Emerald Nursing and Rehabilitation

Inspectors wroteBased on review of facility policy and procedure, clinical record review, and staff interviews, it was determined the facility failed to provide adequate urinary catheter care for four of six residents reviewed (Residents 6, 8, 28, and 47) resulting in actual harm for three of six residents who contracted urinary tract infections requiring subsequent hospitalizations (Resident 6, 28 and 47).

Inspectors wroteBased upon observation and interview, it was determined that the facility failed to ensure appropriate sanitization monitoring and documentation was completed for daily dishwasher sanitization for one of one dishwasher observed.

Inspectors wroteBased on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for four of eight residents reviewed (Residents 2, 5, 8, and 9).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for one of 24 residents reviewed (Resident 2).

Inspectors wroteBased on review of facility policy, review of clinical records and interview with staff, it was determined that the facility failed to obtain accurate weights and verify weights to maintain acceptable parameters of nutritional status for one of 24 residents reviewed (Resident 31).

Inspectors wroteBased upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure medications were administered following facility infection prevention protocol for one of two residents observed (Resident 1).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to post the name, address, and telephone number of the State Survey Agency on two of two units (Station 2 and Station 3).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to post the results of the most recent Department of Health survey in a place readily accessible to residents for two of two units (Stations 2 and 3).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for one three of five residents reviewed resulting in actual harm to one, resident Resdient1. (Resident 1, 2, and 3).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure residents were provided with a clean and homelike environment for one of three bathrooms observed (Resident 2's bathroom).

Inspectors wroteBased on facility policy review, observations and staff interviews it was determined the facility failed to provide PPE and signage for residents who require enhanced barrier precautions for one of six residents reviewed. (Resident 1)Findings Include:Review of facility policy titled Enhanced Barrier Precautions, effective March 2024, revealed EPB (enhanced barrier precautions) are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO (multi-drug resistant organism) colonization .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (personal protective equipment) required .PPE is available outside of the resident rooms. [...]

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews, and interviews with staff, it was determined the facility failed to provide adequate supervision to one of twelve residents reviewed (Resident R1) who was inaccurately assessed as a low risk for elopement. This failure resulted in Resident R1 exiting nursing unit via the elevator and walking out the front entrance doors. The facility was not aware Resident R1 was missing until the resident's daughter called and informed the facility Resident R1 had walked to her house crossing multiple busy streets. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)

Inspectors wroteBased on the review of clinical records, job descriptions, review of facility policy, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of one of twelve residents reviewed (Resident R1) with a diagnosis of Dementia who eloped from the facility. This failure resulted in an Immediate Jeopardy situation for Resident R1. (Resident R1)Findings Include:Review of the job description for the Nursing Home Administrator (NHA) states, Position Summary-this position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet resident's needs in accordance with federal, state and local regulations. [...]

Inspectors wroteBased on observations as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, comfortable, and home-like interior one of two nursing units (2nd floor).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 6 resident clinical records reviewed (Residents 2 and 6). Clinical record review of Resident 2 documented diagnoses that included: [...]

Inspectors wroteBased on clinical record review, observations, and staff interviews it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents' dependent on staff for assistance with incontinence care for two of 15 resident s reviewed (Residents 12, and 16). Review of resident council meeting minutes documented:June 19, 2025, call bells are taking over an hour to be answered, staff turning off call bells without helping the resident or stating they'll be back and never return, Nursing Assistants sitting at the nursing desk on their phone on 2nd and 3rd shift, ear buds in during care. The expectation was for call bells to be answered in 10-20 minutes. May 15, 2025, call bells are not being answered or are being turned off without resident's needs being met (mainly 3rd shift), and ear buds are worn during care. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of one resident reviewed for dialysis (Resident 23). Findings Include: Review of facility policy, titled End Stage Renal Disease, Care of a Resident with, last reviewed on March 31, 2025, read, in part, Residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: [...]

Inspectors wroteBased on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for four of five nurse aides reviewed (Employee 7, 8, 9, and 10).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRRs) were completed at least once a month by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four of five residents reviewed for unnecessary medications (Resident's 14, 23, 30, and 46).

Inspectors wroteBased on facility policy review, observations, and staff interview, it was determined that the facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.

Inspectors wroteBased on review of select facility documentation provided and a staff interview, it was determined that the required members of the facility's Quality Assurance Committee failed to meet on a quarterly basis for two quarters of four reviewed (last quarter of 2024 and first quarter of 2025).

Inspectors wroteBased on clinical record review, resident, and staff interviews, it was determined the facility failed to ensure each resident is treated with dignity and care in a manner and environment that maintains and enhances his or her quality of life for one of 16 residents (Resident 166).

Inspectors wroteBased on facility policy review, personnel file reviews, and staff interview, it was determined that the facility failed to implement written policies and procedures by not conducting a criminal background check upon hire for two of five personnel files reviewed (Employees 4 and 5).

