Emmanuel Nursing Home

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a safe transfer and adequate supervision for a resident during use of a mechanical stand lift. The resident had moderately impaired cognition, required substantial assistance with transfers, and had multiple diagnoses including a progressive neurological condition, osteoporosis, dementia, Parkinson’s disease, malnutrition, anxiety, depression, and a history of falls. The care plan directed staff to use a patient assist lift (PAL/stand lift) with one to two staff for transfers, to use two staff and/or a Hoyer lift when the resident was weak or lethargic, and to provide a safe environment with locked brakes on bed and wheelchair as much as possible. The resident was also care planned as at risk for falls due to gait and balance problems, Parkinson’s disease, dystonia, potential poor safety awareness, sensory deficits, vision/hearing issues, psychotropic medication side effects, benign paroxysmal vertigo, and a history of falls. On the day of observation, a nursing assistant transported the resident in a wheelchair to the resident’s room, positioned the wheelchair, and brought in the EZ stand lift from the bathroom. The nursing assistant locked the brakes on both the wheelchair and the lift, applied the sling, positioned the resident’s feet on the footplate, attached the sling loops, and instructed the resident to hold the handlebars. Standing next to the resident, the nursing assistant used the hand control to lift the resident from the wheelchair, then released the lift brakes, moved the lift away from the wheelchair, closed the lift legs, and pushed the resident into the bathroom. The nursing assistant then positioned the resident over the toilet, locked the lift brakes, lowered the resident onto the toilet, removed the soiled brief, placed a clean brief, used the stand lift to raise the resident off the toilet, completed perineal care, pulled up the brief, and released the lift brakes before moving the lift and resident out of the bathroom. After toileting, the resident’s wheelchair remained in front of the recliner, and the resident chose to transfer to the recliner. While the resident was standing in the EZ stand lift in front of the wheelchair, the wheelchair brakes were not on and the wheelchair wheels were facing the doorway. The nursing assistant walked along the resident’s right side, behind her, and around to the back of the wheelchair, then pushed the wheelchair approximately 10 feet away to the end of the bed. During this time, the resident was left unattended in the stand lift, facing the doorway and unable to see the nursing assistant. The nursing assistant later acknowledged that the resident was left unattended in the lift without the brakes on and stated that this was not safe practice and that the resident could have had an accident if the resident or the lift moved. Interviews and documents further described the resident’s condition and the expectations for safe lift use. The resident reported concern about her strength and ability to stand, especially when tired, and fear of falling when standing due to weakness or fatigue. Therapy records and the PT interview noted a history of vasovagal episodes in the bathroom, poor core strength, retropulsion, Parkinson’s-related movement problems, and limited standing tolerance of two to three minutes with support. The PT and the EZ Way customer support representative both stated that staff were expected to stay next to the resident while in the EZ stand lift and not leave the resident’s side during transfers. The DON and RN staff stated that staff were expected to use the lift brakes when not moving and to remain near the resident during transfers, and that obstacles such as the wheelchair should be addressed without leaving the resident unattended in the lift. Facility policy and manufacturer materials described general lift procedures and training requirements, and interviews indicated that the facility’s policy and manufacturer guidance were viewed by staff as vague regarding when to lock the lift wheels, but did not support leaving a resident alone in the stand lift while staff moved furniture. Overall, the deficiency centers on the nursing assistant leaving a high-risk, cognitively impaired resident unattended in a stand lift without the lift brakes engaged while moving the wheelchair out of the way, despite the resident’s documented fall risk, history of vasovagal episodes, and care plan and professional expectations that staff remain at the resident’s side and ensure safe use of the mechanical lift.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure nebulizer medications were administered safely for one resident who was observed self-administering a nebulizer without having been assessed as safe to self-administer medications. The resident’s quarterly MDS indicated severe cognitive impairment and diagnoses including Alzheimer’s disease, depression, and COPD, and the care plan identified altered respiratory status with shortness of breath on exertion and directed staff to administer inhaled or other medications for respiratory conditions as ordered. The resident’s EHR did not contain a self-administration of medication assessment, and the order summary did not include an order for self-administration. During observation, the resident was lying in bed with a nebulizer mask on her face and steam coming from the mask while no staff were present. A TMA later entered, turned off the nebulizer, removed the mask, and stated she had placed the mask on the resident, turned on the machine, and left the room. The TMA was unsure whether a SAM assessment had been completed or what the process was when a resident did not have an order to self-administer medications. RN staff confirmed no SAM assessment had been completed, and the DON verified the resident was not safe to self-administer medications and that staff were expected to