'F' level severity
Report Facts
Effective date for denial of payments: Sep 13, 2016
Provider agreement termination date: Dec 13, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 1, 2016
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficiency related to 483.13(b), 483.13(c)(1)(i)
Deficiency related to 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to 483.25
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: Mar 2, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to ensure resident was free from sexual/physical abuse due to lack of 1:1 supervision resulting in inappropriate touching.
Failure to immediately report alleged abuse incident to facility administrator and state agency.
Failure to provide necessary care and services to maintain highest practicable physical well-being related to bowel management, fluid intake monitoring, and nursing assessments.
Report Facts
Census: 88
Residents selected for sample: 7
Weight loss: 7
Fecal impaction size: 13
Days without bowel movement: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Reported failure to provide 1:1 supervision and delayed knowledge of abuse incident. | |
| Administrative Nurse B | Reported failure to provide 1:1 supervision and delayed reporting of abuse incident. | |
| Direct Care Staff C | Certified Nurse Aide | Reported observation of inappropriate touching and changes in supervision practices. |
| Licensed Nurse D | Reported changes in supervision practices related to resident #1. | |
| Staff E | Reported learning of abuse incident from staff conversation. | |
| Licensed Nurse F | Described bowel management program and nursing assessments related to resident #6. | |
| Direct Care Staff G | Reported that bowel movements are known only if resident reports them. | |
| Dietary Staff H | Reported food/fluid intake documentation practices and lack of monitoring total fluid intake. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 2, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
D level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Nov 12, 2015
Visit Reason
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.
Findings
All previously cited deficiencies identified by regulation numbers F0223, F0225, F0280, and F0309 were corrected as of the revisit date 11/12/2015.
Deficiencies (4)
Deficiency related to regulation 483.13(b), 483.13(c)(1)(i)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 4
Date: Nov 2, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of abuse involving residents #1, #2, #3, and #5.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to ensure residents remained free from physical abuse (inappropriate touching) when staff failed to monitor resident #1 as care planned.
Failure to thoroughly investigate and report all allegations of abuse involving residents #5, #2, and #3 to the State survey and certification agency.
Failure to review and revise resident #1's care plan with timely and appropriate interventions to manage behaviors.
Failure to provide necessary care and services to manage resident #1's repeated inappropriate behavioral symptoms directed towards staff and residents.
Report Facts
Census: 98
Sampled residents: 6
BIMS score: 0
BIMS score: 6
BIMS score: 3
BIMS score: 10
Zoloft dosage: 50
Zoloft dosage: 100
Zyprexa dosage: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administrative Nurse | Named in multiple findings related to supervision and investigation of resident #1's behaviors |
| Nurse G | Licensed Nurse | Named in findings related to reporting and supervising residents during incidents |
| Staff E | Witnessed inappropriate touching incidents involving resident #1 and #5 | |
| Staff H | Witnessed inappropriate touching incidents involving resident #1 and #5 | |
| Staff I | Witnessed inappropriate touching incidents involving resident #1 and #5 | |
| Staff D | Witnessed inappropriate touching incidents involving resident #1 and #2 | |
| Staff J | Witnessed inappropriate touching incidents involving resident #1 and #5 | |
| Staff F | Provided care and described resident #2's needs and behaviors | |
| Staff M | Described monitoring of resident #1 and supervision during meals | |
| Staff L | Removed and replaced stop sign on resident #1's door and assisted with care | |
| Administrative Staff A | Provided timeline and investigation details related to abuse allegations |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 2, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency was an 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 11
Date: Aug 13, 2015
Visit Reason
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.
Findings
The report shows that all previously cited deficiencies were corrected by 07/17/2015, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (11)
Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.20(b)(2)(ii)
Deficiency related to regulation 483.20(a) - (i)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(m)(2)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 11
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 11
Date: Jun 19, 2015
Visit Reason
The inspection was a health resurvey of Mennonite Friendship Communities Inc nursing facility to assess compliance with federal regulations.
