Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mennonite Friendship Communities Inc during CMS and state inspections, most recent first.
A resident with complex medical needs was involuntarily discharged for non-payment, but the facility failed to provide a discharge notice containing required information such as appeal rights, discharge location, and state agency contacts. The resident's EHR also lacked proper documentation of the discharge reason, and facility policies did not address all necessary discharge procedures.
Failure to Provide Required Discharge Documentation: A resident with respiratory failure w/ hypoxia, hypothyroidism, weakness, and ADL dependence was discharged to another LTC facility, but the record lacked evidence of a written discharge summary, recapitulation of the stay, or med reconciliation provided to the resident or representative. Staff documented discharge coordination and transfer paperwork, but the discharge summary tab and progress notes did not show the required discharge documentation, and an admin nurse confirmed the missing documentation.
The facility failed to secure an activated steam table and a beverage station, leaving them accessible to residents. The steam table, with high water temperatures, was left unattended in an unlocked closet, and the beverage station gate was left open without staff supervision. These actions placed cognitively impaired, independently mobile residents at risk for preventable accidents.
A resident with diabetes mellitus had multiple instances of blood sugar levels exceeding physician-ordered parameters, yet the facility failed to notify the physician as required. Despite having a care plan and guidelines in place, the nursing staff did not adhere to the directive to report significant changes in the resident's condition, placing the resident at risk for hyperglycemic and hypoglycemic episodes.
The facility failed to ensure that the MDS assessments for two residents were properly transmitted and received by CMS. One resident's comprehensive MDS was completed but not submitted, while another's quarterly MDS was submitted but not received. A licensed nurse confirmed the oversight, acknowledging her responsibility for ensuring submissions were completed and accepted, contrary to the facility's policy requiring transmission within seven days.
A deficiency was identified when a nurse failed to verify the placement of a G-tube before administering medications and nutritional feeding to a resident with dysphagia and cerebral infarct. This action was against the facility's policy and physician's orders, placing the resident at risk for complications.
The facility failed to ensure appropriate medication use and documentation for two residents. A resident received Seroquel without an appropriate diagnosis, and the CP did not ensure a specific stop date for PRN Ativan. Another resident was prescribed Risperdal without a documented rationale, and the facility did not follow the CP's recommendation for a dose reduction. These failures placed residents at risk for inappropriate medication use.
A resident with diabetes mellitus had multiple instances of blood sugar levels outside the physician-ordered parameters, yet the facility failed to notify the physician as required. Despite having orders to report blood sugar levels less than 90 ml/dl or greater than 300 ml/dl, the facility did not contact the physician on several occasions, placing the resident at risk for complications.
The facility failed to ensure appropriate physician-documented rationales for the use of antipsychotic medications for two residents. One resident received Seroquel without an approved diagnosis or documented risks versus benefits, and the PRN Ativan lacked a proper stop date. Another resident continued to receive Risperdal without a documented rationale, despite recommendations for a gradual dose reduction. These oversights placed the residents at risk for unnecessary medication use.
A resident with Alzheimer's and major depressive disorder experienced a medication administration error when the facility failed to follow a physician's order to decrease the dosage of Risperdal. The resident received an incorrect dosage for four days, as the Medication Administration Record was not updated in accordance with the facility's policy, placing the resident at risk for adverse effects.
A facility failed to coordinate care between the facility and a hospice provider for a resident with COPD and severe cognitive impairment receiving hospice services. The resident's care plan lacked specific instructions on hospice services, including support visits, supplies, and medications. This deficiency was verified by an administrative nurse, placing the resident at risk for inadequate end-of-life care.
Deficient Involuntary Discharge Notice and Documentation
Penalty
Summary
The facility failed to ensure that the involuntary discharge notice provided to a resident or their representative included all required information. Specifically, the notice did not contain a statement of appeal rights, the location to which the resident would be discharged, or the contact information for the required state agencies. Additionally, the notice did not provide instructions on how to initiate or submit an appeal. The letter did include contact information for the long-term care ombudsman and a list of local LTC facilities, but omitted other regulatory requirements. The notice was issued due to non-payment of services, with documentation indicating the resident had been denied Medicaid services for failure to submit required paperwork. Further review revealed that the resident's electronic health record did not contain a physician order to discharge, although a scanned order was present in the resident documents. The facility's policy on admission, transfer, and discharge referenced compliance with regulations and documentation of the reason for discharge in the clinical record, but did not address providing a written discharge summary, recapitulation of stay, or medication reconciliation to the resident or their representative. The resident involved had significant medical needs, including respiratory failure with hypoxia, hypothyroidism, weakness, and required assistance with personal care.
