Emerald Ridge Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF742Apr 9, 2026

  Based on record review and interviews with staff, power of attorney (POA), Nurse Practitioners, Psychiatrist and Medical Director, the facility failed to ensure Resident #101, who was admitted on [DATE] following a stay at an inpatient psychiatric facility beginning on 1/9/26 for a severe episode of recurrent major depressive disorder with suicidal behavior with attempted self-injury, received the necessary treatment that was person-centered and individualized to meet her needs. The resident's psychiatric diagnoses included major depressive disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and delusional disorders. The inpatient psychiatric facility's discharge summary included an order for antipsychotic medication (olanzapine) every night at bedtime. […]

• Immediate jeopardy, isolatedF689Dec 6, 2021

  Based on record reviews and staff interviews the facility failed to supervise a severely cognitively impaired resident with wandering behaviors from exiting the facility unsupervised while self-propelling in her wheelchair. On 11/22/21 all three staff members working the evening shift left the hall without communicating with each other and as a result they did not respond to the door alarm or initiate an immediate search. As a result, Resident #1 was able to exit through the fire/exit door which opens once the handle is pushed on for 15 seconds. This resulted in Resident #1 falling out of her wheelchair, hitting her head on the sidewalk and sustaining an open fracture to her left thumb. This failure affected 1 of 3 residents reviewed for providing supervision to prevent accidents. […]

• Actual harm, isolatedF686Mar 6, 2025

  Based on record review, observations, and staff and Wound Care Nurse Practitioner (NP) interviews, the facility failed to assess for and identify a pressure ulcer on the buttock before it was assessed as a stage III (full-thickness loss of skin) for 1 of 2 residents (Resident #10) reviewed for pressure ulcers. Findings included: The hospital discharge summary dated 2/7/25 indicated Resident #10 was admitted to the hospital with a left femur fracture and had a surgical procedure to repair her left femur fracture on 2/4/25. The discharge summary reported an x-ray was completed on 2/4/25 that showed a humerus fracture. The discharge summary indicated she had surgical incisions to her left lower extremity. […]

• No harm, potential for more than minimal, patternF565Apr 9, 2026

  Based on record review and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address concerns voiced by residents during Resident Council meetings for 11 of 12 months reviewed (April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, January 2026, February 2026 and March 2026).The findings included: A review of the grievance logs from April 2025 to March 2026 showed that no grievances were filed on behalf of the Resident Council from April 2025 to December 2025. […]

• No harm, potential for more than minimal, patternF755Apr 9, 2026

  Based on record review and interviews with staff and Pharmacist, the facility failed to implement a system to consistently and accurately reconcile controlled medications obtained from home for 1 of 1 resident reviewed for medication management (Resident #8). As a result, a total of 31 tablets of Lorazepam (a controlled medication) were unaccounted for. The facility also failed to keep accurate records of controlled medications for 1 of 2 medication cart narcotic records reviewed.The findings included: 1.Resident #8 was admitted to the facility 1/9/26 for a respite stay with diagnoses that included anxiety disorder. […]