Deficiency Records for Emerald Nursing and Rehab Lancaster LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Emerald Nursing and Rehab Lancaster 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-22 | 2024-03-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-23 | 2024-03-04 | 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 | 2024-01-23 | 2024-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-23 | 2024-03-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-23 | 2024-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-03-04 | 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 | 2024-01-23 | 2024-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-23 | 2024-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-23 | 2024-03-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-22 | 2024-03-04 | 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 | 2024-01-22 | 2024-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-22 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-22 | 2024-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-27 | 2023-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-27 | 2023-10-11 | 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 | 2023-08-27 | 2023-10-11 | Y |
| 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 | 2023-08-27 | 2023-10-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-27 | 2023-10-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-22 | 2023-07-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-22 | 2023-07-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-09 | 2023-06-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-19 | 2023-06-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-06-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-19 | 2023-06-03 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-02-28 | 2023-04-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-28 | 2023-04-14 | 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 | 2023-02-28 | 2023-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-28 | 2023-04-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-28 | 2023-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-28 | 2023-04-14 | 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 | 2023-02-28 | 2023-04-14 | 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 | 2023-02-28 | 2023-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-28 | 2023-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-28 | 2023-04-14 | 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 | 2023-02-28 | 2023-04-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-28 | 2023-04-14 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-23 | 2023-04-14 | 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 | 2023-02-23 | 2023-04-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-02-23 | 2023-04-14 | 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 | 2023-02-23 | 2023-04-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-02-23 | 2023-04-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-02 | 2022-11-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-27 | 2022-11-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-28 | 2022-11-30 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-11-02 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-27 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-27 | 2022-11-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-27 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-27 | 2022-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-07 | 2022-11-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-28 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-28 | 2022-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-28 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-28 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-28 | 2022-11-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-27 | 2022-09-07 | 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 | 2022-07-07 | 2022-08-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-28 | 2022-08-05 | Y |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2021-10-21 | 2021-11-30 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-18 | 2021-11-30 | 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 | 2021-10-18 | 2021-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-18 | 2021-11-30 | 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 | 2021-10-18 | 2021-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-10-18 | 2021-11-30 | 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 | 2021-10-18 | 2021-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-10-18 | 2021-11-30 | N |
