A list of the most recent deficiencies for Emerald Bay Care. 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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-04 | 2023-10-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-18 | 2023-08-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-18 | 2023-08-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-07 | 2023-07-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-07 | 2023-07-25 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-06-07 | 2023-07-25 | 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 | 2023-06-07 | 2023-07-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-07 | 2023-07-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-07 | 2023-07-25 | 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 | 2023-06-07 | 2023-07-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-07 | 2023-07-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-07 | 2023-07-25 | N |
| 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 | 2023-06-07 | 2023-07-25 | 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 | 2023-06-07 | 2023-07-25 | 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 | 2023-06-07 | 2023-07-25 | N |
| Provide or obtain dental services for each resident. | Health | 2023-06-07 | 2023-07-25 | N |
| 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 | 2023-06-07 | 2023-07-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-07 | 2023-07-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-07 | 2023-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-07 | 2023-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-07 | 2023-07-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-07 | 2023-07-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-01 | 2023-07-03 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish methods for sharing information. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-20 | 2023-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-04-28 | 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 | 2023-02-02 | 2023-03-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-02 | 2023-03-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-23 | 2023-02-15 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-19 | 2023-01-06 | 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 | 2022-12-19 | 2023-01-06 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-27 | 2022-11-16 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-10-27 | 2022-11-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-15 | 2022-09-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-15 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-08 | 2022-08-02 | Y |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-12-02 | 2022-02-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-14 | 2022-01-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-14 | 2022-01-18 | 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 | 2021-12-14 | 2022-01-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-14 | 2022-01-18 | 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 | 2021-12-14 | 2022-01-18 | 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 | 2021-12-14 | 2022-01-18 | N |
| Meet other general requirements. | Fire Safety | 2021-12-02 | 2022-01-06 | 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 | 2021-12-02 | 2022-01-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-02 | 2022-01-06 | 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 | 2021-12-02 | 2022-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-02 | 2022-01-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-29 | 2021-05-20 | Y |
| 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 | 2019-04-05 | 2019-05-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-05 | 2019-05-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-04-05 | 2019-05-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-05 | 2019-05-14 | 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 | 2019-04-05 | 2019-05-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-05 | 2019-05-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-05 | 2019-05-14 | 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 | 2019-04-05 | 2019-05-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-05 | 2019-05-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-05 | 2019-05-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-04-05 | 2019-05-14 | N |
| Post nurse staffing information every day. | Health | 2019-04-05 | 2019-05-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-05 | 2019-05-14 | 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 | 2019-04-05 | 2019-05-14 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-04-05 | 2019-05-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-05 | 2019-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-05 | 2019-05-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-05 | 2019-05-14 | N |
| Keep all essential equipment working safely. | Health | 2019-04-05 | 2019-05-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-02 | 2019-05-06 | N |
