The Emeralds At Grand Rapids Llc
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
names of the residents and correlating medications identified in the report.During interview on 12/18/25 at 11:31 a.m., the director of nursing stated the process for medication destruction was to perform a weekly inventory. The DON stated when she destroyed medications, she and another nurse brought the medications to the safe and destroyed them. The DON stated she kept a destruction log of all the medications destroyed. The DON stated the disposal system had a padlock and only herself and the pharmacy had keys.During interview on 12/18/25, at 11:35 a.m., the administrator stated the facility had received a call from the Sherrif on a Saturday that a former employee was in possession of medications from prior residents of the facility. The administrator stated the former employee had not worked at the facility since May of 2025. The administrator stated the facility had done an internal audit and were unable to locate destruction logs. The DON, present during the interview stated the pharmacy had to get the medications out of the safe but they did not reconcile the medications with facility staff. During interview on 12/18/25 at 1:03 p.m., trained medication aide (TMA)-A stated she had signed off on the narcotic log that medications had been destroyed and would go with the DON to place them in the box. TMA-A said there had been times when she was very busy and had signed off in the narcotic book without observing the destruction.During interview on 12/18/25 at 2:41 p.m., the DON said in order to pull the medication destruction box, both the facility and the pharmacy keys were required. The DON stated when she had destroyed medications with the former director of nursing, she had watched her place the medications into
the box. The DON said there was no way the former DON could have gotten the medications back out of
the box. Facility policy Disposal Medication and Medication Related Supplies dated May 2022, indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications.When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container.
It is destroyed in the presence of [two licensed nurses], and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason.All controlled substances remaining in the facility after a resident has been discharged , or the order isdiscontinued, are disposed of:1) In the facility by the [administrator], director of nursing and/or consultant pharmacist (or othersas allowed by state law); OR2) By returning to the Drug Enforcement Administration (DEA); OR3) By retaining for destruction by an agent of the DEA; OR4) By sending to the appropriate state agency or pharmacy as directed by state laws, regulations,and/or the DEA.When controlled medications are destroyed at the facility, licensed staff as allowed by state law willwitness the destruction and ensure that the following information is entered on the individual controlledsubstance accountability record/book:1) Date of destruction.2) Resident's name.3) Name and strength of medication.4) Prescription number.
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The Emeralds at Grand Rapids LLC in GRAND RAPIDS, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GRAND RAPIDS, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Emeralds at Grand Rapids LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.