Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emerald Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide enough qualified nursing staff or ensure a licensed nurse was in charge on each shift. Staff interviews revealed unclear supervisory coverage and frequent weekend staffing shortages, leading to increased resident assignments for CNAs and LPNs and rushed care.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including improper ware washing temperatures, expired and undated food items, unsanitary handwashing practices, and staff hygiene lapses such as incomplete hair covering and failure to wash hands after contamination. These issues were acknowledged by facility leadership.
Sharps containers in two facility wings were found without required liners or inner boxes, resulting in used sharps, connector tubing, and other discarded items being placed directly in the bottom of the containers. Multiple nurses and the DON confirmed the absence of liners, and the containers were not properly maintained until after surveyor intervention.
A resident who was cognitively intact and required physical assistance for self-care was repeatedly unable to access the call light, as it was found wedged between the bedrail and mattress and hanging out of reach. Multiple observations and interviews confirmed the call light was not accessible, and staff had to adjust the bed to retrieve it, contrary to facility policy.
A resident with a heel wound and an order for offloading heels was repeatedly observed with heels resting on pillows or the mattress, rather than being properly offloaded as required by facility policy and physician orders. Staff interviews revealed a lack of understanding of correct offloading technique, and training materials did not include instruction on this preventative measure.
A resident with significant medical needs was found with a Foley catheter strap that was improperly secured, old, and frayed, contrary to physician orders and facility policy. Staff were unable to identify when the strap was last changed or the correct replacement schedule, and documentation of compliance did not match direct observations. Nursing staff demonstrated a lack of knowledge regarding proper catheter strap care, and the issue was not addressed until after surveyor intervention.
A resident with end stage renal disease and a central venous catheter for hemodialysis did not have an order in place to monitor the dialysis access site for bleeding, bruising, or infection, despite care plan requirements and facility protocols. The necessary order was only entered into the electronic system after the issue was identified during review.
The facility failed to accurately reconcile and document controlled substance medications for multiple residents, including administering medication without a current physician order and inconsistencies between the declining inventory sheets and Medication Administration Records. Nursing staff confirmed that documentation did not consistently match between records, affecting residents with various medical conditions who received controlled medications.
Two residents receiving psychotropic medications were not properly monitored for behavioral symptoms and side effects as required by physician orders and facility policy. Nursing staff documented only check marks or yes/no responses in the MAR and TAR, rather than using the specific behavior, intervention, and outcome codes mandated for tracking. This failure resulted in incomplete monitoring of the residents' responses to their medication regimens.
A resident with severe cognitive impairment and multiple diagnoses did not receive scheduled medications within the required time frame. An LPN administered Divalproex Sodium, Carbidopa-Levodopa, and Tramadol more than an hour after the scheduled time, contrary to facility policy. Both the DON and President of Clinical Practice confirmed the delay, resulting in a significant medication error.
Surveyors found that medication and wound care carts were left unlocked and unattended, containing unsecured prescription and OTC drugs accessible to residents, visitors, and staff. A loose, unidentified pill was discovered in a medication cart, and a bottle of Elder Tonic was found without an opening date or readable expiration date. Staff interviews confirmed that these practices were not in line with facility policy, which requires all medications to be properly labeled and secured.
Two residents with orders for pureed diets, both with dysphagia and complex medical histories, were served foods and snacks that did not meet the required pureed consistency, including lumpy oatmeal and inappropriate snacks. Kitchen observations also revealed pureed menu items with irregular textures, not in compliance with IDDSI standards, potentially affecting multiple residents.
Staff failed to follow CDC and facility infection control protocols for Enhanced Barrier Precautions, including improper cleaning and storage of nebulizer equipment after use, failure to perform hand hygiene before entering an EBP resident's room, and improper handling and disposal of blood glucose monitoring supplies. Leadership staff also did not adhere to hand hygiene requirements or ensure proper disposal of potentially contaminated items.
A diabetic resident experienced a significant health event due to the facility's failure to administer insulin and monitor blood sugar levels as per physician's orders. Despite policies requiring verification of medication orders and blood glucose monitoring, these were not followed, leading to the resident's deteriorating condition and eventual hospital transfer. Communication lapses and lack of documentation contributed to the oversight.
