A list of the most recent deficiencies for Mennonite Home. 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-08 | 2023-10-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-08 | 2023-10-28 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-09-08 | 2023-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-08 | 2023-10-28 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-08 | 2023-10-28 | 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 | 2023-09-08 | 2023-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-10-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-06 | 2023-10-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-06 | 2023-10-28 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-09-06 | 2023-10-28 | 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 | 2023-09-06 | 2023-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-06 | 2023-10-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-06 | 2023-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-06 | 2023-10-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-16 | 2022-09-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-16 | 2022-09-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-16 | 2022-09-09 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-16 | 2022-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-01-31 | 2019-03-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-01-31 | 2019-03-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-31 | 2019-03-22 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2019-01-31 | 2019-03-22 | 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 | 2019-01-31 | 2019-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-31 | 2019-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-31 | 2019-03-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-09-11 | 2017-10-31 | N |
| Provide housekeeping and maintenance services. | Health | 2017-09-11 | 2017-10-31 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-09-11 | 2017-10-31 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-09-11 | 2017-10-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-11 | 2017-10-31 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-11 | 2017-10-31 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-09-11 | 2017-10-31 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-09-11 | 2017-10-31 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-11 | 2017-10-31 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-11 | 2017-10-31 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2017-09-05 | 2017-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-09-05 | 2017-10-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-09-05 | 2017-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-05 | 2017-10-31 | N |
