Goodwill Mennonite Home, Inc.

In the surveyor’s words

From the most serious findings on record at Goodwill Mennonite Home, Inc., in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 11, 2025

  Based on interviews and record reviews, it was determined that the facility failed to have an effective system in place to prevent cognitively impaired residents from leaving the facility without appropriate supervision. This was evident for 1 of 3 residents (#102) reviewed for elopement. This deficient practice led to immediate jeopardy for Resident #102 on 11/13/24. Following the incident, the facility implemented effective and thorough corrective measures. The facility's plan and action were verified during this survey; therefore, this deficiency was cited as past noncompliance. The date of correction was 11/13/24. The findings include: Dementia is a term that describes a group of symptoms associated with a decline in memory or other thinking skills. Brief Interview for Mental Status. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2026

  Based on observation, interview and record review it was determined that the facility failed to 1) monitor cooling temperatures for hazardous meats, 2) monitor tray line hot food temperatures, and 3) ensure that staff wore hair coverings and beard restraints. This was evident during the Kitchen task investigation during the recertification survey and has the potential to effect all residents.The findings include: 1) On 6/08/26 at 9:49 AM the initial kitchen tour was conducted. The observation was done with the facility kitchen manager, Staff #4, and included an interview with him. Freezer #5 contained 8 turkey breasts stored with the plastic covering open. Staff #4 said the turkey breasts were cooked this morning and then put in the freezer to cool. […]

• No harm, potential for more than minimal, patternF609Apr 11, 2025

  Based on review of medical records and facility investigation documentation and interviews it was determined that the facility failed to follow requirements for reporting incidents to the State Survey Agency. This was found to be evident for 5 (Resident #30, # 76, #60, #26, and #160 ) out of 5 residents reviewed for potential abuse. The findings include: 1) Review of Resident #30's medical record on 4/8/25 revealed the resident has a diagnosis of Alzheimer's dementia with severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident had a current order, in effect since 7/31/24, for 2 staff to provide care at all times. […]

• No harm, potential for more than minimal, patternF610Apr 11, 2025

  Based on review of medical records, facility investigation documentation, and interviews it was determined that the facility failed to ensure injuries of unknown origin were thoroughly investigated. This was found to be evident for 2(Resident #30 and #26) out of 5 residents reviewed for potential abuse. The findings include: 1) Review of Resident #30's medical record on 4/8/25 revealed the resident had a diagnosis of Alzheimer's dementia with severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident had a current order, in effect since 7/31/24, for 2 staff to provide care at all times. […]

• No harm, potential for more than minimal, patternF758Apr 11, 2025

  Based on observations, record review, and interviews, it was determined that the facility failed to 1) document why a Gradual Dose Reduction (GDR) was contraindicated for the use of psychotropic drug and document specific indications for administering the medicine to a resident and 2) adequately monitor residents for behaviors, side effects, or adverse consequences related to the use of psychotropic drugs. This was evident for 3 (#4, #67, and #7) of 6 residents reviewed for unnecessary medications. The findings include: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. […]