Mennonite Friendship Communities INC
600 W Blanchard Avenue, South Hutchinson, KS 67505 · Non profit - Corporation · 100 certified beds · (620) 663-7175 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,498 in federal fines (most recent 2025-02-05)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.4% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.9% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.2% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 7.6% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.8% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.1% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.8% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.7% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 62.1% | 95.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.8% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.1% | 22.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 55.9% | 73.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 12.3% | 22.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.1% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.80 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.03 | 2.13 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 57 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.8%CMS range 49.9–63.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 6.6–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 66.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 49.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 89.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.0–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 75.4 residents a day — about 75% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.56 hrs/resident/day on weekends vs 4.15 on weekdays — 14% thinner on weekends. RN hours go from 0.47 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · D2025-08-26 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 68 residents. The sample included six residents with one resident reviewed for involuntary discharge. Based on interviews and record review, the facility failed to ensure the involuntary discharge notice issued to Resident (R)1 or their representative contained a statement of appeal rights, the location to which the resident would be discharged and the contact information for the required state agencies (SA). The facility additionally failed to ensure the reason for the involuntary discharge was documented in the resident's medical record. This placed the resident at risk for impaired rights and inappropriate discharge. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included respiratory failure (severely impaired lung function) with hypoxia (inadequate supply of oxygen), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), weakness, and a need for assistance with personal careR1's Discharge - Return Not Anticipated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 68 residents. The sample included six residents with one resident reviewed for involuntary discharge. Based on interviews and record review, the facility failed to provide a written discharge summary, recapitulation of the stay or reconciliation of medications for Resident (R) 1 who discharged . This placed the resident at risk for impaired rights related to continuity of care and missed community healthcare services. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included respiratory failure (severely impaired lung function) with hypoxia (inadequate supply of oxygen), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), weakness, and a need for assistance with personal careR1's Discharge - Return Not Anticipated Minimum Data Set (MDS) dated [DATE] documented R1 had a planned discharge from the facility to another long-term care facility on 06/27/25.R1's EHR under the Physician Orders did not contain an order to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards when staff left an activated steam table in an unlocked closet, with an unsecured gate, and the coffee station left accessible to residents with an unclosed gate. This placed the eight cognitively impaired independently mobile residents at risk for preventable accidents or injuries. Findings included: - On 01/13/25 at 10:10 AM observation revealed an activated steam table located in the 100-hall dining room in an unlocked open bifold door closet, with an unlocked combination padlock on the left-hand side of the trifold wooden white gate, in front of the closet. On 01/13/25 at 10:11 AM, Certified Nurse Aide (CNA) M verified that there was an activated steam table located in the 100-hall dining room in an unlocked bifold door closet, with an unlocked combination padlock on the left-hand side of the trifold wooden white gate. CNA M stated she was unaware who was responsible for keeping the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician for blood sugars outside of physician ordered parameters for one resident, Resident (R) 34. This placed the resident at risk for hyperglycemic (greater than normal amount of glucose in the blood) and hypoglycemic (less than normal amount of sugar in the blood) episodes related to delayed physician involvement. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose type 2, not enough insulin made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R34 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-15 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents. Based on record review and interview the facility failed to verify the Center for Medicare and Medicaid Services (CMS) received transmissions of the Minimum Data Set (MDS) containing the Resident Assessment Instruments (RAI) for two of 65 residents, R34 and R37. Findings included: - R34's Comprehensive MDS, dated [DATE], was completed and signed but not submitted to CMS. R37's Quarterly MDS, dated [DATE], was submitted but not received by CMS. On 01/14/25 at 01:00 PM, Licensed Nurse (LN) K verified the two resident's MDS had not been received by CMS and stated she was responsible to ensure they were submitted and accepted. The facility's MDS Process policy, dated 11/2022, stated staff were to transmit the MDS within seven days of completion. The facility failed to verify CMS received transmissions of the MDS containing the Resident Assessment Instruments for R34 and R37.
