Eben Ezer Lutheran Care Center

In the surveyor’s words

From the most serious findings on record at Eben Ezer Lutheran Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 2, 2023

  Based on record review and staff interviews, the facility failed to ensure two (#58 and #48) of four residents out of 25 sample residents reviewed for abuse were kept free from abuse. Resident #48, with a diagnosis of dementia, had known aggressive and impulsive behaviors to other residents. Resident #48 was walking down the hallway and Resident #58 was walking towards her. Resident #48 pushed Resident #58 and she lost her balance. Resident #58 fell to the ground and fractured her right hip. The facility failed to protect Resident #58 from Resident #48's aggressive behaviors. […]

• Actual harm, isolatedF689Mar 2, 2023

  Based on observations, record review and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#29 and #4) of nine residents reviewed for accidents/hazards out of 25 sample residents. Resident #29 had three falls since admission, had severe cognitive impairment, used a wheelchair for ambulation, and required supervision with transfers. Between 9/21/22 and 11/27/22, Resident #29 experienced three falls: one witnessed and two unwitnessed. After the 11/18/22 fall, the resident sustained a left hip fracture. On admission the resident fall risk was 15. […]

• Actual harm, isolatedF689Oct 6, 2022

  Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) out of three sample residents. Resident #1 was admitted to the facility on [DATE] and was at risk for falls due to weakness, impaired balance and dementia. The facility failed to properly transfer the resident to prevent injury on 7/19/22, which resulted in displaced left femur (hip) bone fracture, hospitalization and surgery. The resident was assessed by staff after complaints of left knee and hip pain and was noted to have edema of the left knee and thigh. […]

• Actual harm, isolatedF689Nov 18, 2021

  Based on observations, interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#54 and #2) of six residents reviewed for falls, out of 32 sample residents. Specifically, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #54 and Resident #2, and falls that resulted in multiple injuries to Resident #54. The lack of supervision and effective interventions resulted in seven unwitnessed falls and one witnessed fall since 1/5/21 that caused multiple fractures and injuries to Resident #54's pelvis, right wrist, left hip, left elbow, left hand and head that caused her extreme pain, required trips to the emergency department and resulted in… […]

• Actual harm, isolatedF758Nov 18, 2021

  Based on observation, record review and interviews the facility failed to ensure that one (#66) of five residents reviewed out of 32 sample residents were free from unnecessary [CONDITION(S)] medications. The facility's failed to document and evaluate the effectiveness of non pharmacological behavioral interventions for Resident #66, a person with dementia; alternatively [CONDITION(S)] medications were prescribed which lead to over-sedation of the resident. The resident resided in a secured memory care unit with other residents and had an alarm system on her door to alert staff when the door opened. […]