remain with the resident throughout the nebulizer treatment when there was no assessment or order allowing self-administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 2 residents, R21 and R5. Both residents had significant cognitive impairment and required extensive assistance with bed mobility and transfers. R21’s records identified severe cognitive impairment, diagnoses including stroke, dementia, and arthritis, and a history of falls. R5’s records identified moderate cognitive impairment, diagnoses including atrial fibrillation, coronary artery disease, and Alzheimer’s disease, and dependence on staff for rolling, sitting up, lying down, and transferring. For R21, the care plan identified fall risk related to spinal stenosis, a possible rotator cuff injury, ADL assistance needs, confusion, and other chronic diagnoses, and included turn aides in the bed for repositioning. Progress notes documented that R21 was found on the floor after a fall, and the intervention remained placement of turn aides in the bed. During observation, R21 had two long blue cylinder-shaped pillows attached to a draw sheet on both sides of the body. Staff interviews indicated the pillows were used for repositioning and to slow R21 down from falling out of bed, but staff were unsure whether the device was a restraint. R21’s record did not contain an order for a restraint or evidence that a restraint assessment had been completed. For R5, the care plan identified dependence on staff for bed mobility and transfers and included turn aids in bed as a fall intervention. During observation, R5 had a blue draw sheet with pillow holders and pillows positioned alongside the body, and staff stated the pillows were used for repositioning and to help prevent falls. Multiple staff members stated the facility did not complete a restraint assessment for the blue turn aids, and some staff were unsure whether R5 could get over the pillows or sit up in bed if desired. The DON stated the turn aid pillows could be considered a restraint if a resident was unable to get over them, and the facility policy defined restraints based on whether the resident could remove the device and whether it restricted movement. The medical records for both residents lacked evidence of a restraint assessment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide routine shaving and other needed grooming assistance for a resident who was dependent on staff for ADLs. The resident had severe cognitive impairment on BIMS, needed moderate assistance with ADLs, and had diagnoses including kidney failure, bladder cancer, and palliative care. The resident’s care plan indicated assistance was needed for ADLs, and progress notes from 2/5/26 to 2/10/26 did not identify any refusal of shaving or other cares. Despite this, multiple observations showed approximately 0.5 to 1 cm of facial hair on the neck, chin, cheeks, and sides of the face over several days, while the mustache was trimmed to the upper lip. During observations, the resident was seen in a recliner and in the dining room with facial hair present, and on one occasion stated he wanted to brush his teeth and shave after breakfast. Staff did not offer to shave or brush his teeth after breakfast during a later observation. Interviews showed staff expected shaving to be offered daily and refusal to be documented, but nursing assistants stated they had not attempted the resident’s cares on some shifts and no refusal had been charted or reported. The resident’s family member stated the resident preferred to be shaved daily and that his shaver had been brought in for staff use. The DON stated residents should be shaved per preference and refusals documented, and facility policy required documentation of refusal and intervention taken.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to disinfect a multi-use glucometer after use for a resident who required blood glucose monitoring before meals and at bedtime. During an observation, an LPN sanitized hands, applied gloves, removed a glucometer, strip, and lancet from a medication cart, and assisted with a blood glucose check for the resident, who had intact cognition and diagnoses including hypertension, renal insufficiency, and diabetes mellitus. After the test, the LPN removed gloves, sanitized hands, wiped the glucometer with an alcohol pad, and placed it back into the medication cart. During interview, the LPN stated the glucometer should have been disinfected per manufacturer guidelines with a Sani-wipe before being placed back in the drawer, and the IP and DON both stated the glucometer was used for multiple residents and should have been disinfected between residents. The manufacturer’s instructions for the Assure Platinum multi Blood Glucose Monitoring System stated the glucometer was to be disinfected with a commercially available EPA-registered disinfectant detergent or germicide wipe after every resident use. The facility policy on cleaning and disinfection of resident care items and equipment stated reusable items are to be cleaned and disinfected according to CDC recommendations between residents. The report also noted CMS F-Tag 880 guidance stating surveyors may cite when meters are not cleaned and disinfected after a blood glucose test. The facility also failed to follow enhanced barrier precautions for a resident with a left chest mastectomy incision and a JP drain. The resident had orders for oxycodone as needed for pain and a care plan requiring EBP for high-contact activities while in the room. During observation, an RN entered the room, washed hands, and applied gloves, but did not wear a gown while emptying the JP drain. The RN removed the drain contents in the bathroom, removed gloves, and washed hands before leaving the room. During interview, the RN stated a gown should have been worn, and the RN, another RN, and the DON all confirmed gowns were expected for residents on EBP during this type of care.