- Potential for harm · D2025-01-15 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents of which one was reviewed for the G-Tube (Gastrostomy- surgical creation of an artificial opening into the stomach through the abdominal wall) feeding management. Based on observation, record review, and interview, the nurse failed to listen for the placement of the G-tube before administering medications and nutritional feeding for Resident (R)45. This placed the resident at risk for complications related to the feeding tube. Finding included: - R45's Electronic Health Record (EHR) revealed diagnoses of recorded a diagnosis of dysphasia (swallowing disorder), and cerebral infarct (damage to tissue in the brain due to loss of oxygen in the area). R 45's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R45 had short- and long-term memory loss with severely impaired cognition. The MDS recorded R45 required extensive assistance with transfers, bed mobility, dressing, toilet use, and personal hygiene. The MDS recorded the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication or required physician documentation for Resident (R) 38's and R27's use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and for the lack of a specific 14-day stop date for R38's as needed (PRN) Ativan (an antianxiety medication). This placed the residents at risk for inappropriate use of medication and related complications. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnoses of dementia without behavior disturbance (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars outside of physician ordered parameters for one resident, Resident (R) 34. This placed the resident at risk for hyperglycemic (greater than normal amount of glucose in the blood) and hypoglycemic (less than normal amount of sugar in the blood) episodes and adverse effects related to medications. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose type 2, not enough insulin made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R34…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The Facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)38 and R27 had an approved diagnosis or a physician-documented rationale which included risks versus benefits for R38's use of Seroquel (antipsychotic - class of medications used to treat major mental conditions which cause a break from reality) and for R27's use of Risperdal (an antipsychotic medication) The facility further failed to ensure a 14-day stop date to be reassessed on a regular basis for R38. This placed the residents at risk for unnecessary medications and related complications. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnoses of dementia without behavior disturbance (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents with six reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow physician orders when administering medication to Resident (R) 27, resulting in a medication error continuing for 4 days. This placed R27 at risk for adverse effects from the medication. - R27's Electronic Medical Record documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and recurrent major depressive disorder (MDD - mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R27 had verbal behaviors, was independent with eating, wheelchair mobility, required supervision for walking, and moderate staff assistance for dressing and transfers. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2025-01-15 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 16 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 41. This placed the residents at risk for inadequate end-of-life care. Findings included: - R41's Electronic Health Record (EHR) revealed diagnoses of Chronic Obstructive Pulmonary Disease chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dysphagia (swallowing difficulty). R41's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R41 had a Brief Interview for Mental Status score of six which indicated severe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 69 residents with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary by the staff's failure to date and reseal open food items and the failure to use gloves appropriately when serving food. Findings included: - On 03/07/23 at 07:47 AM, observation of the refrigerator located in the food service area of the kitchen revealed an approximately 3-inch stack of sliced cheese wrapped in plastic wrap. The cheese had no open date or use by date written on the packaging. Dietary staff CC verified the opened, undated cheese and disposed the cheese. On 03/07/23 at 08:05 AM, dietary staff DD observed passing room trays on 100 hall. After giving a resident her tray, she assisted the resident with setting up her food. She picked up the resident's toast, butter, and jelly with the same gloved hands used to pass out all room trays on the food cart. On 03/08/23 at 01:05 PM, dietary staff BB reported she had been told by her staff about the cheese found on initial tour and had reminded her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-09 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 69 residents which included a sample of 17 residents. Based on observation, interview, and record review, the facility failed to handle, store, and process linen and biohazard waste (infectious waste deemed a threat to public health or environment) in a manner to prevent the cross contamination and spread of infection in resident (R)69's isolation room and one of four soiled utility rooms. Findings included: - On 03/08/23 at 11:00 AM, observed a red bag lined container, used for disposal of trash/used PPE in resident's (R)69's isolation room lacked a cover to contain the overflowing used personal protective equipment (PPE). Maintenance staff FF and GG PPE and entered the resident's room. After completing a maintenance task in the room, Maintenance Staff FF and GG removed their used/soiled PPE, placed it in the container, and shoved it down in the