A list of the most recent deficiencies for Emmanuel Center For Nursing. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-11 | 2024-02-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-11 | 2024-02-22 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-11 | 2024-02-22 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-01-11 | 2024-02-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-11 | 2024-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-11 | 2024-02-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-11 | 2024-02-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-01-11 | 2024-02-22 | 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 | 2024-01-11 | 2024-02-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-11 | 2024-02-22 | 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 | 2024-01-11 | 2024-02-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-11 | 2024-02-22 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-01-11 | 2024-02-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-23 | 2024-02-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-23 | 2024-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-23 | 2024-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-23 | 2024-02-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-23 | 2024-02-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-23 | 2024-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-15 | 2023-06-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-20 | 2023-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-03-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-20 | 2023-03-01 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-03-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-20 | 2023-03-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-20 | 2023-03-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-20 | 2023-03-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-20 | 2023-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-24 | 2023-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-24 | 2023-02-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-24 | 2023-02-20 | 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 | 2022-10-06 | 2022-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-06 | 2022-11-01 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-10-06 | 2022-11-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-06 | 2022-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-11-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-09-15 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-06-30 | 2022-09-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-30 | 2022-09-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-30 | 2022-09-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-11 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | 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 | 2022-03-11 | 2022-04-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-11 | 2022-04-25 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-21 | 2022-04-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-21 | 2022-04-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-21 | 2022-04-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-21 | 2022-04-21 | N |
