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Deficiency Records for Emerald Bay Care
A list of the most recent deficiencies for Emerald Bay Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Emerald Bay Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-12 | 2024-10-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-12 | 2024-10-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-08-07 | 2024-08-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-18 | 2024-07-31 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-06-18 | 2024-07-31 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-06-18 | 2024-07-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-18 | 2024-07-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-18 | 2024-07-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-06-18 | 2024-07-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-06-18 | 2024-07-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-18 | 2024-07-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-18 | 2024-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-18 | 2024-07-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-18 | 2024-07-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-06-18 | 2024-07-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-18 | 2024-07-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-06-18 | 2024-07-31 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-06-18 | 2024-07-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-18 | 2024-07-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-18 | 2024-07-31 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-06-18 | 2024-07-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-10 | 2024-07-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-10 | 2024-06-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-22 | 2024-06-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-22 | 2024-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-22 | 2024-06-21 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-10 | 2024-06-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-10 | 2024-06-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-10 | 2024-06-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-10 | 2024-06-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-14 | 2024-04-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-14 | 2024-04-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-27 | 2024-03-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-27 | 2024-03-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-24 | 2024-03-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-24 | 2024-03-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-04 | 2023-10-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-18 | 2023-08-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-18 | 2023-08-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-07 | 2023-07-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-07 | 2023-07-25 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-06-07 | 2023-07-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-07 | 2023-07-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-07 | 2023-07-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-07 | 2023-07-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-07 | 2023-07-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-07 | 2023-07-25 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-07 | 2023-07-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-07 | 2023-07-25 | N |
| Provide or obtain dental services for each resident. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-07 | 2023-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-07 | 2023-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-07 | 2023-07-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-07 | 2023-07-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-01 | 2023-07-03 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish methods for sharing information. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-20 | 2023-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-04-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-02 | 2023-03-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-02 | 2023-03-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-23 | 2023-02-15 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-19 | 2023-01-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-19 | 2023-01-06 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-27 | 2022-11-16 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-10-27 | 2022-11-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-15 | 2022-09-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-15 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-08 | 2022-08-02 | Y |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-12-02 | 2022-02-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-14 | 2022-01-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-14 | 2022-01-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-14 | 2022-01-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-14 | 2022-01-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-14 | 2022-01-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-14 | 2022-01-18 | N |
| Meet other general requirements. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
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