Ebenezer Integrated Care & Rehab

In the surveyor’s words

From the most serious findings on record at Ebenezer Integrated Care & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF806Feb 27, 2025

  Based 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. […]

• Actual harm, isolatedF689Dec 5, 2025

  Based 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.Findings include:R1's face sheet dated 12/4/25, indicated R1 had diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following unspecified cerebrovascular disease affecting right dominant side,… […]

• No harm, potential for more than minimal, patternF883Feb 27, 2025

  Based 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. Findings include: R15 R15's discharge Minimum Data Set (MDS) dated [DATE], indicated R15 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of diabetes which puts him at higher risk for pneumococcal diseases. […]

• No harm, potential for more than minimal, patternF550Apr 22, 2021

  Based on observation, interview, and document review, the facility failed to ensure resident's rights to privacy for 5 of 5 (R2, R3, R14, R50, and R80) residents when staff walked into their rooms without receiving permission and failed to conceal a urinary drainage bag from public view for 1 of 6 residents (R346) reviewed for dignity. Findings include: R2's Admission Record dated 4/22/21, indicated R2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact and independent with activities of daily living (ADLs). R2's care plan dated 1/18/21, did not address the resident right of dignity/privacy. R3's Admission Record dated 4/22/21, indicated R3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF684Apr 1, 2026

  Based 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.Findings include:R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact, dependent on staff for most activities of daily living (ADLs), required insulin injections every day of the seven-day lookback period and had a diagnosis of diabetes mellitus (disease that leads to elevated blood glucose). R28's care plan revised 3/12/26, indicated R28 had diabetes mellitus type 2 and instructed staff to monitor blood sugars per provider order and as needed. […]