Mennonite Memorial Home

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 15, 2022

  Based on medical record review, review of hospital documentation, review of fall investigations and staff interviews, policy review, the facility failed to ensure appropriate assistive devices (gait belt) were utilized during a resident transfer and failed to ensure staff utilized the appropriate amount of assistance during bed mobility resulting in avoidable falls. This resulted in Actual Harm on 10/13/22 when Resident #66 who was identified as being unsteady when ambulating was assisted to the bathroom without staff utilizing a gait belt resulting in the resident having an avoidable fall and the resident was subsequently transferred to the hospital for evaluation/treatment of a subarachnoid hemorrhage. […]

• No harm, potential for more than minimal, widespreadF761Nov 18, 2024

  Based on observation and staff interview, the facility failed to ensure medications were not expired. This had the possibility to affect all 57 residents residing in the facility. The facility census was 57. Findings include: Observation at 10:50 A.M. of the large supply room with Licensed Practical Nurse (LPN) #498 revealed the following over-the-counter medications for residents: one bottle of fiber powder dated best by ,d+[DATE], one bottle of Calcium D 5 micrograms dated best by ,d+[DATE], one bottle of oyster calcium 500 milligrams (mg) dated best by ,d+[DATE] and three bottles dated best by ,d+[DATE], one bottle of melatonin 3 mg dated best by ,d+[DATE], and one bottle of acetaminophen liquid 500 mg in 15 milliliters dated best by ,d+[DATE]. […]

• No harm, potential for more than minimal, widespreadF727Nov 14, 2023

  Based on review of facility's posted nursing hours, review of licensure staffing tool, and staff interview, the facility failed to ensure there was a Registered Nurse (RN), working in the facility for 8 hours a day, 7 days a week. This has the potential to affect all 55 residents residing in the facility. The current census is 55. Findings include: Review of the facility's daily posted nursing hours for 10/28/23, 10/29/23, and 11/12/23 revealed there was no RN scheduled to work in the facility. Review of the licensure staffing tool dating from 11/07/23 to 11/13/23 revealed on 11/12/23 no hours for a RN, including the DON, were listed on the staffing tool. Interview on 11/14/23 at 1:40 P.M. with the Administrator verified there was no RN coverage for 10/28/23, 10/29/23, and 11/12/23. […]

• No harm, potential for more than minimal, patternF677Jun 3, 2025

  Based on record review, staff interviews and review of facility policy, the facility failed to ensure residents were provided with assistance for activities of daily living (ADL's). This affected 10 (#10, #11, #12, #13, #14, #15, #16, #20, #21 and #22) residents residing on the secured dementia unit. The facility census was 58. Findings include: Review of medical record for Resident #10 revealed admission date of 04/21/25 with diagnoses including pneumonia, atrial fib and heart failure. The resident remained in the facility. Review of Resident #10's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. […]

• No harm, potential for more than minimal, patternF600Apr 15, 2024

  Based on medical record review, staff interview, review of facility census, review of the facility self-reported incidents (SRIs), review of facility investigations, and policy review, the facility failed to ensure residents were free from verbal abuse and mistreatment. This affected one (#32) of two residents reviewed for abuse and had the possibility to affect 31 (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) residents residing on the hallway. […]