Mennonite Friendship Communities Inc

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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. [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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). [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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. [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.