Findings
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.
Deficiencies (11)
Failed to post required telephone numbers for state complaint hotline and Medicare/Medicaid services in a prominent location and legible print size.
Failed to notify physician after significant change in resident condition including medication errors and abnormal blood sugars for resident #119.
Failed to promote resident dignity by placing clothing protectors on residents without asking if they wanted one.
Failed to complete comprehensive significant change MDS within 14 days after resident decline in multiple areas for resident #119.
Failed to accurately assess and code MDS regarding weight loss and urinary incontinence for residents #70 and #133.
Failed to ensure coordination of facility and hospice services to meet needs of resident #77.
Failed to identify root cause of multiple falls and implement interventions to prevent further falls for residents #133 and #119.
Failed to provide resident #119 with medications from June 6-9, 2015, failed to administer Novolog as ordered, and failed to notify physician of abnormal blood sugars.
Failed to remove and dispose of expired medications found in the 100 hall medication room.
Failed to ensure housekeeping staff followed manufacturer instructions for disinfectant use, specifically allowing disinfectant to remain wet for 10 minutes.
Failed to provide evidence that the physician, director of nursing, and at least 3 other staff attended quarterly QAA meetings.
Report Facts
census: 105
blood sugar readings: 427
blood sugar readings: 416
blood sugar readings: 422
blood sugar readings: 424
blood sugar readings: 50
weight: 369
weight: 314
weight loss: 8
fall risk score: 15
fall risk score: 8
fall risk score: 12
fall risk score: 15
skin tear size: 6
skin tear size: 3
number of expired medication bottles: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse J | Licensed Nurse | Reported medication administration issues and failure to notify physician for resident #119 |
| Administrative Nurse B | Administrative Nurse | Unaware of missed medications for resident #119 and expected staff to notify physician |
| Consultant V | Pharmacy Consultant | Reported pharmacy contacted on 6/9/15 for resident #119 medication order |
| Physician W | Physician | Reported not contacted about missed medications and blood sugar issues for resident #119 |
| Staff C | Housekeeping Staff | Observed not following disinfectant wet time instructions |
| Staff D | Housekeeping Staff | Reported disinfectant should remain wet for 10 minutes |
| Administrative Staff A | Administrative Staff | Confirmed lack of QAA meeting attendance signatures |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 19, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiencies found at 'F' level
Report Facts
Denial of Payment for New Admissions effective date: Sep 19, 2015
Termination recommendation date: Dec 19, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Todd Schlosser | Administrator | Facility administrator named in the report |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Jun 11, 2015
Visit Reason
This document is a Plan of Correction submitted by Mennonite Friendship Communities in response to deficiencies cited during a prior survey inspection.
Findings
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.
Deficiencies (11)
Inadequate posting of required information, replaced with larger, more visible posting.
Failure to timely notify physician of medication errors and provide medications as ordered.
Failure to respect resident wishes regarding wearing clothing protectors.
Incomplete or inaccurate resident assessments and significant change documentation.
Inaccurate MDS coding and chart reviews.
Omission of hospice initiation date in care plan and lack of staff communication about hospice role.
Inadequate fall interventions and failure to communicate interventions to staff.
Improper medication administration related to insulin and failure to communicate medication errors.
Possession of expired medications (Fish Oil) and failure to monitor medication expiration.
Improper use of disinfectant spray by housekeeping staff not following manufacturer's instructions.
Failure to document attendance at QA meetings with signature sheets.
Report Facts
Deficiencies cited: 11
Corrective action completion date: Jul 17, 2015
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 21, 2015
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 23, 2015
Visit Reason
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.
Findings
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.
Report Facts
Denial of payment effective date: Apr 12, 2015
Noncompliance correction deadline: Sep 23, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter |
| Gregg Brandush | Branch Manager | Authorized the letter |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Mar 23, 2015
Visit Reason
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).
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to provide timely and thorough nursing assessments of a 2nd degree burn to resident #1 over a 12-day period.
