Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mennonite Home during CMS and state inspections, most recent first.
Medication refrigerator temperature logs were not maintained for 2 medication rooms. Blank logs were observed for multiple dates in both the 2nd and 3rd floor med refrigerators, which stored insulin, other meds, and flu vaccines. An LPN acknowledged the missing entries and the DNS provided no additional information.
A resident with hospice care, Alzheimer’s disease, severe cognitive impairment, and a need for substantial to maximum assist with eating was left waiting in the dining room while other residents were served. A CNA assisted with one bite and then walked away, the resident sat alone before being served breakfast, and a full beverage remained untouched for an extended period without staff assistance. Staff stated dependent residents waited until other residents were served first, and the DNS acknowledged the extended wait times did not meet facility standards.
Failure to obtain informed consent for antidepressant use. A resident admitted with mild depressive disorder was ordered Duloxetine for depression and pain, but the record showed no documentation that the risks and benefits were reviewed or that consent was obtained from the resident or responsible party. The Administrator stated he could not locate any information showing the review or consent had occurred.
Failure to provide hygiene and grooming care for a resident with hospice care and severe cognitive impairment. The resident needed substantial to maximum assistance with hygiene, but care documentation showed no bathing or nail care for an extended period. A family member observed poor oral hygiene, dirty fingernails, overgrown toenails, and foul-smelling feet, while a CNA acknowledged she had not completed all hygiene tasks and the RNCM could not explain why bathing or nail care were not provided.
Missed anti-seizure medications. A resident with stroke and hemiplegia had orders for Briviact and Clobazam, but the MAR showed multiple missed doses because the meds were not available. A CMA said he did not order the anti-seizure meds when he saw they were out, and an LPN said she was only notified after the resident had already missed doses. The physician stated these meds were important for seizure prevention and that missed doses could result in a grand mal seizure.
A resident with Alzheimer's and non-ambulatory status fell and sustained injuries during a transfer using a Hoyer lift due to improper attachment of the sling's leg straps. The incident was obscured by a blanket, and staff failed to verify the sling's setup, leading to the resident slipping out and falling.
The facility failed to maintain sanitary conditions during meal service, risking foodborne illness. Staff were observed not following proper glove use and hand hygiene protocols. A CNA and RNCM did not change gloves after touching multiple surfaces, while a cook served food without gloves. A server handled trays with ungloved hands, and a CMA assisted a resident without hand hygiene.
A resident with kidney disease experienced a lack of dignity during meal service when their lunch was delayed by 18 minutes compared to another resident at the same table. Despite inquiries from both residents, staff failed to serve meals in a timely manner, contrary to the administrator's expectation of serving one table at a time.
A facility failed to obtain timely informed consent for the use of lorazepam, an anti-anxiety medication, for a resident with dementia. The resident's MAR indicated that lorazepam was administered on multiple occasions before the consent was completed by the resident's representative. This oversight was confirmed by an LPN, highlighting a deficiency in the facility's process for ensuring informed consent.
A facility failed to complete a comprehensive assessment within the required timeframe for a resident admitted with respiratory failure. Although several MDS assessments were completed, the annual MDS due in September was not done on time, as confirmed by the administrator. This oversight risked unassessed needs for the resident.
A resident admitted with Alzheimer's and Type 2 Diabetes was inaccurately assessed for hand contractures. The Admission MDS did not reflect limitations, despite the care plan noting impaired functional status and interventions for contractures. Observations confirmed contractures, and a family member and LPN acknowledged their presence at admission, but they were not coded on the MDS.
A facility failed to provide appropriate care for a resident with limited ROM, leading to worsening hand contractures. The resident, with Alzheimer's and Type 2 Diabetes, had a care plan to prevent contracture progression, but staff did not follow it. A CNA was unaware of the interventions, and a family member noted that devices were not used regularly, making it harder to manage the contractures. The LPN confirmed the care plan was not followed.
