Immanuel Campus of Care

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to protect the right to be free from physical abuse for two residents (Residents #170, #171). The deficient practice could lead to additional resident-to-resident altercations, creating an unsafe environment.

Inspectors wroteBased on observation, record review, interviews, and facility policy review the facility failed to ensure one of thirty-three sampled residents (#36) was free from physical restraint related to bed rails. The universe was one hundred and seventy-eight. The deficient practice could cause a resident to suffer physical injury from entrapment or psychosocial harm related to restraint use.

Inspectors wroteBased on observations, record review, interviews, and facility policy review the facility failed to ensure a comprehensive care plan with interventions was developed, revised, and implemented related to safety and prevention for two of thirty-three sampled residents (#36 and #30) regarding use of bed rails, concave mattress and use of nicotine. The universe was one hundred and seventy-eight. The deficient practice could result in the resident's needs not being met.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1The facility failed to protect resident right to make informed decisions and choices for one resident. Based on review of clinical and administrative records, resident and staff interviews, and review of facility policy, the facility failed to protect one out of three resident's right (#20) to make informed decisions and choices. The deficient practice could lead to a vulnerable resident not understanding their legal rights.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of one Resident (#6) out of the five sampled residents to be free from abuse by another resident (#10). The deficient practice could result in other residents being abused. The facility census was 168.

Inspectors wroteBased on a closed record review, staff interviews, review of facility documentation, policy, and procedures, the facility failed to ensure that the resident's representative was notified of an injury for one resident (#222). The deficient practice could result in resident representatives not being informed of resident's injuries.

Inspectors wroteBased on clinical record review, resident and staff interviews, and review of facility policy, the facility failed to protect the rights of one resident (#16) to be free from abuse from another resident (#3). The deficient practice could result in residents being physically or emotionally harmed.

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation, and policy review, the facility failed to develop and implement policies and procedures for documenting and reporting alleged violations involving abuse, in accordance with federal and state laws and regulations. The deficient practice resulted in an alleged violation concerning abuse (involving Resident #16 and Resident #3) not being investigated timely and reported within the mandatory two-hour timeframe to Adult Protective Services (APS) and the State Agency. This deficient practice could result in further allegations not being documented or reported in a timely manner, which could impact residents' quality of life and care.

Inspectors wroteBased on clinical record reviews, facility documentation, and staff interviews, the facility failed to ensure that an alleged violation involving abuse (involving Resident #16 and Resident #3) was reported to the State Agency and Adult Protective Services (APS) within the required timeframe of two hours. The deficient practice could cause a delay in response to potential abuse, putting residents at risk.

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident #222 to be free from abuse by another resident #333. The deficient practice could result in further abuse.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#32) did not abuse another resident (#121). The deficient practice could result in residents being physically harmed.

Inspectors wroteBased on record review, staff and resident interviews, facility documentation, and facility policy and procedure, the facility failed to ensure adequate supervision to prevent a non-prescribed medication overdose for one resident (#12). The deficient practice could result in an avoidable accidental overdose of residents. Findings Include: -Regarding Resident #24: -Resident #24 was admitted to the facility on [DATE] with diagnoses that included asthma, major depressive disorder, and opioid use with unspecified opioid induced disorder. A care plan-initiated [DATE] revealed no focus related to substance abuse or dependency. A quarterly Minimum Data Set (MDS) assessment dated on [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated resident was cognitively intact. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1 and #2) were free from physical abuse. The deficient practice could result in further incidents of staff to resident abuse.

Inspectors wroteBased on review of clinical records and policy, and staff interviews the facility failed to ensure that the medication administration records accurately reflected targeted behavior monitoring as specified within physician orders for residents (# 118, # 123). The deficient practice may result in administering unnecessary medication and/or undesirable medication-induced harm.

Inspectors wroteBased on onsite investigation, interviews, review of facility documentation and policy, the facility failed to ensure that one resident # 64 was treated with dignity and respect and that the resident was cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing the resident 's individuality. The deficient practice could result in a lower quality of life for residents in the facility.

