Inspection visit
Fire Safety inspection
Citations
16 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0031GeneralS&S Fpotential for harm
Provide emergency officials' contact information.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0034GeneralS&S Fpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0222SeriousS&S Limmediate jeopardy
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the January 15, 2025 survey of MENNONITE FRIENDSHIP COMMUNITIES INC?
This was a inspection survey of MENNONITE FRIENDSHIP COMMUNITIES INC on January 15, 2025. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MENNONITE FRIENDSHIP COMMUNITIES INC on January 15, 2025?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address patient/client population and determine types of services needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.