Ebony Lake Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ebony Lake Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Jan 15, 2026

  Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 3 of 4 medication carts (300 Hall Nurse Cart, Blue Med-Aide Cart, and 200 Hall Nurse Cart) reviewed for labeling and storage.The facility failed to ensure the 300 Hall Nurse Cart belonging to LVN-E was free from personal items.The facility failed to ensure the Blue Med-Aide Cart belonging to Medication Aide-D was free from medications without labels. […]

• No harm, potential for more than minimal, patternF812Jan 15, 2026

  Based on observation, interviews and record review, the facility failed to store, distribute and sever food in accordance with professional standards for food service safety for 1 of 2 refrigerators (1 of 2 kitchen refrigerator) and 3 of the 3 steam table wells reviewed for storage, preparation, and sanitation. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was labeled and dated. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was sealed properly. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was not expired and spoiled. -The facility failed to ensure 3 of 3 the steam table wells were cleaned. -These failures could place residents at risk of complications from food contamination. […]

• No harm, potential for more than minimal, isolatedF580Apr 29, 2026

  Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for change in condition. LVN D failed to identify a significant change in condition experienced by Resident #1 on 4/10/26. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.Finding included: Record review Resident #1's face sheet dated 04/28/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes… […]

• No harm, potential for more than minimal, isolatedF656Apr 29, 2026

  Based on observation, interview, and interview the facility failed to develop and implement a comprehensive care plan for each resident that included measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 (Resident #1) of 3 residents. The facility failed to develop a care plan to address Resident #1's the use of a mechanical lift during transfer. This failure places the resident at risk of inappropriate transfers with resulting injury. The findings included: Record review Resident #1's face sheet dated 04/28/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively,… […]

• No harm, potential for more than minimal, isolatedF689Apr 29, 2026

  Based on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being repositioned in bed for 1 (Resident #1) of 3 residents reviewed for accidents and hazards, CNA E failed to use two staff assist as required by Resident #1's care plan for bed mobility Resident #1 sustained a fall, on 4/9/26. This deficient practice has the potential to affect all residents in the building who require assistance with bed mobility by 2 staff members by causing falls and injuries. […]