Deficiency Records for Ebony Lake Nursing and Rehabilitation Center
Updated as of October 01, 2022
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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-01 | 2022-04-23 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-01 | 2022-04-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-01 | 2022-04-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-16 | 2022-03-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-16 | 2022-03-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-16 | 2022-03-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-22 | 2020-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-22 | 2020-10-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-10-21 | 2020-10-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-10-21 | 2020-10-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-08-14 | 2020-08-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-08-14 | 2020-08-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-07-23 | 2020-07-24 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-05-14 | 2020-05-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-05-14 | 2020-05-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-05-14 | 2020-05-18 | Y |
| 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 | 2020-05-14 | 2020-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-15 | 2020-04-17 | Y |
| 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 |
| 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 |
