Pennsylvania Department of Health
EMERALD NURSING AND REHABILITATION
Patient Care Inspection Results

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EMERALD NURSING AND REHABILITATION
Inspection Results For:

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EMERALD NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on4, 2026, in response tocomplaints at Emerald Nursing and Rehabilitation, it was determined that the facility was not in compliance under the requirement of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on facility policy review, observations and staff interviews it was determined the facility failed to provide PPE and signage for residents who require enhanced barrier precautions for one of six residents reviewed. (Resident 1)

Findings Include:

Review of facility policy titled Enhanced Barrier Precautions, effective March 2024, revealed "EPB (enhanced barrier precautions) are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO (multi-drug resistant organism) colonization...Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (personal protective equipment) required...PPE is available outside of the resident rooms.

Observation of Resident 1 on February 4, 2026 at approximately 12:05PM revealed the resident had an indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine into an external bag). Further observations revealed there was no PPE in the room and there was no sign for EBP.

Two Licensed Practical Nurses E2 and E3 confirmed the lack of signage on February 4, 2026, at approximately 2:45PM.

These findings were relayed to the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 3:30 p.m.

28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services





 Plan of Correction - To be completed: 03/10/2026

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."


1) Enhanced Barrier Protection PPE and signage was provided for Resident 1. No adverse effects are noted.
2) An initial audit was completed to validate residents requiring EBP's to have appropriate signs and PPE.
3) Nursing Home Administrator, DON, Unit Manager, IP, reeducated related to following infection control practices related to EBP signage and PPE.
4) NHA/ Designee will complete random audits to validate residents requiring EBP's to have signs and PPE weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of facility staffing data, it was determined that the facility failed to ensure a minimum number of 1 nurse aide per 10 residents on day shift, and 1 nurse aide per 11 residents on evening shift, and 1 nurse aide per 15 residents on night shift for the three weeks of facility staffing reviewed (week of December 27,2025, week of January 3, 2026, and week of January 11, 2026).

Findings include:

Review of the week of December 27, 2025 revealed the following dates on day shift did not meet the requirement of one nurse aide per 10 residents during day shift:

December 27, 2025 and December 31, 2025.

Review of the week of December 27, 2025 revealed the following dates on evening shift did not meet the requirement of one nurse aide per 11 residents during the evening shift:

December 28, 2025 and December 31, 2025

Review of the week of December 27, 2025 revealed the following dates on night shift did not meet the requirements of one nurse aide per 15 residents during the night shift:

December 28, 2025, December 29, 2025, January 1, 2026, and January 2, 2026.

Review of the week of January 3, 2026 revealed the following date on evening shift did not meet the requirement of one nurse aide per 11 residents during the evening shift:

January 8, 2026

Review of the week of January 10, 2026 revealed the following dates on day shift did not meet the requirement of one nurse aide per 10 residents during day shift:

January 10, 2026, January 12, 2026, January 14, 2026

Review of the week of January 10, 2026 revealed the following date on evening shift did not meet the requirement of one nurse aide per 11 residents during evening shift:

January 10, 2026, January 11, 2026, and January 13, 2026

Review of the week of January 10, 2026 revealed the following dates on night shift did not meet the requirement of one nurse aide per 15 residents during evening shift:

January 10, 2026, January 12, 2026, January 14, 2026, January 15, 2026

Interview with NHA on February 11, 2026 at 6:52 PM via phone call confirmed that the aide staffing ratios were not met on the above days.





 Plan of Correction - To be completed: 03/10/2026

1) Facility has identified and recognized past noncompliance with nurse aide ratios.
2) Facility has audited for a week following the survey to identify additional gaps with nurse aide ratios.
3) Nursing Home Administrator, Scheduler, Nursing Administration, and RN Supervisors reeducated about the importance of finding replacement to keep the ratios and the state regulation P5520. A new emphasis has been set to become agency free by the end of the year with increased interviews being set. A new design of call off system instituted to track call offs and find replacement staff
4) The Nursing Home Administrator, or designee, will audit 5x a week the daily staffing grids to assist with compliance with P5520 for one month and 3x a week for 2 months. These audits will be reviewed at QAPI.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of facility staffing data, it was determined that the facility failed to ensure a minimum of one LPN (Licensed Practical Nurse) per 40 residents on the night shift for the 21 day period reviewed from December 27, 2026 through January 16, 2026.

Findings include:

A review of facility staffing data for the 21 day period from December 27, 2025 through January 16, 2026 revealed the following dates that did not meet the minimum requirements of one LPN per 40 residents on the night shift.

December 29, 2025, December 30, 2025, January 1, 2026, January 2, 2026, and January 15, 2026

The aforementioned findings were conveyed to the Nursing Home Administrator in a telephone interview on February 11, 2026 at 6:52PM.





 Plan of Correction - To be completed: 03/10/2026

1) Facility has identified and recognized past noncompliance with nurse ratios.
2) Facility has audited for a week following the survey to identify additional gaps with nurse aide ratios.
3) Nursing Home Administrator, Scheduler, Nursing Administration, and RN Supervisors reeducated about the importance of finding replacement to keep the ratios and the state regulation P5530. A new emphasis has been set to become agency free by the end of the year with increased interviews being set. A new design for the call off system instituted to track call offs and find replacement staff.
4) The Nursing Home Administrator, or designee, will audit 5x a week the daily staffing grids to assist with compliance with P5530 for one month and 3x a week for 2 months. These audits will be reviewed at QAPI.


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