Emmanuel Care Center - Travis

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for two of eight sampled residents (Resident 1 and Resident 8) when:Resident 1's blood pressure medication was administered without parameters (specific thresholds set by a doctor indicating when to administer or hold medications);Resident 3's hazardous medication (medication that can cause serious health problems requiring special handling to protect healthcare workers, residents, and the environment) was not handled safely during administration;Resident 8's vital signs (measurements of the body's most basic functions) were not taken before administration of blood pressure (BP) medications;Resident 8's blood pressure medication was administered outside the physician-ordered hold parameters;Resident 8's evening medications were not administered as ordered; and,Resident 8's elbow splint was not applied as ordered by the physician.These failures resulted in Resident 1 and Resident 8 receiving antihypertensive medication outside physician's hold parameters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate hydration and nutrition was provided for two of eight sampled residents (Resident 1 and Resident 4) when:Resident 1's fluid restriction (FR- limiting daily intake of all liquids often due to kidney or heart conditions) order was not followed; andResident 4's weight refusals were not documented. These failures increased the potential for Resident 1 to experience fluid overload and for Resident 4 to have significant weight changes. 1.A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed), attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a system to ensure the safe and secure disposal and reconciliation for controlled substances (medications with a high potential for abuse and addiction) in accordance with federal and state regulations when:1. The consultant pharmacist was not present on site to witness the disposal of controlled substances for the month of [DATE].2. Controlled substance medications were not accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR, an accountability record) for one of two randomly selected residents (Resident 4).These failures resulted in an increased risk for controlled substance medication loss, misuse, and potential harm to residents.1. During an interview and record review on [DATE] at 8:40 a.m. with the Director of Nursing (DON). The DON described the facility's process for controlled substance destruction. She stated that when a resident's-controlled substance medications are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with industry standards when:Food was labeled inconsistently,The can opener tip was chipped but still in use, and The blue cutting board was deeply gouged. These failures had the potential of leading to cross contamination of the 6 residents eating facility prepared meals. 1. During the initial kitchen tour on 12/2/25 at 8:50 a.m. in the dry storage area, containers of bulk food items were stored in large plastic containers. One such container held long grain rice that lacked a received date or an opened date, but indicated a use by date of 5/22/35. Another container which held barley, also lacked a received date or an opened date, but indicated a use-by date of 12-6-35. During a concurrent interview of the Dietary Services Supervisor (DSS), the DSS concurred that the dates were close to 10 years away and believed they may coincide with the manufacturer's storage guidance but was unable to show the packaging to confirm this.Review of the Dry Goods Storage Guide hanging in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper treatment and care to maintain good foot health was provided for one of 8 sampled residents (Resident 8) when podiatry services (services focused on diagnosis, treatment, and prevention of conditions affecting the foot, ankle, and lower leg) were not provided for Resident 8 as ordered by the physician.This failure had the potential to result in Resident 8's decreased overall quality of life and well-being, and the potential for Resident 8 to experience discomfort.Findings:During a review of Resident 8's admission records, the records indicated Resident 8 was admitted to the facility in January 2025 with diagnoses that included cerebrovascular disease (conditions that affect the blood vessels and blood flow to the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body), dementia (a progressive state of decline in mental abilities), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen use was documented consistently for one of eight sampled residents (Resident 3).This failure had the potential to not accurately assess Resident 3's need and response to oxygen therapy. A review of the admission Record indicated Resident 3 was admitted [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis and weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain stroke- loss of blood flow to a part of the brain) affecting right dominant side, and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).A review of Resident 3's physician order dated 10/8/25 indicated an order for oxygen at 2 liters (L- unit of measurement) per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide appropriate pain management for one of eight sampled residents (Resident 4) when Resident 4's pain level per pain scale assessment (a numerical system used to gauge a resident's pain intensity, where 0 is no pain and 10 is worst possible pain) did not correlate with pain medication provided. This failure had the potential for Resident 4's pain to not be treated effectively. