Silsbee Oaks Health Care LLP

Inspectors wroteBased on record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 3 of 3 residents reviewed for MDS transmission. (Resident #s #3, #87, and #98) The facility failed to complete and transmit a Discharge MDS assessment for Resident #3 within 14 days of completion. The facility failed to initiate and complete Discharge MDS assessments for Resident #s #87 and #98 within 14 days of discharge. These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 12 residents (Resident #5 & #9) reviewed for advanced directives. The facility failed to ensure Resident #5 who was listed as DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was missing the doctor's medical identification number and did not have the POA's signature at the bottom of the document. The facility failed to ensure Resident #9 who was listed as DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information and did not have Witness sign date or printed name. This failure could place residents at risk of not having their end-of-life wishes honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards and provide assistive devices to each president to prevent avoidable accidents 1 of 6 residents (Resident #117), reviewed for accidents and hazards. The facility failed to ensure Resident #117 had fall mats in place bedside while she was in bed. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 10 residents (Resident #90) reviewed for respiratory therapy. The facility failed to keep the oxygen concentrator filter clean for Resident #90. This failure could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 30 residents (Resident #10) observed for infection control. The facility failed to ensure CNA A and CNA B followed the EBP and infection control procedures for Resident #10 on 01/28/26. This failure could place the residents at risk of cross-contamination and the development of infection.

Inspectors wroteBased on interview and record review, the facility failed to provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for 1 (Resident #13) of 29 residents reviewed for following physician's orders. The facility failed to implement Resident #13's care plan when the blood pressure and/or heart rate was below prescribed parameters and did not notify the physician in October 2024. (10/07, 10/8, 10/15, 10/16, 10/21, 10/23, 10/25, 10/26, and 10/28). Th failure placed residents, who required blood pressure and heart rate monitoring, at risk for complications due to delayed physician intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental service to meet the needs of 1 of 29 residents reviewed for dental services. (Resident #132) The facility did not assist Resident #132, who had missing teeth and dental decay, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision after a resident expressed suicidal ideations (she wanted to die). The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions for suicidal thoughts and attempts which could lead to residents sustaining serious injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents, who were unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene for 1 of 28 residents reviewed for ADL care. (Resident #15) The facility did not shave Resident #15's upper lip and chin hairs. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 storage area located in the DON's office of drugs for destruction reviewed for drug storage. The facility failed to ensure controlled drugs for destruction were stored in a separately locked, permanently affixed compartment for storage until destroyed. This failure could place residents at risk for possible drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, complete and accurately documented medical records for each resident, for 1 of 27 residents (Resident #5) reviewed for accurate records. The facility failed to document Resident #5's baths for 08/01/23 - 08/29/23. This failure could place residents at risk for inaccurate and missing documentation in their records.