Emerald South Nursing and Rehabilitation Center

Emerald South Nursing and Rehabilitation Center

1175 Delaware Ave

Buffalo, NY 14209

(716) 885-6733

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

Services: Respite Care (Short Term), Baseline Services

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 pain13.903743/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened03/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine90.504453/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine91.47543/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication2.958573/1/2017
471Percentage of short-stay residents who made improvements in function57.030743/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased16.199378003/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain1.299078003/1/2017
403Percentage of high risk long-stay residents with pressure ulcers5.019304003/1/2017
404Percentage of long-stay residents who lose too much weight0.864554003/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder56.250001003/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder2.734193003/1/2017
407Percentage of long-stay residents with a urinary tract infection1.729107003/1/2017
408Percentage of long-stay residents who have depressive symptoms12.345681003/1/2017
409Percentage of long-stay residents who were physically restrained0.564971003/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury5.932203003/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine80.205654003/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine96.610171003/1/2017
419Percentage of long-stay residents who received an antipsychotic medication26.909091003/1/2017
451Percentage of long-stay residents whose ability to move independently worsened25.030343003/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication14.371258003/1/2017

Complaints

Number of Standard Health Deficiencies:85
Number of Live Safety Code Deficiencies:60
Number of Total Deficiencies:145
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):162
Intakes received per 100 occupied beds (last three years):162.6
Percent of total intakes received that were facility self reported incidents (last three years):56
On-site complaint investigations (last three years):39
Complaint investigations resulting in citations (last three years):31
Complaint investigations resulting in citations per 100 occupied beds (last three years):31.1
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:18
Complaint Citations in deficiency category: Resident Rights:10
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):31

