Emporia Presbyterian Manor
EMPORIA PRESBYTERIAN MANOR in EMPORIA, KS — inspection on March 4, 2026.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
05/29/25-Half portions at meals to lose weight.
11/12/25-Mechanicl soft consistency. 02/04/26-Supervision to partial assistance with meals On 03/02/26 at 9:15 AM, Certified Nurse's Aide (CNA)M stood by R19's right side and assisted him with eating a bite of bacon.
On 03/04/26 at 08:11 AM, CNA O stated staff have all been in serviced to sit next to the resident the CNA was helping.
She stated nursing staff were never to stand over a resident to assist the resident with eating.
On 03/04/26 at 08:35, Licensed Nurse (LN) I stated she was unsure how staff should be positioned when assisting residents with eating. LN I stated she had seen staff stand and sit. 03/04/26 at 08:04 Administrative Nurse D stated staff have been in serviced to sit in a chair, and converse with the resident the staff were assisting.
The facility's Resident Rights and Responsibility's policy dated 02/25 documented the community would ensure the residents' right to a dignified existence, self-determination and person-centered care with access to person and services inside and outside the community.
The community would protect and promote the rights of each resident.
The community would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
review, and interview, the facility failed to ensure reasonable accommodation of needs when staff
Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), unsteadiness on feet, muscle weakness, and repeated falls.The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition.
The MDS documented R8 was dependent on staff for toileting and needed supervision or touching assistance from staff with eating.The Falls Care Area Assessment (CAA) dated 01/22/26 documented R8 was at risk for falls related to a history of falls, impaired mobility, weakness, dementia, urinary catheter, and required assistance with transfers/mobility.R8's Care Plan documented the following:01/28/26- R8 had been instructed to use call light for assistance.01/28/26- R8 was dependent on one or two staff for toileting throughout the day to manage bowel incontinence.On 03/03/26 at 10:20 AM, R8 sat in his room in front of the TV in his Broda chair (specialized wheelchair with the ability to tilt and recline). R8's pancake light laid in the middle of his bed. R8 could not reach his call light to call for assistance.On 03/03/26 at 10:21 AM, Certified Nursing Aide (CNA) N stated R8's call light was out of reach. CNA N stated R8's call light should be where he could reach the light and use the light. CNA N placed R8's light next to him on his bedside table, within his reach.On 03/04/26 at 08:34 AM, Licensed Nurse (LN) I stated residents call lights should always be within a resident's reach.
She stated it was every staff member's duty to ensure call lights were within reach.On 03/04/26 at 08:04 AM, Administrative Nurse D stated residents should always have their call light where they can reach it.
She stated the facility does on the spot training and in services on where to place a residents call light.The facility's Call Light System policy, revised 04/19 documented the community would have a call button or pull cord located next to each bed and in each resident's bathroom.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
(PHI) private on a medication cart that sat against the wall in A hall.
Findings included: - On 03/03/26
laptop computer sitting on the top.
Certified Medication Aide (CMA) R walked away from the medication cart and into a resident's room. CMA R left the computer screen unlocked and opened and R58's PHI was on the screen, visible to all who passed by the medication cart.
The information visualized included R58's medications, date of birth , allergy information, and code status. On 03/03/26 at 08:37 AM, CMA R stated she had stepped away from the cart to help a resident.
She stated the policy was to ensure the CMA locked the medication cart and pushed the hide button. On 03/04/26 at 08:17 AM, Licensed Nurse (LN) I stated medication carts should be locked and the screen on the laptop should be closed, or staff could push the hide button, if the laptop was out of the staff's visual.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the policy was to lock the medication cart.
She stated nursing staff have the option to close the laptop or push the hide the screen button.
She stated staff have been in-serviced on how the medication cart and laptop should be left, when the laptop or cart was not in their line of sight.
The facility's Confidentiality policy, revised on 02/25 documented confidentially must be maintained in all areas of health information, whether oral, written, or electronic.
Personnel must keep residents' information confidential except as permitted for continuity of care.
Although information sharing was necessary in the healthcare environment confidentiality was breached when the information can be intercepted by unauthorized persons and connected to a specific individual.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
was completed at 07/01/25 at 12:14 PM, but the vital signs were documented at 03:32 PM.
The fourth
were time-stamped 06/29/25 at 07:00 AM, prior to the fall, and no assessment was completed.
The
07:00 AM, prior to the fall, and no assessment was completed.
The seventh shift check lacked a time it was completed, but the vital signs were time-stamped 06/29/25 at 07:00 AM, prior to the fall, and no assessment was completed.