Failure to Provide Required Discharge Documentation
Penalty
Summary
The facility failed to provide a written discharge summary, recapitulation of the stay, or medication reconciliation for a resident who was discharged to another long-term care facility. The resident’s EHR documented diagnoses including respiratory failure with hypoxia, hypothyroidism, weakness, and a need for assistance with personal care. The resident’s MDS documented a planned discharge to another LTC facility, and the EHR contained a scanned discharge order and transfer/discharge instructions form showing the resident was discharged with attachments such as demographic data, diagnostic results, advance directives, immunization records, and a copy of the current MAR. Progress notes showed staff communicated with the resident’s representative and the receiving facility about the discharge arrangement, referral, and pickup. The discharge instructions form was signed by staff and the resident’s representative, but page three of the form was left blank for special care needs, antibiotics, transmission-based precautions, and other discharge paperwork. The EHR’s discharge summary tab was documented by staff as containing discharge instructions, recapitulation, and education, but review of the record showed no evidence that a written discharge summary, recapitulation of the stay, or medication reconciliation was provided to the resident or the resident’s representative. During interview, Administrative Nurse D confirmed the discharge summary tab lacked documentation of a written discharge summary, recapitulation of stay, and medication reconciliation. The nurse also stated the transfer/discharge instructions form in the resident documents was an old form formerly used for hospital transfers and did not include those elements. Administrative Nurse D further confirmed the resident was discharged for non-payment of services and that the facility’s records did not show the discharge summary, recapitulation of stay, or medication reconciliation in the progress notes.
Failure to Secure Steam Table and Beverage Station
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by an activated steam table being left unattended and unsecured in an unlocked closet in the 100-hall dining room. The steam table, with water temperatures reaching up to 160.1 degrees Fahrenheit, was accessible to residents due to an unlocked gate. Staff members, including a Certified Nurse Aide and a Certified Dietary Manager, were unaware of who was responsible for securing the gate, and the steam table was left unsupervised while residents were present in the dining room. This oversight was contrary to the facility's policy, which mandates that steam tables must be continually staffed and never left unattended in areas accessible to residents. Additionally, the facility failed to secure a beverage station, which included a hot chocolate machine and a coffee dispenser with temperatures as high as 160 degrees Fahrenheit. The gate to the beverage station was left open without staff supervision, leaving it accessible to residents. The facility's policy requires that hot beverage equipment be placed in safe areas and that security gates be closed when staff are not present to monitor access. These lapses in supervision and security placed eight cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.
Failure to Notify Physician of Blood Sugar Irregularities
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar levels were outside the physician-ordered parameters. The resident, who had diagnoses of diabetes mellitus, depression, and anxiety, was supposed to have their blood sugar levels monitored and reported to the physician if they fell below 90 ml/dl or exceeded 300 ml/dl. Despite this directive, there were multiple instances documented in December 2024 and January 2025 where the resident's blood sugar levels exceeded the upper limit, yet the physician was not notified. This oversight was confirmed by a licensed nurse who acknowledged the failure to contact the physician as required. The resident was actively managing their blood sugar routines with the assistance of a Dexcom blood glucose monitoring machine and received insulin daily. The facility's guidelines mandated that clinical care problems and significant changes in a resident's condition be communicated to the physician in a timely manner. However, the nursing staff did not adhere to these guidelines, resulting in a lack of timely physician involvement. This placed the resident at risk for hyperglycemic and hypoglycemic episodes due to the delayed notification of the physician.
Failure to Transmit MDS Data to CMS
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents were properly transmitted and received by the Center for Medicare and Medicaid Services (CMS). Specifically, the comprehensive MDS for one resident was completed and signed but not submitted, while the quarterly MDS for another resident was submitted but not received by CMS. This issue was confirmed by a licensed nurse who acknowledged her responsibility for ensuring the MDS submissions were completed and accepted. The facility's policy required that MDS data be transmitted within seven days of completion, which was not adhered to in these cases.
Failure to Verify G-Tube Placement Before Administration
Penalty
Summary
A deficiency was identified in the care of a resident with a G-tube at the facility. The resident, who had a diagnosis of dysphagia and cerebral infarct, required a feeding tube for nutritional maintenance. The care plan specified that staff should assess tube placement, patency, and residual before and after meals and medication administration. However, during an observation, a licensed nurse failed to check the placement of the G-tube before administering medications and nutritional feeding to the resident. The facility's policy on enteral tube use and care required verification of tube placement by aspirating stomach contents before administering feedings or medications. Despite this, the nurse administered medications and nutritional supplements without confirming the tube's placement, which was against the physician's orders and the facility's policy. This oversight placed the resident at risk for complications related to the feeding tube.
Failure to Ensure Appropriate Medication Use and Documentation
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication for the use of Seroquel, an antipsychotic medication, for Resident 38. The CP's monthly medication review noted that the resident received Seroquel for depression, which was not an acceptable diagnosis for the medication. Despite the CP's request for a different diagnosis or a reduction in medication, the physician did not provide an appropriate rationale or indication for the continued use of Seroquel. Additionally, the CP failed to ensure a specific 14-day stop date for Resident 38's PRN Ativan, an antianxiety medication, which was required by the facility's policy. For Resident 27, the facility did not follow the CP's recommendation to obtain the physician's rationale for the continued use of the antipsychotic Risperdal, prescribed for dementia with behaviors. The CP requested clarification of the diagnosis and documentation of what had been tried and failed, but the physician did not provide a rationale for the continued use of Risperdal. The facility's records showed that the resident had no documented behaviors that would justify the use of Risperdal, and the medication was not reduced as recommended by the CP. The facility's policies required the CP to document drug regimen reviews and report any irregularities to the attending physician, medical director, and director of nursing. However, the CP did not consistently report irregularities, such as the lack of appropriate diagnoses for antipsychotic medications and the absence of a specific stop date for PRN medications. This failure placed the residents at risk for inappropriate use of medication and related complications.
