Emerson Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Emerson Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jan 4, 2021

  Based on observation, interview, and record review, the facility failed to effectively implement actions to contain the spread of COVID-19, a highly contagious virus, by: 1) Failure to cohort residents (placing residents in a separate room/unit during infection outbreaks) who tested positive for COVID-19, in order to prevent transmission to residents without COVID-19 infections. 2) Failure to implement a system that ensured all healthcare personnel and/or essential visitors were screened for COVID-19, prior to being allowed to access resident care areas. 3) Failure to maintain an infection prevention and control program which demonstrated ongoing analysis and trending of COVID-19 infections. […]

• Actual harm, isolatedF600Apr 8, 2021

  Based on interview and record review, the facility failed to ensure one of five sample residents (Resident 4), was free from verbal and physical abuse. This failure resulted in actual harm to the resident, who experienced a fall with a [CONDITION(S)], as a result of rough handling by a nursing assistant, who also verbally abused the resident during the transfer. Findings included . Review of the facility's policy titled Abuse-Washington, revised on 08/2019, showed abuse was defined as the willful infliction of injury with resulting physical harm. Willful was further defined as an individual who acted deliberately, not that the individual must have intended to inflict injury or harm. […]

• Actual harm, isolatedF689Apr 8, 2021

  Based on observation, interview, and record review, the facility failed to ensure assessments and a care plan for falls were timely and accurate, and failed to implement appropriate supervision to prevent falls for one of five sample residents (Resident 1), reviewed for falls. These failures resulted in actual harm to Resident 1, who sustained a [CONDITION(S)] during an unwitnessed fall. Findings included . Review of the 01/26/21 annual assessment showed Resident 1 was alert and oriented, required extensive assistance of two staff for transfers due to unsteadiness, and had prior falls in the facility. Per the electronic medical record, the resident was last assessed for falls on 01/24/2020. […]

• No harm, potential for more than minimal, widespreadF727Jul 28, 2025

  Based on interview and record review, the facility failed to ensure the Director of Nursing (DNS) did not serve as a charge nurse when the facility had an average daily occupancy over 60. This failure placed all residents at risk of lack of oversight for care provided, unmet care needs, and a diminished quality of life.Findings included . Review of the facility assessment dated [DATE] showed the facility's average daily census was 75-80. The assessment identified Staff B as the DNS. The staffing plan showed the facility required one DNS to meet the care requirements of the facility resident population during day-to-day operations and during emergencies. […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2025

  Based on observation, interview and record review, the facility failed to ensure gloves were changed and hand hygiene was completed when indicated during the lunch meal service, foods were served at the appropriate temperatures and food was labeled and dated as required. The facility further failed to maintain the required dish washing machine temperatures. These failures placed residents at risk for food-borne illnesses. Findings included .<Expired/undated food>During an observation on 07/21/2025 at 9:58 AM, the refrigerator on the Tucson Hall dining room revealed three frozen drinks. There was a name on one of the drinks, the other two drinks were not labeled and none of the drinks had dates of when they had been placed in the freezer. […]