Failure to provide adequate supervision to prevent accidents when unlicensed staff applied an overheated Bed Buddy rice pack to resident #1's shoulder, resulting in 2nd degree burns.
Report Facts
Census: 109
Residents sampled: 3
Burn assessment gap: 12
Bed Buddy heating time: 3
Blister size: 7
Blister size: 5
Blister and surrounding redness size: 8.5
Blister and surrounding redness size: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff D | Heated the Bed Buddy in the microwave and assisted with placement on resident #1's shoulder. | |
| Direct Care Staff E | Assisted with placement of the Bed Buddy on resident #1's shoulder and reported lack of training on safe use of Bed Buddies. | |
| Licensed Nurse C | Licensed Nurse | Removed dressing from resident #1's wound and confirmed the burn injury. |
| Administrative Nurse B | Administrative Nurse | Reported licensed nurses should record all skin and wound assessments and confirmed lack of timely nursing assessments; provided notarized statement summarizing events leading to injury. |
| Physician F | Physician | Physician's nurse reported the burn was a 2nd degree burn from hot rice pack placement. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 24, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Facility had 'F' level deficiencies related to Life Safety Code compliance.
Report Facts
Enforcement effective date: Dec 24, 2014
Provider agreement termination date: Mar 24, 2015
Plan of Correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Sep 23, 2014
Visit Reason
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.
Findings
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.
Deficiencies (5)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii),(c)(2)-(4)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(k)
Report Facts
Correction completion date: Aug 15, 2014
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jul 23, 2014
Visit Reason
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.
Complaint Details
This plan of correction is in response to a complaint investigation survey conducted on 07/23/2014 regarding multiple deficiencies at the facility.
Findings
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.
Deficiencies (5)
Elopement risk and incident reporting deadlines not met
Skin breakdown risk assessment and prevention measures inadequate
Safety awareness and elopement risk evaluation for cognitively impaired residents insufficient
Nutritional status monitoring and intervention for residents with significant weight loss lacking
Oxygen equipment competency and monitoring protocols deficient
Report Facts
Plan of correction completion date: Aug 15, 2014
Frequency of Risk meetings: 2
Braden Scale thresholds: 15
Braden Scale threshold: 19
Weight loss review periods: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Schlosser | Administrator | Administrator responsible for implementation of plan of correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Person who added Plan of Correction on 07/24/2014 | |
| Mary Jane Kennedy | Person who modified Plan of Correction on 09/24/2014 |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 23, 2014
Visit Reason
An abbreviated survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers, indicating avoidable pressure ulcers and inadequate preventive care.
Report Facts
Enforcement effective date: Aug 22, 2014
Noncompliance follow-up deadline: Jan 23, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions regarding the enforcement letter |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 5
Date: Jul 23, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of elopement, pressure ulcers, accident hazards, nutrition, and oxygen therapy.
Complaint Details
The complaint investigations #77122 and #77135 focused on allegations of abuse, neglect, mistreatment, elopement, pressure ulcers, accident hazards, nutrition, and oxygen therapy.
Findings
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.
Deficiencies (5)
Failure to immediately report an elopement and complete investigation within 5 days.
Failure to prevent development of facility-acquired stage II and III pressure ulcers.
Failure to accurately assess elopement risk resulting in resident elopement and fall.
Failure to provide planned snacks to prevent weight loss contributing to 7.8% weight loss in 3 months.
Failure to implement planned continuous oxygen therapy to maintain oxygen saturation above 90%.
