Emerald Trace

In the surveyor’s words

From the most serious findings on record at Emerald Trace, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 15, 2023

  Based on observation, interview, record review, review of the facility's fall investigation reports, review of a police report, and review of the facility's policies, it was determined the facility failed to ensure it had a system in place for adequate supervision and monitoring to ensure residents at risk for elopement received the necessary supervision to maintain their safety and prevent elopement for two (2) residents (Residents #57 and #115) out of a sample of sixty-nine; and to prevent accidents/falls, to determine the root cause of falls, to evaluate falls, implement individualized interventions, and to monitor the effectiveness of interventions to prevent falls for two (2) residents (Resident #13 and #17) out of a sample of sixty-nine. 1. […]

• Actual harm, isolatedF656Dec 15, 2023

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop and implement a person-centered care plan for falls for two (2) residents (Residents #13 and #17). The facility also failed to develop and/or implement a person-centered care plan to ensure adequate supervision was provided for one (1) resident (Resident #115). Additionally, the facility failed to develop/implement a person-centered care plan to ensure exit seeking behaviors were identified and adequate interventions were put in place for Residents #114 and #113. The number of sampled residents was sixty-nine (69). 1. […]

• No harm, potential for more than minimal, patternF565Aug 22, 2025

  Based on observation, interview, review of the facility's documents, and review of the facility's handbook, the facility failed to support and encourage residents to organize and participate consistently in the Resident Council meeting for 2 out of 5 sampled residents, Resident (R) 6 and R38. The findings include: Review of the facility's Resident Handbook - Grievances and Complaints, undated, revealed, Residents may also voice grievances during the Resident Council meetings. Review of the facility's monthly activity calendars, dated from 02/2025 to 07/2025, revealed there were no scheduled Resident Council meetings noted on the calendar. […]

• No harm, potential for more than minimal, patternF812Aug 22, 2025

  Based on observation, interview, and review of the facility's policy, the facility failed to store frozen green beans appropriately. Observation on 08/19/2025 of the main kitchen freezer in building B revealed the frozen green beans were taken out of the cases by staff, placed onto the shelf, and not dated according to facility policy.The findings include:Review of the facility's policy titled, Food and Supply Storage, revised 01/2025, revealed all food would be stored in a manner to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption. […]

• No harm, potential for more than minimal, patternF761Dec 15, 2023

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure opened and in-use medications were labeled with the opened date and were not expired on one (1) of four (4) medication carts and in one (1) of four (4) medication rooms. The findings include: Review of the facility's policy titled, Storage of Medications, undated, revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Further review revealed outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock and disposed of according to procedures for medication disposal. […]