Failure to Maintain Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were always available to meet residents' needs and to have a licensed nurse in charge on each shift. During a facility tour, surveyors found that no specific person was designated as in charge, and nursing staff were unclear about who to contact in case of an emergency. The staff board listed unit supervisors, but none were present on the units during the survey. Interviews with nursing staff revealed uncertainty about supervisory coverage, particularly on weekends. Multiple staff members reported that staffing shortages, especially on weekends, resulted in increased resident assignments for CNAs and LPNs. CNAs described having to care for more residents than usual due to staff call-outs, with some reporting assignments of 12 or more residents. An LPN reported being responsible for 30 residents at times. Staff consistently indicated that these staffing patterns led to rushed care and difficulty meeting residents' needs. The DON acknowledged awareness of low weekend staffing and recent management changes.
Deficiencies in Food Safety, Sanitation, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, preparation, and sanitation practices during two visits to the facility's main kitchen. The mechanical ware washing machine failed to reach the required 160°F for hot water sanitizing, and residue was found on its spray arms and nozzles. The Food Service Director acknowledged that the machine defaults to chemical sanitizing when hot water is insufficient. During meal service, a staff member poured coffee into the only handwashing sink in the dining room, and another staff member washed her hands in the same sink without cleaning it first. Single-serve condiments and disposable utensils were stored directly under a pest control device with a glue board. Additional observations included clogged and soiled air conditioning filters, a refrigerator operating at 59°F (above the required 41°F), expired food items, undated raw ground beef, and food containers with no expiration dates. Cooking pots were coated with a black residue, and several light bulbs in the hood area were not working. The dry storage area contained expired thickened liquids, and the Food Service Director was observed with a hairnet that did not fully cover her hair. The Director also incorrectly calibrated a thermometer for food temperature checks. Further observations included a dietary aide without a facial hairnet, a cook who donned new gloves without washing hands after touching contaminated surfaces, and a staff member plating food while wearing large loop earrings. These findings were acknowledged by the Food Service Director and the Administrator during interviews. The report documents failures to adhere to professional standards for food safety and sanitation, as well as lapses in staff hygiene and food handling protocols.
Failure to Provide Liners for Sharps Containers in Resident Rooms
Penalty
Summary
The facility failed to provide liners for sharps containers in two out of four wings, as observed during resident room tours. Multiple wall-mounted sharps containers in resident rooms were found to contain used sharps, connector tubing, and other discarded items directly in the bottom of the containers, without any red container receptacle liners or inner boxes to house the waste. These observations were documented with photographic evidence and occurred in both the east and south wings, including the newer section of the 400 South wing. The facility's policy requires that regulated medical waste, including contaminated sharps, be managed according to federal, state, and local regulations, and that sharps containers be closable, puncture-resistant, leak-proof, and properly maintained. Interviews with several nursing staff, including RNs, LPNs, and the DON, confirmed that the sharps containers in resident rooms did not have liners or inner boxes as required. The containers were not emptied, cleaned, lined, or properly maintained until after surveyor intervention. The deficiency was identified through direct observation and staff interviews, with no mention of specific residents' medical histories or conditions at the time of the deficiency.
Call Light Accessibility Not Ensured for Resident Requiring Assistance
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident who required physical assistance for self-care needs. According to the facility's policy, staff are required to ensure that the call light is accessible to residents during every interaction in the resident's room. However, during multiple observations and interviews, it was found that the call light for this resident was not accessible. Specifically, the call light cord was wedged between the bedrail and the bottom of the mattress, with the bulb hanging close to the floor and out of the resident's reach. Photographic evidence was obtained during these observations. The resident, who was cognitively intact as indicated by a BIMS score of 14, reported on several occasions that he could not reach the call light when he needed assistance, including when he needed help to get changed. Staff confirmed the call light was not accessible and had to adjust the bed to retrieve the call bell cord. These findings were based on policy review, observation, interview, and record review.
Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow its own policy and physician orders regarding the prevention and treatment of pressure ulcers for a resident with a documented heel wound. The facility's wound care policy required the use of pressure-relieving surfaces and offloading of heels as preventative measures. However, review of staff training materials revealed that Certified Nursing Assistants (CNAs) were not trained on the specific policy requirements for utilizing pressure-relieving surfaces and floating heels. The resident in question was cognitively intact but required physical assistance for self-care and had a care plan and physician order in place to offload heels with a pillow while in bed. Multiple observations over several days showed that the resident's heels were consistently not offloaded as required. Instead, the heels were found resting directly on pillows or the mattress, rather than being suspended off the surface to relieve pressure. Interviews with staff confirmed a lack of understanding of proper offloading technique, as one CNA acknowledged that the resident's heels were not appropriately offloaded and that the pillow should have been positioned under the calf to keep the heel off the edge. Photographic evidence was obtained to document these findings.
Failure to Properly Secure and Maintain Foley Catheter Strap
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including Alzheimer's Disease, Chronic Kidney Disease, and Diabetes Mellitus, was observed with a Foley catheter strap that was not properly secured as per physician orders and facility policy. During peri and Foley catheter care, surveyors observed that the catheter strap was old, frayed, discolored, and triple wrapped around the resident's leg, causing it to slip and not remain anchored in place. Staff present during the procedure were unable to state when the strap was last changed or how often it should be replaced, and acknowledged that the strap was not fitting properly. Further interviews with nursing staff revealed a lack of knowledge regarding the proper placement and replacement schedule for the catheter strap. Record review showed that staff had documented compliance with physician orders to monitor and keep the leg strap on, but direct observation contradicted these records, as the strap was not properly secured or changed until after surveyor intervention. The facility's policy required catheter care every shift and as needed, with monitoring and documentation, but these procedures were not followed. The Director of Nursing confirmed that the catheter strap should be routinely monitored, positioned, and changed according to protocol.
Failure to Monitor Dialysis Catheter Site
Penalty
Summary
A deficiency was identified when the facility failed to monitor the central venous catheter (CVC) access site for a resident who required dialysis. The resident, who had diagnoses of end stage renal disease and anemia and was dependent on renal dialysis, was readmitted to the facility with a right upper chest catheter for hemodialysis. Although the care plan documented the need to check the access site daily for signs and symptoms of infection, pain, or bleeding, a review of the physician's orders did not show an order to monitor the CVC dialysis site for bleeding, bruising, or signs of infection. Interviews with the DON and a registered nurse confirmed that monitoring the CVC access site is part of facility protocol and should be documented in the electronic system. However, a chart review revealed that the order to assess the hemodialysis site for bruising, bleeding, or symptoms of infection was not entered into the electronic system until after the surveyor's inquiry, indicating that the required monitoring was not in place prior to that time.
Controlled Substance Documentation and Physician Order Deficiencies
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled substance medications for four out of nine sampled residents, and did not obtain a physician order for a controlled medication for one resident. For one resident with dementia, schizoaffective disorder, and major depressive disorder, Lorazepam was administered after the physician's order had expired, and there was no current order in place. Additionally, discrepancies were found between the declining inventory sheet (DIS) and the Medication Administration Record (MAR), with some administrations recorded on the DIS but not on the MAR, and vice versa. For another resident with a history of nasal bone fracture and injury as a pedestrian, Percocet was administered with inconsistencies between the DIS and MAR, including documentation of administration at times that did not match between the two records. Similarly, a resident with osteomyelitis had Oxycodone administrations recorded on the DIS that did not correspond with entries on the MAR, and vice versa. These discrepancies were confirmed during interviews with nursing staff, who acknowledged that the DIS and MAR should correlate but did not in these cases. A fourth resident with cerebral infarction, spinal stenosis, and colon cancer also had inconsistencies in the documentation of Oxycodone administration. The narcotic sheet indicated a dose was removed and signed out by a nurse, but this administration was not documented on the MAR. Staff interviews confirmed that every removal of a controlled substance should be documented on both the narcotic sheet and the MAR with matching details, but this was not consistently done.