Report Facts
Census: 98
Weight loss percentage: 7.8
Weight loss percentage: 7.9
Oxygen flow rate: 2
Days delayed reporting elopement: 4
Braden score: 16
Braden score: 17
Fall risk score: 11
Medication Pass 2.0 volume: 60
Medication Pass 2.0 frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Named in delayed reporting of elopement and oxygen therapy findings |
| Staff A | Administrative Staff | Confirmed elopement reporting by Staff D |
| Staff N | Direct Care Staff | Reported repositioning and toileting of resident #3 |
| Staff P | Licensed Nursing Staff | Reported skin assessments and oxygen therapy for resident #3 |
| Staff Q | Licensed Nursing Staff | Assessed pressure ulcers and monitored oxygen saturations |
| Staff R | Licensed Nursing Staff | Assessed resident #3 on readmission and confirmed wound measurements |
| Staff C | Direct Care Staff | Reported resident #2 mobility and wandering behavior |
| Staff V | Direct Care Staff | Reported oxygen tank checks and oxygen saturation monitoring for resident #3 |
| Staff J | Direct Care Staff | Reported oxygen monitoring and tank checks for resident #3 |
| Staff E | Licensed Nursing Staff | Reported snack pass system and resident #1 nutrition status |
| Staff F | Administrative Nursing Staff | Monitored snack documentation and resident nutrition |
| Staff L | Direct Care Staff | Reported snack offering and documentation |
| Staff M | Direct Care Staff | Reported snack offering and documentation |
| Staff B | Consultant Staff | Reported nutrition interventions and snack documentation |
| Physician U | Physician | Expected notification of resident medical changes |
| Physician T | Physician | Commented on resident #1 weight loss and nutrition |
| Administrative Nursing Staff G | Administrative Nursing Staff | Confirmed lack of snack documentation in resident #1 chart |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 5, 2014
Visit Reason
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.
Findings
The report documents that multiple deficiencies previously cited under various regulations were corrected by the revisit date of 06/05/2014.
Deficiencies (4)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: May 7, 2014
Visit Reason
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.
Findings
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.
Deficiencies (4)
Care plan for resident #71 revised to include intervention regarding foot position and pressure.
Interventions to continue for resident #71's pressure sore with modifications and staff education.
Care plan for resident #136 reviewed and fall risk reassessed with additional skid strips placed.
Facility has quarterly QA committee and sub-groups to monitor quality of care including pressure ulcers and falls.
Report Facts
Plan of correction completion date: May 7, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Schlosser | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 7, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
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.
Deficiencies (1)
Deficiency under regulation 26-40-305 (c)(1)(2) previously cited
Inspection Report
Follow-Up
Deficiencies: 7
Date: Apr 7, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-02-28.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers were corrected as of the revisit date 2014-04-07.
Deficiencies (7)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 4
Date: Apr 7, 2014
Visit Reason
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.
Complaint Details
The revisit and complaint investigation #65316 focused on care plan revisions, pressure ulcer treatment and prevention, fall risk management, and quality assurance program effectiveness.
Findings
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.
Deficiencies (4)
Failed to revise the care plan to include necessary treatment and services to prevent redevelopment and promote healing of a pressure ulcer for resident #71.
Failed to provide necessary treatment and services to prevent redevelopment and promote healing of a pressure ulcer for resident #71.
Failed to ensure resident environment remained free of accident hazards and provide adequate supervision and assistance devices to prevent accidents for resident #136.
Failed to maintain an effective quality assurance program to monitor and ensure implementation of corrective action plans related to pressure ulcers, falls, and care plan revisions.
Report Facts
Facility census: 108
Residents in sample: 7
Residents reviewed for pressure ulcers: 3
Braden score: 15
Pressure ulcer size: 0.5
Fall risk score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Licensed Nursing Staff | Confirmed pressure ulcer reopened as stage III and interventions in place |
| Staff N | Administrative Nursing Staff | Reported expectations for care plan adherence and staff education on pressure ulcers and falls |
| Staff E | Licensed Nursing Staff | Performed dressing changes and educated resident on pressure ulcer prevention |
| Staff K | Licensed Nursing Staff | Performed dressing changes and discussed pressure ulcer care with resident |
| Staff A | Direct Care Staff | Reported resident repositioning needs during shift change |
| Staff B | Direct Care Staff | Provided care and repositioning to resident |
| Staff C | Direct Care Staff | Confirmed repositioning schedule and care plan adherence |
| Staff G | Direct Care Staff | Reported fall risk procedures and resident behavior |
| Staff F | Licensed Nursing Staff | Reported fall causes and expectations for staff |
| Staff D | Licensed Nursing Staff | Explained turning schedule based on tissue tolerance testing |
| Staff L | Direct Care Staff | Reported pressure ulcer prevention interventions |
| Staff H | Direct Care Staff | Assisted resident with pressure ulcer care |
| Staff I | Direct Care Staff | Assisted resident with pressure ulcer care |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Mar 28, 2014
Visit Reason
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.
