Ebenezer Ridges Geriatric Care Center

In the surveyor’s words

From the most serious findings on record at Ebenezer Ridges Geriatric Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Nov 5, 2021

  Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines were followed to prevent or minimize the transmission of COVID-19 for 1 of 7 resident (R6) who was not immediately placed on transmission-based precautions (TBP) after exhibiting signs and symptoms of COVID-19. R6 later died from COVID. This had the ability to affect all 41 residents residing on the 3rd floor at the time R6 resided in the facility as well as any staff working on the unit who provided cares. The IJ began on [DATE] when R6 noted to staff he had a productive cough. Staff failed to immediately implement CDC guidelines for TBP. R6 tested positive for COVID-19 on [DATE]. […]

• Immediate jeopardy, patternF678Apr 8, 2021

  Based on interview and document review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with Provider Orders for Life-Sustaining Treatment (POLST) for 1 of 1 resident (R1), found without a pulse or respirations. CPR was not immediately initiated and R1 died . This deficient practice had the potential to affect 42 of 106 residents who resided at the facility who had orders for CPR to be performed. The Immediate Jeopardy (IJ) began on [DATE], at 4:32 p.m. when R1 was found without a pulse or respirations, and CPR was not immediately initiated. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 12:53 p.m. […]

• Immediate jeopardy, isolatedF689Aug 5, 2026

  Based on interview and document review, the facility failed to collaborate care with hospice agency to ensure proper training and safety with mechanical lift transfers, when hospice aide (H)-A and facility registered nurse (RN)-A did not follow manufacturer instruction in properly securing the lift sling for 1 of 1 resident (R1). This resulted in an immediate Jeopardy (IJ) when R1 fell from the lift and sustained a fracture. The IJ began on 7/30/26, at 7:30 am. when H-A hooked up the Hoyer sling to get R1 ready for shower and requested RN-A to assist with transfer to the shower chair. H-A did not cross the leg straps and during the transfer R1 slid out of the Hoyer sling and hit her leg on the bed while RN-A was attempting to lower R1 to the floor. […]

• Immediate jeopardy, isolatedF689Oct 3, 2022

  Based on interview and record review, the facility failed to ensure one of three residents (R2) was free from accidents and received adequate assistance when R2 was transferred by two staff in a mechanical lift with the wrong size and type of sling. R2 fell through the sling to the floor. As a result of the identified noncompliance, immediate Jeopardy (IJ) was called due to the risk of serious injury, serious harm, serious impairment that was likely to occur. The immediate jeopardy began on 9/23/22, when the facility failed to use the correct size and type of sling for a mechanical lift transfer and R2 fell to the floor. The administrator and the director of nursing (DON) were notified of the immediate jeopardy at 1:30 p.m. […]

• Actual harm, isolatedF760Jul 29, 2025

  Based on interview and record review the facility failed to ensure that 1 of 3 residents (R1) reviewed was free from a significant medication error. R1 was given another residents insulin causing her to be sent to the hospital for treatment. Findings include: R1's clinical physician orders dated 7/15/25 - 7/29/25 did not indicate R1 was ordered insulin. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) was a 15 indicating she was cognitively intact. R1 did not receive any injections including insulin. […]