Cycle 1
Health 2025-01-15 · Fire 2025-01-15
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
South Hutchinson, KS
Mennonite Friendship Communities Inc
5-star overall rating with 4-star inspections with $14,498 in total fines with 11 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
600 W Blanchard Avenue, South Hutchinson, KS
(620) 663-7175
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,611
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.21
Baseline 20.45% · Performance 20.87% · Measure score 1.21 · Achievement 1.21 · Improvement 0
Healthcare-associated infections
3.78
Baseline 6.44% · Performance 6.71% · Measure score 3.78 · Achievement 3.78 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.67
Baseline 4.68 hours · Performance 4.69 hours · Measure score 5.67 · Achievement 5.67 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 6.75% · Lower 95% interval 6.6% |
| Discharge to community | 57.79% |
50.57%
7.2 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 58.99% · Lower 95% interval 49.89% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.65% |
95.27%
0.4 pts better
|
Numerator 66 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 68.52% |
53.69%
14.8 pts better
|
Numerator 37 · Denominator 54 |
| Discharge mobility score | 55.56% |
50.94%
4.6 pts better
|
Numerator 30 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 69 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 5% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 0.66% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 151 |
| Staff flu vaccination coverage | 9.29% |
42%
32.7 pts worse
|
Numerator 21 · Denominator 226 |
| Discharge function score | 70.37% |
56.45%
13.9 pts better
|
Numerator 38 · Denominator 54 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 33 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 36.11% |
25.2%
10.9 pts better
|
Numerator 13 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.2
1.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
91.8%
2.2 pts better
|
93.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 91.5% · Q3 95.2% · Q4 97.0% · 4Q avg 94.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 62.1% |
95.5%
33.4 pts worse
|
95.5%
33.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 62.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
4.4%
3.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
5.6%
3.8 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.8% · Q4 1.6% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.0%
2.5 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 2.0% · Q4 3.6% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
23.2%
13.6 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 11.8% · Q3 5.7% · Q4 7.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
19.8%
5.5 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 28.9% · Q3 23.9% · Q4 23.5% · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.2% |
18.4%
7.2 pts better
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 11.2% · Q3 16.0% · Q4 2.8% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
18.8%
6 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 14.6% · Q3 13.7% · Q4 15.1% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.8%
0.5 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.1% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.0% |
3.1%
4.9 pts worse
|
1.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 9.1% · Q3 10.2% · Q4 7.8% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
23.2%
5.8 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 26.9% · Q3 19.7% · Q4 6.4% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.6%
1.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.9% · Q3 5.2% · Q4 5.2% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.1% |
75.6%
15.5 pts worse
|
81.7%
21.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.2% · Q2 62.7% · Q3 53.4% · Q4 54.5% · 4Q avg 60.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
11.7%
2.1 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.2%
About the same
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.8% · Q3 2.4% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.9% |
73.5%
17.6 pts worse
|
79.7%
23.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.4% |
23.0%
10.6 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 10.4% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-09 · Fire 2023-03-09
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-09-08 · Fire 2021-09-08
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2025-01-15
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-21
F · Potential for more than minimal harm
2023-03-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-03-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-12
F · Potential for more than minimal harm
2021-09-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-29
F · Potential for more than minimal harm
2021-09-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-29
D · Potential for more than minimal harm
2021-09-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-26
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-26
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-01-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-15
F849 · Administration Deficiencies
Health
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.
Corrected 2025-02-20
F · Potential for more than minimal harm
2023-03-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-14
F · Potential for more than minimal harm
2021-09-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-16
E · Potential for more than minimal harm
2021-09-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-16
Penalties and ownership
What sits behind the stars
$14,498
2025-02-05
Fine
Fine · fine $14,498
Fine
Ownership
Mennonite Friendship Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Lee, Janice
Corporate Director · Individual
Liepins, Richard
Operational/Managerial Control · Individual
Martens, Joretta
Corporate Director · Individual
Mille, Robert
Operational/Managerial Control · Individual
Mille, Robert
Corporate Director · Individual
Miller, Arlyn
Corporate Director · Individual
Miller, Martha
Corporate Director · Individual
Miller, Myron
Corporate Director · Individual
Miller, Timothy
Corporate Director · Individual
Miller, Verton
Corporate Director · Individual
Nisly, J Marvin
Corporate Director · Individual
Nisly, Keith
Corporate Director · Individual
Schmidt, Chris
Corporate Director · Individual
Veh, Dawn
Operational/Managerial Control · Individual
Veh, Dawn
Corporate Director · Individual
Wedel, Russell
Corporate Officer · Individual
Yoder, Caleb
Corporate Director · Individual
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1-star overall rating with 2-star inspections with $70,179 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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#3
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4-star overall rating with 4-star inspections with $8,590 in total fines with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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