On 03/03/26 at 07:45 AM, R40 was independent in her room and walked into the bathroom.
On 03/03/26 at 7:51 AM, R40 independently walked with her walker to the dining area, R40 parked her walker next to the wall and got into her chair without assistance.
On 03/04/26 at 8:44 AM, Certified Nurse Aide (CNA) P stated when a resident fell, the nurses assessed the resident and documented vital signs for several days after.
On 03/04/26 at 9:00 AM, Certified Nurse Aide (CNA) H stated the nurse completed a head-to-toe assessment when a resident fell.
The nurse checked vital signs and started neurological assessments, notified the doctor and family.
The nurse on duty opened the neurological assessment that they used to document the follow up neuros.
The nurse completed the Post Fall Assessment and started the risk management.
The nurse always started neurological checks if the fall was not witnessed or if the resident hit their head.
On 03/04/26 at 12:03 PM, Administrative Nurse D stated when a resident fell the nurse was to assess the resident for injury which included vital signs and a neurological assessment.
They assist the resident up or call emergency medical assistance.
Start the neurological assessments unless you can prove they did not hit their head.
Complete the other assessments.
The facility's policy Neurological Assessment dated` 02/03/25 documented the neurological screening is conducted by a licensed nurse on residents who sustain a head injury.
The neurologic screening in the EMR is completed every 15 minutes for an hour, them ever 30 minutes for an hour, then every hour for four hours, then every four hours for 16 hours, then every shift for three days.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
Based on record review, interview and observation,
included:- R3's Electronic Medical Records (EMR) documented diagnoses, which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R3's 05/06/2025 admission Minimum Data Set (MDS) documented R3 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition.
The MDS noted R3 had a diagnosis of diabetes and received an insulin injection every day in the look back period of seven days.
The Nutrition Care Area Assessment (CAA) documented R3 was at risk for impaired nutrition related to a stroke, morbid obesity, and diabetes. R3's Care Plan dated 05/06/25 documented that R3 takes insulin and oral diabetes medications and directed staff to monitor and document side effects and effectiveness.
Intervention on 08/03/25 directed the staff to check her fasting blood sugar as ordered and to notify the provider of readings less than 60 milligrams per deciliter (mg/dl) or greater than 350 mg/dl. R3's Physician Orders in the EMR documented an order for blood glucose monitoring two times a day.
Call the doctor if the blood glucose level is less than 60 mg/dl or over 350 mg/dl; dated 07/29/25.
Review of R3's blood glucose record under the Weights and Vitals tab for July 2025 through February 2026 found the following:07/07/25 a blood glucose level of 376 mg/dl07/08/25 a blood glucose level of 377 mg/dl07/09/25 a blood glucose level of 393 mg/dl07/11/25 a blood glucose level of 409 mg/dl07/12/25 a blood glucose level of 363 mg/dl07/13/25 a blood glucose level of 362 mg/dl07/14/25 a blood glucose level of 423 mg/dl07/15/25 a blood glucose level of 382 mg/dl07/18/25 a blood glucose level of 382 mg/dl07/19/25 a blood glucose level of 418 mg/dl07/21/25 a blood glucose level of 406 mg/dl07/22/25 a blood glucose level of 365 mg/dl07/23/25 a blood glucose level of 418 mg/dl08/01/25 a blood glucose level of 411 mg/dl08/13/25 a blood glucose level of 366 mg/dl08/27/25 a blood glucose level of 596 mg/dl09/01/25 a blood glucose level of 357 mg/dl09/05/25 a blood glucose level of 372 mg/dl09/09/25 a blood glucose level of 442 mg/dl09/10/25 a blood glucose level of 369 mg/dl09/17/25 a blood glucose level of 442 mg/dl09/29/25 a blood glucose level of 455 mg/dl10/03/25 a blood glucose level of 386 mg/dl11/03/25 a blood glucose level of 391 mg/dl11/11/25 a blood glucose level of 357 mg/dl11/24/25 a blood glucose level of 363 mg/dl12/31/25 a blood glucose level of 397 mg/dl01/10/26 a blood glucose level of 352 mg/dl01/12/26 a blood glucose level of 351 mg/dl01/27/26 a blood glucose level of 369 mg/dl02/04/26 a blood glucose level of 421 mg/dl02/14/26 a blood glucose level of 359 mg/dl02/20/26 a blood glucose level of 358 mg/dl02/22/26 a blood glucose level of 353 mg/dl02/24/26 a blood glucose level of 355 mg/dl R3's Progress Notes in the EMR lacked notification to the provider for blood glucose over 350 mg/dl for the above dates.