The facility failed to implement and timely investigate fall interventions for two residents, resulting in one resident sustaining a fracture. A resident with Parkinson's and dementia fell due to the absence of a required motion sensor, while another resident with severe cognitive impairment experienced multiple falls with delayed investigations. The LPN admitted to being behind on investigations, and the DNS and Administrator acknowledged the need for timely analysis to prevent neglect or abuse.
Medication Refrigerator Temperature Logs Not Maintained
Penalty
Summary
The facility failed to ensure appropriate medication storage temperatures were logged and maintained for 2 of 2 medication rooms reviewed. On 3/25/26, surveyors observed that the third floor medication refrigerator temperature logs were blank on multiple dates in March 2026, including 3/1, 3/4, 3/7 through 3/8, 3/13 through 3/19, and 3/21 through 3/24. The refrigerator contained insulin and other medications. An LPN acknowledged the blank logs and the contents of the refrigerator, and the DNS acknowledged the blank temperature logs and provided no additional information. The second floor medication refrigerator temperature logs were also blank on multiple dates in March 2026, including 3/11 through 3/13 and 3/18 through 3/19. That refrigerator contained insulin and flu vaccines. An LPN acknowledged the blank logs and the refrigerator contents, and the DNS again acknowledged the blank temperature logs and provided no additional information.
Delayed Assistance With Meals and Fluids
Penalty
Summary
The facility failed to ensure a dignified dining experience for Resident 32, who was admitted with hospice care and Alzheimer's disease. The 1/28/26 care plan stated the resident needed limited to one-on-one assistance with all food and fluids, assistance as needed with meals, and two-person assistance with mobility. The 2/3/26 admission MDS indicated the resident was severely cognitively impaired and required substantial to maximum assistance with eating. During observations in the dining room, Resident 32 was left waiting while other residents were served and ate. On 3/23/26 at 12:31 PM, after a CNA assisted with one bite, the CNA walked away and did not return for 15 minutes, during which the resident did not independently feed himself/herself and no other staff approached to help. On 3/25/26 at 8:08 AM, the resident sat alone at a table while three other residents ate together and staff served their breakfasts; the resident was not served until 44 minutes later. Later that day, the resident had a full beverage in front of him/her from 12:19 PM to 1:17 PM without staff assistance or a meal being offered. Staff stated dependent residents waited until all other residents were served before staff were available to assist them, and the DNS acknowledged that extended wait times for dependent residents in the dining room did not meet facility standards.
Failure to Obtain Consent for Antidepressant Use
Penalty
Summary
The facility failed to inform a resident and the resident's responsible party of the risks and benefits of psychotropic medication use and failed to ensure consent was obtained for Duloxetine. Resident 4 was admitted in 2025 with diagnoses including mild episode of depressive disorder, and a 12/13/25 physician order directed Duloxetine to be administered for depression and pain. Review of the clinical record showed no indication that the risks and benefits of the antidepressant were reviewed or that consent was obtained for its use. On 3/25/26 at 1:54 PM, the Administrator stated he was unable to locate any information showing that the risks and benefits were reviewed or that consent had been obtained for Resident 4's use of the antidepressant.
Failure to Provide Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide hygiene and grooming care for one resident who was admitted with hospice care and Alzheimer's disease. The resident's care plan indicated one-person assistance was needed for hygiene and bathing, and the admission MDS showed substantial to maximum assistance was required for hygiene tasks, the resident was dependent for mobility, and the BIMS score was 1, indicating severe cognitive impairment. Daily care documentation for March 2026 showed the resident received no bathing or nail care from 3/1/26 to 3/19/26. During observation on 3/26/26, a family member expressed concern about the resident's cleanliness, fingernails, and toenails, and removed the blanket and socks to inspect the resident. White build-up was observed around and between the resident's teeth, brown substance was noted under all fingernails, toenails extended past the toe tips, and a large amount of white build-up was removed from around the left big toenail. The resident's feet were observed to have a foul odor. Staff reported that hospice had begun bathing the resident, but facility staff remained responsible for hygiene and grooming care, and one CNA acknowledged she had not washed the resident's hands or brushed the resident's teeth because she did not have time to complete all hygiene care that morning. Staff also stated hygiene tasks were to be completed daily and as needed, and nail care weekly and as needed, but the RNCM was unable to identify a reason the facility did not provide bathing or nail care services from 3/1/26 to 3/19/26.
