Ebenezer Integrated Care & Rehab

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure fasting blood glucose (BG) testing was performed before a meal for 1 of 2 residents (R28) observed who required insulin (medication used to lower blood glucose) based on a sliding scale.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure active interventions were implemented to reduce the risk of falls for 1 of 2 residents (R46) who had repeated falls and was reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to assist in obtaining routine dental services for 1 of 1 resident (R1) reviewed for dental services.

Inspectors wroteBased on interview and document review the facility failed to follow care plan interventions required to provide safe transfers for 1 of 3 residents (R1) who required the use of a walker, gait belt, wheelchair and assist of one staff for transfer assistance. This resulted in actual harm when R1 was ambulated without contact guard assist and a wheelchair behind her, fell, and sustained a fracture of the shoulder. The facility implemented corrective action prior to the start of the survey, so therefore, the deficiency was issued at Past Noncompliance.

Inspectors wroteBased on document review, interview and observation, the facility failed to implement proper infection control when three staff were observed not following enhanced barrier precautions or hand hygiene during direct care for 2 of 4 (R3, R4, R5) residents reviewed for infection prevention.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents with food allergies received the appropriate tray for 1 of 1 resident (R23) reviewed who had a listed anaphylactic reaction (a severe, potentially life threatening allergic response) to ginger. This resulted in an immediate jeopardy (IJ). The IJ began on 12/14/24, when R23 was served a meal tray which included honey ginger chicken and after a few bites experienced an anaphylactic reaction. R23 had an order for epinephrine to be used in the case of an anaphylactic reaction however, R23 was not given the epinephrine. This resulted in R23 requiring transfer to the emergency department for treatment. The administrator and director of nursing (DON) were informed of the IJ on 2/25/25 at 3:46 p.m. The facility implemented corrective action and the IJ was removed on 2/26/25 at 7:20 p.m. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure 4 of 4 residents (R15, R33, R54, R110) were offered and/or provided updated vaccinations for pneumococcal disease and 2 of 5 residents (R33, R110) for influenza in accordance with the Centers for Disease Control (CDC) vaccinations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained during cares for 1 of 2 residents (R35) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 1 of 1 residents (R44) observed with medications at bedside.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential harm was reported to the State Agency (SA) in the required timeframe for 1 of 1 residents (R23) reviewed for anaphylactic reaction.

Inspectors wroteBased on interview and document review, the facility failed to investigate an incident of anaphylactice reaction and need for emergency services for 1 of 1 residents (R23) reviewed for anaphylactic reaction.

Inspectors wroteBased on interview and document review the facility failed to notify the physician of a change in condition for 1 of 1 resident with congestive heart failure (CHF) and a significant weight gain. The facility further failed to ensure appropriate wound care orders were followed for 1 of 1 resident (R35) reviewed for wound care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adaptive equipment was used for 1 of 1 residents reviewed for adaptive equipment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure hand hygiene was completed during incontinent cares for 2 of 4 residents (R31 and R9) who were observed for cares. Furthermore, the facility failed to ensure urine was cleaned in a manner to prevent infection for 1 of 1 residents (R31) reviewed for clean environment.

Inspectors wroteBased on interview and document review, the facility failed to determine causal factors and develop new interventions to prevent falls for 1 of 1 residents (R1) reviewed for falls who had a history of falls and slid out of wheelchair while transporting to appointment.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision when staff allowed a family member to take a resident into the community where R4 subsequently fell and was hospitalized . R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 had impaired cognition with diagnoses including dementia. R4's care plan dated 7/24/24, indicated was an elopement risk due to cognitive ability, and history of wandering during the night and when out in the community. R4 was also a fall risk due to confusion and deconditioning. R4's hospital Discharge summary dated [DATE], included a note by the hospital social worker which indicated there was an open vulnerable adult protection case as of 4/21/24. R4 had been placed in an assisted living and family member (FM)-B removed R4 against medical advice. FM-B also had lost R4 in their apartment building. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were free of significant medication errors for 2 of 3 residents (R2, R3) reviewed for medication errors. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had severely impaired cognition, with diagnoses including dementia and depression. R2's hospital discharge orders dated 6/14/24 included vortioxetine (an antidepressant medication) 5 milligrams (mg) daily for adjustment disorder with mixed anxiety and depressed mood. R2's Medication Administration Records (MAR) for June 2024 and July 2024 lack indication vortioxetine was administered. R2 missed 16 doses in June 2024 and 17 doses in July 2024. R2's Consultant Pharmacist (CP) note dated 7/17/24 indicated the hospital discharge order for vortioxetine could not be located in R2's electronic health record (EHR) Physician Orders list. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure handwashing and appropriate glove usage was implemented for 1 of 1 resident (R9) observed for personal cares.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a pressure relief air mattress was assessed for safe size in relation to the bed frame and grab bars for 1 of 1 residents (R51) reviewed for accidents.

Inspectors wroteBased on interview and document review, the facility failed to ensure the necessary coordination of services between the facility and the hospice agency for 1 of 1 residents (R2) reviewed for hospice services.