Deficiency Records for Ebony Lake Nursing and Rehabilitation Center
Updated as of October 01, 2020
This is not the most recent data for Ebony Lake Nursing and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Ebony Lake Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-25 | 2020-03-13 | Y |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-02-25 | 2020-03-13 | Y |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-21 | 2019-08-22 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-28 | 2019-07-03 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-28 | 2019-07-03 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-28 | 2019-07-03 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-02 | 2019-05-14 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-05-14 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-02 | 2019-05-14 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-02 | 2019-05-14 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-02 | 2019-05-14 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-02 | 2019-05-14 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-02 | 2019-05-14 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-02 | 2019-05-14 | N |
Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-05-14 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-05-02 | 2019-05-14 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-05-01 | 2019-05-03 | N |
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-10-25 | 2018-10-26 | Y |
Ensure each resident receives an accurate assessment. | Health | 2018-10-25 | 2018-10-26 | Y |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-25 | 2018-10-26 | Y |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-25 | 2018-10-26 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-25 | 2018-10-26 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-04 | 2018-09-05 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-04 | 2018-09-05 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-21 | 2018-04-30 | N |
Provide properly protected cooking facilities. | Fire Safety | 2018-03-21 | 2018-04-30 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-21 | 2018-04-30 | N |
Be properly staffed | Fire Safety | 2018-03-21 | 2018-04-30 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-21 | 2018-04-30 | N |
Keep residents' personal and medical records private and confidential. | Health | 2018-03-22 | 2018-04-30 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-22 | 2018-04-30 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-22 | 2018-04-30 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-22 | 2018-04-30 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-22 | 2018-04-30 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-03-22 | 2018-04-30 | N |
Observe each nurse aide's job performance and give regular training. | Health | 2018-03-22 | 2018-04-30 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-22 | 2018-04-30 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-22 | 2018-04-30 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-22 | 2018-04-30 | N |
Ensure that residents are free from significant medication errors. | Health | 2018-03-22 | 2018-04-30 | N |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-03-22 | 2018-04-30 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-22 | 2018-04-30 | N |
Provide and implement an infection prevention and control program. | Health | 2018-03-22 | 2018-04-30 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-21 | 2017-12-22 | Y |
Try to resolve each resident's complaints quickly. | Health | 2017-11-16 | 2017-11-19 | Y |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-11-16 | 2017-11-19 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2017-10-20 | 2017-11-03 | Y |
Keep residents' personal and medical records private and confidential. | Health | 2017-09-29 | 2017-10-04 | Y |
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-18 | 2017-09-09 | Y |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-08-18 | 2017-09-09 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-18 | 2017-09-09 | Y |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-28 | 2017-08-11 | Y |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-30 | 2017-07-17 | Y |
Provide housekeeping and maintenance services. | Health | 2017-06-08 | 2017-06-26 | Y |
Provide timely notification to the resident before transfer or discharge. | Health | 2017-03-02 | 2017-03-29 | N |
Tell the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2017-03-02 | 2017-03-29 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-02 | 2017-03-29 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-03-02 | 2017-03-29 | N |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-02 | 2017-03-29 | N |
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-03-02 | 2017-03-29 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-02 | 2017-03-29 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-02 | 2017-03-29 | N |
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-02 | 2017-03-29 | N |