Findings
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.
Deficiencies (10)
Failure to properly report and document alleged incidents of Abuse, Neglect and Exploitation (ANE).
Improper assistance with dining affecting resident dignity and respect.
Inadequate cleaning and maintenance of assistive equipment and towel bars in semi-private rooms.
Insufficient assessment, documentation, and monitoring of residents at risk for skin bruising.
Lack of proper tissue tolerance testing and monitoring for residents at risk of pressure ulcers.
Inadequate fall prevention interventions and care plan updates.
Failure to ensure food and drink are served and prepared in a sanitary manner.
Expired medications not properly tracked and removed.
Improper infection control procedures related to toileting assistance.
Ventilation system maintenance deficiencies in multiple facility areas.
Report Facts
Corrective action completion date: Mar 28, 2014
Staff in-service dates: Mar 21, 2014
Staff meeting dates: Mar 18, 2014
Staff meeting dates: Mar 20, 2014
Skin education in-service date: Mar 26, 2014
Dietary meeting date: Mar 13, 2014
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 9
Date: Feb 28, 2014
Visit Reason
The inspection was conducted as a health resurvey including review of allegations of abuse, resident care, housekeeping, medication management, infection control, and safety.
Findings
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.
Deficiencies (9)
Failure to immediately report an alleged verbal abuse involving resident #95 to administration and state officials.
Failure to assist residents to eat in a dignified manner by not sitting with residents during meals.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failure to monitor bruising for a resident at risk for excessive bruising and bleeding.
Failure to consistently implement interventions to heal a pressure ulcer and prevent further pressure ulcers for a resident with a history of pressure ulcers.
Failure to ensure the resident environment remained free of accident hazards and to maintain effective fall prevention interventions for residents at high risk for falls.
Failure to prepare and serve food in a sanitary manner including improper handling of ready to eat foods, failure to ensure proper food temperatures, and improper handling of resident drinking and food surfaces.
Failure to properly dispose of expired medications including insulin and cough syrup with codeine.
Failure to ensure staff changed gloves after providing perineal care to prevent cross-contamination and infection.
Report Facts
Residents sampled: 22
Residents affected by housekeeping deficiency: 10
Residents affected by expired insulin: 4
Residents affected by expired insulin: 6
Residents affected by expired narcotics: 17
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 7, 2012
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.70(f)
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 7, 2012
Visit Reason
This document is a Plan of Correction submitted by Mennonite Friendship Communities addressing deficiencies cited in a prior inspection report.
Findings
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.
Deficiencies (3)
Resident affected received physician order to try removal of catheter; catheter was removed for a trial period but family and resident preferred to retain catheter.
South Hall utility room will have a coded entry lock installed and thumb knobs removed from inside handles to improve security.
Pagers have been provided for staff in the dementia unit and training provided to improve communication.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Renae Kersenbrock | VP of Health Services | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 3
Date: Nov 9, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation into complaint #56631.
Complaint Details
The visit was triggered by complaint #56631 and included a health resurvey.
Findings
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.
Deficiencies (3)
Failure to remove an indwelling catheter to prevent urinary tract infections and restore bladder function for 1 of 3 sampled residents.
Failure to maintain a safe environment by not securing hazardous chemicals accessible to cognitively impaired residents.
Failure to have a functional resident call system on the locked dementia unit to ensure direct communication to caregivers.