container with their ungloved hand. They agreed the used PPE should have been emptied and the lid closed to prevent cross contamination and the spread of infection. Staff FF and GG reported the housekeeping…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility census totaled 69 residents with 17 residents sampled, that included five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow physician's orders for Resident (R)12, related to physician ordered insulin. This failure placed the resident at risk for adverse effects related to medication use. Findings included: - R12's diagnoses from the Electronic Health Record (EHR) included diabetes mellitus, type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and dementia (progressive mental disorder characterized by failing memory, confusion). The 10/24/22 quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R12 received insulin injections daily in the seven-day look-back period. The 01/22/23 annual MDS documented the resident had a BIMS of 15, indicating intact cognition. R12 received insulin injections daily in the seven-day look-back period. The 01/22/23 Care Area Assessment (CAA)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 69 with 17 residents in the sample that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow up in a timely manner on the recommendations made by the pharmacist for Resident (R)12. This caused the resident to receive unnecessary medications for a total of 19 days. - R12's diagnoses from the Electronic Health Record (EHR) included diabetes mellitus, type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and major depressive disorder (a major mood disorder). The 10/24/22 quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R12 received an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-09-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 77 residents, with one main kitchen. Based on observation, interview, and record review the facility failed to store foods and dishes in a safe and sanitary manner by the failure of staff to perform hand hygiene and use gloves appropriately in the kitchen and during meal service. Findings included: - On 09/01/21 at 08:35 AM during initial tour of the main kitchen the following were observed: In the walk-in refrigerator, noted one eight-ounce (oz) boost breeze with a use by date of 06/29/21, one eight oz boost breeze with a use by date of 08/10/21, one eight oz ensure plus with a use by date of 08/01/21. Dietary Staff (DS) R removed these items. One stack of 12 different sized metal bowls were stacked upright. On 09/01/21 at 08:35 AM DS U stated, that is the way we always stack them. On 09/01/21 at 09:10 AM DS Y prepared spinach for the noon meal and had frozen spinach in a pan. DS Y then took an unopened bag of frozen spinach and placed it on top of the open raw spinach in the pan and cut it open to add to the open raw spinach. Placing the plastic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-09-08 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 77 residents with 18 residents in the sample. Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to Centers for Medicare & Medicaid Services (CMS) in a timely manner for four residents reviewed. Residents (R)9, R4, R2, and R5. Findings included: - Record review on 09/07/21 at 09:17 AM revealed: R5's Death in Facility MDS completed on 05/19/21 and no transmission date R2's Quarterly MDS signed as complete on 06/25/21 and no transmission date R4's Quarterly MDS signed as complete on 07/02/21 and no transmission date R9's Quarterly MDS signed as complete on 07/06/21 and no transmission date During an interview on 09/07/21 at 03:00 PM Administrative Nurse D acknowledged the assessments were not submitted to CMS in a timely manner. She reported she did not know if she transmitted the assessments or if the other MDS Coordinator or the DON transmitted them. During an interview on 09/07/21 at 03:10 PM Administrative Nurse A reported it was Administrative Nurse E who transmitted the MDS and Administrative Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents with 20 included in the sample. Based on observation, interview, and record review the facility failed place urinary drainage bags in dignity bags to keep the drainage bag away from public view for Residents (R) 38 and R 9. Findings included: - R38's Physician Orders dated 03/22/21 revealed the following diagnoses: neurogenic bladder, (dysfunction of the urinary bladder caused by a lesion of the nervous system), overactive bladder (bladder control problem which leads to a sudden urge to urinate), and chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. The resident had an indwelling urinary catheter. The resident received diuretic medications. The Quarterly Minimum data set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-08 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 77 residents with 20 sampled, including one for hospitalization. Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 39. Findings included: - R39's Minimum Data Set (MDS) tracking form dated August 2021 revealed the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R39's Electronic Health Record (EHR) lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge and bed hold to R39's Office of the State Long-Term Care Ombudsman. Observation of 09/02/21 at 03:06 PM R39 sat in the day room in her wheelchair actively watching television, and the staff checked on R39 often. On 09/08/21 at 11:50 AM a request for logs of R39's transfers from the facility to the hospital in the time period July 2021 to August…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-08 · tag F0625 — isolatedNotify 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 77 residents with 20 sampled including one for hospitalization. Based on observation, interview, and record review the facility failed to provide a copy of the facility bed hold policy to Resident (R) 39 or her representative for her 07/31/21 