Review of the Drug Regimen Review (DRR) from August 2025 to February 2026 showed no documentation that the blood sugars were identified by the pharmacist as being out of range. On 03/02/26 8:19 AM, R3 laid in bed with her over bed table close to the side of the bed. R3 stated she preferred to stay in bed and staff bring her breakfast to her. On 03/04/26 at 12:03 PM, Administrative Nurse D stated she expected the pharmacist to know when a medication was out of the parameter and to notify the facility.
The facility's Drug Regimen Review dated 08/2024 documented the pharmacist will complete a drug regimen review monthly and when needed, and identify medication without proper monitoring.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
the facility failed to follow orders for notification of the provider for blood sugars out of range for
which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R3's 05/06/2025 admission Minimum Data Set (MDS) documented R3 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition.
The MDS noted R3 had a diagnosis of diabetes and received an insulin injection every day in the look back period of seven days.
The Nutrition Care Area Assessment (CAA) documented R3 was at risk for impaired nutrition related to a stroke, morbid obesity and diabetes.R3's Care Plan dated 05/06/25 documented that R3 takes insulin and oral diabetes medications and directed staff to monitor and document side effects and effectiveness.
Intervention on 08/03/25 directed the staff to check her fasting blood sugar as ordered and to notify the provider of readings less than 60 milligrams per deciliter (mg/dl) or greater than 350 mg/dl.R3's Physician Orders in the EMR documented an order for blood glucose monitoring two times a day.
Call the doctor if the blood glucose level is less than 60 mg/dl or over 350 mg/dl; dated 07/29/25.Review of R3's blood glucose record under the Weights and Vitals tab for July 2025 through February 2026 found the following:07/07/25 a blood glucose level of 376 mg/dl07/08/25 a blood glucose level of 377 mg/dl07/09/25 a blood glucose level of 393 mg/dl07/11/25 a blood glucose level of 409 mg/dl07/12/25 a blood glucose level of 363 mg/dl07/13/25 a blood glucose level of 362 mg/dl07/14/25 a blood glucose level of 423 mg/dl07/15/25 a blood glucose level of 382 mg/dl07/18/25 a blood glucose level of 382 mg/dl07/19/25 a blood glucose level of 418 mg/dl07/21/25 a blood glucose level of 406 mg/dl07/22/25 a blood glucose level of 365 mg/dl07/23/25 a blood glucose level of 418 mg/dl08/01/25 a blood glucose level of 411 mg/dl08/13/25 a blood glucose level of 366 mg/dl08/27/25 a blood glucose level of 596 mg/dl09/01/25 a blood glucose level of 357 mg/dl09/05/25 a blood glucose level of 372 mg/dl09/09/25 a blood glucose level of 442 mg/dl09/10/25 a blood glucose level of 369 mg/dl09/17/25 a blood glucose level of 442 mg/dl09/29/25 a blood glucose level of 455 mg/dl10/03/25 a blood glucose level of 386 mg/dl11/03/25 a blood glucose level of 391 mg/dl11/11/25 a blood glucose level of 357 mg/dl11/24/25 a blood glucose level of 363 mg/dl12/31/25 a blood glucose level of 397 mg/dl01/10/26 a blood glucose level of 352 mg/dl01/12/26 a blood glucose level of 351 mg/dl01/27/26 a blood glucose level of 369 mg/dl02/04/26 a blood glucose level of 421 mg/dl02/14/26 a blood glucose level of 359 mg/dl02/20/26 a blood glucose level of 358 mg/dl02/22/26 a blood glucose level of 353 mg/dl02/24/26 a blood glucose level of 355 mg/dl R3's Progress Notes in the EMR lacked notification to the provider for blood glucose over 350 mg/dl for the above dates. On 03/02/26 8:19 AM, R3 laid in bed with her over bed table close to the side of the bed.
R3 stated she preferred to stay in bed and staff bring her breakfast to her. On 03/04/26 at 12:01 PM, Certified Medication Aide (CMA) R stated that the CMAs do the Accu-check (blood glucose monitoring test) and stated there are no parameters of when to notify the nurse or doctor. CMA R stated she notified the nurse if the blood sugar was under 100 mg/dl or over 185 mg/dl. On 03/04/26 at 12:03 PM, Administrative Nurse D stated nursing staff should notify the physician if the resident was symptomatic.
Administrative Nurse D said staff usually faxed the doctor if the blood sugar was over /dl if the resident is not symptomatic.
