Emerald Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Emerald Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 20, 2023

  Based on interview and record review, the facility failed to ensure emergency procedures were followed for Resident #1 who was choking for 1 of 1 sampled resident reviewed for choking. The facility staff also failed to ensure a resident had a clear airway prior to starting resuscitation after the resident became unresponsive. Additionally, the staff could not locate Resident #1's Do Not Resuscitate Order (DNRO) after the resident became unresponsive. Resident 31 was resuscitated, transferred to the hospital and later died . On [DATE], it was determined that the findings of the survey posed Immediate Jeopardy to the health and safety of the residents residing in the facility. The facility's Executive Director was informed of the Immediate Jeopardy on [DATE] at 4:50 PM. […]

• No harm, potential for more than minimal, widespreadF725Jun 11, 2025

  Based on observations, interviews, and record review, the facility failed to ensure sufficient qualified nursing staff were always available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. The findings include: On Sunday 06/08/25 at 9:15 AM an initial tour of the facility was conducted. During the entrance, the surveyors were informed that the Director of Nursing (DON) was in the building, however, after further investigation, the receptionist stated that the DON was on her way. During the tour, nursing staff were interviewed, and no specific person was designated as in charge. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2025

  ). During an observation of the mechanical ware washing machine, as part of the initial kitchen tour, it was noted that the water temperature of the rinse cycle did not reach the 160 degrees necessary for hot water sanitizing, and that there was an accumulation of residue on the spray arms and nozzles inside of the ware washing machine. At the time of the observation, the Food Service Director acknowledged the concerns and stated that the machine will default automatically to chemical sanitizer when hot water sanitizing was not working appropriately. 4). During an observation of lunch being served to the residents in the Dining Room, on 06/08/25 at 1:04 PM, the following were noted a. […]

• No harm, potential for more than minimal, patternF584Jun 11, 2025

  Based on review of policy and procedure, observation and interview, the facility failed to provide liners for sharps containers for 2 out of 4 wings in the facility. The findings included: Review of the facility policy titled, Regulated (Biohazard) Medical Waste provided by the Director of Nursing (DON), implemented 03/2021 documented in the Policy Statement: It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored and transported as per Federal, State and local guidance and regulations. […]

• No harm, potential for more than minimal, isolatedF558Jun 11, 2025

  Based on policy review, observation, interview and record review, the facility failed to ensure the call light was in reach for 1 of 33 sampled residents (Resident #463). The findings included: Review of the policy titled, Call-Light System, issued 09/2020, documented in part, 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring the resident access to the call light. 2. With every interaction in the resident's room, staff will ensure the call light is within reach of the resident and secured. Review of the record revealed that Resident #463 was admitted to the facility on [DATE] with a readmission on [DATE]. […]