EMERALD SOUTH NURSING AND REHABILITATION CENTER

Nursing Home Inspector

1175 DELAWARE AVE
BUFFALO, NY 14209
Erie County
Phone: 716-885-6733
Provider Number: 335593
Last Inspection: 02/16/2017

About the Nursing Home

Number of Beds: 122
Number of Residents: 73
Beds Available: 49
Percent Occupancy: 60%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

37

Facility
18

County
14

NY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

37

2017
77

2016
56

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

2/16/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 4/12/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/12/2017
 
Failed To: Provide a tasty and well-balanced diet that meets the nutritional needs of each resident. Pattern : Minimal 4 4/12/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/12/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 4/12/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 4/12/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/12/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 4/12/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 4/12/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/12/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 4/12/2017
 

3/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 4/20/2016
 
Failed To: 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. Isolated : Minimal 3 4/20/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 5/4/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/20/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 4/20/2016
 
Failed To: Give notice to the resident before a room or roommate change. Isolated : Minimal 3 4/20/2016
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Isolated : Minimal 3 5/4/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 4/20/2016
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Pattern : Minimal 4 4/20/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 4/20/2016
 
Failed To: Completely assess the resident at least every twelve months. Isolated : Minimal 3 4/20/2016
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Pattern : Minimal 4 4/20/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 4/20/2016
 
Failed To: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Pattern : Minimal 4 4/20/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/20/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 4/20/2016
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Minimal 3 4/20/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Potential 3 4/20/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 4/20/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 4/20/2016
 
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 4/20/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/20/2016
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Pattern : Minimal 4 4/20/2016
 

3/10/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Pattern : Potential 3 5/8/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 5/8/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 5/8/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 5/8/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 5/8/2015
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 5/8/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/8/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 5/8/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 5/8/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 5/8/2015
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Isolated : Minimal 3 5/8/2015
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated : Minimal 3 5/8/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 5/8/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 5/8/2015
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 5/8/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/8/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 5/8/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/7/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/27/2017
 
Failed To: 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. Isolated : Minimal 3 10/27/2017
 

12/1/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/25/2017
 

9/6/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 10/13/2016
 
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 10/13/2016
 
Failed To: 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. Isolated : Minimal 3 10/13/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 10/13/2016
 

7/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 unknown
 

1/13/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain comfortable and safe temperature levels. Widespread : Minimal 5 2/16/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 2/16/2016
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 2/16/2016
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 2/16/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 73 145.81 167.28
Registered Nurses 0.48 0.79 0.74
Licensed Practical / Vocational Nurses 1.37 0.98 0.84
Certified Nursing Assistants 2.58 2.43 2.30
Total Staff Hours 4.42 4.20 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of high risk long-stay residents with pressure ulcers 4 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 77 92 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 76 94 96
of long-stay residents experiencing one or more falls with major injury 3 2 2
of long-stay residents who have depressive symptoms 14 7 8
of long-stay residents who lose too much weight 2 5 6
of long-stay residents who received an antianxiety or hypnotic medication 18 15 15
of long-stay residents who received an antipsychotic medication 31 13 13
of long-stay residents who self-report moderate to severe pain 0 4 3
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 20 21 16
of long-stay residents whose need for help with daily activities has increased 17 16 13
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 2 2 3
of low risk long-stay residents who lose control of their bowels or bladder 56 57 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 62 80 81
of short-stay residents who had an outpatient emergency department visit 12 10 9
of short-stay residents who made improvements in function 59 68 68
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 4 10 9
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 78 82 82
of short-stay residents who were rehospitalized after a nursing home admission 18 19 21
of short-stay residents who were successfully discharged to the community 47 55 48
of short-stay residents with pressure ulcers that are new or worsened 0 1 0