Deficiency Records for Emerald Nursing and Rehab Legacy Pointe LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Emerald Nursing and Rehab Legacy Pointe 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-03 | 2024-01-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-30 | 2024-01-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-30 | 2024-01-03 | 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 | 2023-11-30 | 2024-01-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-30 | 2024-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2024-01-03 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-11-30 | 2024-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-30 | 2024-01-03 | 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 | 2023-11-28 | 2024-01-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-28 | 2024-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-28 | 2024-01-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-25 | 2023-07-06 | 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 | 2023-05-25 | 2023-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-25 | 2023-07-06 | 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 | 2023-05-25 | 2023-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-07-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Meet other general requirements. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-16 | 2022-12-19 | 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 | 2022-11-16 | 2022-12-19 | 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 | 2022-11-16 | 2022-12-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-16 | 2022-12-19 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-17 | 2022-12-15 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-11-17 | 2022-12-15 | N |
| 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 | 2022-11-17 | 2022-12-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-17 | 2022-12-15 | 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 | 2022-11-17 | 2022-12-15 | 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 | 2022-11-17 | 2022-12-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-17 | 2022-12-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-17 | 2022-12-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-17 | 2022-12-15 | 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 | 2022-11-17 | 2022-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-17 | 2022-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2022-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-24 | 2022-09-19 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-30 | 2022-08-02 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-06-30 | 2022-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-08-02 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-06-30 | 2022-08-02 | Y |
| 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 | 2022-06-30 | 2022-08-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-30 | 2022-08-02 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-30 | 2022-08-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-08-02 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-03-21 | 2022-04-27 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-21 | 2022-04-27 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-21 | 2022-04-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-04 | 2022-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2022-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2022-02-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-30 | 2022-02-02 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-09-30 | 2022-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2022-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2022-02-02 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-11-04 | 2021-12-04 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-11-04 | 2021-12-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2021-12-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-04 | 2021-12-04 | Y |
| Post nurse staffing information every day. | Health | 2021-11-04 | 2021-12-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2021-12-02 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-09-30 | 2021-11-03 | Y |