Penalty

Inspection fine: $82,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that therapeutic and modified diets were implemented and served in accordance with physician orders for three residents with dysphagia and high aspiration risk. One resident with dementia, dysphagia, aphasia, and a strict NPO order following a stroke was brought to the dining room after a therapy session, even though she did not normally dine there. The dining assistant, who had not used the available tablet to verify diet orders and believed the resident was someone else, served her a regular textured meal consisting of a ham or turkey sandwich with cheese and juice. The resident’s significant other observed her eating a sandwich and salad, and a staff member then stated she was not supposed to have food. The RN assessed the resident, found her SpO2 at 71%, and she was sent to the ED, where documentation indicated a transient hypoxic episode after being given lunch despite strict NPO status, with concern for an aspiration event. Another resident with multiple sclerosis, mild cognitive impairment, and dysphagia had a physician order for a Level 4 pureed texture diet with thin liquids. Her care plan identified a regular diet with pureed meats and directed staff to serve the diet as ordered. She had a recent history of choking and regurgitation episodes, including an event where she was spitting up food, had wheezing in the lower lung lobes, and required an ED visit with EGD and extraction of a food bolus. Despite this history and the ordered pureed diet, surveyors observed her in the dining room eating a hotdish made from stuffing with chunks of turkey, which dining staff identified as appropriate for a regular or minced and moist diet, not a pureed diet. At the time of observation, dining assistants acknowledged that diet information was available on iPads and diet slips but admitted they sometimes did not use them, and no such tools were in use until prompted by the surveyor. A third resident with dementia, expressive aphasia, and dysphagia had physician orders and a care plan for a Level 4 pureed texture diet with Level 2 mildly thick liquids. The care plan also documented that his family member could provide thin liquids and different textures only when present and that snacks left by the family for use in the resident’s absence were to be compatible with his modified diet. Progress notes documented prior concerns about pocketing food, a choking episode in the dining room where he was not breathing and had turned purple, and subsequent changes to a pureed diet and restrictions on snacks in his room. Despite these orders and documented risks, surveyors observed him independently propelling himself in his wheelchair near the dining room while eating Oreo cookies without staff supervision. The DON later confirmed there was no signed consent for a liberalized diet and that the family member did not want him to have Oreo cookies, and the facility’s own therapeutic diet policy required that snacks be compatible with the therapeutic diet.

Removal Plan

• Review the facility process for ensuring the correct resident receives the correct diet as prescribed by the provider.
• Review and revise care plans for accuracy.
• Educate all staff with competency on resident care plan revisions, the facility procedure for implementing physician-ordered diets, diet textures, and protections from negative outcomes.
• Implement meal tray audits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure professional standards of care were followed while waiting for emergency medical services for a resident with a full code status. The resident, who had a history of congestive heart failure, chronic obstructive pulmonary disease, and other serious health conditions, experienced a change in condition that worsened while a trained medication aide and a police officer awaited the arrival of emergency medical services. The nurse was not notified of the resident's deteriorating condition, which resulted in harm. The resident's care plan and physician orders indicated the need for continuous oxygen and monitoring of respiratory status. Despite these directives, the resident's condition was not adequately assessed or communicated to the nurse. The trained medication aide, who was present with the resident, did not initiate CPR or notify the nurse of the resident's critical condition. The nurse, who was at the nurse's station, did not participate in the assessment or intervention until after emergency services arrived. There was a significant delay in emergency response due to poor communication and lack of coordination among staff. Emergency medical services and police officers experienced difficulty accessing the facility and locating the resident's room, which contributed to a delay in care. The resident was found unresponsive with labored breathing and no pulse, and CPR was not initiated until emergency services arrived. The facility's failure to follow professional standards of care and ensure timely intervention resulted in the resident's death.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's administrator failed to ensure that emergency responders had timely access to the building during an emergency situation involving a resident identified as R1. The incident involved a delay in emergency services reaching R1, who was a full code and required immediate medical attention. The police officer and EMS were dispatched following a 911 call but faced difficulties entering the facility and locating R1's room due to a lack of staff guidance and communication. Upon arrival, the police officer had to wait several minutes before being let into the building by a staff member who approached the entrance in a non-urgent manner. Similarly, EMS personnel experienced a delay as they were not immediately directed to R1's room and were unaware of the critical nature of the situation. This resulted in a significant delay in initiating CPR, which was only started after R1 was found unresponsive and without a pulse. The report highlights a lack of clear policies and procedures for emergency access to the facility, as well as poor communication among staff regarding the resident's condition and the urgency of the situation. The absence of a designated protocol for handling such emergencies contributed to the delay in care, ultimately leading to R1's