Emmanuel Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF808Jan 28, 2026

  Based on observation, interview and document review the facility failed to ensure modified diet orders were served in accordance with physician's orders for 3 of 4 residents (R1, R2, R3) who were at risk of aspiration and choking. This resulted in an immediate jeopardy for R1 and R3 when R1 was served food despite a strict order for nothing by mouth (NPO) and R3 who had a history of dysphasia (difficulty swallowing) and was served non pureed meat, not in accordance with the prescribed diet. The IJ began on 1/19/26, when dining assistant (DA) served R1 a regular textured meal consisting of a sandwich against physician's orders for NPO. […]

• Actual harm, isolatedF684Feb 20, 2025

  Based on interview and record review the facility failed to ensure professional standards of care were followed while waiting for emergency medical services for 1 of 3 residents (R1) reviewed for quality of care. This resulted in harm when a trained medication aide (TMA) and a police officer were awaiting EMS arrival when R1's change in condition worsened and the nurse was not notified. Findings include: R1's care plan since admitted d [DATE] to print date [DATE], identified R1's advanced directive: full code and directed staff follow POLST guidelines. R1 had CHF and directed staff to check breath sounds and monitor/document for labored breathing, use of accessory muscles while breathing, and monitor oxygen settings. […]

• Actual harm, isolatedF689Feb 1, 2023

  Based on interview, observation, and document review, the facility failed to ensure residents were assessed to safely operate or provide necessary supervision to keep residents safe while utilizing an electric recliner for 2 of 6 residents (R3, R6) reviewed, who utilized an electric recliner. This resulted in actual harm when R3 lifted self in electric recliner using the remote causing a fall which resulted in a fracture. Findings include: R3's quarterly Minumum Data Set (MDS) dated [DATE], included a diagnosis of Parkinson's disease and had severely impaired cognition. R3 required extensive assistance by staff with transfers and ambulation. R3 had three falls since previous assessment 8/02/22, two of which resulted in injuries. […]

• Actual harm, isolatedF689Aug 19, 2022

  Based on observation, interview and document review, the facility failed to evaluate and develop potential interventions to prevent further coffee [CONDITION(S)] for 1 of 1 resident (R27) who experienced two instances of coffee [CONDITION(S)]. This deficient practice resulted in actual harm to R27 who suffered a second degree burn (partial thickness burn, involving the epidermis (top layers of skin) and part of the dermis (underneath the epidermis) layer of skin, appears red, blistered, and may be swollen and painful) from spilt hot coffee. Findings include: R27's Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS) dated [DATE], identified R27 had diagnoses which included Alzheimer's disease, diabetes, [CONDITION(S)] and above the knee amputation of the left leg. […]

• Actual harm, isolatedF689Mar 23, 2022

  Based on observation, interview and document review the facility failed to conduct a thorough fall investigation and failed to ensure all staff implemented individualized fall interventions in accordance with the care plan in order to prevent and/or reduce the risk of falls for 1 of 3 residents (R1) who had a history of falls with injuries and major injury. This resulted in actual harm for R1, who required emergency transfer to the hospital for [CONDITION(S)] that required staples. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of dementia and had severe cognitive impairment. Further review of MDS indicated R1 did not ambulate, required extensive assist of two staff members for transfers, dressing and toileting. […]