Emmanuel Nursing Home

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe transfer for 1 of 3 residents (R3) reviewed for accidents when staff failed to stay next to R3 while in the stand lift and staff walked away from the stand lift to move wheelchair out of the way.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 3 resident s (R30) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 3 resident s (R30) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had severe cognitive impairment and had diagnosis which included Alzheimer's depression, and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 2 of 2 resident (R21, R5) reviewed for restraints. Findings Include: R21's quarterly Minimum Data Set, dated [DATE], identified R21 had severe cognitive impairment and diagnoses which included: stroke, dementia and arthritis. R21's MDS identified R21 required partial/moderate assistance with rolling left to right and lying to sitting. R21 required substantial/maximal assistance with sitting to standing and transfers. In addition, R21's MDS identified R21 has two or more falls with no injury and restraints were not used. R21's Care Area Assessment (CAA) dated 5/14/25, identified R21 was at risk for falls related to her impaired mobility and cognitive functions and need for activities of daily living (ADL) assistance. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that routine shaving was provided for one of two (R18) individuals reviewed for activities of daily living (ADLs) who were dependent on staff for their care.

Inspectors wroteBased on observation and interview, the facility failed to disinfect a multi-use glucometer (a machine that is used for blood glucose monitoring) after use for 1 of 2 residents (R41) reviewed for blood glucose monitoring. Further the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 3 residents ( R62) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure modified diet orders were served in accordance with physician's orders for 3 of 4 residents (R1, R2, R3) who were at risk of aspiration and choking. This resulted in an immediate jeopardy for R1 and R3 when R1 was served food despite a strict order for nothing by mouth (NPO) and R3 who had a history of dysphasia (difficulty swallowing) and was served non pureed meat, not in accordance with the prescribed diet. The IJ began on 1/19/26, when dining assistant (DA) served R1 a regular textured meal consisting of a sandwich against physician's orders for NPO. R1's oxygen saturation level was 71% (a normal blood oxygen level is between 95% and 100%, regardless of age) and was taken to the emergency department (ED) by ambulance. In addition, on 1/27/26 at 12:32 p.m., R3 was seated at a table in the dining room. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure professional standards of care were followed while waiting for emergency medical services for 1 of 3 residents (R1) reviewed for quality of care. This resulted in harm when a trained medication aide (TMA) and a police officer were awaiting EMS arrival when R1's change in condition worsened and the nurse was not notified.

Inspectors wroteBased on observation, interview, and document review the facility's administrator failed to provide oversight, develop policies and procedures to ensure emergency responders had access to enter the building when called for emergent resident needs for 1 of 1 resident (R1) reviewed. A police officer (PO) and emergency medical services (EMS) arrived at the facility following a 911 call, were not able timely access the resident by entry to the building and the resident room.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner that promoted dignity for 3 of 4 (R2, R3, R4) reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide range of motion (ROM) (refers to how far you can move or stretch a part of your body) services to prevent a potential decrease in range of motion for 1 of 1 resident (R21) reviewed who required range of motion for restorative nursing exercises.

Inspectors wroteBased on observation, interview and document review, the facility failed to accurately assess and implement safe smoking interventions for 1 of 1 resident (R6) reviewed for smoking.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 4 residents ( R34) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to implement hand hygiene for 3 of 3 residents (R3, R4, R5) observed during medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure sufficient staffing to provide routine assistance with activities of daily living (ADL's) for 1 of 1 resident (R11) who was dependent on staff for ADL's. In addition, one resident ( R31) and 3 of 5 of the resident council members (R11, R17 and R1) voiced concerns with an inadequate number of staff to routinely meet their needs in a timely manner.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 1 of 2 hallways observed for linen transportation.

Inspectors wroteBased on interview and document review, the facility failed to ensure 4 of 5 residents (R1, R11, R18 and R31) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications (SAM) for 1 of 1 resident (R33) reviewed for medication administration.

Inspectors wroteBased on interview and document review, the facility failed to develop a comprehensive person-centered care plan which included interventions and a goal related to smoking safety for 1 of 1 residents (R47) reviewed for accidents.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and monitor for 1 of 1 resident (R33) who was reviewed for non-pressure related skin issues related to a bruise obtained from the patient assisted lift (PAL) for transfers.

Inspectors wroteBased on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 residents (R33) reviewed for hearing.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure safe smoking interventions for 1 of 1 resident (R47) reviewed for smoking. In addition, the facility failed to ensure safe transfers with a patient assist lift (PAL) for 1 of 4 residents (R33) reviewed for accidents.