Manly Specialty Care

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or restlessness for 1 of 1 resident sampled (Resident #39). The facility identified a census of 36.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews the facility failed to report allegations of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) for 2 of 3 residents reviewed (Resident #5, Resident #39, and Resident #20). The investigation determined the facility failed to report when Resident #39 pushed Resident #5 in one incident and grabbed her in another incident. in addition, the facility failed to report when Resident #39 poked Resident #20 in the head. The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews the facility failed to investigate and review interventions to ensure interviews are adequate to prevent further abuse for a known resident with a history of aggression for resident-to-resident abuse for 2 of 3 resident reviewed. (Residents #5, #20, and #39). Resident #39 grabbed Resident #5 and poked Resident #20 in the head. The facility reported a census of 36 residents.

Inspectors wroteBased on record review, facility policy review and staff interviews the facility failed to ensure staff protected and prevented resident-to-resident abuse for 1 of 3 reviewed (Resident #45). Resident #39 hit Resident #45 on the right upper arm. At the time of the incident Resident #45 sat with a staff member. The staff member failed to intervene until after Resident #39 hit Resident #45. Resident #39 had a known history of resident-to-resident altercations and the facility failed to evaluate the effectiveness of the interventions to prevent harm to other residents, see F609 and F610 for additional information regarding additional incidents. The facility reported a census of 36 residents.

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to maintain a sanitary kitchen; failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. The facility reported a census of 36 residents.

Inspectors wroteBased on facility records, review of the Facility Assessment, and staff interviews, the facility failed to have a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full time Registered Dietician. The facility reported a census of 41 residents. Findings Include: On 2/24/25 at 10:20 AM, Staff A, [NAME] stated the facility didn't have a kitchen manager and haven't had one for approximately six months. She stated worked there for approximately three years. Staff A stated she assisted with some duties such as ordering supplies but she is not officially the kitchen manager. On 2/26/25 at 10:12 AM, the Administrator stated the prior Certified Dietary Manager, still worked at the facility but no longer in that position worked approximately 25 hours a week. He added she occasionally did pick up extra shifts. [...]

Inspectors wroteBased on record review, policy review and staff interviews, the facility failed to ensure all residents received medication as ordered by a physician; and failed to prevent potentially serious medication errors when staff administered the wrong medications or dosage from 5/8/24 to 2/21/25 for 8 of 8 residents reviewed (Residents #6, #8, #35, 38, #44, #145, #146, #147, and #148). The facility reported a census of 41 residents.

Inspectors wroteBased on observation, facility documentation, staff, and resident interview, the facility failed to follow the posted menu and serve the appropriate portions for 3 of 3 residents who received pureed diets (Residents #13, #21, and #24). In addition, the facility failed to serve the ordered therapeutic menu for 5 of 5 residents with an order for low sodium diets. Additionally, 2 residents, (Residents #8 and #11) didn't get the substitution menu as they requested. 2 other residents (Residents #20 and #38) didn't receive their double proteins as directed on their menu cards. In addition, the facility had 19 residents with an order for the NIP (Nutritional Intervention Program), adding extra foods/calorie/nutrition to their meals. Of the 19 residents with the NIP on their menu cards, 9 of them didn't receive any extra food on their trays. The facility reported a census of 41 residents. [...]

Inspectors wroteBased on observation, staff interviews, guidance from the 2022 Food and Drug Administration (FDA) Food Code, and facility policy, the facility failed to serve food within the acceptable temperature range. The facility reported a census of 41 residents.

Inspectors wroteBased on record review, staff interviews, and Resident Assessment Instrument (RAI) Manual the facility failed to accurately code 2 of 12 residents' (Residents #1 and #33) Minimum Data Set (MDS) Assessment. The facility reported a census of 41 residents.

Inspectors wroteBased on observations, clinical record review, and staff interview, the facility failed to follow the comprehensive Care Plan for 1 of 12 (Resident #24) reviewed for Care Plans. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident and staff interview the facility failed to update resident Care Plans for 2 of 12 residents reviewed (Residents #7 and #33) for Care Planning. The facility reported a census of 41 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide the Dietitian approved menu for 4 of 4 residents who were on a pureed diet (Residents #12, #22, #37 and #38). During the lunch observation on 4/24/24, observed four residents did not receive pureed bread per therapeutic menu. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to send notice to State Long Term Care Ombudsman of transfer for 2 of 3 residents reviewed (Residents #13 and #26). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for 1 of 1 reviewed (Resident # 36). The facility reported a census of 37 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly care for and accurately document pressure ulcers for 1 of 3 residents reviewed (Resident #23). During a pressure ulcer dressing change, observed the staff failed to use a cleanser to clean Resident #23's sacral/coccyx (tailbone area) pressure ulcer. During record review of this resident's pressure ulcers, determined the facility didn't update the stages of the pressure ulcers with worsening changes. The facility reported a census of 37 residents.

Inspectors wroteBased on interviews and record review, the facility failed to forward a pharmacy recommendation for the physician to re evaluate the renewal of a 14-day PRN (as needed) Haloperidol (Haldol)(antipsychotic) for 1 of 5 residents reviewed for medication regimen review (Resident #33). The facility reported a census of 37 residents.

Inspectors wroteBased on facility record review, staff interview, and policy review, the facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities are necessary. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, record review, staff interview and policy review the facility failed perform proper hand hygiene and proper personal protective equipment guidelines to prevent the spread of potential infection and germs during peri cares for 1 of 1 resident reviewed (Resident # 13). The facility reported a census of 37 residents.

Inspectors wroteBased on interview with staff, family and medical professionals, and record and policy review the facility failed to adequately plan for resident's discharge for 1 of 4 residents reviewed. Resident #1 was admitted to the facility after surgery to install a feeding tube. The facility failed to teach her how to use the feeding tube pump, and failed to ensure she had all the needed supplies and medications when she returned home. This failure resulted in the hospitalization of the resident related to dehydration, failure to thrive and urinary tract infection, therefore causing an Immediate Jeopardy to the health, safety and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 1/1/24, on 1/10/24 at 9:57 AM. The facility removed the Immediate Jeopardy on 1/10/24 with the following actions: a. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to prevent accidents and injuries from falls for 2 of 3 residents reviewed. Resident #2 had a change in condition with increased weakness and fell from the EZ Stand mechanical lift while being transferred. During a transfer with the EZ Stand, staff failed to tighten the waist belt for Resident #4. The facility reported a census of 40 residents.