Immanuel Campus of Care

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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 clinical record review, staff interviews, facility investigation, and policy and procedures, the administrator failed to conduct a thorough investigation of abuse for residents (#1, #2, #3, #4, #5, #6).Â

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of eight residents (#1, #3, #6, #11, #13, #14, #27, #28) to be free from abuse by other resident(s) (#2, #4, #5, #8, #10, #14, #29, #30). Â

Based 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.Â

Based 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) as soon as possible but no more than 24 hours after an event.