Missed anti-seizure medications
Penalty
Summary
The facility failed to ensure a resident received prescribed seizure medications for 1 of 1 sampled resident reviewed for medications. Resident 25 was admitted with diagnoses including stroke and hemiplegia, and a 1/22/26 physician order prescribed Briviact 50 mg twice daily and Clobazam 10 mg at bedtime. The 2/2026 MAR showed missed doses of Clobazam on 2/3/26, 2/4/26, and 2/5/26, and a missed dose of Briviact on 2/5/26, each documented as medication not available by a CMA. The CMA stated he was able to order medications but did not order the resident’s anti-seizure medication when he saw it was out, and said nursing staff were responsible for contacting the physician about missed medications but he could not recall whether he informed nursing staff. An LPN stated she was notified on 2/5/26 that the resident was out of Briviact and would not receive the second dose that day, and she was unaware of the three missed Clobazam doses until that date. The physician stated Briviact and Clobazam were important for preventing seizures and that missed doses could result in a grand mal seizure, and the RNCM acknowledged the resident missed anti-seizure medications on 2/3/26, 2/4/26, and 2/5/26.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure an environment free from accident hazards, resulting in an incident involving a resident who was transferred using a Hoyer lift. The resident, who had been diagnosed with Alzheimer's and restless leg syndrome, was non-ambulatory and considered a fall risk. During a transfer from a recliner to a wheelchair, the resident slid from the sling and fell to the floor, sustaining a left leg femoral fracture and an avulsion injury to the left foot. The incident occurred because the sling's leg straps were not properly attached to the Hoyer lift, as confirmed by video footage and staff interviews. The facility's policy and procedure on mechanical lifts required adherence to the manufacturer's instructions, which included ensuring the sling was properly connected to the hooks of the swivel bar before moving the patient. However, during the transfer, a blanket covered the resident's legs, obscuring the view of the sling's placement. Staff involved in the transfer did not verify the placement of the straps before lifting the resident. The video footage revealed that the straps were not crisscrossed through the resident's legs, allowing the resident to slip out of the sling. Interviews with staff members involved in the incident indicated a lack of verification of the sling's proper setup. One CNA stated she was not sure about the placement of the sling due to the blanket covering the resident's legs, while another CNA did not double-check the straps before proceeding with the transfer. The facility's administration acknowledged that the improper setup of the sling contributed to the resident's fall and subsequent injuries.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during meal service in two dining rooms, which placed residents at risk for foodborne illness. On multiple occasions, staff members were observed not adhering to proper glove use and hand hygiene protocols. For instance, a CNA on the third floor dining room was seen touching various surfaces such as cupboards, clean cups, plates, and serving utensils without changing gloves. Similarly, a cook on the second floor dining room served food without wearing gloves, directly touching plates and utensils. An RNCM also failed to change gloves after touching multiple surfaces during meal service. Additionally, a server was observed handling meal trays with ungloved hands before sanitizing them, and an infection preventionist confirmed that staff should change gloves and sanitize hands after touching equipment. Another incident involved a CMA who moved a chair and assisted a resident with their meal without performing hand hygiene. The CMA acknowledged the failure to perform hand hygiene after moving the chair and before assisting the resident with their meal.
Failure to Ensure Dignity in Meal Service
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal service, specifically affecting Resident 29. Resident 29, who was admitted to the facility with a diagnosis of kidney disease, was observed during a lunch meal seated at a dining table with another resident. Staff delivered lunch to the other resident but not to Resident 29, proceeding to serve other residents in the dining room instead. The other resident at the table repeatedly asked staff about the whereabouts of Resident 29's meal, and staff acknowledged the delay, stating that the meal was being prepared. Resident 29 also inquired about their meal and received the same response. The other resident chose to stop eating and wait for Resident 29 to be served. Ultimately, Resident 29 received their meal 18 minutes after the other resident at the table had been served. The facility's administrator stated that the expectation was for staff to serve meals one table at a time, ensuring each resident at the table received their meal before moving on to another table. This expectation was not met, resulting in a delay and lack of dignity for Resident 29 during the dining experience.
