A list of the most recent deficiencies for Methodist Manor Retirement Com. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-13 | 2023-03-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-09 | 2023-03-24 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-03-09 | 2023-03-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-09 | 2023-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-03-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-09 | 2023-03-24 | N |
| Develop a communication plan. | Fire Safety | 2023-03-13 | 2023-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-13 | 2023-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-30 | 2022-09-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-30 | 2022-09-17 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-14 | 2022-01-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-12-14 | 2022-01-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-12-14 | 2022-01-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-12-09 | 2022-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-09 | 2022-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-09 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-12-09 | 2022-01-09 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-12-14 | 2021-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-14 | 2021-12-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-10-17 | 2019-11-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-10-17 | 2019-11-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-10-17 | 2019-11-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-17 | 2019-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-17 | 2019-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-17 | 2019-11-17 | N |
| Post nurse staffing information every day. | Health | 2019-10-17 | 2019-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-17 | 2019-11-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-18 | 2019-11-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-18 | 2019-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-18 | 2019-10-18 | N |
