Emerald South Nursing and Rehabilitation Center

Emerald South Nursing and Rehabilitation Center

1175 Delaware Ave

Buffalo , NY 14209

7168856733

www.pscwny.org/harbour-hawthorn-home.html

Services: Baseline Services, Respite Care (Short Term)

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:122
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:122

Administrative

Ownership: Proprietary--LLC

Operated by: Opal Care LLC
1175 Delaware Avenue
Buffalo, NY 14209

Permanent Facility Identifier: 251

Operating Certificate: 1401338N

Medicaid Certified

Medicare Certified

Medicare Number: 335593

Statistics

Employee Flu Vaccination Rate: 0%

Occupancy Rate: 0%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain6.67009/1/2018
425Percentage of short-stay residents with pressure ulcers that are new or worsened0.00009/1/2018
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine38.35009/1/2018
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine30.21009/1/2018
434Percentage of short-stay residents who newly received an antipsychotic medication2.86009/1/2018
471Percentage of short-stay residents who made improvements in function85.75009/1/2018

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased21.74009/1/2018
402Percentage of long-stay residents who self-report moderate to severe pain1.12009/1/2018
403Percentage of high risk long-stay residents with pressure ulcers6.29009/1/2018
404Percentage of long-stay residents who lose too much weight1.12009/1/2018
405Percentage of low risk long-stay residents who lose control of their bowels or bladder51.75009/1/2018
406Percentage of long-stay residents with a catheter inserted and left in their bladder0.41009/1/2018
407Percentage of long-stay residents with a urinary tract infection0.75009/1/2018
408Percentage of long-stay residents who have depressive symptoms10.65009/1/2018
409Percentage of long-stay residents who were physically restrained0.00009/1/2018
410Percentage of long-stay residents experiencing one or more falls with major injury2.60009/1/2018
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine72.93009/1/2018
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine53.16009/1/2018
419Percentage of long-stay residents who received an antipsychotic medication28.42009/1/2018
451Percentage of long-stay residents whose ability to move independently worsened34.74009/1/2018
452Percentage of long-stay residents who received an antianxiety or hypnotic medication13.50009/1/2018

Complaints

Number of Standard Health Deficiencies:100
Number of Live Safety Code Deficiencies:72
Number of Total Deficiencies:172
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:1
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :1
Total intakes received (last three years):164
Intakes received per 100 occupied beds (last three years):198.1
Percent of total intakes received that were facility self reported incidents (last three years):50
On-site complaint investigations (last three years):35
Complaint investigations resulting in citations (last three years):23
Complaint investigations resulting in citations per 100 occupied beds (last three years):27.8
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:9
Complaint Citations in deficiency category: Resident Rights:11
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:1
Complaint Citations in deficiency category: Other Services:0
Complaint Citations across all deficiency categories (last three years):23

