Deficiency Records for The Emeralds at St Paul LLC
Updated as of February 01, 2020
This is not the most recent data for The Emeralds at St Paul LLC. For the most recent information, click here.
A list of the most recent deficiencies for The Emeralds at St Paul LLC. 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? |
|---|---|---|---|---|
| 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 | 2019-10-30 | 2019-12-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-10-30 | 2019-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-30 | 2019-12-10 | N |
| Be properly staffed | Fire Safety | 2019-10-30 | 2019-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-30 | 2019-12-10 | 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 | 2019-10-31 | 2019-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-31 | 2019-12-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-31 | 2019-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-12-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-31 | 2019-10-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-26 | 2019-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-19 | 2019-06-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-17 | 2019-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-04-17 | 2019-05-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-01-24 | 2019-02-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-24 | 2019-02-20 | Y |
| 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 | 2018-12-03 | 2019-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-03 | 2019-02-20 | 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 | 2018-12-03 | 2019-02-20 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-27 | 2019-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-27 | 2019-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-27 | 2019-01-31 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-11-27 | 2019-01-31 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2018-11-27 | 2019-01-16 | 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 | 2018-11-27 | 2019-01-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-27 | 2019-01-16 | 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 | 2018-11-27 | 2019-01-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-11-27 | 2019-01-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-11-27 | 2019-01-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-27 | 2019-01-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-11-27 | 2019-01-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-27 | 2019-01-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-03 | 2019-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-03 | 2019-01-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-12-03 | 2019-01-16 | N |
| Provide activities to meet all resident's needs. | Health | 2018-12-03 | 2019-01-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-03 | 2019-01-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-12-03 | 2019-01-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-12-03 | 2019-01-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-03 | 2019-01-16 | 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 | 2018-12-03 | 2019-01-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-12-03 | 2019-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-03 | 2019-01-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-03 | 2019-01-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-03 | 2019-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-27 | 2018-10-26 | 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 | 2018-09-27 | 2018-10-26 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2018-09-27 | 2018-10-26 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2018-09-27 | 2018-10-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-23 | 2018-06-28 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-02-08 | 2018-05-04 | 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 | 2018-02-08 | 2018-05-04 | 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 | 2018-02-08 | 2018-05-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-08 | 2018-05-04 | 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 | 2018-02-08 | 2018-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-08 | 2018-05-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-02-08 | 2018-05-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-07 | 2018-03-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-02-07 | 2018-03-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-02-08 | 2018-03-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-08 | 2018-03-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-02-08 | 2018-03-20 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-02-08 | 2018-03-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-02-08 | 2018-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-08 | 2018-03-20 | N |
| Provide activities to meet all resident's needs. | Health | 2018-02-08 | 2018-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-08 | 2018-03-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-02-08 | 2018-03-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-02-08 | 2018-03-20 | 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 | 2018-02-08 | 2018-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-08 | 2018-03-20 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2018-02-08 | 2018-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-08 | 2018-03-20 | 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 | 2018-02-08 | 2018-03-20 | Y |
| Provide or obtain dental services for each resident. | Health | 2018-02-08 | 2018-03-20 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-07 | 2018-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-07 | 2018-02-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-07 | 2018-02-14 | N |
| Meet other general requirements. | Fire Safety | 2018-02-07 | 2018-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-07 | 2018-02-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-02-07 | 2018-02-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-02-07 | 2018-02-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-02-07 | 2018-02-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-07 | 2018-02-12 | N |