facility-initiated hospitalization. Findings Include: - Review of R39's Minimum Data Set (MDS) tracking form dated August 2021 revealed the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R39's Electronic Health Record lacked evidence of written notification of the facility-initiated hospitalization transfer and bed hold to R39 or her representative. Observation of 09/02/21 at 03:06 PM R39 sat in the day room in her wheelchair actively watching television, and the staff checked on R39 often. On 09/08/21 at 11:37 AM Social Services Designee (SSD) Staff J stated the bed holds were done at the time of the admission to the nursing facility and the facility did not give a bed hold policy to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 77 residents, with 20 included in the sample, and one resident reviewed for oxygen use. Based on interview, observation, and record review, the facility failed to ensure the care plan included information on the use of oxygen for Resident (R) 186. Findings included: - Review of R186's Electronic Health Record (EHR) revealed the following diagnoses: acute respiratory failure with hypoxia (inadequate supply of oxygen) or hypercapnia (excessive carbon dioxide in the bloodstream), sleep apnea (disorder of sleep characterized by periods without respirations), and acute pulmonary edema (accumulation of extravascular fluid in the lung tissues). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R186 received oxygen therapy. The Activities of Daily Living (ADL)/ Rehabilitation Potential Care Area Assessment (CAA) dated 08/14/21 revealed R186 admitted with diagnoses of pulmonary edema and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 77 residents with 20 included in the sample, and two reviewed for urinary catheter. Based on observation, interview, and record review the facility failed to provide necessary services to decrease the risk of a urinary tract infection when the staff failed to ensure Resident (R) 9's urinary catheter drainage bag did not come in direct contact with the floor. Findings included: - R9's signed Physician Orders dated 07/21/21 revealed the following diagnoses: neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and overactive bladder (bladder control problem which leads to a sudden urge to urinate). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, hygiene, dressing, and bathing. The resident had an indwelling urinary catheter. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 77 residents, with 20 included in the sample, and one resident reviewed for oxygen use. Based on observation, interview, and record review the facility failed to ensure staff changed out the oxygen tubing and the bubbler humidifier as scheduled and failed to ensure staff properly/sanitarily stored the residents oxygen tubing when not in use for Resident (R)186. Findings included: - Review of R186's Electronic Health Record (EHR) revealed the following diagnoses: acute respiratory failure with hypoxia (inadequate supply of oxygen) or hypercapnia (excessive carbon dioxide in the bloodstream), sleep apnea (disorder of sleep characterized by periods without respirations), and acute pulmonary edema (accumulation of extravascular fluid in the lung tissues). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R186 received oxygen therapy. The Activities of Daily Living (ADL)/ Rehabilitation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility census totaled 77 residents with 20 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure a sanitary environment by the failure of staff to change gloves and perform hand hygiene when going from dirty to clean areas, while changing the brief for one resident. Resident (R) 12. Findings included: - Observation on 09/07/21 at 10:25 AM revealed Certified Nurse Aide (CNA) G and CNA O toileting R12. CNA G pulled R12s pants down and removed his wet brief. CNA G removed R 12's pants due to being wet and a new clean pair placed on the resident along with a clean brief. CNA G then reached back to adjust the lift in the bathroom never changing her gloves from the wet brief. The resident was partially lifted to do peri care with wet wipes. CNA G performed peri care on the resident with gloved hands. She then pulled up and adjusted the clean brief and pants still wearing the gloves used for peri-care. During an interview on 09/07/21 at10:30 AM CNA G reported she should have probably changed her gloves more than she did.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$14,498 in federal fines across 1 penalty.
- $14,498 — penalty dated 2025-02-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MENNONITE FRIENDSHIP COMMUNITIES, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/17/1972 |
| LEE, JANICE | Individual | CORPORATE DIRECTOR | — | since 05/21/2018 |
| MARTENS, JORETTA | Individual | CORPORATE DIRECTOR | — | since 05/17/2021 |
| MILLE, ROBERT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/21/2023 |
| MILLER, ARLYN | Individual | CORPORATE DIRECTOR | — | since 05/31/2022 |
| MILLER, MARTHA | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| MILLER, MYRON | Individual | CORPORATE DIRECTOR | — | since 05/16/2022 |
| MILLER, TIMOTHY | Individual | CORPORATE DIRECTOR | — | since 05/31/2022 |
| MILLER, VERTON | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| NISLY, J MARVIN | Individual | CORPORATE DIRECTOR | — | since 05/16/2022 |
| NISLY, KEITH | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| SCHMIDT, CHRIS | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| VEH, DAWN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/11/2021 |
| YODER, CALEB | Individual | CORPORATE DIRECTOR | — | since 05/17/2021 |
| WEDEL, RUSSELL | Individual | CORPORATE OFFICER | — | since 05/16/2022 |
| LIEPINS, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
CMS files one row per role, so the 20 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175379. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.