Complete Care at Silver Lake LLC

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to ensure chicken salad sandwiches were served at the proper temperature. This deficient practice had the potential to affect 112 out of 114 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the kitchen area was free from fruit flies. The facility failed to keep the kitchen clean and ensure bait boxes remained under the three compartments sink to deter pests as recommended by their pest control provider. This created the potential for the harborage of insects and vermin which had the potential to affect 114 out of 114 residents.

Inspectors wroteBased on observations, interviews, record review and policy review, the facility failed to ensure a call light was within reach for one resident (Resident (R) 1) out of 39 sampled residents reviewed for call lights. This failure had the potential to create a situation where the resident would need help and could not reach the call light, causing the resident's needs to go unmet. Findings Include:Review of 1's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed admission date of 10/07/25 with diagnoses which included Schizophrenia and intellectual disabilities. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/25, located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 11) reviewed for unnecessary medications, continued to receive as needed (PRN) psychotropic medication (lorazepam) beyond 14 days, without an evaluation and documentation of the clinical indications to use the medication beyond the 14 days. This failure had the potential to place the resident at risk of adverse consequences.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of one resident (R)6 receiving wound care/treatment out of a total of 39 sampled residents. This deficient practice placed R6 at risk of worsening wounds, new wound development, and for unmet resident care needs and goals for care.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure residents maintained good hygiene for two (Resident (R) 20 and 75) of five residents reviewed for activities of daily living (ADL) in the sample of 39 residents. This failure has the potential for the residents to develop skin infections, social isolation, and a general decline in health.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure one resident (Resident (R) 71) of two residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene out of a total survey sample of 39 residents. This failure has the potential for the residents to develop a general decline in health.

Inspectors wroteBased on observation, record reviews, interviews, and facility policy review, the facility failed to follow care plan interventions to set the low air loss (LAL) mattress at 150 for one of one (Resident (R)66) out of a total of 39 sampled residents. This deficient practice placed R66 at risk of worsening non-pressure wounds, new wound development, and for unmet resident care needs and goals for care.

Inspectors wroteBased on observation, record reviews, interviews, and facility policy review, the facility failed to follow physician orders and care plan interventions for one of one Resident (R)73 to set the low air loss (LAL) mattress at 250 out of 39 sampled residents. This deficient practice placed R73 at risk of worsening pressure wounds, new wound development, and for unmet resident care needs and goals for care.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure the indwelling urinary catheter tubing and collection bag were not in contact with the floor and a securement device was in place for one resident (Resident(R)24) of one resident reviewed for indwelling urinary catheters out of 39 sampled residents. This failure placed the residents at risk for transmission of infection to the urinary tract or injury from tension, pulling, and accidental dislodgement of the catheter from the bladder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was implemented to prevent the transmission of communicable diseases, including ensuring staff adherence to required personal protective equipment (PPE) and isolation precautions for two residents (Resident (R)2 and R91) who were in Contact/Droplet isolation out of 114 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent residents from sustaining injuries from falls and/or a burn from hot water for three (Residents (R) 40, R96, and R38) of eight sampled residents reviewed for accidents out of a total sample of 32. R40 was assessed to require two staff members for bed mobility; however, the resident was repositioned by one staff member and slid out of bed, which resulted in actual harm of bilateral femur fractures. R96 suffered actual harm of second degree burns when water, which had been heated in the microwave for three to four minutes, spilled on her. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure cold storage units contained interior temperature gauges, kitchen floors and walls were kept clean and in good repair, and leftovers were cooled down correctly, in one of one kitchen. This deficient practice had the potential to affect 107 of 107 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Antibiotic Stewardship Program was consistently implemented. The facility failed to document criteria for the use of antibiotics, antibiotics used, and results of culture and sensitivity testing. The facility failed to analyze antibiotic stewardship data to plan process improvements. This failure placed all 111 of 111 residents at risk for adverse events related to administration of antibiotics.

Inspectors wroteBased on observation, record review, and interview, the facility failed to 1.) complete wound care in a manner to prevent cross contamination for one of one resident (Resident (R) 78) reviewed for wound care out of a total sample of 32, and 2.) wear the proper Personal Protective Equipment (PPE) when entering into a contact isolation room for one of 27 residents (room [ROOM NUMBER]) noted to be COVID positive. These failures put the vulnerable population of residents at greater risk of developing infections and the increased risk of staff spreading infections throughout the facility by not adhering to the isolation precautions.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 113) reviewed for communication out of a total sample of 32 was communicated with in a language the resident could understand. R113 was Spanish speaking only, and the lack of providing communication in the resident's language could potentially cause frustration and possible unmet care needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure two residents (Resident (R) 24 and R82) of 32 sampled residents were free from physical abuse from R90, when R90 punched R24 and R82. The abuse caused by R90 had the potential to cause harm to all current residents throughout the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to report an allegation of abuse within two hours to the state agency for one of seven residents (Resident (R) 71) reviewed for abuse out of 32 sampled residents. This had the potential to affect all the residents in the facility who were at risk of abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide written notification of a hospital transfer to the resident and responsible party (RP) for one of five residents (Resident (R) 62) reviewed for hospitalization of 32 sample residents. The failure had the potential to affect the residents and/or their representatives concerning the reason for the transfer and the resident's appeal rights.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide written notification of the bed hold policy to the resident and responsible party (RP) for one of five residents (Resident (R62) reviewed for hospitalization of 32 sample residents. The failure had the potential to affect the residents planning on returning to the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement an effective discharge care plan for two of two residents (Resident (R) 46 and R82) reviewed for discharge planning out of a total sample of 32. Specifically, the facility failed to have an individualized discharge care plan in place. This failure had the potential to cause confusion and unmet care needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide medically related social services to meet the resident's needs for one of 32 sampled residents (Resident (R) R90). This failure caused the resident to not receive the required care expected to be provided by the Social Services Director (SSD).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to serve food that was palatable and at the appropriate temperature for three of five residents (Resident (R) 62, R46, and R11) reviewed for food palatability out of 32 sample residents. This deficient practice could potentially cause residents to lose weight and decrease quality of life.

Inspectors wroteBased on record review and interview, it was determined that for six (6) out of twenty-four (24) residents reviewed, the facility failed to have input from all required interdisciplinary team members at these residents' care plan meetings.

Inspectors wroteBased on interview and record review, it was determined that for one (R77) out of two residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed.

Inspectors wroteBased on interview and record review, it was determined that for two (R66 and R269) out of twenty-four (24) residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plan for an identified need.

Inspectors wroteBased on observation, interview and record review, it was determined that for two (R39 and R62) out of four residents reviewed for range of motion and mobility, the facility failed to provide appropriate services, equipment, and assistance to maintain function and mobility.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R77) out of three sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services.

Inspectors wroteBased on record review and interview, it was determined that for two (R61 and R306) out of twenty-five residents clinical records reviewed, the facility failed to ensure that each residents' record was complete and accurately documented.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process.