Immanuel Campus Of Care

In the surveyor’s words

From the most serious findings on record at Immanuel Campus Of Care, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 24, 2025

  Based on record review, staff and resident interviews, facility documentation, and facility policy and procedure, the facility failed to ensure adequate supervision to prevent a non-prescribed medication overdose for one resident (#12). The deficient practice could result in an avoidable accidental overdose of residents. Findings Include: -Regarding Resident #24: -Resident #24 was admitted to the facility on [DATE] with diagnoses that included asthma, major depressive disorder, and opioid use with unspecified opioid induced disorder. […]

• Actual harm, isolatedF600Apr 19, 2024

  Based on clinical record reviews, resident and staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of 21 residents (#34, #183, 164, #104, #128, #156, #169, #144, #28, #184, #170, #77, #172, #182, #1, #47, #98, #196, #134, #142 and #86) to be free from abuse by another resident. The sample size was 77. The deficient practice could result in further abuse and resident(s) sustaining injury from resident to resident abuse. […]

• Actual harm, isolatedF689Jun 30, 2021

  Based on clinical record reviews, review of facility documents, staff interviews and review of facility policies and procedures, the facility failed to ensure that one resident (#2) received adequate supervision to prevent resident #2 from assaulting one resident (#1) which resulted in a fractured nasal bone. The deficient practice could result in further incidents of aggression towards additional residents in the facility. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included TBI (Traumatic Brain Injury), dementia with behavioral disturbance, restlessness, agitation, and alcohol dependence. […]

• No harm, potential for more than minimal, widespreadF925Jan 22, 2021

  Based on observations, interviews, review of facility documentation, and policies and procedures, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of rodents. The facility census was 161 residents. The deficient practice could result in ongoing rodent problems. Findings include: -Regarding the kitchen: Review of a facility pest control invoice revealed that on January 21, 2021, the pest control company had serviced the facility's main kitchen. The invoice indicated that there was no activity in the dry storage area in the 24 hours after the pest control company had sealed a hole in the wall. On January 21, 2021 at 10:00 a.m., an observation was conducted of the first-floor main kitchen. […]

• No harm, potential for more than minimal, patternF757Jan 31, 2025

  Based on review of clinical records and policy, and staff interviews the facility failed to ensure that the medication administration records accurately reflected targeted behavior monitoring as specified within physician orders for residents (# 118, # 123). The deficient practice may result in administering unnecessary medication and/or undesirable medication-induced harm. Findings include: -Resident # 118 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, and insomnia. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 11, which indicated the resident was moderately cognitively impaired. […]