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in July 2025 with multiple diagnoses including chronic venous insufficiency (valves in the leg veins are weak causing blood to pool in the legs), spinal stenosis in the lumbar region (narrowing of the spinal canal in the lower back that compressed nerves causing pain, weakness, or numbness in the legs and buttocks), and osteoarthritis (cartilage in joints is worn down causing bones to rub against each other causing pain and stiffness) of the left knee, ankle, and foot. A review of Resident 4's Minimum Data Set (MDS- federally mandated assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the pharmacy recommendation was implemented for one of eight sampled residents (Resident 1) when the site of the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection was not documented.This failure had the potential for Resident 1 to receive insulin injections on the same site and for Resident 1 to develop thickened skin affecting insulin absorption. A review of the admission Record indicated Resident 1 was admitted with diagnoses including end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed), and type 2 diabetes mellitus (DM- disorder characterized by difficulty in blood sugar control and poor wound healing).A review of Resident 1's physician orders indicated Humalog injection as per sliding scale (a rapid-acting insulin is adjusted based on the current blood sugar level)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 3) was free of a significant medication error when staff did not flush the resident's gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) as ordered by the physician and in accordance with the facility's policy and procedure. This failure resulted in the potential for tube clogging, which may disrupt the delivery of medication and nutrition, increasing the risk for complications such as dehydration, undernourishment and harm to the resident. During a medication observation on 12/3/25 at 8:52 a.m., Licensed Nurse (LN) 4 was observed preparing seven medication preparations for Resident 3 including four oral tablets, two liquid medications and one liquid nutritional supplement. LN 4 crushed each medication tablet, placed the contents in separate medication cups and diluted them. Then, she prepared the liquid formulations into separate medication cups. Afterwards she brought the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility failed to ensure that a prepared medication was not returned to the medication cart for one of eight sampled residents (Resident 8).This practice resulted in prepared, unsealed, unlabeled medication being available for use, creating a risk for medication error and the potential for resident harm.During a medication pass observation with Licensed Nurse (LN 1) on 12/2/25 at 1:10 p.m., at the medication cart, LN 1 retrieved Resident 8's dose of hydralazine 50 mg (a medication used to treat high blood pressure) from a sealed, pharmacy-supplied blister pack. She popped the tablet into a medication cup, placed it in a plastic bag to crush it, then returned the crushed medication to the cup and mixed it with applesauce.LN 1 entered Resident 8's room and explained the medication was for hypertension (high blood pressure). The resident refused the medication despite several offers.On 12/2/25 at 1:21 p.m., LN 1 returned to the medication cart and stated that the resident refused [the medication]. She then labeled the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure coordination of care between the hospice team (care designed to provide supportive care for physical, psychological, spiritual, and emotional needs to a terminally ill resident) and the facility for one of 8 sampled residents (Resident 6), when the resident's clinical records did not include hospice documents. This failure placed Resident 6 at risk for not receiving services necessary to promote comfort and quality of life. Findings: A review of the admission Record indicated the facility admitted Resident 6 in early 2025 with multiple diagnoses which included end stage heart failure (a condition when the heart becomes weaker and it's too weak to pump blood through the body effectively causing severe fatigue and shortness of breath). A review of Resident 6's clinical records contained a physician order dated 3/19/2025, which indicated Resident 6 was admitted to the hospice services. A review of Resident 6's electronic records and a Hospice Binder located at the nursing station was conducted on 12/3/25 at 12:15 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure performance improvement projects (PIP) were developed when high risk or problem-prone areas in the facility were not identified for a census of 8.This failure decreased the facility's potential to correct systemic issues that can affect residents' health and safety.Findings:During an interview on 12/4/25 at 4:24 p.m. with the Administrator (ADM), the ADM stated that during the facility's Quality Assurance and Performance Improvement (QAPI, a systematic approach to improving the quality of care and resident life in healthcare settings) meetings, the QAPI members present and discussed the most pressing issues within the facility. The ADM stated the QAPI team identified high risk and problem-prone areas including kitchen management during their monthly meetings. The ADM acknowledged that no PIPs were conducted to address the identified issues and stated, we could have picked a lot of projects to do the PIP. The ADM further stated that the QAPI team should have created a PIP based on the issues discussed during the QAPI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.