Methodist Manor Retirement Community

In the surveyor’s words

From the most serious findings on record at Methodist Manor Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF689May 9, 2024

  Based 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. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #89 documented diagnoses of hypertension, renal failure, hyperlipidemia and chronic respiratory failure with hypoxia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. […]

• No harm, potential for more than minimal, patternF812Apr 16, 2026

  Based 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. Findings include:On 4/13/26 at 11:20 AM during the initial kitchen observation freezer items observed opened without an open date include chicken wings, corn beef, chicken patties, white turkey patties, meat balls, bread dough (rolls), large box of multiple resealable plastic bags of different kinds of frozen meat that were not specified to the type of meat on any of the bags and… […]

• No harm, potential for more than minimal, patternF880Apr 16, 2026

  Based 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.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. […]

• No harm, potential for more than minimal, patternF656Mar 27, 2025

  Based 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. Findings include: 1. Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Resident #21's MDS included diagnoses of non-alzheimer's dementia, depression, alcohol dependence with alcohol-induced persisting dementia, restlessness and agitation. […]

• No harm, potential for more than minimal, patternF887Mar 27, 2025

  Based 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. Findings include: 1. Resident #12's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The MDS documented Resident #12 was not up to date with the COVID-19 vaccination. Review of the clinical record revealed Resident #12 had received a COVID vaccination on 10/24/21. […]