Mennonite Home

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 16, 2022

  Based on observation, interview and record review it was determined the facility failed to ensure residents were free from abuse for 5 of 5 sampled residents (#s 2, 3, 4, 5 and 6). Due to the facility's lack of supervision and monitoring Resident 2, Resident 3, Resident 4, Resident 5 and Resident 6 were sexually abused. This was determined to be an Immediate Jeopardy (IJ) situation. Findings include: Resident 1 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 had a BIMS score of 15 which indicated she/he was cognitively intact. Resident 3 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Mar 4, 2025

  Based on observation, interview, and record review, it was determined the facility failed to ensure an environment free from accident hazards for 1 of 3 (#10) sampled residents reviewed for accidents. The facility failed to properly attach the sling with the lower leg straps to the Hoyer (a mechanical lift device used to transfer residents) during a transfer. As a result, Resident 10 sustained a left leg femoral (largest leg bone) fracture and an avulsion injury to the left foot (occurs when an injury causes a ligament or tendon to break off a small piece of a bone that is attached to it). Findings include: Resident 10 was admitted to the facility in 8/2015, with diagnoses including Alzheimer's and restless leg syndrome. […]

• Actual harm, isolatedF689Jul 24, 2024

  Based on interview and record review it was determined the facility failed to timely evaluate and analyze repeated falls to ensure fall interventions were effective for 1 of 3 sampled residents (#4) and failed to ensure fall interventions were followed for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 fell and sustained a fracture. Findings include: 1. Resident 1 was admitted to the facility in 2018, with a diagnosis of Parkinson's disease. A 11/2/23 Significant Change MDS revealed Resident 1 had dementia and did not ask staff for ADL assistance. Resident 1 was assessed to be at risk for falls and interventions included a motion sensor (device placed near the resident and alerts staff when the resident moves) was to be used when she/he sat in a recliner. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2024

  Based on observation, interview, and record review it was determined the facility failed to serve food in a sanitary manner for 2 of 2 dining rooms. This placed residents at risk for foodborne illness. Findings include: On 11/18/24 at 12:14 PM the lunch meal service was observed on the third floor dining room. Staff 7 (CNA) donned gloves and touched multiple surfaces including cupboards, clean cups, clean plates, a refrigerator and serving utensils multiple times throughout the meal and did not change her gloves. On 11/18/24 Staff 7 stated gloves were to be worn in the kitchen, and staff should change gloves after touching multiple surfaces in the kitchen before touching clean plates, cups, or food items. […]

• No harm, potential for more than minimal, widespreadF880Sep 8, 2023

  Based on interview it was determined the facility failed to implement a water management program for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to water-borne illnesses. Findings include: On 9/8/23 at 8:59 AM Staff 13 (IP) and Staff 14 (Environmental Services Director) confirmed the facility did not have a program and system in place for the prevention of the spread of water-borne pathogens, such as Legionella, in the facility's main water system.