Albany, OR

Mennonite Home

3-star overall rating with 3-star inspections with $17,934 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

5353 Columbus Street Se, Albany, OR

(541) 928-7232

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

95

Certified beds

Average residents

35

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1989-08-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.60

Registered nurse staffing

LPN hours / resident day

1.15

Licensed practical nurse staffing

Aide hours / resident day

4.79

Nurse aide staffing

Weekend hours

5.62

Weekend nurse staffing

RN turnover

33%

Annual RN turnover

Total nurse turnover

31%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.5% 4.5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.4%	95.2% 0.8 pts worse	95.5% 1.1 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	2.4% 0.8 pts worse	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	3.8%	4.7% 0.9 pts better	11.4% 7.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	2.3%	5.0% 2.7 pts better	5.4% 3.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.1%	12.5% 3.4 pts better	19.6% 10.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	15.4%	14.7% 0.7 pts worse	16.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	28.7%	24.1% 4.6 pts worse	16.3% 12.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	41.4%	15.8% 25.6 pts worse	14.9% 26.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	1.7% 0.2 pts better	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	5.6%	2.0% 3.6 pts worse	1.7% 3.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.1%	22.2% 0.1 pts better	19.8% 2.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	5.5%	6.5% 1 pts better	5.1% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.1%	85.4% 4.7 pts better	81.7% 8.4 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.7% 1.7 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	67.7%	81.2% 13.5 pts worse	79.7% 12 pts worse	Short Stay · 2024Q3-2025Q2

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-21 · Fire 2024-11-21

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-09-08 · Fire 2023-09-08

8 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2019-01-31 · Fire 2019-01-31

1 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-01-10

E · Potential for more than minimal harm 2024-11-21

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 2025-01-10

F · Potential for more than minimal harm 2023-09-08

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

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 2023-10-28

F · Potential for more than minimal harm 2023-09-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-10-28

F · Potential for more than minimal harm 2019-01-31

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2019-03-22

F · Potential for more than minimal harm 2019-01-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-03-22

E · Potential for more than minimal harm 2019-01-31

K163 · Construction Deficiencies

Fire Safety

Install noncombustible or limited-combustible interior walls.

Corrected 2019-03-22

E · Potential for more than minimal harm 2019-01-31

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 2019-03-22

D · Potential for more than minimal harm 2019-01-31

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2019-03-22

D · Potential for more than minimal harm 2019-01-31

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-03-22

Inspection history

Recent health citations

G · Actual harm 2025-03-04

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 2025-04-23

F · Potential for more than minimal harm 2024-11-21

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 2025-01-10

D · Potential for more than minimal harm 2024-11-21

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 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-01-10

G · Actual harm 2024-07-24

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 2024-09-12

F · Potential for more than minimal harm 2023-09-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F642 · Resident Assessment and Care Planning Deficiencies

Health

Ensure a qualified health professional conducts resident assessments.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

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 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

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 2023-10-28

D · Potential for more than minimal harm 2019-01-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-22

Penalties and ownership

What sits behind the stars

$9,110 2025-03-04

Fine

Fine · fine $9,110

Fine

$8,824 2024-07-24

Fine

Fine · fine $8,824

Fine