Memory Care Center at Emerald

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 3, 2023

  On 03/30/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; conduct a root cause analyses for each fall; monitor and evaluate the effectiveness of the interventions; and modify the care plan with each fall. Res #14 had 23 falls in the last five months. Of the 23 falls, 19 did not have updated interventions to help prevent future falls. Res #14's last fall resulted in a fractured hip. The care plan had not been updated since 11/15/22. Res #57 had sustained six falls in three weeks. The third fall resulted in a fractured arm and the last two did not have updated interventions to help prevent future falls. […]

• Actual harm, isolatedF600Jun 2, 2026

  Based on record review and interview, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 (#64) for 3 sampled residents reviewed for abuse.The administrator identified 58 residents resided in the facility.Findings:A facility policy titled Abuse, Neglect and Exploitation, dated 01/2024, read in part, Resident must not be subject to abuse by anyone, including, but no limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardian, friends, or other individuals. Prevention of abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation. […]

• Actual harm, isolatedF689May 31, 2024

  Based on record review and interview, the facility failed to protect the resident's right to be free from neglect for one (# 1) of four residents reviewed for neglect. The Administrator reported the facility census was 53. Findings: A facility policy titled Abuse, Neglect and Exploitation, revised 01/24, read in part, .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Resident #1 had diagnoses which included severe unspecified dementia with anxiety and senile degeneration of the brain. […]

• No harm, potential for more than minimal, widespreadF727Jun 2, 2026

  Based on record review and interview, the facility failed to ensure they had a full-time DON for 8 of 30 dates reviewed for the employment of a DON.The administrator identified 58 residents resided in the facility.Findings:An email sent to the facility administrator from the former DON, dated 05/25/26 at 4:11 p.m., showed the facility's DON resigned effective that date.On 05/29/26 at 10:20 a.m., the administrator stated the facility did not have a full-time DON. They stated they did not have anyone who had accepted the responsibilities of the DON position. The administrator stated the former DON had resigned on Monday, 05/25/26 via an email. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2024

  Based on observation and interview, the facility failed to ensure proper food service sanitation, cleaning and storage requirements were followed. The ADON identified all 56 residents who resided at the facility received food from the kitchen. Findings: An undated, Sanitation of Dining and Food Service Areas policy, read in part, The Dining Service staff will uphold sanitation of the dining areas. The policy also read, All staff will be trained on the frequency of cleaning. The policy also read, Staff will be held responsible for all cleaning tasks. An undated Sanitizing and Disinfectant Solutions policy, read in part, Bleach solution should be at a concentration of greater than or equal to 50 to 100 ppm. […]