Deficiency Records for Emerald Nursing and Rehabilitation Mercy
Updated as of March 01, 2019
This is not the most recent data for Emerald Nursing and Rehabilitation Mercy. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2018-09-18 | 2018-11-09 | 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 | 2018-09-18 | 2018-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Be properly staffed | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-09-25 | 2018-11-09 | 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 | 2018-09-25 | 2018-11-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-25 | 2018-11-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-25 | 2018-11-09 | 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 | 2018-09-25 | 2018-11-09 | 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 ne | Health | 2018-09-25 | 2018-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-25 | 2018-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-25 | 2018-11-09 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-09-25 | 2018-11-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-07 | 2018-04-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-07 | 2018-04-20 | Y |
| 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 | 2018-03-07 | 2018-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-07 | 2018-04-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-07 | 2018-04-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-07 | 2018-04-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-07-21 | 2017-08-09 | 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 | 2017-07-21 | 2017-08-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-21 | 2017-08-09 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-07-12 | 2017-08-09 | N |
| Provide housekeeping and maintenance services. | Health | 2017-07-12 | 2017-08-09 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-12 | 2017-08-09 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-07-12 | 2017-08-09 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-12 | 2017-08-09 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-07-12 | 2017-08-09 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-12 | 2017-08-09 | N |
| Provide or obtain dental services for each resident. | Health | 2017-07-12 | 2017-08-09 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2017-07-12 | 2017-08-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-07-12 | 2017-08-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-07-12 | 2017-08-09 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-07-12 | 2017-08-09 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-12 | 2017-08-09 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-12 | 2017-08-09 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-07-12 | 2017-08-09 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-12 | 2017-08-09 | Y |
| Use approved construction type or materials. | Fire Safety | 2017-07-21 | 2017-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-21 | 2017-07-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-14 | 2017-03-31 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-03-14 | 2017-03-31 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-14 | 2017-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-14 | 2017-03-31 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-14 | 2017-03-31 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-14 | 2017-03-31 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-14 | 2017-03-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-01-23 | 2017-03-31 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-01-23 | 2017-03-31 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-23 | 2017-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-01-23 | 2017-03-31 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-23 | 2017-03-31 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-23 | 2017-03-31 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-23 | 2017-03-31 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-01-23 | 2017-02-16 | Y |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-01-23 | 2017-02-16 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-01-23 | 2017-02-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-07-07 | 2016-09-21 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-07-07 | 2016-09-21 | Y |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-07-08 | 2016-08-21 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-07-08 | 2016-08-21 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-07-08 | 2016-08-21 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-07-08 | 2016-08-21 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-07-08 | 2016-08-21 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-07-07 | 2016-08-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-07-07 | 2016-08-19 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-07-07 | 2016-08-19 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-07-07 | 2016-08-19 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-07-07 | 2016-08-19 | Y |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-07-07 | 2016-08-19 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-07-07 | 2016-08-19 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-07-07 | 2016-08-19 | Y |
