Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MENNONITE FRIENDSHIP COMMUNITIES INC

SOUTH HUTCHINSON, KS · 100 certified beds · Last Life Safety survey January 15, 2025

CMS Certification Number 175379 · first certified August 1996

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within KS

46 citations — more than 93% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 16 citations; the earlier surveys in the window averaged 15. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: September 2026 to November 2026. This facility’s last Life Safety survey was January 2025. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

16 of the 46 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 46 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	46
Median facility in KS	27
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
September 8, 2021	19
March 9, 2023	11
January 15, 2025	16

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0920	Ensure proper usage of power strips and extension cords.	3	2025-01-15
E-0024	Establish policies and procedures for volunteers.	3	2025-01-15
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2025-01-15
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	3	2025-01-15
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2025-01-15
E-0007	Address patient/client population and determine types of services needed.	2	2025-01-15
K-0363	Install corridor and hallway doors that block smoke.	2	2025-01-15
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2023-03-09

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 16
Smoke Deficiencies 15
Gas, Vacuum, and Electrical Systems Deficiencies 7
Egress Deficiencies 4
Other 4

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	16
Smoke Deficiencies	15
Gas, Vacuum, and Electrical Systems Deficiencies	7
Egress Deficiencies	4
Miscellaneous Deficiencies	3
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 15, 2025 — 16 citations

Citations issued on January 15, 2025
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (February 21, 2025)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (February 21, 2025)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (February 21, 2025)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (February 21, 2025)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (February 21, 2025)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (February 21, 2025)
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (February 21, 2025)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (February 21, 2025)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (February 21, 2025)
K-0222	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.	Deficient, Provider has date of correction (February 21, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (February 21, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 21, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 21, 2025)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (February 21, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 21, 2025)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (February 21, 2025)

March 9, 2023 — 11 citations

Citations issued on March 9, 2023
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (May 12, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (May 12, 2023)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (May 12, 2023)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (May 12, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (May 12, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (May 12, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (May 12, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (May 12, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (May 12, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (May 12, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (May 12, 2023)

September 8, 2021 — 19 citations

Citations issued on September 8, 2021
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (November 29, 2021)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (November 29, 2021)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (November 29, 2021)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (November 29, 2021)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (November 29, 2021)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (November 29, 2021)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (November 29, 2021)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (November 29, 2021)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (November 29, 2021)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (November 29, 2021)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (November 29, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 29, 2021)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (November 29, 2021)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (November 29, 2021)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (November 29, 2021)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (November 29, 2021)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (November 29, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 29, 2021)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (November 29, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.