The nurse should document if she faxed or called and what the physician's response was.
The facility's Notification Parameters- Primary Care Provider (PCP) dated 02/03/25 documented notification of the PCP in a timely, efficient, and effective manner can be accomplished when a system is consistently followed by licensed nursing staff.
Licensed nursing staff have the responsibility of contacting a PCP anytime a resident has developed a clinical problem requiring PCP intervention.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
review, and interviews, the facility failed to ensure Resident (R) 8 remained free of significant
level blood potassium in the blood) ordered by physicians.
Findings included:- R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of fluid overload, hypokalemia (low potassium), hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), unsteadiness on feet, muscle weakness, and repeated falls.The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition.
The MDS documented R8 received a diuretic (a medication to promote the formation and excretion of urine).R8's Dehydration/Fluid Maintenance Care Area Assessment (CAA) dated 01/22/26 documented a risk for dehydration related to the use of diuretics, impaired mobility, a wound, dementia, and constipation.R8's Care Plan documented the following:01/28/26-R8 was at risk for adverse reactions related to polypharmacy, and the use of Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R8 would be free from adverse drug reactions through the review date.R8?s EMR under the Discontinued Orders tab revealed the following physician order:Potassium oral tablet, give 40 milliequivalent (mEq) by mouth three times a day related to hypokalemia until 02/17/26
Review of the R8's Medication Administration Record (MAR) for February 2026 documented on 02/13/26: Pending confirmation, potassium oral tablet give 40 mEq by mouth three times a day related to hypokalemia until 02/17/2026.
Start Date 02/14/2026 08:00 AM -Discontinue Date 02/20/2026.R8's clinical record lacked evidence that the potassium dose was administered or rescheduled and lacked evidence the physician was notified that the medication was not administered as ordered on starting 02/14/2026.On 02/13/26 at 05:00 PM, a Health Status Note documented the nurse received an order form Nurse Practitioner.
The note stated new order for R8 whose potassium level was low; take Potassium 40 mEq three times a day for three days then recheck A Comprehensive Metabolic Panel (CMP) (a routine blood test) and magnesium level on Tuesday, 02/17/26.On 02/18/26, a Fax Form Non-Immediate Communication was faxed to the physician documented facility had received a verbal or [NAME] on 02/13/26 for Potassium 40 mEq three times a day for three days related to low potassium levels.
This medication was missed and R8 did not receive the prescribed dose.
Potassium level was rechecked on 02/17/26 with result of 3.8.
The physician's response was, no need for potassium at this time.On 02/20/26 at 07:08 AM under Heath Status Note documented received response from physician concerning the following clarification requests: R8 does not require strict intake and output monitoring.
Exchange Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) with a 16French (type of foley) today and every 30 days.
Potassium rechecked on 02/17/26 with a result of 3.8, no need for potassium.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the potassium for R8 was missed.
She stated the nurse on duty had not worked for several years.
Administrative Nurse D stated the nurse on duty put the order in Pending, and the order never went on the MAR.
She stated the second check for each order was the medical records nurse, since the order was stuck in Pending the second check was unable to catch the error.
Administrative Nurse D stated as soon as the error was caught, a note was faxed to the physician.The facility's Medication Error policy, revised 02/25, documented the community would ensure that residents are free of any significant medication errors.
Medication errors would be immediately reported to the physician and director of nursing or designee.
Medication errors would be documented on care Incident Tracking Report.
Notify resident's responsible party. If medication errors originated at the pharmacy, the pharmacy would be notified immediately.
Medication errors would be tracked for quality insurance purposes.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
Based on observation,
hormone that lowers the level of glucose in the blood) flex pens when initially opened.
Findings included:- On 03/02/26 at 07:15 AM, observation of the Medication cart located in the nurse's room revealed R11's Lantus (long-acting insulin) flex pen was not labeled with an opened date or an expiration date. R11's second Lantus insulin flex pen had an illegible date written on the pen as it had smeared and was not legible. On 03/02/26 at 07:20 AM, License Nurse G verified the nurses should label and date the insulin flex pens with the date opened. On 03/04/26 at 10:20 AM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened.
Medlineplus.gov directs open, unrefrigerated insulin pen can be used within 28 days; after that time, they must be discarded.
The facility's Medication Storage policy, dated 02/03/25, documented medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.
Medications are accessible only to licensed nurses, pharmacy personnel, or staff members lawfully authorized to administer medications.
Medications are labeled for individual residents and stored separately from floor stock medications when not in the medication cart.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
Based on observation, record review, and interview, the facility failed to provide timely dental care for
dated [DATE], recorded R6 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.
