Deficiency Records for Mennonite Friendship Communities Inc
Updated as of April 01, 2024
A list of the most recent deficiencies for Mennonite Friendship Communities Inc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-11 | 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 | 2023-04-11 | 2023-05-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-11 | 2023-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-11 | 2023-05-12 | 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 |
| 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 |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-04-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Meet other general requirements. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-12 | 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 | 2021-10-12 | 2021-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-12 | 2021-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-12 | 2021-11-29 | 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 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-16 | Y |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-08 | 2021-10-01 | Y |
| 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 | 2019-11-13 | 2019-12-20 | 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 | 2019-11-13 | 2019-12-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-13 | 2019-12-20 | N |
| 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 | 2019-11-13 | 2019-12-20 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-11-13 | 2019-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-13 | 2019-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-13 | 2019-12-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-05 | 2019-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-05 | 2019-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-05 | 2019-10-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-05 | 2019-10-03 | N |
