Deficiency Records for The Emerald Peek Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Emerald Peek Rehabilitation and Nursing Center. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2022-11-17 | 2023-01-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-16 | 2023-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-16 | 2023-01-10 | 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 | 2021-12-22 | 2022-02-18 | N |
| Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-22 | 2022-02-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-22 | 2022-02-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-22 | 2022-02-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-22 | 2022-02-05 | 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 | 2021-12-22 | 2022-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-22 | 2022-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-02-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-22 | 2022-02-05 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-22 | 2022-02-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-22 | 2022-02-05 | 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 | 2019-01-18 | 2019-03-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-18 | 2019-03-11 | 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 | 2019-01-18 | 2019-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-18 | 2019-03-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-18 | 2019-03-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-18 | 2019-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-18 | 2019-03-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-01-18 | 2019-02-20 | 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 | 2019-01-18 | 2019-02-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-01-18 | 2019-02-20 | N |
| Provide housekeeping and maintenance services. | Health | 2017-05-16 | 2017-07-01 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-05-16 | 2017-07-01 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-05-16 | 2017-07-01 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2017-05-16 | 2017-07-01 | 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 | 2017-05-15 | 2017-07-01 | N |
