Emerald Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Emerald Health & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF803Jul 24, 2025

  Based on observations, records reviews, and staff interviews, the facility failed to follow the approved menu related to portion size. Seven (7) of 7 residents with physician-ordered large or double portions were served a single portion (Residents #21, #26, #36, #37, #6, #47, and #52). Seven (7) of 7 residents ordered a pureed diet received 4 ounces (oz.) of chili instead of 6 oz as specified on the menu (Residents #22, #2, #11, #1, #74, #80, and #90). Twelve (12) residents with an order for a regular or mechanical soft, low concentrated sweets diet received a full slice of cake rather than a half slice of cake as indicated on the menu (Residents #29, #30, #41, #49, #65, #69, #70, #72, #75, #79, #84, and #93). This deficient practice affected 26 of 91 residents.The findings included: 1. […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2025

  Based on observations, record review, and interviews with staff, the facility failed to ensure dishware and cookware were washed and sanitized according to the manufacturer's recommendations for 1 of 1 dishwashing machine and 1 of 1 three compartment sink. This practice had the potential to affect food served to residents.The findings included: 1. The NSF Machine Operating Requirements as Manufactured by American Dish Service, Model AF3DS Operating Requirements posted information on the dishwasher indicated that wash and rinse cycles should reach a temperature of 120 degrees F. The posted information included the sanitizer level in a low-temperature dish machine was required to be 50 parts per million (ppm). […]

• No harm, potential for more than minimal, patternF727May 28, 2024

  Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week for 1 of 36 days reviewed for sufficient staffing (4/13/24). Findings included: A review of the daily nursing staffing sheets for the month of April 2024 and May 1-6,2024 indicated there was no RN scheduled for 4/13/2024. A review of the daily census posting sheets for the month of April 2024 and May 1-6, 2024 recorded there was one RN for eight hours on 4/13/2024 during the day shift (7a.m. to 3 p.m.). The census was recorded as 88 residents on 4/13/2024. There was also no RN recorded for the evening shift (3p.m. to 11p.m.) and the night shift (11p.m. to 7 a.m.) on 4/13/2024. […]

• No harm, potential for more than minimal, patternF759May 28, 2024

  Based on observation, record review, staff interview, pharmacy interview and Physician interview, the facility failed to have a medication error rate less than 5% as evidenced by 6 medication errors out of 29 opportunities, resulting in a medication error rate of 20.69% for 1 of 2 residents observed during the medication administration observations. Finding included: Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, Myasthenia Gravis (an autoimmune condition that causes muscle weakness that gets worse with activity and better with rest), anxiety disorder and atrial fibrillation (irregular heart rate). […]

• No harm, potential for more than minimal, patternF812May 28, 2024

  Based on observations and staff interviews, the facility failed to maintain kitchen equipment in a clean and sanitary condition to prevent cross contamination by failing to clean under the shelf of 1 of 1 steam table observed. This practice had the potential to affect food served to the residents in the facility. The findings included: During an observation of the kitchen on 5/08/24 at 8:36 AM, the five well steam table was observed with dark dried food particles under the 5-foot steam table shelf. During an observation of the kitchen on 5/10/24 at 8:23 AM, the five well steam table was observed with dark dried food particles under the 5-foot steam table shelf. […]