Report Facts
Facility census: 115
Sample size: 23
Residents with indwelling catheters in sample: 3
Residents independently mobile with cognitive impairment: 19
Residents on locked dementia unit: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff I | Provided information about the resident with the indwelling catheter and the decision to keep it in place. | |
| Direct care staff H | Reported on resident transfer method and assistance needed. | |
| Maintenance staff A | Reported that soiled utility doors should have been locked and noted lack of audible call system signals. | |
| Administrative staff B | Reported that chemicals should be locked and that staff on the locked dementia unit now had pagers for the call system. | |
| Direct care staff F and G | Reported not carrying pagers for the wireless call system on the locked dementia unit. | |
| Licensed staff E | Reported staff did not carry pagers because residents could not use call lights. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 5, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2012-08-06.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.20(b)(2)(ii)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 5, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation for the Mennonite Friendship Communities facility.
Findings
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.
Deficiencies (2)
A significant change assessment will be completed by resident #2. The RAI manual significant change criteria will be reviewed by all facility MDS Coordinators and Interdisciplinary team members. When residents have falls that result in fractures, an Interdisciplinary Team will be consulted to make decisions regarding the necessities for significant change assessments.
The Care Plan for Resident #2 will be reviewed to evaluate fall interventions for appropriateness and resident's wishes. Front line staff will be educated as to protocols for alarm usage and replacement. Random audits will be performed weekly by a delegated nurse on residents that are fall risks with alarms in place. Audits will be monitored by Director of Nursing.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Renae Kersenbrock | Administrator | Submitted the Plan of Correction |
| Mary Jane Kennedy | Modified the Plan of Correction | |
| Irina Strakhova | Added the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 2
Date: Aug 6, 2012
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #KS00056898 regarding the facility's compliance with resident care requirements.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to conduct a comprehensive assessment for one resident within 14 days after a significant change in physical and mental condition.
Failed to ensure one resident with recent falls received adequate supervision and assistive devices (bed alarm) to prevent accidents.
Report Facts
Census: 117
Residents sampled: 3
Days since readmission: 41
Date of readmission: Jun 22, 2012
Date of Medicare 5 day assessment: Jul 24, 2012
Date of Medicare 14 day assessment: Jul 30, 2012
Date of Care Plan: Jul 5, 2012
Date intervention added: Jun 25, 2012
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 5, 2012
Visit Reason
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.
Complaint Details
Investigation was conducted due to a complaint alleging abuse. The results of the investigation were negative, indicating no impact on residents.
Findings
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.
Deficiencies (1)
Failure to ensure proper protocol for reporting abuse, neglect, and exploitation.
Report Facts
Complete Date: Jul 5, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Renae Kersenbrock | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 5, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
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.
Deficiencies (1)
Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) previously cited
Report Facts
Deficiency correction date: Jul 5, 2012
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Date: Jun 5, 2012
Visit Reason
The inspection was conducted as a complaint survey for complaint #57335, investigating allegations of mistreatment, neglect, or abuse at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to immediately report an allegation of abuse to the administrator and prevent further potential abuse by suspending the alleged perpetrator immediately.
Report Facts
Census: 120
Residents cared for by alleged perpetrator: 17
Number of allegations reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Interviewed regarding the abuse allegation and reporting; did not immediately send alleged perpetrator home | |
| Direct care staff C | Alleged perpetrator who shoved a resident into a chair | |
| Direct care staff A | Reported witnessing the alleged abuse | |
| Administrative Nurse G | Received the abuse report from Licensed nursing staff B and initiated further investigation | |
| Administrative Nurse E | Confirmed failure to immediately notify administrative staff or prevent further abuse | |
| Administrative staff D | Confirmed failure to immediately notify administrative staff or prevent further abuse | |
| Maintenance staff F | Witness interviewed during investigation; did not see the alleged abuse |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N078005 POC OV9V11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Deficient practice related to timely assessment and documentation of wounds in residents with significant skin injuries.