Failure to Obtain Timely Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to timely inform the resident representative of the risks and benefits of psychotropic medication use for a resident with dementia, leading to a lack of informed consent. The resident was admitted to the facility with a diagnosis of dementia, and their cognition was severely impaired. The resident's medication administration record (MAR) showed an order for lorazepam, an anti-anxiety medication, as needed, which was administered on three occasions before a consent for treatment was completed. The consent was only obtained after the medication had been administered, as confirmed by an interview with the LPN Resident Care Manager.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within the required timeframe for a resident who was admitted in June 2018 with a diagnosis of respiratory failure. The Minimum Data Set (MDS) assessments for this resident were completed on several occasions, including an annual MDS in September 2023 and quarterly MDS assessments in December 2023, March 2024, and June 2024. However, the annual MDS due in September 2024 was not completed within the required timeframe, as confirmed by the facility administrator on November 18, 2024. This oversight placed residents at risk for unassessed needs.
Failure to Accurately Assess Resident's Hand Contractures
Penalty
Summary
The facility failed to ensure accurate assessments for a resident with limited range of motion, specifically regarding hand contractures. The resident, admitted in October 2024 with Alzheimer's disease and Type 2 Diabetes, was noted in the Admission MDS to have no limitations in upper extremities. However, the active care plan indicated impaired functional status in various activities and included interventions for bilateral hand contractures. Observations on November 18, 2024, confirmed the presence of hand contractures, and no splinting was observed. A family member confirmed the contractures were present upon admission, and the LPN Resident Care Manager acknowledged that the contractures were not coded on the MDS.
Failure to Prevent Decline in Resident's Range of Motion
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decline in range of motion for a resident with limited ROM. The resident, admitted in October 2024 with Alzheimer's disease and Type 2 Diabetes, had impaired functional status in various activities and was at risk for worsening hand contractures. The care plan included interventions to prevent progression of bilateral hand contractures by inserting a rolled ace wrap or washcloth into the resident's hands daily. However, on November 18, 2024, the resident was observed with contractures in both hands, and no interventions were noted. A CNA was unaware of any specific care related to the contractures, and a family member reported that intervention devices were not being used regularly, leading to increased difficulty in managing the contractures. The LPN resident care manager confirmed that the contractures were present upon admission and that the care plan interventions were not followed by the staff.
Failure to Implement and Timely Investigate Fall Interventions
Penalty
Summary
The facility failed to ensure effective fall interventions for two residents, leading to significant incidents. Resident 1, diagnosed with Parkinson's disease and dementia, was assessed to be at risk for falls and required a motion sensor when seated in a recliner. However, on the day of the incident, the motion sensor was not placed by the CNA after transferring the resident to the recliner. As a result, Resident 1 attempted to walk unassisted, fell, and sustained a right arm fracture. The investigation revealed that the motion sensor was not in place at the time of the fall, and the fall was only reported after a former resident notified the staff. Resident 3, with severe cognitive impairment and poor safety awareness, experienced multiple falls within a short period. The investigations into these falls were significantly delayed, with some taking over a month to complete. The LPN Resident Care Manager admitted to being behind on completing these investigations. The DNS and Administrator acknowledged that timely investigations are crucial to ensure care plans are followed and to analyze falls to prevent neglect or abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Albany | 2.6 mi | ★★★★★ | 14 | 0 |
| Timberline Post Acute | 3.4 mi | ★★★★★ | 8 | 0 |
| Corvallis Manor Nursing & Rehabilitation Center | 8.4 mi | — | 20 | 0 |
| Avamere Rehabilitation Of Lebanon | 8.6 mi | ★★★★★ | 28 | 0 |
| Lebanon Veterans Home | 8.8 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mennonite Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.