Methodist Manor Retirement Community

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to properly store and label food items with open dates. The facility failed to identify items that were outside of original packaging and did not discard expired items. The facility did not complete appropriate hand hygiene when preparing food in accordance with professional standards. The facility reported a census of 85 residents.

Inspectors wroteBased on observation, Electronic Health Records (EHR) review, policy review and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, that was on Enhanced Barrier Precautions (EBP) for 1 of 1 reviewed (Resident #8) and with missed opportunities for hand hygiene when personal cares were completed on a resident with a catheter for 1 of 3 reviewed (Resident #3). The facility reported a census of 85 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely assessment and interventions for 1 of 3 residents reviewed. Resident #1 reported signs and symptoms of a Urinary Tract Infection (UTI) and staff did not follow through to get a urinalysis (UA) order until 6 days later. The clinical chart lacked vital signs and nursing notes during this timeframe. The facility reported a census of 84 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 4 out of 21 residents reviewed for comprehensive care plans (Residents #21, #73, #33, and #78). The facility reported a census of 89 residents.

Inspectors wroteBased on clinical record review, staff interviews, Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the COVID-19 (coronavirus disease) immunization for 4 of 5 resident reviewed (Resident #12, #21, #40 and #77). The facility reported a census of 89 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to notify the physician regarding a change in a resident's condition after a fall (Resident #5). The facility reported a census of 89 residents.

Inspectors wroteBased on clinical record review, staff interview, facility investigation review and policy review the facility failed to report an allegation of abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 2 of 2 residents reviewed (Residents #21 and #49). The facility also failed to report the allegation of abuse/suspected crime to the law enforcement center. The facility reported a census of 89 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 of 21 residents reviewed (Resident #78). The facility reported a census of 89 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASRR) evaluation report into a resident's assessment, care planning, and transition of care for 1 resident reviewed (Resident #78). The facility reported a census of 89 residents.

Inspectors wroteBased on observations, record review, staff interviews and policy reviews, the facility failed to change and label oxygen tubing for 1 of 2 residents reviewed (Resident #33). The facility reported a census of 89.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the family/responsible party of a change in the resident's condition requiring physician's notification for 2 of 3 residents reviewed (Resident #2 and #3). The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility record review, the facility failed to provide adequate nursing supervision to prevent a fall for 1 of 1 residents reviewed (Residents #89). The facility reported a total census of 90 residents.

Inspectors wroteBased on staff documentation, staff interview, policy review, & observations, the facility failed to ensure resident dishes and kitchen equipment reached the appropriate sanitizing hot temperature when utilizing the dish machine to reduce the risk of bacteria growth and cross contamination with 3 out of 4 dish machines in the facility. The facility failed to ensure food thermometers were sanitized appropriately when obtained food temperatures. The facility reported a census of 90 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to complete the appropriate Minimum Data Set (MDS) assessment for 1 resident reviewed for discharge (Resident #87). The facility reported a census of 90 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASSR) evaluation for 1 of 2 resident reviewed with a new mental health diagnosis and medication revision (Resident #5). The facility reported a census of 90.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 2 out of 18 residents (Residents #22 and #15) reviewed for comprehensive care plans. The facility reported a census of 90 residents.

Inspectors wroteBased on observations, record review, staff interviews, resident interview and policy review, the facility failed to change oxygen tubing for 1 of 2 resident reviewed (Resident #8) for respiratory services. The facility reported a census of 90 residents. Findings Include: The Minimum Data Set (MDS) assessment for Resident #8 dated 3/9/24 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of heart failure (inability for the heart to pump enough blood), chronic respiratory failure with hypoxia, pneumonia and obstructive sleep apnea. The MDS documented Resident #8 was on oxygen therapy while a resident at the facility. [...]

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to provide an appropriate clinical rationale for a gradual dose reduction (GDR) declination for 1 out of 3 residents reviewed for unnecessary medications. (Resident #14) The facility reported a census of 90 residents.

Inspectors wrote2. An email dated 5/8/24 from the Administrator documented the facility had 1 resident on the lower level with a pureed diet (Resident #48). The Clinical Physician's Orders dated 5/9/24 documented Resident #48 had an order for a pureed texture diet. On 5/8/24 at 11:49 a.m. food for the noon meal arrived to the lower level. Staff transferred food to the steam table and took temperatures of the food. Staff M, [NAME] stated having 1 pureed diet on the lower level, Resident #48. Staff M sorted menus and the dietary aide served resident's liquids. Staff M put on pink gloves and started serving the resident's food. Staff M served the resident on a pureed diet a #12 scoop of pureed meat. When the meal service ended, Staff M verified only serving the resident on a pureed diet a #12 scoop of pureed meat. There were 2, #12 scoops of pureed hamburger remaining. On 5/9/24 at 2:00 p.m. [...]

Inspectors wroteBased on observations, record review and staff interview, the facility failed to provide infection prevention practices by not performing appropriate cleaning of the tube adaptor for 1 of 1 resident (Resident #53). The facility reported a census of 90.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a system to monitor long term use of antibiotics for 2 of 3 residents reviewed (Resident #61 and #15). The facility reported a census of 90 residents.