Inspectors wrote-Regarding Resident #12: Resident #12 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, bipolar disorder, major depressive disorder, and auditory hallucinations. A care plan revised November 24, 2020 revealed that resident #12 had a potential to be verbally abusive. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 which indicated that the resident was cognitively intact. -Regarding Resident #400 Resident #400 was admitted to the facility on [DATE] with diagnoses that included paraplegia, paranoid personality disorder, restlessness and agitation. A quarterly MDS dated [DATE] included a BIMS score of 15 which indicated that the resident was cognitively intact. On January 29, 2025 at 10:58 a.m. a phone interview attempt was made with resident #12, however resident did not answer the phone call. [...]

Inspectors wroteBased on observation, documentation, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure that residents (#55 and #33) were allowed to leave their rooms during a COVID-19 outbreak. The deficient practice could result in residents not being treated with dignity and respect or afforded their rights.

Inspectors wroteBased on documentation, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure that residents (#55 and #33) were offered activities when they were COVID-19 positive and the residents on their unit were not allowed to attend activities in the common area. The deficient practice could impact the psychosocial well being of residents.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#77) was provided the supervision needed to maintain her health and safety. The deficient practice could result in residents being harmed physically and psychologically.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure that a resident (resident #1) was free from verbal abuse from staff members. The deficient practice could lead to further abuse of residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, review of facility documentation and policy, the facility failed to ensure that the skin assessment was complete and accurately documented in the clinical record for one resident (#43). The deficient practice could result in inaccurate information of the condition or status of the resident that could affect the care provided to the resident.

Inspectors wroteBased on clinical record reviews, resident and staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of 21 residents (#34, #183, 164, #104, #128, #156, #169, #144, #28, #184, #170, #77, #172, #182, #1, #47, #98, #196, #134, #142 and #86) to be free from abuse by another resident. The sample size was 77. The deficient practice could result in further abuse and resident(s) sustaining injury from resident to resident abuse.

Inspectors wroteBased on clinical record review, facility documents, staff interviews and facility policy, the facility failed to ensure that a resident (#90) was provided with care consistent with professional standards.

Inspectors wroteBased on clinical record review, facility documents, staff interviews and facility policy, the facility failed to ensure that a resident (#90) did not elope.

Inspectors wroteBased on clinical documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that three residents (#15, #165, #31) had access to their personal phones and were afforded privacy when making phone calls. The deficient practice could result in the rights and personal choices of the residents being denied.

Inspectors wroteThe facility failed to ensure that 3 resident had reasonable access to the use of a telephone. Based on observation, interviews and record review, the facility failed to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard or timed for three sampled residents (#418) (#100) and ) (#35).

Inspectors wroteBased on facility documentation, staff interviews, and the the facility policy and procedures, the facility failed to ensure that two residents (#27 and #53) were free from abuse. The deficient practice could result in residents being physically and psychosocially injured.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one sampled resident (#160) needs were addressed in the resident's care plan and admission process for left breast lump, unspecified malignant neoplasm of bone and articular cartilage, liver cirrhosis, and viral Hepatis C infection. The deficient practice could result in residents' needs not being addressed. The facility census was 165 at the time of the survey.

Inspectors wroteBased on observation, interviews and record review, the facility failed to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard or documented for one sample resident (#418)

Inspectors wroteBased on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a Pre- admission Screening and Resident Review (PASARR) Level 2 referral was completed for one resident (#48). The deficient practice could lead to residents not receiving needed care and services.

Inspectors wroteBased on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to provide bowel care for one resident (#1) in accordance with standards of practice. The deficient practice could result in residents being constipated resulting in bowel obstructions.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident (#176) were free from physical abuse of another. The sample size was 4. The deficient practice could result in resident(s) sustaining physical injuries and/or psychosocial harm.