Emerald Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hot liquids at a safe drinking temperature for 1 of 4 residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm in which they sustained burns on their right thigh from hot coffee. This failed practice placed the residents at risk for burn injuries, pain, and adverse health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that unless the facility had a full-time Registered Dietician (RD), that the Dietary Manager (Staff H, Dietary Manager (DM)) had the competencies and skill sets to carry out food and nutrition services for their resident population. This failure placed residents at risk of receiving dietary services from staff who had not completed an academic program in nutrition or dietetics accredited by an appropriate national accreditation organization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired foods in 1 of 1 walk in refrigerator, 1 of 1 stand-alone refrigerator, and 1 of 1 dry storage area used to store food items for the entire resident population, reviewed for safe and sanitary kitchen. Additionally, the facility failed to follow the thawing process of foods or consistently monitor cooked food temperatures prior to serving the food. This failed practice placed residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]).

Inspectors wroteBased on interview and record review, the facility failed to implement 4 of 8 components (identify, protect, report, and investigate), of their abuse/neglect policy/procedure for 3 of 3 residents (Residents 9, 35, and 40) reviewed for allegations of abuse/neglect. This failure placed the residents at risk for unrecognized abuse and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report potential allegations of abuse and/or neglect to the State Agency (SA) for 3 of 3 residents (Residents 9, 35, and 40) reviewed for abuse/neglect. This failed practice placed the residents at risk for unidentified and ongoing abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and thorough investigation had been completed for reported allegations of abuse and/or neglect for 3 of 3 residents (Residents 9, 35, and 40) reviewed for abuse and neglect. The failure to conduct a thorough investigation including root cause, contributing factors, and identifying preventative measures to rule out abuse/neglect placed the residents at risk for further unmet care needs and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were completed for residents following significant change in status or with newly evident or possible serious mental disorders for 3 of 7 residents (Resident 23, 59, and 31) reviewed for unnecessary medications. This failure resulted in a potential delay in access to Level 2 PASARR services and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system to evaluate, and document demonstrated competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares) and skill sets for 3 of 3 Licensed Nurses (Staff D,M and Q) reviewed for staff competencies. This deficient practice placed all residents at risk of receiving care from inadequately trained staff and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light and bedside table was within reach and easily accessible for 1 of 3 residents (Resident 13) reviewed for reasonable accommodations. This deficient practice prevented the resident from independently accessing personal items such as their bedside beverage, using the call light, and placed them at risk for unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR), (an assessment to ensure individuals with serious mental illness (SMI) or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were completed prior to admission and/or corrected or updated as required to reflect a Level 2 screening was completed for 2 of 7 residents, (Residents 4 and 9) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteNumber of residents sampled: Number of residents cited: Review of the resident's medical records showed they admitted to the facility with diagnoses to include hydronephrosis (one or both kidneys cannot drain from the kidney to the bladder) with obstruction from kidney stones (hard, pebble like pieces of material that form in the kidneys) and kidney disease. Review of the 01/02/2026 significant change comprehensive assessment showed Resident 31's cognition was severely impaired, required the use of an RC, and did not experience pain. Additional review of Resident 31's medical records showed they had been admitted to Hospice services on 01/02/2026 for a primary diagnosis of Cerebrovascular disease (conditions that affect blood flow to your brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly assess, monitor, and identify the potential need for positioning and Range of Motion (ROM) services to prevent a contracture (a permanent tightening of the muscles, tendons, and skin often leading to rigidity of joints) or decrease in ROM to the affected hand of 1 of 2 residents (Resident 51) with hemiplegia (paralysis to one side of the body) reviewed for restorative services. This deficient practice placed residents at risk for unidentified contractures, decrease in ROM, and potentially the increase in dependence of others to complete Activities of Daily Living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the ordered therapeutic diet with modified texture of food and liquids for 1 of 3 residents (Resident 51) reviewed for nutrition. This deficient practice placed residents at risk of choking or aspirating (when food or liquid accidentally enters the airway and lungs instead of going into the stomach) on their food and liquids and potentially causing health complications including death.

Inspectors wroteBased on observation and interview, the facility failed to maintain a bedside suction machine in a clean and sanitary manner that met infection control standards of practice for 1 of 2 residents (Resident 60) reviewed for infection control related to respiratory equipment. This deficient practice placed residents at risk of the transmission of infectious organisms (germs such as bacteria, viruses, fungi or parasites) with the potential of developing Healthcare Associated Infections [(HAIs) an infection a person gets while receiving treatment for a different condition].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired foods were discarded for 1 of 1 dry storage area and failed to consistently monitor refrigerator temperatures for 2 of 3 refrigerators (the kitchen snack refrigerator and a small black refrigerator), reviewed for food safety. These failures placed residents at an increased risk for food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (UTI, a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 3 residents (Resident 7), reviewed for urinary catheter care. This failure placed the residents at risk of developing medical complications, secondary to an infection in the bladder.

Inspectors wroteBased on observation, interview and record review the facility failed to secure all medication in 1of 1 locked medication room and to limit access to authorized personal consistent with professional practice. This failure allowed one unauthorized staff member (Staff E) to access medication in the medication storage room and increasing the risk for diversion of controlled (narcotic) medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nursing Services (DNS) had an active nursing license while providing care to residents in the facility for 1 of 6 staff (Staff R) reviewed for staff qualifications. This failure placed residents at risk of receiving care from an unlicensed staff health professional and unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide correct implementation of infection control practices for indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) equipment for 2 of 4 residents (Resident 29 and Resident 52) reviewed for use of urinary catheters. This failure placed residents with catheter bags at risk for infections and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a complete and thorough investigation into resident-to-resident altercations including protecting the residents involved from further physical or psychological harm for 4 of 6 residents (Residents 4, 5, 6, and 7) reviewed for abuse. This failed practice placed the residents at risk for continued exposure to unidentified physical and verbal abuse, unidentified injuries, and unmet emotional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained for 2 of 2 residents (Resident 26, and 21) by staff not performing hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's environment during hydration pass, personal care, and wound care dressing change). These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of infections) and the development of communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed and revised to accurately reflect care needs for 1 of 3 residents (Resident 40) reviewed for dental services and choices, and 1 of 1 resident (Resident 66) reviewed for transfers and meal assistance. The failure to revise care plans to reflect current care needs placed the residents at risk for inadequate or unsafe care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received ongoing communication and collaboration with the dialysis (a process to remove waste products and excess fluid from the blood when the kidneys stop working properly) center for 3 of 3 residents (Resident 40, 44, and 38) reviewed for dialysis services. The failure to communicate and collaborate with the dialysis center as required, placed the residents at risk for unnoticed significant changes in their health status, delay in care, and death.