Failure to Monitor and Document Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of residents receiving psychotropic medications, as required by physician orders and facility policy. For one resident with diagnoses including Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety, the care plan and physician orders specified the use of behavior codes to track symptoms and side effects related to antipsychotic therapy. However, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that behaviors were either not documented or only marked as '0' for no behaviors, without use of the required codes. Nursing staff confirmed that the electronic system only allowed for a yes/no response, and the Director of Nursing acknowledged that documentation was not being completed according to the specific orders. For another resident with multiple diagnoses, including dementia, psychotic disturbance, and anxiety, physician orders required the use of specific behavior, intervention, and outcome codes to monitor the effects of several psychotropic medications. Review of the MAR showed that, on multiple occasions, only check marks and nurses' initials were recorded, with no behavior codes or appropriate intervention codes documented. In one instance, an intervention code not listed in the physician order was used. The required outcome codes were also not documented, with only check marks and initials present for several days. Interviews with nursing staff indicated that they believed they were monitoring and documenting behaviors as required, but the documentation did not align with the specific codes outlined in the physician orders. The Medical Director noted the importance of monitoring behaviors and side effects for residents on multiple psychotropic medications and indicated that medication adjustments might be necessary based on such monitoring. The lack of proper documentation and monitoring represents a failure to ensure that residents' drug regimens are free from unnecessary drugs and that their mental, physical, and psychosocial well-being is being appropriately managed.
Significant Medication Error Due to Late Administration
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's Disease, dementia, and major depressive disorder, did not receive scheduled medications within the facility's defined time frame. The resident, who had severely impaired cognition and was under hospice care, was prescribed several medications to be administered at specific times. During a medication administration observation, an LPN was found preparing and administering the resident's 9:00 AM medications significantly later than scheduled, with the actual administration occurring at 11:05 AM. The facility's policy and staff interviews confirmed that medications are to be given within one hour before or after the scheduled time, which was not followed in this instance. The medications involved included Divalproex Sodium, Carbidopa-Levodopa, and Tramadol, all of which were administered outside the acceptable time window. The LPN acknowledged the delay, and the medication administration system indicated the late administration with a pink color code. Both the DON and the President of Clinical Practice confirmed the facility's expectations for timely medication administration, and verified that the medications were given late. This failure to administer medications within the required time frame constituted a significant medication error for the resident.
Failure to Secure and Properly Label Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. During an observational tour, an unlocked wound care cart was found on the East wing containing various resident prescription and over-the-counter topical medications, as well as wound care supplies. The cart was unattended and accessible to residents, visitors, and staff. A registered nurse admitted to being the last to use the cart and acknowledged it should have been locked. Additionally, an unlocked medication administration cart was observed on the East wing, containing twenty-four active prescription and OTC medications, all unsecured and unattended. Both a licensed practical nurse and a registered nurse/unit manager confirmed that the cart should have been locked and not left unattended. On a separate occasion, a medication cart on the Center wing was found to contain a loose, unidentified pill in one of its drawers, which staff acknowledged should not have been present and should have been secured. Further, a medication storage observation revealed a bottle of Elder Tonic in a medication cart without an opening date label and with an unreadable expiration date. The LPN present could not provide the required information and stated that nurses are supposed to check for expiration and opening dates during shift changes. The DON confirmed that facility policy requires all medications to be properly labeled and secured at all times.
Failure to Provide Proper Pureed Diet Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for residents requiring pureed diets. One resident with severe cognitive impairment, multiple diagnoses including dysphagia, and a care plan specifying a pureed diet with nectar thickened liquids, was observed with pre-packaged snacks on their overbed table that were not consistent with their prescribed diet. The Speech Language Pathologist (SLP) confirmed that these snacks were not appropriate for a pureed diet and identified risks associated with not following the prescribed diet. Another resident, cognitively intact but with diagnoses including dysphagia and a care plan for a pureed, nectar thickened, renal diet, was observed with oatmeal that contained lumps and was not smooth, contrary to the requirements for a pureed diet. The SLP reviewed a photo of the oatmeal and confirmed it did not meet the pureed diet standard. The resident was unable to be interviewed during the observation as they fell asleep during the meal. Additionally, during a kitchen observation, pureed foods such as seasoned spinach and chorizo and cheddar quiche were found to have irregular textures, including lumps and fibrous strands, and did not meet the IDDSI standard for pureed foods. The Food Service Director acknowledged these findings. The facility's policy requires pureed foods to be smooth and require no chewing, but this standard was not met for at least two residents and in the main kitchen, potentially affecting 22 residents.
