Emmanuel Center for Nursing

In the surveyor’s words

From the most serious findings on record at Emmanuel Center for Nursing, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 10, 2026

  Based on a review of clinical records, facility policies, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to protect one of five residents reviewed (Resident 5) from abuse and neglect by not implementing the individualized care plan intervention requiring two staff members for bed mobility assistance, resulting in actual harm in the form of a spiral fracture of the distal left femur. This deficiency is cited as past noncompliance. Findings include: A review of the facility policy titled Freedom from Abuse, Neglect and Exploitation last reviewed by the facility in December 2025, revealed the facility will take appropriate steps to prevent occurrence of abuse, neglect, and misappropriation of resident property. […]

• Actual harm, isolatedF689Sep 15, 2022

  Based on review of clinical records and select facility incident reports, and staff interview it was determined that the facility failed to timely implement individualized safety measures/assistance devices during wheelchair transport to prevent accident and serious injury, a lower leg fracture, for one resident (Resident 69) out of five residents reviewed. Findings include: A review of the clinical record revealed that Resident 69 had diagnoses, which included [CONDITION(S)] (a chronic condition in which the heart does not pump blood as well as it should), spinal stenosis (narrowing of the spaces in the spine), and polyosteoarthritis (type of arthritis in which five or more joints are affected with joint pain). […]

• No harm, potential for more than minimal, widespreadF812Dec 23, 2024

  Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department and in the 100-Hall and 200-Hall medication room refrigerators. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF812Jan 11, 2024

  Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of two resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, patternF565Aug 7, 2026

  Based on review of clinical records, facility policies, Resident Council meeting minutes, grievances filed at the facility, and resident and staff interviews, it was determined that the facility failed to act upon and effectively address recurring concerns raised by the Resident Council regarding prolonged staff response times to residents' requests for care and assistance and failed to demonstrate its response and rationale for addressing the recurring concerns. The same concerns were identified during three consecutive Resident Council meetings conducted and remained ongoing during a Resident Council group interview conducted on August 5, 2026, when six out of six residents interviewed (Residents 2, 22, 38, 48, 53, and 62) reported continued concerns regarding prolonged staff response… […]