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Deficiency Records for Mennonite Friendship Communities Inc
View the most recent health deficiencies and inspection results for Mennonite Friendship Communities Inc. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Mennonite Friendship Communities Inc. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-08-26 | 2025-09-26 | Y |
| Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Health | 2025-08-26 | 2025-09-25 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-01-15 | 2025-02-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2025-01-15 | 2025-02-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-01-15 | 2025-02-20 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2025-01-15 | 2025-02-20 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-01-15 | 2025-02-20 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-01-15 | 2025-02-20 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2025-01-15 | 2025-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-15 | 2025-02-20 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2025-01-15 | 2025-02-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-01-15 | 2025-02-20 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-09 | 2023-05-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-04-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-09 | 2023-04-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-04-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Meet other general requirements. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-09-08 | 2021-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-08 | 2021-10-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-09-08 | 2021-10-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-09-08 | 2021-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-08 | 2021-10-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-08 | 2021-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-08 | 2021-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-08 | 2021-10-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-08 | 2021-10-01 | N |