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
Multiple Deficiencies8/6/20047000
1/13/2016 0:00:00Physical Environment1/3/20172000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/13/2016Complaint2
12/1/2016Complaint2
3/10/2015Certification2
3/7/2016Certification2
5/29/2014Certification3
5/8/2013Complaint2
7/14/2016Complaint2
7/22/2013Certification2
8/5/2014Complaint2
9/6/2016Complaint2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN11
HealthFACILITY IS FREE OF ACCIDENT HAZARDS211/25/2017
HealthINFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.2110/13/2016
HealthFACILITY IS FREE OF ACCIDENT HAZARDS3110/13/2016
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE2110/13/2016
HealthPROPER NOTICE BEFORE TRANSFER/DISCHARGE OF RESIDENT2110/13/2016
HealthORGANIZATION AND ADMINISTRATION222/16/2016
HealthPLANS TO MEET EMERGENCIES/DISASTERS232/16/2016
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING222/16/2016
HealthCOMFORTABLE AND SAFE TEMPERATURE LEVELS232/16/2016
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION232/16/2016
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING214/20/2016
HealthRESIDENT ASSESSMENT AUTOMATED DATA PROCESSING224/20/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS224/20/2016
HealthQUARTERLY REVIEW OF ASSESSMENTS224/20/2016
HealthRESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE214/20/2016
HealthFACILITY PROVIDES SUFFICIENT FLUID INTAKE214/20/2016
HealthFACILITY IS FREE OF ACCIDENT HAZARDS224/20/2016
HealthFREQUENCY OF ASSESSMENTS - NO LATER THAN 14 DAYS224/20/2016
HealthCOMPREHENSIVE ASSESSMENTS214/20/2016
HealthRESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE214/20/2016
HealthDIGNITY214/20/2016
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE214/20/2016
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.214/20/2016
HealthASSESSMENT CONDUCTED AT LEAST EVERY 12 MONTHS214/20/2016
HealthASSESSMENT AFTER A SIGNIFICANT CHANGE214/20/2016
HealthNURSE STAFFING124/20/2016
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS214/20/2016
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM214/20/2016
LSCVENTILATING EQUIPMENT214/20/2016
LSCCOOKING EQUIPMENT224/20/2016
LSCFURNISHING AND DECORATIONS224/20/2016
LSCWASTEBASKETS224/20/2016
LSCMEDICAL GAS SYSTEM224/20/2016
LSCOTHER224/20/2016
LSCGENERATORS INSPECTED/TESTED224/20/2016
LSCEMERGENCY PLAN224/20/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME234/20/2016
LSCPORTABLE FIRE EXTINGUISHERS224/20/2016
LSCSPRINKLER SYSTEM MAINTENANCE234/20/2016
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION224/20/2016
HealthPLANS TO MEET EMERGENCIES/DISASTERS224/20/2016
LSCSMOKE PARTITION CONSTRUCTION224/20/2016
LSCHAZARDOUS AREAS - SEPARATION224/20/2016
LSCEXIT ACCESS224/20/2016
LSCFIRE DRILLS224/20/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS214/20/2016
LSCTESTING OF FIRE ALARM224/20/2016
HealthHOUSEKEEPING AND MAINTENANCE SERVICES225/4/2016
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT215/4/2016
LSCTESTING OF FIRE ALARM225/8/2015
LSCPORTABLE FIRE EXTINGUISHERS225/8/2015
LSCVENTILATING EQUIPMENT225/8/2015
LSCCOOKING EQUIPMENT225/8/2015
HealthRESIDENT CALL SYSTEM225/8/2015
LSCSPRINKLER SYSTEM MAINTENANCE225/8/2015
LSCWASTEBASKETS225/8/2015
LSCMEDICAL GAS SYSTEM225/8/2015
LSCOTHER225/8/2015
LSCGENERATORS INSPECTED/TESTED225/8/2015
LSCEMERGENCY PLAN225/8/2015
HealthORGANIZATION AND ADMINISTRATION215/8/2015
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME225/8/2015
LSCAUTOMATIC SPRINKLER SYSTEM225/8/2015
LSCFIRE DRILLS225/8/2015
LSCEXIT SIGNS225/8/2015
LSCCORRIDOR WIDTH225/8/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS215/8/2015
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN215/8/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS215/8/2015
HealthASSESSMENT AFTER A SIGNIFICANT CHANGE215/8/2015
HealthHOUSEKEEPING AND MAINTENANCE SERVICES225/8/2015
HealthMEDICALLY RELATED SOCIAL SERVICES215/8/2015
HealthACCOMMODATION OF NEEDS AND PREFERENCES225/8/2015
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES215/8/2015
HealthSURVEY RESULTS READILY ACCESSIBLE TO RESIDENTS125/8/2015
HealthCRIMINAL HISTORY RECORD CHECK REQUIRED NOTIFICATION TO DOH PER CESSATION OF EMPLOYMENT125/8/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS225/8/2015
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATION215/8/2015
HealthTHERAPEUTIC DIET PRESCRIBED BY PHYSICIAN215/8/2015
LSCSTAIRS AND SMOKE PROOF TOWERS225/8/2015
LSCHAZARDOUS AREAS - SEPARATION225/8/2015
LSCSMOKE PARTITION CONSTRUCTION225/8/2015
LSCDOORS IN FIRE AND SMOKE PARTITIONS225/8/2015
LSCCORRIDOR DOORS225/8/2015
LSCCORRIDOR WALLS225/8/2015
HealthFACILITY MAINTAINS QA COMMITTEE225/8/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS215/8/2015
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM215/8/2015
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS215/8/2015
LSCFURNISHING AND DECORATIONS225/8/2015
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.216/18/2013
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM216/18/2013
HealthFACILITY IS FREE OF ACCIDENT HAZARDS216/18/2013
HealthRESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS216/18/2013
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING216/18/2013
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS216/18/2013
HealthPASARR REQUIREMENTS FOR MI AND MR216/18/2013
HealthCOMPREHENSIVE ASSESSMENTS216/18/2013
HealthSERVICES PROVIDED MEET PROFESSIONAL STANDARDS216/18/2013
LSCPORTABLE FIRE EXTINGUISHERS227/27/2014
LSCEMERGENCY PLAN227/27/2014
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS227/27/2014
LSCMEDICAL GAS SYSTEM227/27/2014
LSCHAZARDOUS AREAS - SEPARATION227/27/2014
LSCFURNISHING AND DECORATIONS227/27/2014
LSCCOOKING EQUIPMENT227/27/2014
LSCSPRINKLER SYSTEM MAINTENANCE227/27/2014
LSCFIRE DRILLS227/27/2014
HealthDEPARTMENT CRIMINAL HISTORY REVIEW DOH PROPOSED DISAPPROVAL/DIRECT CARE PROHIBITED227/29/2014
HealthCRIMINAL HISTORY RECORD CHECK PROCESS COMPLETED, AUTHORIZED PERSON(S) ASSIGNED & DOH NOTIFIED227/29/2014
HealthCRIMINAL HISTORY RECORD CHECK SUBJECT'S SIGNED INFORMED CONSENT REQUIRED127/29/2014
HealthDEPARTMENT CRIMINAL HISTORY REVIEW FELONY CHARGES/DIRECT CARE & SUPERVISION PROHIBITED227/29/2014
HealthINFECTION CONTROL227/29/2014
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN127/29/2014
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS217/29/2014
HealthRANGE OF MOTION TREATMENT AND SERVICES227/29/2014
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/29/2014
HealthCRIMINAL HISTORY RECORD CHECK REQUIRED NOTIFICATION TO DOH PER CESSATION OF EMPLOYMENT127/29/2014
HealthDEPARTMENT CRIMINAL HISTORY REVIEW AUTHORIZED PERSON(S)/CONFIDENTIALITY OF INFORMATION127/29/2014
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE218/29/2014
LSCSMOKE PARTITION CONSTRUCTION228/29/2014
LSCAUTOMATIC SPRINKLER SYSTEM228/29/2014
LSCCORRIDOR DOORS228/29/2014
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING218/29/2014
LSCHAZARDOUS AREAS - SEPARATION229/21/2013
LSCTESTING OF FIRE ALARM229/21/2013
LSCSPRINKLER SYSTEM MAINTENANCE229/21/2013
LSCCOOKING EQUIPMENT229/21/2013
LSCWASTEBASKETS229/21/2013
LSCMEDICAL GAS SYSTEM229/21/2013
LSCOTHER229/21/2013
LSCSMOKE PARTITION CONSTRUCTION229/21/2013
LSCDOORS IN FIRE AND SMOKE PARTITIONS229/21/2013
HealthDIGNITY219/21/2013
HealthHOUSEKEEPING AND MAINTENANCE SERVICES229/21/2013
HealthFREQUENCY OF ASSESSMENTS - NO LATER THAN 14 DAYS219/21/2013
HealthAPPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES229/21/2013
HealthFACILITY IS FREE OF ACCIDENT HAZARDS219/21/2013
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION229/21/2013
HealthCORRIDORS HAVE FIRMLY SECURED HANDRAILS229/21/2013
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS229/21/2013
LSCCONSTRUCTION TYPE229/21/2013
LSCCORRIDOR WALLS229/21/2013
LSCCORRIDOR DOORS229/21/2013
HealthPROPER CARE & SERVICES FOR RESIDENT W/ NASO-GASTRIC TUBE219/7/2016