Silver Bluff

Inspectors wroteBased on observations and staff interviews, the facility failed to dispose of food stored past the use by date in 1 of 3 refrigerators (walk-in refrigerator). Furthermore, the facility failed to maintain clean air vents located directly above the kitchen's tray line free from gray debris and practice hand hygiene during tray line service for 1 of 4 kitchen staff (Kitchen Staff #1) observed in the kitchen. The deficient practice had the potential to affect food served to residents.

Inspectors wroteBased on observation, record review, and interviews with the Wound Care Nurse Practitioner (NP), Medical Director (MD) and staff, the facility failed to follow up when a Wound Care NP recommended the staff contact the primary care provider about the condition of the wound and if antibiotics needed to be ordered for a resident who showed symptoms of a wound infection. This deficient practice affected 1 of 2 residents reviewed for pressure ulcers (Resident #11).

Inspectors wroteBased on record review, observations and interviews with staff, resident, Nurse Practitioner and Pharmacist, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication ordered not to be crushed was administered crushed and medication omissions (3 medication errors out of 34 opportunities), resulting in a medication error rate of 8.82% for 1 of 3 residents (Resident #116) observed during medication pass.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to date an opened insulin pen and discard an expired stock medication available for use in 1 of 5 medication carts (500 hall long-side medication cart). Additionally, the facility failed to store a heparin flush syringe in a locked cart instead of leaving it unsecured on a resident's bedside table (Resident #8).

Inspectors wrotePayor source: MedicaidBased on record review, and resident and staff interviews, the facility failed to hold aspirin (an antiplatelet medication that helps prevent blood clots) which resulted in Resident #55 not being able to have an ordered tooth extraction in November 2025 for 1 of 1 resident reviewed for providing dental services (Resident #55).

Inspectors wroteBased on observation, staff interviews and record reviews, the facility failed to secure an unopened vial of inhaler and an opened tube of ointment in the medication cart for 1 of 1 room (room [ROOM NUMBER]), failed to date an opened bottle of eye medication and 7 opened pens of insulin for 3 of 6 medication carts (200 halls, 300 halls, and 400 halls), and failed to lock 1 of 6 medication carts during observations for medication storage audits (300 halls).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to protect a resident's right to be free from physical restraint when Nurse Aide (NA) #2 held Resident #61's wrists/hands in front of her chest during incontinence care when Resident #61 started swinging her arms and kicking her legs. In addition, NA #1 and NA Student #1 observed NA #2 smacking Resident #61 with an open hand on the wrist following the completion of incontinence care. This was for 1 of 3 residents reviewed for physical restraint (Resident #61).

Inspectors wroteBased on observations, record review, test tray, and resident, resident representative, and staff interviews, the facility failed to provide palatable food that was appetizing in temperature for 3 of 3 residents reviewed with food concerns (Resident #42, Resident #59, and Resident #103).

Inspectors wroteBased on record review, observation, resident, staff, and family interviews, the facility failed to honor a resident's (Resident #49) right to choose their preferred method of bathing and the resident's right to refuse a shower. On 4-22-23, Resident #49 had refused her shower three times and on the third refusal Nurse #1 was informed of Resident #49's refusal to take a shower. Nurse #1 informed Nursing Assistant (NA) #1 and NA #2 that the resident had to take a shower regardless of Resident #49's refusal. Nurse #1 and 5 NAs (NA #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and stating she did not want to get out of bed and have a shower, out of the bed, into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the likelihood of suffering serious physical and psychosocial harm. [...]

Inspectors wroteBased on record review, staff, family and resident interviews, the facility failed to protect Resident #49's right to be free from physical and emotional abuse for one of two sampled residents reviewed for abuse. On 4-22-23 Resident #49 had refused a shower three times and on the third refusal, six staff members (Nurse #1, Nursing Assistant (NA) #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and pushing staff away, out of bed and into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the high likelihood of suffering other serious physical and psychosocial harm. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion). [...]

Inspectors wroteBased on record review, staff, and family interviews the facility failed to follow their abuse policy in the areas of identification, immediately reporting an allegation of abuse to the Administrator, and reporting an allegation of abuse to the state agency within two hours. This occurred for 1 of 2 residents (Resident #49) reviewed for reporting.

Inspectors wroteBased on observations, record review and resident and staff interviews the facility failed to provide protection for residents during the investigation of an allegation of abuse for 1 of 2 residents (Resident #18) reviewed for abuse.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to (1) perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound, and before applying a clean dressing to a wound and (2) provide a clean field for wound care materials for 1 of 1 staff member observed for wound care (Nurse #4).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to post complete and accurate daily nurse staffing information for 2 of the 5 days reviewed (6/06/23 and 6/07/23).