Ebony Lake Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for change in condition. LVN D failed to identify a significant change in condition experienced by Resident #1 on 4/10/26. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.

Inspectors wroteBased on observation, interview, and interview the facility failed to develop and implement a comprehensive care plan for each resident that included measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 (Resident #1) of 3 residents. The facility failed to develop a care plan to address Resident #1's the use of a mechanical lift during transfer. This failure places the resident at risk of inappropriate transfers with resulting injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being repositioned in bed for 1 (Resident #1) of 3 residents reviewed for accidents and hazards, CNA E failed to use two staff assist as required by Resident #1's care plan for bed mobility Resident #1 sustained a fall, on 4/9/26. This deficient practice has the potential to affect all residents in the building who require assistance with bed mobility by 2 staff members by causing falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 1 (Resident's #1) CNA A failed to wash her hands or use hand sanitizer between change of gloves change while providing perineal care for Resident #1. The failure could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #2) of 7 residents reviewed for Advance Directives. The facility failed to ensure Resident #2's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature for Resident #2. This failure could affect all residents who have implemented advance directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #3) of 7 residents reviewed for medical records accuracy, in that: 1. The facility failed to provide physician or NP documentation in the electronic medical record for Resident #1 from 01/01/2026 through 03/24/2026. 1. The facility failed to provide physician or NP documentation in the electronic medical record for Resident #3 from 02/21/2026 through 03/24/2026. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (400 hallway) of 5 medication carts. The facility failed to ensure that the nurses medication cart for the 400 hall was secured by a lock when it was left unattended by GVN A. These failures could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 3 of 4 medication carts (300 Hall Nurse Cart, Blue Med-Aide Cart, and 200 Hall Nurse Cart) reviewed for labeling and storage. The facility failed to ensure the 300 Hall Nurse Cart belonging to LVN-E was free from personal items. The facility failed to ensure the Blue Med-Aide Cart belonging to Medication Aide-D was free from medications without labels. The facility also failed to ensure the 200 Hall Nurse Cart belonging to LVN-C was locked and secured. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, distribute and sever food in accordance with professional standards for food service safety for 1 of 2 refrigerators (1 of 2 kitchen refrigerator) and 3 of the 3 steam table wells reviewed for storage, preparation, and sanitation. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was labeled and dated. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was sealed properly. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was not expired and spoiled. -The facility failed to ensure 3 of 3 the steam table wells were cleaned. -These failures could place residents at risk of complications from food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of six residents (Resident #23) reviewed for medication errors. The facility failed to ensure Resident #23's blood pressure/pulse altering medications (Amlodipine) was not given outside of the blood pressure parameters during the month of December 2025 per the physician's orders. This failure could place residents at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease processes, and potential hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the meals served reflected the culture and ethnic needs of the resident population in accordance with established national guidelines for all residents when the facility failed to ensure menus were accommodated for all residents for 1 of 3 meals observed. The facility failed to reflect, based on a facility's reasonable efforts, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of six Residents (Resident #88) that were reviewed for infection control and transmission-based precautions policies and practices. The facility failed to ensure the WCN performed hand hygiene after removing gloves while prepping Resident #88's supplies for wound care. This failure could place residents at risk of infection through cross contamination of pathogens and infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 12 residents' reviewed for residents' rights. The facility failed to ensure CMA A locked the medication cart computer screen and left an unidentified resident's picture exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 2 reviewed for accuracy and completeness of clinical records. The facility failed to accurately document in Resident #1's electronic medical record when she had her staples removed. This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #2), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #2's physician ordered Cozaar was held when her blood pressure was found to be out of parameters for administration. This failure could place residents at risk for not receiving medication as ordered.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for medical records accuracy, in that: Resident #2's April 2025 MAR documentation was inaccurate. Staff signed off on physician ordered medication as administered when it was not. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Resident #34) reviewed for comprehensive care plans. Resident #34's comprehensive care plan was not revised after the code status was changed from DNR to a Full Code. This failure could place residents at risk for inadequate care during an emergent situation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #8) of 6 residents reviewed for respiratory care in that: 1, The facility failed to date and/or change the suction canister, suction tubing, and suction device for Resident #8. 2. The facility failed to ensure there was a physician order to change the suction canister, suction tubing, suction device, oxygen tubing, and nebulizer for Resident #8. These failures could place residents that had a need for oxygen or suctioning at risk of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook E) of 3 kitchen staff reviewed for storage, preparation and sanitation. The facility failed to ensure [NAME] E performed hand hygiene for at least 20 seconds while prepping resident meals for breakfast. This failure could place residents at risk for cross-contamination and infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #31) of 6 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document in the treatment administration record when Resident #31 received supplemental oxygen. This failure could result in residents' records not accurately reflecting the administration of treatments and could result in further error and a decline in heath.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records. The facility did not document nursing assessments, communications with nurse practitioner, orders received, or health progress for R #1's change (constipation) on 10/17/23. R #1 was diagnosed with constipation and a UTI. This failure could place residents at risk of not having an accurate representation of their medical condition and not receiving needed services.

Inspectors wroteBased on observations and interview the facility failed to provide privacy for 2 of 8 residents observed for medication administration (Residents #61 and Resident #50) in that: -Resident #61's room door was left open during medication administration offering no privacy to resident. -Resident #50's room door was left open during medication administration offering no privacy to resident. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment, for 1 (Resident #3) of 1 resident observed for safe, comfortable, homelike environment. The facility failed to remove nail orange stick from Resident #3's bed after nail care had been attempted. These failures could place residents at risk of not being in a safe environment placing them at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 (Resident #3) of 16 residents reviewed for indwelling urinary catheters. The facility failed to ensure Resident #3's urinary catheter leg strap was applied. This failure could affect resident with an indwelling urinary catheter and place them at risk of tugging or pulling out the catheter.