Deficiency Records for Emerald Nursing and Rehabilitation Mercy
Updated as of March 01, 2024
A list of the most recent deficiencies for Emerald Nursing and Rehabilitation Mercy. 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-07 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-20 | 2023-10-20 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-09-20 | 2023-10-20 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-09-20 | 2023-10-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-08 | 2023-07-23 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-19 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-19 | 2023-05-12 | 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 | 2023-04-19 | 2023-05-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-19 | 2023-05-12 | Y |
| 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 | 2023-02-09 | 2023-05-12 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2023-02-09 | 2023-05-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-09 | 2023-05-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-09 | 2023-05-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-09 | 2023-05-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-09 | 2023-05-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-04 | 2023-05-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-04 | 2023-05-10 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-09 | 2023-05-09 | 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 | 2023-02-09 | 2023-05-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-09 | 2023-05-09 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-09 | 2023-04-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-09 | 2023-04-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-09 | 2023-04-14 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-02-09 | 2023-04-13 | 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 | 2023-02-14 | 2023-03-31 | 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 | 2023-02-14 | 2023-03-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-14 | 2023-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-14 | 2023-03-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-14 | 2023-03-31 | 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 | 2023-02-14 | 2023-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-14 | 2023-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-11-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-27 | 2022-11-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-12 | 2022-11-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-12 | 2022-11-04 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-27 | 2022-11-04 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-03-03 | 2022-03-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-03 | 2022-03-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-03 | 2022-03-25 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-03 | 2022-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-03-25 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-03 | 2022-03-25 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-03 | 2022-03-25 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-25 | 2021-12-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-25 | 2021-12-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-25 | 2021-12-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-10-25 | 2021-12-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-25 | 2021-11-26 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-25 | 2021-11-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-10-25 | 2021-11-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-25 | 2021-11-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-25 | 2021-11-23 | 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 | 2021-10-25 | 2021-11-23 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2021-10-25 | 2021-11-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-25 | 2021-11-23 | 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 | 2021-10-25 | 2021-11-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-25 | 2021-11-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-25 | 2021-11-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-26 | 2021-11-22 | 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 | 2021-10-26 | 2021-11-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-26 | 2021-11-22 | 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 | 2021-10-26 | 2021-11-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-26 | 2021-11-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-26 | 2021-11-22 | 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 | 2021-10-26 | 2021-11-22 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-26 | 2021-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-26 | 2021-11-22 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-10-26 | 2021-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-26 | 2021-11-22 | Y |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-10-25 | 2021-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-20 | 2021-08-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-10 | 2021-03-12 | 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 | 2019-09-12 | 2019-12-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-12 | 2019-12-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-12 | 2019-12-17 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-08 | 2019-12-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-10-08 | 2019-12-02 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-10-08 | 2019-12-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-12 | 2019-10-14 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-09-12 | 2019-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-12 | 2019-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-12 | 2019-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-12 | 2019-10-14 | 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 | 2019-09-12 | 2019-10-14 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-09-12 | 2019-10-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-12 | 2019-10-14 | 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 | 2019-09-12 | 2019-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-12 | 2019-10-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-12 | 2019-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-12 | 2019-10-14 | 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 | 2019-09-12 | 2019-10-14 | 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 | 2019-09-12 | 2019-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-09-12 | N |
