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Inspection visit

Health inspection

Emerald Nursing & Rehab Legacy Pointe llcCMS #28523913 citations on this visit
13 citations recorded

Citations

13 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0698GeneralS&S Dpotential for harm

    F698 - Dialysis

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0561GeneralS&S Dpotential for harm

    F561 - Self-determination

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0628GeneralS&S Dpotential for harm

    F628 - Documentation

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0679GeneralS&S Dpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0791GeneralS&S Dpotential for harm

    F791 - Dental Services

    Provide or obtain dental services for each resident.

  • 0803GeneralS&S Epotential for harm

    F803 - Menus and nutritional adequacy

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the July 22, 2025 survey of Emerald Nursing & Rehab Legacy Pointe llc?

This was a inspection survey of Emerald Nursing & Rehab Legacy Pointe llc on July 22, 2025. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Emerald Nursing & Rehab Legacy Pointe llc on July 22, 2025?

Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate dialysis care/services for a resident who requires such services."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.