Immanuel Campus of Care

Based on record review and interview, the manager failed to ensure that a caregiver documents the services provided in the resident's medical record. Findings include: 1. A review of R1's medical record revealed that R1 receives personal care services. Further review shows R1's bathing needs will be done with max assistance. A review of R1's activities of daily living for February 2026 revealed scheduled bath/shower days on Monday and Friday between 2 pm and 10 pm, and skin checks will be completed. The following dates show no documentation of bath/showers and skin checks: February 2, 6, 9, 13, 20, 23, and 27. 2. In an interview, R2 and R4 reported that services were provided, which included assistance with bathing. 3. In an interview, the findings were reviewed with E1, and no additional documentation was provided.

Based on a record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for two out of three sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's service plan showed a section titled "Bladder", which stated "Is incontinent of bladder Wears Briefs needs staff to check every 2 hours" and a section titled "Bowels, which stated "Is incontinent of bowels. Wears Brief staff to change and wipe." A review of R1's activities of daily living (ADLs) revealed no documentation on the following dates and times for brief changes: December 9, 2025: 1400, 1600, 1800, and 2000 December 16, 2025: 1400, 1600, 1800, and 2000 December 17, 2025: 1400, 1600, 1800, and 2000 December 19, 2025: 600, 800, 1000, and 1200 December 20, 2025: 600, 800, 1000, and 1200 December 21, 2025: 600, 800, 1000, and 1200 December 22, 2025: 600, 800, 1000, and 1200 December 23, 2025: 600, 800, 1000, 1200, 1400, 1600, 1800, and 2000 December 24, 2025: 600, 800, 1000, 1200, 1400, 1600, 1800, and 2000 December 25, 2025: 600, 800, 1000, and 1200 2. A review of R3's service plan showed a section titled "Bladder", which states "Bladder incontinence care needs to provided. Wears adult briefs. Check every 2 hours. Staff x1 assist with incontinent care." A review of R3's ADLs revealed no documentation on the following dates and times for brief changes: December 16, 2025: 1400, 1600, 1800, and 2000 December 17, 2025: 1400, 1600, 1800, and 2000 December 20, 2025: 600, 800, 1000, and 1200 December 21, 2025: 600, 800, 1000, and 1200 December 22, 2025: 600, 800, 1000, and 1200 December 23, 2025: 600, 800, 1000, 1200, 1400, 1600, 1800, and 2000 December 24, 2025: 600, 800, 1000, 1200, 1400, 1600, 1800, and 2000 December 25, 2025: 600, 800, 1000, and 1200 3. In an interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on April 4, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that medication administered to a resident was documented in the resident's medical record. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Administration of Medications - General Guidelines", which stated: "Medication Administration is documented on the resident's Medication Administration Record at the time medication is given by the person who administered the medication. The resident's Medication Administration is initialed by the person administering the medication in this space provided under the date and on the line for the specific medication dosage administration. Initials on the Medication Administration Record and record are verified with a full signature in this space provided." 2. A review of R1's medical records revealed current medication orders showing various medications, including: Lunesta Oral Tablet 2 MG (Eszopiclone) Melatonin Oral Tablet 10 MG (Melatonin) Remeron Oral Tablet 15 MG (Mirtazapine) Tamsulosin HCI Oral Capsule 0.4 MG (Tamsulosin HCI) tiZANidine HCI Oral Tablet 4 MG (Tizanidine HCI) traZODone HCI Oral Tablet 150 MG (Trazodone HCI) 3. Further review of R1's medication administration record revealed no documentation on the following dates and times: Lunesta Oral Tablet 2 MG (Eszopiclone) Give 1 tablet by mouth at bedtime for Insomnia: December 4, 2025, at 2000 Melatonin Oral Tablet 10 MG (Melatonin) Give 1 tablet by mouth at bedtime for Insomnia: December 4, 2025, at 2000 Remeron Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for depression: December 4, 2025, at 2000 Tamsulosin HCI Oral Capsule 0.4 MG (Tamsulosin HCI) Give 1 capsule by mouth at bedtime for BPH: December 4, 2025, at 2000 tiZANidine HCI Oral Tablet 4 MG (Tizanidine HCI) Give 1 tablet by mouth at bedtime for muscle spasms: December 4, 2025, at 2000 traZODone HCI Oral Tablet 150 MG (Trazodone HCI) Give 1 tablet by mouth at bedtime for depression: December 4, 2025, at 2000 4. In an interview, R1 reported that he takes the medication that the caregiver provides. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed no documentation of freedom from infectious TB by way of two-step TB testing as required. 4. In an interview, E1 acknowledged E2's personnel records did not contain evidence of freedom from infectious tuberculosis on or before the date E2 provided services at or on behalf of the assisted living facility and as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed an "Assisted Living Admission Packet" acknowledgement signature page which included R1's orientation to exits form the assisted living facility. the document was signed on October 27, 2024. Based on R1's acceptance date, the orientation was not provided within 24 hours after R1's acceptance. 3. In an interview, E1 acknowledged R1 did not have proper documentation of being oriented to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance.