Inspection Reports for Ebony Lake Nursing and Rehabilitation Center

The facility failed to ensure residents' personal and medical records were kept private and confidential, specifically failing to lock medication cart computer screens exposing resident information. Additionally, the facility failed to maintain complete and accurate clinical records, notably lacking documentation of staple removal for a resident, which could risk inadequate nursing care.

The complaint involved inaccurate medication administration and documentation for Resident #2, where staff administered Cozaar despite blood pressure readings being out of parameters and signed the MAR incorrectly. The complaint was substantiated based on interviews and record reviews.

The facility failed to ensure that Resident #2's medication (Cozaar) was held when blood pressure readings were out of the prescribed parameters, resulting in medication being administered despite contraindications. Staff incorrectly documented medication administration on the MAR, and failed to notify nurses when medications were held. The facility policy and staff training on medication administration parameters were not properly followed.

The facility failed to ensure that suction canisters, suction tubing, suction devices, oxygen tubing, and nebulizer supplies were properly dated, changed, and ordered by a physician for Resident #8, potentially placing residents at risk of infection. Observations and interviews confirmed that suction supplies were not changed weekly as required and lacked physician orders for changes.

The complaint investigation focused on issues including failure to update care plans after status changes, inadequate respiratory care and infection control, improper hand hygiene in food preparation, and incomplete clinical documentation of oxygen therapy.

The facility failed to update a resident's care plan to reflect a change in code status, failed to provide appropriate respiratory care including timely changing of suction supplies, failed to ensure proper hand hygiene by kitchen staff, and failed to accurately document oxygen administration in clinical records. These deficiencies posed risks of inadequate emergency care, infection, cross-contamination, and inaccurate treatment records.

The complaint investigation found that Resident #1's medical records lacked documentation of a change in condition (constipation) on 10/17/23, including missing progress notes and change of condition forms. Staff interviews revealed inconsistent documentation practices, and the facility provided in-service training to address these issues.

The facility failed to document nursing assessments, communications with the nurse practitioner, orders received, and health progress notes for Resident #1's change in condition on 10/17/23. Interviews with nursing staff confirmed that vital signs and changes in condition were not consistently documented, despite orders being carried out. The facility acknowledged the documentation failure and provided additional training to staff.

The complaint investigation found substantiated issues regarding privacy violations during medication administration for Residents #50 and #61, unsafe environment due to a nail stick left in Resident #3's bed, and improper catheter care for Resident #3.

The facility failed to provide privacy during medication administration for two residents, left a nail stick in a resident's bed posing a safety risk, and did not ensure proper application of a urinary catheter leg strap for one resident, potentially placing residents at risk of harm.

The complaint investigation revealed substantiated deficiencies related to pressure ulcer care, medication regimen review, and infection control practices. Specific failures included improper wound care techniques, lack of physician response to pharmacist recommendations, and inadequate hand hygiene by staff.

The facility failed to provide appropriate wound care for residents with pressure ulcers, did not ensure physician response to pharmacist recommendations for medication adjustments, and lacked proper infection control practices including hand hygiene and wound care procedures. These failures posed risks of infection, improper medication use, and deterioration of residents' conditions.