The Emeralds at Grand Rapids LLC

In the surveyor’s words

From the most serious findings on record at The Emeralds at Grand Rapids LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 4, 2026

  Based on interview, and document review the facility failed to reduce the risk of falls for 1 of 3 residents (R1) reviewed when R1 was care planned to use two staff for transfers with a mechanical lift and nursing assistant (NA)-A attempted a mechanical lift transfer with one staff, R1 fell from the sling onto the floor sustaining a left femur fracture, head laceration and injury to left toes. The immediate jeopardy began on [DATE] when NA-A attempted a mechanical lift transfer with one staff, R1 fell from the sling onto the floor sustaining a left femur fracture, head laceration, and injury to left toes. R1 was care planned to use two staff for transfers with a mechanical lift and was identified on [DATE]. […]

• Immediate jeopardy, isolatedF803Mar 22, 2024

  Based on interview and document review the facility failed to provide the physician ordered textured diet for 1 of 3 residents (R1) who subsequently choked and required the Heimlich Maneuver. This was an Immediate Jeopardy (IJ) for R1 who required hospitalization following the choking incident where she was determined to have aspirated and required mechanically assisted ventilation. The IJ began on 3/9/24, at approximately 6:30 p.m. when R1 was found by nursing assistant (NA)-A in the common area of the unit observed as pale, lips blue and unable to speak. R1 was administered the Heimlich Maneuver, suction and was sent to the hospital where she subsequently required mechanically assisted ventilation. […]

• Immediate jeopardy, isolatedF689Oct 13, 2023

  Based on interview and document review the facility failed to maintain resident safety when a resident (R1) who was assessed to be at risk for elopement verbalized his intent to leave the facility, left without staff knowledge and was returned to the facility by two strangers. Further, R1 was allowed to discharge home against medical advice from the facility even though he had been assessed to have cognitive impairment and admitted due to recurrent falls. This resulted in an immediate Jeopardy (IJ) situation for R1. The IJ began on 9/30/23, when R1 left the facility without staff knowledge. R1 was found by two strangers on a highly-trafficked four lane highway with a cut on his nose. Additionally, within two hours of R1' s return to the facility, R1 wanted to return home. […]

• Actual harm, isolatedF689Mar 7, 2024

  Based on observation, interview and document review the facility failed to ensure an environment free from hazards. This resulted in actual harm to R1 who sustained a second degree burn when his knee rested against the baseboard heater and he was unable to move his knee or call for help. The deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Admission Record indicated he admitted to the facility on [DATE], with diagnosis that included encephalopathy (disease in which the functioning of the brain is affected), Diabetes, transient ischemic attack (a short period of symptoms similar to those of a stroke) and a tracheostomy (a direct airway through an incision in the trachea). […]

• Actual harm, isolatedF689Mar 4, 2021

  Based on observation, interview, and document review, the facility failed to ensure safety interventions were in-place, prior to a resident leave of absence (LOA), and additional interventions were developed for subsequent unapproved outings and/or intoxication for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who left the facility for four hours, was sent to the emergency department (ED) when he returned, received intravenous (IV) fluids, and was diagnosed with [REDACTED]. Findings include: R1's Admission Record printed 3/4/21, indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had intact cognition. […]