Improper use and monitoring of hot rice packs (Bed Buddies) leading to potential burn blisters.
Report Facts
Plan of Correction completion date: 2015
QA Committee meeting date: 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Schlosser | Administrator | Submitted the Plan of Correction to KDADS |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N078005 POC 0D1S11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Resident was asked to wear a wanderguard bracelet and to allow staff to assist her when she wants to go outside; resident added to list for checks every 2 hours at night; care plan updated accordingly.
Batteries were replaced in the cited doorbell; doorbells checked for proper working condition; doorbell was direct wired to eliminate battery need; maintenance plan updated.
Report Facts
Deficiency completion date: May 26, 2017
Deficiency correction date: May 3, 2017
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N078005 POC 9N0B11
Visit Reason
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.
Findings
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.
Deficiencies (4)
New accommodations were found for cited resident in a home with a special care unit related to involuntary discharge documentation and procedures.
New accommodations were found for cited resident regarding proper information for Department of Administrative Hearings, Ombudsman, and Disability Rights Center in involuntary discharge letters.
Notice of bed hold policy was sent to cited resident's DPOA; policy review for compliance regarding transfers/discharges without notice of bed-hold.
New accommodations found related to residents' right to return to the facility after discharge and policy development addressing this right.
Report Facts
Complete Date: Mar 16, 2018
Complete Date: Feb 23, 2018
Complete Date: Feb 28, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Peck | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N078005 POC EUB811
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as 'mennonite friendship communities complaint 03022016'.
Findings
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.
Deficiencies (3)
Resident will be seated at the nursing station for meals with staff and accompanied when out of room; care plan updated accordingly.
Nurse coached on immediate reporting of suspected abuse, neglect, or exploitation; staff inserviced on abuse reporting protocols.
Nurses educated on assessment and documentation protocols for residents who self-toilet with diminished cognitive skills; fluid intake tracking implemented.
Report Facts
Correction completion date: Apr 1, 2016
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N078005 POC KX2S11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Mennonite Friendship facility.
Complaint Details
This Plan of Correction is related to a complaint investigation at Mennonite Friendship facility.
Findings
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.
Deficiencies (4)
Resident was placed in hospital for psych evaluation and medication monitoring; future concerns regarding abuse will be investigated with immediate interventions and care plan revisions.
Resident interviews were completed; future investigations of abuse, neglect, and exploitation will include interviews with alert and oriented residents and be discussed in weekly Risk Meetings.
Care plans have been reviewed and revised; all care plans will be updated when new interventions are put into place and reviewed quarterly during MDS process.
Interventions for cited resident were reviewed and updated; staff working with residents with repeated inappropriate behaviors will be oriented before working in their neighborhood.
Report Facts
Deficiency correction completion dates: Nov 5, 2015
Deficiency correction completion dates: Nov 12, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Peck | VP for Health Care Services | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N078005 POC L49P11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the Mennonite Friendship complaint inspection dated 09/28/2016.
Complaint Details
This Plan of Correction is related to the Mennonite Friendship complaint investigation dated 09/28/2016.
Findings
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.
Deficiencies (4)
Resident was informed of medications in his Dr. Pepper with med passes; requirement added to orientation checklist and weekly risk meetings.
Care plan for cited resident to be reviewed and revised to show current interventions; all care plans reviewed for compliance.
Door code labels for wanderguard moved to higher location; cognitively impaired residents assessed for wanderguard placement; door codes changed; daily door checks performed.
Medications received from Hospice reviewed to assure availability; policy updated for medication unavailability procedures; staff instructed on MAR review and notification.
Report Facts
Complete Date: Oct 13, 2016
Complete Date: Oct 15, 2016
Complete Date: Oct 28, 2016
Complete Date: Oct 15, 2016
Complete Date: Oct 17, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Leigh Peck | Administrator | Submitted Plan of Correction to KDADS |
| Irina Strakhova | Modified Plan of Correction |
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