Failure to Notify Physician of Blood Sugar Levels Outside Parameters
Penalty
Summary
The facility failed to notify the physician of blood sugar levels outside of the ordered parameters for a resident diagnosed with diabetes mellitus, depression, and anxiety. The resident, who had intact cognition and was independent in most activities of daily living, was managing his blood sugar routines with the help of a Dexcom continuous glucose monitor. Despite having clear physician orders to notify the physician if blood sugar levels were less than 90 ml/dl or greater than 300 ml/dl, the facility did not contact the physician on multiple occasions when the resident's blood sugar levels exceeded these parameters. The resident's blood sugar levels were documented as being out of the specified range on several dates in December 2024 and January 2025, yet the physician was not notified. Licensed Nurse G acknowledged the oversight and confirmed that the physician should have been contacted. The facility's guidelines and blood glucose monitoring policy required staff to communicate significant changes in a resident's condition to the physician, but this protocol was not followed, placing the resident at risk for complications and adverse effects related to medications.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents, R38 and R27, had appropriate physician-documented rationales for the use of antipsychotic medications, Seroquel and Risperdal, respectively. For R38, the facility did not provide an approved diagnosis or a documented rationale that included the risks versus benefits for the use of Seroquel. Additionally, the facility did not ensure a 14-day stop date for the PRN Ativan, which was incorrectly documented with a stop date of 01/01/2035. This oversight placed R38 at risk for unnecessary medication use and related complications. R38's medical records indicated diagnoses of dementia without behavior disturbance, anxiety, and depression. Despite receiving multiple medications, including an antipsychotic, the records lacked evidence of a physician-documented rationale for Seroquel. Observations and interviews revealed that R38 could be rude and had some behaviors, but there was no clear documentation supporting the necessity of Seroquel. The facility's policy required that psychotropic medications be prescribed only when indicated by assessment and medical necessity, with a clear diagnosis or condition documented, which was not adhered to in R38's case. For R27, the facility also failed to obtain a physician's rationale for the continued use of Risperdal for dementia with behaviors. The resident's records showed a history of Alzheimer's disease and recurrent major depressive disorder, with documented verbal behaviors. Despite recommendations from the consultant pharmacist for a gradual dose reduction and clarification of the diagnosis, the facility did not provide a rationale for the continued use of Risperdal. The facility's policy required a gradual dose reduction and behavioral interventions unless clinically contraindicated, which was not properly documented or followed for R27.
Medication Administration Error for Resident with Alzheimer's and MDD
Penalty
Summary
The facility failed to adhere to physician orders when administering medication to Resident 27, resulting in a medication error that persisted for four days. Resident 27, who has diagnoses of Alzheimer's disease and recurrent major depressive disorder, was supposed to have their Risperdal dosage reduced according to a physician order dated January 10, 2025. However, the Medication Administration Record (MAR) did not reflect this change, and staff continued to administer the previous dosage of 0.5 mg twice daily from January 11 to January 14, 2025, which was four doses more than ordered. The error was identified when a licensed nurse verified that the MAR had not been updated to reflect the physician's order to decrease the Risperdal dosage. The facility's Medication Administration policy requires staff to review new medication orders and implement them within 24 hours, which was not followed in this case. This oversight placed Resident 27 at risk for adverse effects from the medication, as the facility did not follow the physician's directive to decrease the dosage.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and the hospice provider for a resident receiving hospice services. The resident, identified as R41, had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and dysphagia, and was documented to have severe cognitive impairment. The resident's care plan indicated a terminal prognosis and the need for hospice services, directing staff to provide comfort and observe for signs of pain. However, the care plan lacked specific instructions on the services provided by hospice, including the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, and hospice contact information. The facility's policy on hospice services outlined the need for an individualized plan of care developed before hospice care begins, which should include an assessment of the resident's and family's needs for services. Despite this, the facility did not have a coordinated care plan with the hospice provider, as verified by Administrative Nurse D. This lack of coordination placed the resident at risk for inadequate end-of-life care, as the facility did not ensure the integration of care and services provided by both the facility and the hospice provider.
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Illustrative
What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near South Hutchinson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hutchinson Operator, Llc | 4.2 mi | ★★★★★ | 25 | 0 |
| Diversicare Of Hutchinson | 4.4 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Hutchinson Village | 4.6 mi | ★★★★★ | 17 | 0 |
| Wesley Towers Inc | 4.6 mi | ★★★★★ | 17 | 0 |
| Buhler Sunshine Home | 11.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.