A list of the most recent deficiencies for Immanuel Campus of Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-03 | 2023-12-22 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-20 | 2023-12-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-28 | 2023-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-14 | 2023-09-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-27 | 2023-09-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-14 | 2023-07-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-14 | 2023-07-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-14 | 2023-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-11 | 2023-06-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-01 | 2022-11-01 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-09-01 | 2022-11-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-01 | 2022-11-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-01 | 2022-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-11-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-02 | 2022-10-31 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-09-02 | 2022-10-31 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-02 | 2022-10-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-02 | 2022-10-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-02 | 2022-10-31 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-09-02 | 2022-10-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-02 | 2022-10-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-13 | 2022-01-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-30 | 2021-08-03 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-06-30 | 2021-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-30 | 2021-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-30 | 2021-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-30 | 2021-08-03 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-25 | 2020-10-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-03-11 | 2020-04-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-11 | 2020-04-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-11 | 2020-04-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-11 | 2020-04-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-03-11 | 2020-04-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-03-11 | 2020-04-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-10 | 2019-02-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-01-10 | 2019-02-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-01-10 | 2019-02-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-10 | 2019-02-24 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-10 | 2019-02-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-01-10 | 2019-02-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-10 | 2019-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-10 | 2019-02-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-10 | 2019-02-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-01-10 | 2019-02-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-01-10 | 2019-02-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-10 | 2019-02-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-10 | 2019-02-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-10 | 2019-02-24 | N |