The assessment revealed R6 required staff assistance for personal hygiene, oral hygiene, toilet hygiene and had no oral or dental issues.The Care Area Assessment (CAA), dated 04/28/25, for activities of daily living (ADLs) failed to identify or document any sign/symptoms of dental problems or pain due to the broken, decayed, and missing teeth.The Activities of Daily Living (ADL) Care Plan, dated 01/12/26, recorded R6 required limited to extensive staff ADLs such as grooming, dressing, toileting and dressing.
The Care Plan documented R6 had his own teeth, and they were in poor condition, carries and missing teeth and he required set up to partial assistance with oral cares.
The care plan documented dental appointments would be set up as scheduled, needed and requested.
The Interdisciplinary Notes dated 07/07/25, documented R6 had a dental appointment with Health Department -Dental due to a lost tooth and mouth pain.
The notes documented R6 saw a dentist and the dentist documented he had extensive gross caries.
The dentist recommended that staff brush R6's teeth and the patient would return to have fillings and extractions completed.
However, the note documented the extractions would have to be performed by an oral surgeon not at the dentist's office.
The 03/03/26 at 11:10 Interdisciplinary Notes, documented the resident was seen at the facility by a dental hygienist for a routine periodontal maintenance exam, and she documented R6 had pain in his upper left mouth and to the root tip area.
The notes documented in the visual exam revealed moderate inflammation in the area and R6 would need further evaluation with the dentist. On 03/02/26 at 10:30 AM, R6 stated he had broken missing teeth, and had pain located in his right upper jaw area. R6 stated he had difficulty eating due to the tooth pain.
Observation of R6's mouth revealed he had missing, decayed teeth and some broken off. On 03/04/26 at 09:30 AM, Administrative Nurse D verified the resident had broken, decaying teeth and had a dental appointment on 07/07/25 and verified the dentist's notes recommended filling and extractions.
Upon review, Administrative Nurse D could not find any written documentation if a follow-up appointment was made after the 07/07/25 appointment and if it not the reason and follow treatment appointment was not made.
Administrative Nurse verified there was no documentation in R6's medical records.
Administrative Nurse D verified if R6 would have pain he should be evaluated by a dentist for recommendations and verified the residents should not have dental pain and not get treated for the pain.
The facility's Dental Service policy, dated 02/03/25, documented residents are assessed for oral/dental needs initially, periodically and reviewed annually.
The residents are referred to a dentist requested from the primary care physician for any identified or verbalized oral complaint/issue.
Staff assist the residents to make an appointment and arrange transportation to and from the dentist's office.
The policy documented for emergencies or oral discomfort, staff would obtain an order from the primary care physician and arrange for dental appointment within three days.
The policy documented if the resident or responsible party refuses dental treatment, the nurse's notes it in the medical record and documents education as to risks to health status if no dental services are provided.
The policy documented staff would record in the medical record interventions used to facilitate residents' ability to eat and drink while awaiting dental services.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
staff make a new order, any task or change gloves they should wash their hands or use hand
residents.
All food items should be labeled with a use by and the date it was wrapped.
All dedicated
replaced new one or the compromised item should be washed and sanitized before use again.
Any thermometer used should be sanitized between uses.
The facility Policy 5.01 HACCP Food Handling Principles dated 02/2026, documented that utensils, equipment, and surfaces are clean and sanitized prior to, and between uses.
Employees are trained in safe food service techniques and personal hygiene annually, or more often as needed.
All products are labeled and dated with the receiving date.
Once opened, products are covered to prevent contamination and dated with an open date.
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Emporia Presbyterian Manor 2300 Industrial Road Emporia, KS 66801
Review of R3's clinical record revealed the PCV13 was administered on 10/30/15, and the PSV23 was administered on 11/12/04. R3's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the nurse who admitted the resident was responsible for ensuring the resident or family signed a consent or declination for immunizations.
Administrative Nurse D stated the signed consent or declination form was uploaded in the resident's chart and Administrative Nurse D was notified if the resident was to receive any immunizations.
Administrative Nurse D stated she was unable to find the consent or declination for R3 as the room the forms had been stored in had flooded.
She stated R3 had signed the consent on 03/03/26 and the immunization was administered.The facility's Immunizations-Pneumococcal policy, revised 04/14/25, documented residents were provided the opportunity and encouraged to receive the Pneumococcal vaccines. At the time of admission, the nurse would determine the residents' vaccination history by resident information, the family or primary care provider and document on the immunization record.