Emporia Presbyterian Manor

Inspectors wroteThe facility reported a census of 51 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food borne illness to the residents of the facility. This placed the residents at risk for food-borne illness.

Inspectors wroteThe facility had a census of 51. The sample included 14 residents. Based on record review, interview, and observation revealed the facility failed to provide care for Resident (R)11 and R19 in a manner that protected and promoted their dignity.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure reasonable accommodation of needs when staff failed to ensure Resident (R)8's call light was within his reach.

Inspectors wroteThe facility had a census of 51 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to keep Resident (R) 58s protected health information (PHI) private on a medication cart that sat against the wall in A hall.

Inspectors wroteThe facility reported a census of 51 residents; the sample included 14 residents, with 9 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide follow-up fall assessments for Resident (R) 4 and failed to assess for R7's ability to safely use an electric recliner until after a fall occurred.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents, including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the consulting pharmacy failed to identify blood sugars out of range for Resident (R) 3.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents, including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to follow orders for notification of the provider for blood sugars out of range for Resident (R) 3.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 8 remained free of significant medication errors when staff failed to administer his potassium (a medication for hypokalemia (low level blood potassium in the blood) ordered by physicians.

Inspectors wroteThe facility had a census of 51 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to ensure staff labeled Resident (R)11's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened.

Inspectors wroteThe facility had a census of 51 residents. The sample included 14 residents with one reviewed for dental care. Based on observation, record review, and interview, the facility failed to provide timely dental care for one sampled resident, Resident (R) 6.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer and administer or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for Resident (R)3Findings included:- Review of R3's clinical record revealed the PCV13 was administered on 10/30/15, and the PSV23 was administered on 11/12/04. R3's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication. On 03/04/26 at 08:04 AM, Administrative Nurse D stated the nurse who admitted the resident was responsible for ensuring the resident or family signed a consent or declination for immunizations. [...]

Inspectors wroteThe facility reported a census of 46 residents with six residents selected for review and four residents sampled for notification of change. Based on record review and interview, the facility failed to notify the physician timely regarding lack of monthly catheter changes and failed to assess, document, and notify the physician with a change in condition when staff alerted the Licensed Nurse of swelling and redness to R2's penis and scrotum on 08/14/24 at 09:00 PM. On 08/15/24 at 03:52 PM, over 18 hours later, R2 required emergency medical transport for further evaluation and treatment.

Inspectors wroteThe facility reported a census of 46 residents with five residents selected for review, including three residents sampled for accidents. Based on record review and interview, the facility failed to investigate a fall on 07/16/24, conduct a complete assessment, and implement a new intervention following the fall for Resident (R)1, that had previous falls in the facility. On 07/17/24, R1 had an additional fall, which the facility failed to complete an assessment and implement a new intervention following the fall. Additionally, the facility failed to notify the responsible party and the physician following falls on 07/16/24 and 07/17/24.

Inspectors wroteThe facility had a census of 48 residents. The sample included 13 residents. Based on record review and interview, the facility failed to ensure the required members, including the infection preventionist, attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility identified a census of 48 residents. The facility had three medication carts. Based on observation, record review, and interview, the facility failed to ensure reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently and per industry standards. This placed residents at risk of medication misappropriation.

Inspectors wroteThe facility had a census of 48 residents, with three reviewed for the Center for Medicare and Medicaid Services (CMS) beneficiary liability notices. Based on record review and interview, the facility failed to provide a CMS Form 10055 which included the estimated costs for Resident (R) 32 and R41. This placed the residents at risk for uninformed decisions regarding skilled services.

Inspectors wroteThe facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide a clean, comfortable, and homelike environment in Resident (R) 35's room. This placed the resident at risk for impaired comfort and dignity.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to identify and assess risk factors for ileus (obstruction of the intestines, caused by immobility of the bowel) and bowel obstruction (a blockage of the flow of bowel stream) and failed to provide the necessary care and services to respond to symptoms related to an ileus for Resident (R) 37, who admitted to the facility with a diagnosis of ileus on 10/21/21. R37's care plan lacked direction to staff regarding bowel management. On 08/21/22 R37 reported abdominal pain, nausea, and vomiting. She had a liquid stool on that day. On 08/22/22 R37 reported abdominal pain and the staff failed to assess bowel sounds or consider the symptoms relative to the resident's history of ileus. [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility lacked posting of the Ombudsman and State Hotline contact numbers which placed the residents at risk of unmet care concerns and impaired ability to contact to the state agencies.

Inspectors wroteThe facility has a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to employ a full time certified dietary manager for the 36 residents who reside in the facility and receive their meals from one of one kitchen, placing the residents at risk for inadequate nutrition

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to educate residents routinely of their Resident Rights which placed the resident at risk for inability to exercise their rights.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, The facility failed to place interventions on the care plan to prevent falls for Resident (R) 9, and R12, failed to add interventions related to the positioning device for R1, and bowel management for R37. This placed the residents at risk for uncommunicated care needs. - The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for five sampled residents. Resident (R) 9, R32, R22, and R26. This placed the residents at risk for complications related to poor hygiene.

Inspectors wrote- The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two injury falls and had a wander alarm (designed to help protect residents against elopement). [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents with one reviewed for positioning. Based on observation, interview and record review the facility failed to ensure proper positioning and utilize the positioning devicefor sampled Resident (R)1. This deficient practice placed the resident at risk for further decrease in range of motion.

Inspectors wroteThe facility had a census of 36 residents. The sample included 14 residents with three reviewed for bowel and bladder. Based on observation, interview, and record review the facility failed to provide catheter (tube inserted into the bladder to drain urine) care routinely, including monitoring urinary output as ordered and directed by the plan of care. This deficient practice placed R1 at risk for complications of urinary catheter use.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents, with three reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary dementia (progressive mental disorder characterized by failing memory and confusion) for Resident (R) 32, who had dementia related behaviors. This placed the resident at risk decreased quality of life and unmet needs.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide routine pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs for one of six reviewed for unnecessary medications, when staff failed to reorder R26's lidocaine 5% patch(a soft, stretchy adhesive patch containing 5% lidocaine (700 mg), daily, for the topical treatment of pain). This placed the resident at risk for ineffective medication regimen.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to the facility failed to ensure Resident (R)190's medication administration was free from significant errors when staff crushed an extended-release medication. This placed the residents at risk for the medications being improperly released.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to maintain Resident (R) 15's oxygen tubing, nasal cannula and breathing treatment mask in a sanitary fashion which placed R15 at risk for respiratory illness.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to post the previous state inspection information in a location accessible to residents and visitors, which placed the residents at risk for impaired information.