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
Multiple Deficiencies8/6/20047000
1/13/2016Physical Environment1/3/20172000
9/16/2016Quality of Care12/19/201610000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/13/2016Complaint2
12/1/2016Complaint2
2/16/2017Certification2
3/10/2015Certification2
3/7/2016Certification2
5/8/2018Certification1
7/14/2016Complaint2
8/5/2014Complaint2
9/6/2016Complaint2
9/7/2017Complaint2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthRequirements Before Submitting a Request for225/8/2018
HealthCriminal History Record Check Process225/8/2018
HealthCriminal History Record Check Process225/8/2018
HealthDepartment Criminal History Review215/8/2018
LSCEP Training Program135/8/2018
HealthSafe/Clean/Comfortable/Homelike Environment125/8/2018
HealthDevelop/Implement Abuse/Neglect Policies225/8/2018
HealthReporting of Alleged Violations225/8/2018
HealthInvestigate/Prevent/Correct Alleged Violation225/8/2018
HealthNotice Requirements Before Transfer/Discharge125/8/2018
HealthComprehensive Assessments & Timing125/8/2018
HealthPASARR Screening for MD & ID215/8/2018
HealthBaseline Care Plan125/8/2018
HealthCare Plan Timing and Revision215/8/2018
HealthADL Care Provided for Dependent Residents215/8/2018
HealthQuality of Care215/8/2018
HealthTreatment/Svcs to Prevent/Heal Pressure Ulcer215/8/2018
HealthIncrease/Prevent Decrease in ROM/Mobility215/8/2018
HealthFree of Accident Hazards/Supervision/Devices215/8/2018
HealthDialysis215/8/2018
HealthPharmacy Srvcs/Procedures/Pharmacist/Records225/8/2018
HealthFree of Medication Error Rts 5 Prcnt or More225/8/2018
HealthGoverning Body225/8/2018
HealthResident Records - Identifiable Information215/8/2018
HealthInfection Prevention & Control225/8/2018
HealthEssential Equipment, Safe Operating Condition235/8/2018
LSCBuilding Construction Type and Height225/8/2018
LSCMeans of Egress - General225/8/2018
LSCEgress Doors225/8/2018
LSCDoors with Self-Closing Devices225/8/2018
LSCStairways and Smokeproof Enclosures225/8/2018
LSCRamps and Other Exits215/8/2018
LSCExit Signage225/8/2018
LSCVertical Openings - Enclosure225/8/2018
LSCCooking Facilities215/8/2018
LSCAlcohol Based Hand Rub Dispenser (ABHR)225/8/2018
LSCFire Alarm System - Testing and Maintenance225/8/2018
LSCSprinkler System - Installation225/8/2018
LSCSprinkler System - Maintenance and Testing225/8/2018
LSCPortable Fire Extinguishers225/8/2018
LSCCorridors - Construction of Walls215/8/2018
LSCCorridor - Doors225/8/2018
LSCSubdivision of Building Spaces - Smoke Barrie225/8/2018
LSCHVAC225/8/2018
LSCEvacuation and Relocation Plan225/8/2018
LSCSmoking Regulations215/8/2018
LSCSoiled Linen and Trash Containers215/8/2018
LSCPortable Space Heaters215/8/2018
LSCElectrical Systems - Other225/8/2018
LSCElectrical Equipment - Power Cords and Extens225/8/2018
LSCGas Equipment - Cylinder and Container Storag225/8/2018
HealthInfection Control225/8/2018
HealthOrganization and Administration215/8/2018
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES2112/1/20161/25/2017
HealthNOTICE OF RIGHTS, RULES, SERVICES, CHARGES219/6/201610/13/2016
HealthNOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE219/6/201610/13/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS219/6/201610/13/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES319/6/201610/13/2016
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)219/7/201710/27/2017
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS219/7/201710/27/2017
HealthCOMFORTABLE & SAFE TEMPERATURE LEVELS231/13/20162/16/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING221/13/20162/16/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION231/13/20162/16/2016
HealthWRITTEN PLANS TO MEET EMERGENCIES/DISASTERS231/13/20162/16/2016
HealthOrganization and Administration221/13/20162/16/2016
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)212/16/20174/12/2017
HealthDIGNITY AND RESPECT OF INDIVIDUALITY212/16/20174/12/2017
HealthDEVELOP COMPREHENSIVE CARE PLANS212/16/20174/12/2017
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING212/16/20174/12/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES212/16/20174/12/2017
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES222/16/20174/12/2017
HealthPROVIDED DIET MEETS NEEDS OF EACH RESIDENT222/16/20174/12/2017
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY222/16/20174/12/2017
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS212/16/20174/12/2017
HealthSAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRON222/16/20174/12/2017
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE212/16/20174/12/2017
LSCCorridor Access212/16/20174/12/2017
LSCHazardous Areas - Enclosure222/16/20174/12/2017
LSCSprinkler System - Maintenance and Testing222/16/20174/12/2017
LSCCorridor - Doors222/16/20174/12/2017
LSCEvacuation and Relocation Plan222/16/20174/12/2017
LSCElectrical Systems - Essential Electric Syste222/16/20174/12/2017
LSCElectrical Systems - Essential Electric Syste222/16/20174/12/2017
LSCElectrical Equipment - Power Cords and Extens222/16/20174/12/2017
LSCElectrical Equipment - Testing and Maintenanc222/16/20174/12/2017
LSCGas Equipment - Cylinder and Container Storag222/16/20174/12/2017
HealthOrganization and Administration212/16/20174/12/2017
HealthPhysical Environment222/16/20174/12/2017
HealthStandards of Construction for New Existing NH222/16/20174/12/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)213/7/20164/20/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS213/7/20164/20/2016
HealthDIGNITY AND RESPECT OF INDIVIDUALITY213/7/20164/20/2016
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE213/7/20164/20/2016
HealthCOMPREHENSIVE ASSESSMENTS213/7/20164/20/2016
HealthCOMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT223/7/20164/20/2016
HealthCOMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE213/7/20164/20/2016
HealthCOMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS213/7/20164/20/2016
HealthQUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS223/7/20164/20/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS223/7/20164/20/2016
HealthENCODING/TRANSMITTING RESIDENT ASSESSMENT223/7/20164/20/2016
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING213/7/20164/20/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES223/7/20164/20/2016
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE213/7/20164/20/2016
HealthSUFFICIENT FLUID TO MAINTAIN HYDRATION213/7/20164/20/2016
HealthPOSTED NURSE STAFFING INFORMATION123/7/20164/20/2016
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS213/7/20164/20/2016
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS213/7/20164/20/2016
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION223/7/20164/20/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE213/7/20164/20/2016
HealthWRITTEN PLANS TO MEET EMERGENCIES/DISASTERS223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD233/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCMISCELLANEOUS223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/7/20164/20/2016
HealthStandards of Construction for New Existing NH233/7/20164/20/2016
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT213/7/20165/4/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES223/7/20165/4/2016
HealthResponsibilities of Providers; Required Notif123/10/20155/8/2015
HealthRIGHT TO SURVEY RESULTS - READILY ACCESSIBLE123/10/20155/8/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES213/10/20155/8/2015
HealthREASONABLE ACCOMMODATION OF NEEDS/PREFERENCES223/10/20155/8/2015
HealthPROVISION OF MEDICALLY RELATED SOCIAL SERVICE213/10/20155/8/2015
HealthHOUSEKEEPING & MAINTENANCE SERVICES223/10/20155/8/2015
HealthCOMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE213/10/20155/8/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS213/10/20155/8/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP213/10/20155/8/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS213/10/20155/8/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES223/10/20155/8/2015
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS213/10/20155/8/2015
HealthTHERAPEUTIC DIET PRESCRIBED BY PHYSICIAN213/10/20155/8/2015
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS213/10/20155/8/2015
HealthINFECTION CONTROL, PREVENT SPREAD, LINENS213/10/20155/8/2015
HealthRESIDENT CALL SYSTEM - ROOMS/TOILET/BATH223/10/20155/8/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE213/10/20155/8/2015
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCMISCELLANEOUS223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
LSCLIFE SAFETY CODE STANDARD223/10/20155/8/2015
HealthOrganization and Administration213/10/20155/8/2015
HealthStandards of Construction for New Existing NH223/10/20155/8/2015
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS218/5/20148/29/2014
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING218/5/20148/29/2014
HealthNG TREATMENT/SERVICES - RESTORE EATING SKILLS217/14/20169/7/2016