Inspection Reports for
The Gardens at Immanuel

36-420.04 — The facility failed to maintain a copy of the documentation provided to an emergency responder for a resident who required emergency services on November 2, 2024.

Care instructions documentation — The manager failed to ensure that care instructions from a home health agency were documented in the resident's service plan for one resident receiving home health services.

R9-10-808 — The service plans for two residents receiving directed care services did not include required elements such as skin maintenance, cognitive stimulation, weight documentation, and coordination of communications.

Medication documentation — The manager failed to ensure that administration of oxygen was documented in the resident's medical record as ordered for one resident receiving medication administration.

Dietary provision — The manager failed to ensure that two residents were provided diets meeting their nutritional needs as specified in their service plans, which did not specify diet details.

A manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services, as required by facility policy. Documentation was missing or incomplete for two of three personnel records reviewed.

R9-10-113 — The manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis as specified, including incomplete risk assessments and improperly timed tuberculosis skin tests for two of three employees sampled.

The manager failed to ensure two of three personnel records contained documentation that a caregiver or assistant caregiver received orientation before providing assisted living services. Orientation checklists were present but not completed.

The manager failed to ensure a caregiver documented the services provided in the resident's medical record for one of two residents sampled. The service plan required blood glucose monitoring documentation which was not found.

The manager failed to implement policies and procedures covering cardiopulmonary resuscitation training for applicable employees, including demonstration of CPR ability, for one of two sampled employees. The deficient practice posed a risk to resident health and safety if employees were unable to perform life-saving measures in an emergency.

The manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver, as observed when the assistant caregiver provided personal care without direct supervision.

The manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. A cabinet containing toxic cleaning chemicals was accessible because magnetic locks were switched off.