Failure to Follow Infection Control Protocols for EBP and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to CDC guidelines and its own policies regarding infection prevention and control, specifically in the application of Enhanced Barrier Precautions (EBP) and the handling of medical equipment. In one instance, a resident with a history of cerebral infarction, hemiplegia, diabetes, and pleural effusion received nebulizer therapy from an LPN who, after administering the treatment, placed the used nebulizer mask back into a plastic bag without cleaning or disinfecting it as required by facility policy. The LPN did not follow the procedure of rinsing, drying, and storing the equipment properly after use, and did not clean the equipment even after being observed for an extended period post-treatment. Another deficiency involved a resident with partial arterial traumatic amputation, diabetes, peripheral vascular disease, immunodeficiency, and a local skin infection, who was under EBP. During a blood glucose monitoring procedure, an LPN failed to perform hand hygiene before entering the resident's room, placed uncleaned supplies on the resident's meal table without disinfecting it, and did not allow the alcohol to dry before pricking the resident's finger. The LPN also brought a whole container of glucose strips into the room, used it during the procedure, and then returned it to the medication cart without disinfecting it, contrary to both CDC guidelines and facility policy. The LPN also failed to disinfect the resident's table after the procedure and did not discard supplies that should not be reused. Additionally, the Assistant Director of Nursing (ADON) entered the EBP resident's room without performing hand hygiene, despite clear signage indicating EBP protocols. The ADON admitted to not following hand hygiene protocols, even though he was aware of the EBP status. The Infection Preventionist confirmed that reusable supplies should not be brought into EBP rooms and that any such items must be discarded if they enter the room. The Director of Nursing (DON) was informed of the improper handling of the glucose strip container but did not take immediate corrective action. These actions and inactions demonstrate a failure to implement and follow infection prevention and control protocols as required.
Failure to Administer Insulin and Monitor Blood Sugar Levels
Penalty
Summary
The facility failed to follow physician's orders for administering insulin and monitoring blood sugar levels for a diabetic resident, leading to a significant health event. The resident, who had a history of Type II Diabetes Mellitus, was admitted with other diagnoses including a fracture and hypertension. Despite having intact cognition, the resident experienced an elevated blood sugar level of 499 mg/dL, which was not properly managed according to the physician's orders. The facility's policies required verification of medication orders and blood glucose monitoring, but these were not adhered to in this case. On multiple occasions, the resident's blood sugar levels were not recorded, and insulin doses were not administered as ordered. Specifically, there was no documentation of insulin administration for several prescribed doses, including long-acting insulin in the morning and at bedtime, as well as fast-acting insulin before meals. The lack of documentation and administration of these medications contributed to the resident's deteriorating condition, which included symptoms such as sweating, altered mental status, and somnolence, raising concerns for diabetic ketoacidosis. Interviews with staff revealed communication lapses and a failure to document new orders or changes in the resident's condition. The LPN responsible for the resident's care did not document the administration of insulin or the resident's blood sugar levels, and there was no evidence of communication with the physician regarding the elevated blood sugar levels. The Director of Nursing acknowledged that the physician's orders were not followed, which ultimately led to the resident being transferred to the hospital for further evaluation and management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 345 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kindred Hospital South Florida Hollywood | 2.6 mi | ★★★★★ | 0 | 0 |
| Golfcrest Nursing Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Aventura | 3.2 mi | ★★★★★ | 0 | 0 |
| Sierra Lakes Nursing & Rehabilitation Center | 3.4 mi | ★★★★★ | 11 | 1 |
| Westlake Nursing And Rehab Center | 3.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Emerald Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.