death. The facility's failure to provide adequate oversight and guidance in emergency situations was a critical factor in this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely responses to call lights, compromising the dignity and care of three residents. Resident R2, with severe cognitive impairment and mobility issues, experienced significant delays in call light responses, ranging from 20 minutes to nearly an hour. This led to situations where R2 had to use a urinal or attempt self-transfer to avoid accidents, despite being at risk for falls. R2 expressed frustration and a sense of neglect due to these delays. Resident R3, who had intact cognition but required assistance with personal hygiene and toileting, also faced delays in call light responses, with one instance taking nearly three hours. These delays resulted in frequent incontinence episodes, causing embarrassment and discomfort for R3. The resident's daughter corroborated these issues, noting that her parents felt like a burden to the staff and often refrained from using the call light due to the long wait times. Resident R4, with intact cognition and a history of incontinence, experienced similar issues with call light response times, sometimes waiting over an hour for assistance. This led to frequent accidents and skin issues due to prolonged exposure to moisture. Interviews with staff and family members highlighted a lack of adequate staffing and the inability to meet residents' needs promptly, further exacerbating the residents' feelings of frustration and embarrassment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary range of motion (ROM) services to a resident, identified as R21, who required these services as part of a restorative nursing program. R21, who was cognitively intact, had a history of hemiplegia, cerebral infarction, heart failure, and hypertension, and required extensive assistance with activities of daily living (ADLs). Despite being care planned for ROM exercises during morning and evening care, these exercises were not consistently provided, as confirmed by multiple staff interviews and the resident's own account. Interviews with various staff members, including nursing assistants, registered nurses, and the clinical manager, revealed a lack of awareness and execution of R21's ROM program. Some staff members were unaware of the program, while others incorrectly believed it was not in place. The clinical manager acknowledged that ROM was supposed to be completed with morning and evening cares and that it was important to prevent potential complications such as contractures. However, the task of documenting ROM completion had been removed from the computer system to save time, leading to a lack of accountability and follow-through. The physical therapist and the Rehab and Therapy Director confirmed the importance of ROM for R21, especially for his left arm, and noted that therapy staff did not have the capacity to follow up on ROM programs. The director of nursing stated that ROM was included in the care plan for nursing staff to complete after therapy discharge, emphasizing its importance in preventing decline. Despite these acknowledgments, the facility's failure to ensure consistent implementation of the ROM program for R21 resulted in a deficiency in care, as the resident experienced increased stiffness in his knee and expressed a desire for the stretching exercises to be resumed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately assess and implement safe smoking interventions for a resident, identified as R6, who was reviewed for smoking. R6 had diagnoses including diabetes mellitus, anemia, and hypertension, and required extensive assistance with activities of daily living. Despite these needs, R6 was assessed as safe to smoke independently without supervision or a smoking apron. However, the assessment lacked information regarding burn holes found in R6's clothing, which were indicative of potential safety hazards. Observations and interviews revealed that R6 frequently smoked without supervision, resulting in ashes falling onto her clothing and burn holes in her jacket. Staff members, including nursing assistants and a laundry supervisor, noticed these burn holes but did not take immediate action to reassess R6's smoking safety. R6 was observed smoking outside the facility grounds, allowing ashes to fall on her pants and jacket without making any effort to remove them, further indicating a lack of adequate supervision and safety measures. The facility's smoking policy required assessments to determine residents' ability to smoke safely, but the policy was not effectively implemented in R6's case. The clinical manager and director of nursing were aware of the burn holes in R6's clothing but did not initially consider the use of a smoking apron or closer supervision. This oversight led to a deficiency in ensuring a safe environment for R6 while smoking, as the facility did not adequately address the potential hazards associated with R6's smoking habits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement appropriate infection prevention and control measures, specifically in the use of personal protective equipment (PPE) and hand hygiene. During observations, it was noted that staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident who required extensive assistance with activities of daily living and had a catheter due to urinary retention. Staff members were observed performing high-contact activities such as transferring the resident without wearing the required gowns, only using gloves, despite the presence of signage indicating the need for both gowns and gloves. Additionally, the facility did not ensure proper hand hygiene practices during medication administration for three residents. An LPN was observed failing to perform hand hygiene after removing soiled gloves and before administering medications to multiple residents. This lapse in protocol was acknowledged by the LPN during an interview, who admitted to not performing hand hygiene as required. The infection preventionist and the director of nursing confirmed the expectations for PPE use and hand hygiene, which were not met during the observed incidents. The facility's policies on Enhanced Barrier Precautions and Handwashing/Hand Hygiene were not followed, leading to deficiencies in infection control practices.