Inspectors wroteBased on facility policy reviews, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of transfer, or the facility bed-hold policy at the time of transfer, for one of three residents reviewed for hospitalizations (Resident 3). Findings Include: Review of facility policy, titled Facility Bed-Hold and Return to Facility Policy and Procedure last reviewed March 31, 2025, read, in part, Before a resident is transferred to the hospital, the facility must provide written information to the resident or the resident representative regarding the facility's bed hold and return policy. [...]

Inspectors wroteBased on record review, observations, and staff interview, it was determined that the facility failed to receive proper treatment and assistive devices to maintain vision and hearing abilities for one of 21 residents reviewed (Resident 36). Findings Include: Review of Resident 36's clinical record revealed diagnoses of Dementia (a decline in mental ability, such as memory, thinking, and reasoning, that is severe enough to interfere with daily life) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). Observations of Resident 36 on May 19, 2025, at 1:09 PM; May 20, 2025, at 1:01 PM; and May 21, 2025, at 12:01 PM, revealed Resident 36 lying in bed not wearing hearing aids. Review of Resident 36's care plan failed to reveal any care plan regarding hearing aids. [...]

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for one of two residents reviewed for falls (Resident 46).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of three residents reviewed for nutritional status (Resident 46).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of 16 Residents reviewed (Resident 166).

Inspectors wroteBased on review of facility meal assessment form, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide coffee that was at a palatable and appealing temperature.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post daily current staffing, including the facility name, date, census, and total hours of nursing staff directly responsible for resident care per shift for the following dates: May 19, 20, and 21, 2025.

Inspectors wroteBased on a review of facility policy, clinical record and facility documentation, observations, resident and staff interview, it was determined that the facility failed to ensure that one of two residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident 1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture involving the neck of the right humerus (long bone of the upper arm).

Inspectors wroteBased on resident interviews, and review of clinical records, it was determined that the facility failed to afford residents the opportunity to select their preferred method of bathing and incorporate those preferences into the residents' personal care routine for three of five residents reviewed (Residents 8, 29, and 59).

Inspectors wroteBased on observation, and staff interview, it was determined the facility failed to maintain a clean homelike environment for one of two floors (2nd floor). Findings Include: During an environmental. tour conducted of the 2nd floor nursing unit on April 16, 2024, at aproximately 9:45 a.m., the following were observed: At 9:45 a.m., room [ROOM NUMBER] was observed to have an air conditioner with a thin layer of dust covering the unit. At 9:46 a.m., room [ROOM NUMBER] was observed to have an air conditioner with a thin layer of dust covering the unit. At 9:46 a.m., room [ROOM NUMBER] was observed to have an air conditioner with a thin layer of dust covering the unit. At 9:46 a.m., room [ROOM NUMBER] was observed to have an air conditioner with a thin layer of dust covering the unit. [...]

Inspectors wroteBased on facility policy and procedure review, facility documentation review and staff interview it was determined the facility failed to perform criminal background checks for 3 of five personnel records reviewed. (Employees E1, E2, and E5) Findings Include: Review of facility policy and procedure titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2022, revealed the facility will not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Review of Employee E1, E2, and E5's personnel records revealed the facility failed to obtain a criminal background check prior to hire. Interview with the Nursing Home Administrator on April 19, 2024 at 11:30 a.m. [...]

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to follow physician orders for three of 15 residents reviewed. (Residents 17, 30, and Resident 42)

Inspectors wroteBased on clinical record review, facility policy and procedure review and staff interview it was determined the facility failed to monitor the nutritional status for five of nine residents reviewed. (Residents 16, 17, 35, 42, and Resident 47).

Inspectors wroteBased on observations, staff and resident interview, and clinical record review, it was determined that the facility failed to ensure that a bathroom was accessible to one of 15 residents reviewed (Resident 56).

Inspectors wroteBased on clinical record review and observation, it was determined the facility failed to update care plans to accurately reflect the resident's current status for one of 15 residents reviewed (Resident 56).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to report critical results of laboratory studies to the physician in a timely manner for one of 15 residents reviewed (Resident 56).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to maintain accurate record for one of 24 residents reviewed. (Resident 14) Findings Include: Review of Resident 14's admission Skin Evaluation, dated April 1, 2024 revealed the resident had no pressure ulcers. Review of Resident 14's Wound Care Notes, dated April 2, 2024 revealed a Stage 3 pressure ulcer (a wound caused by prolonged pressure which has subcutaneous fat visible, but bone, tendon, or muscle is not exposed) to the sacrum (triangular bone at the base of the spine) measuring 1.5 centimeters (cm) long x 0.3 cm wide x 0.2 cm deep. Review of Resident 14's Weekly Skin/Body Checks, dated April 3, 2024 revealed the resident had no pressure ulcers. [...]