Silver Cross Health & Rehab

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a safe, functional, and homelike environment for residents in a common area, Specifically, the facility failed to repair missing floor tiles in the dining room, a high-traffic area for four (4) out of 4 days of survey.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items were stored under sanitary conditions by not removing expired food from the dry storage area for one (1) of three (3) observation days. This failure had the potential to result in foodborne illness for residents consuming food from the kitchen. Findings Include:A record review of the facility's First IN First Out (FIFO) policy undated revealed a product rotation is important for both quality and safety reasons. FIFO means that the first batch product prepared in storage should be used first. Identify the food items use by or expiration date. Throw out food that has passed its manufacturers use or expiration date. On 12/8/25 at 10:20 AM an initial tour of the kitchen revealed the following items were expired and found in the dry storage room: [...]

Inspectors wroteBased on resident and staff interviews, facility policy review, and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident #25) was treated with dignity and respect by staff during care and communication. Findings Include:A record review of the facility Resident's Rights policy revealed the resident has a right to be treated with respect and dignity. On 12/10/25 at 4:30 PM, in an interview with Licensed Practical Nurse (LPN) # 4, she stated there had been concerns raised regarding a nurse, LPN #3, who was reported for interactions with multiple residents, including Resident #25 and Resident #11, and who often works the A hall. LPN 4 described the issue as related to tone and arguing with residents. [...]

Inspectors wroteBased on observation, interview, facility policy review and record review, the facility failed to ensure that one (1) of three (3) residents (Resident #8) assessed as moderately cognitively impaired was properly evaluated for the safe self-administration of medication. Findings Include:A record review of the facility's policy, Self-Administration of Medication and Bedside Medication with a revised date of 3/10/25 revealed this facility's policy is that residents may self-administer their medications given the approval of the interdisciplinary or care planning team. A resident may administer his/her own medications if the disciplinary team determines that this practice is safe. A Self-Administration evaluation should be completed in the Electronic Health Record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation of advance directive status for one (1) of seventeen (17) sampled residents, Resident #5.

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to implement the care plan interventions related to hearing needs and activity of daily living (ADL) needs for one (1) of 17 sampled residents (Resident #10). Specifically, the facility failed to follow up on a June 2025 audiology appointment that documented the need for further evaluation, failed to ensure the resident had functional hearing aids per her preferences and needs, and failed to coordinate care in accordance with the resident's care plan and physician orders. [...]

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to ensure grooming needs were met in accordance with the resident's preferences and needs for one (1) of three (3) residents reviewed for activities of daily living (Resident #10). Specifically, the facility failed to provide facial shaving per resident request and failed to document refusal of care when shaving was not provided, resulting in unaddressed personal hygiene needs and potential negative impact on resident dignity. Findings Include:A record review of the facility's policy, Activities of Daily Living revised 9/16/22 revealed, .Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care.3. [...]

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to ensure timely follow-up and coordination of care related to hearing needs for one (1) of three (3) residents reviewed for sensory impairment (Resident #10). Specifically, the facility failed to ensure the resident's hearing aids were functional, to act on evaluation results that indicated further follow-up was needed, and to implement or revise care plan interventions related to hearing loss. These failures resulted in the resident experiencing prolonged difficulty hearing and unmet sensory needs. Findings Include:A record review of the facility's Physician Order Review policy dated 1/9/15 revealed, Purpose: To ensure safety and comply with standards of care. To verify the necessity to initiate, continue or change appropriate treatments as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received care consistent with professional standards of practice and physician orders for the treatment of a pressure ulcer for one (1) of three (3) residents reviewed for pressure ulcers (Resident #38). Findings Include:Record review of Resident #38's physician orders revealed an order dated 12/10/25 to cleanse the Stage 3 pressure ulcer to the coccyx with normal saline, pat dry, apply Medi-Honey to the wound bed, place calcium alginate over the honey, and cover with border foam dressing daily. On 12/10/2025 at 10:58 AM, wound care was observed being administered to Resident #38 by Registered Nurse (RN) #1 with the assistance of Licensed Practical Nurse (LPN) #1. During the procedure, RN #1 applied Zinc Oxide ointment around the edges of the wound after completing the ordered wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that professional nursing standards were followed during percutaneous endoscopic gastrostomy (PEG) tube care for one (1) of one (1) resident (Resident #44) reviewed for enteral nutrition. Findings Include:On 12/10/2025 at 10:00 AM in an observation of Registered Nurse #1 (RN)/Wound care provide peg tube care to Resident #44, she cleaned the PEG site with a gauzed soaked in wound cleaner. She cleaned the site using the same gauze in a circular motion four times without discarding and replacing it with a new gauze for each wipe, as per infection control standards. On 12/10/2025 at 10:12 AM in an interview with RN #1 stated she should have discarded the gauze and got another one while cleaning the site. She stated it could cause Resident #44 to get an infection. [...]

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to maintain appropriate infection prevention and control practices during enteral medication administration for one (1) of three (3) residents reviewed for infection control concerns (Residents #27). Findings Include: A record review of the facility's policy Infection Prevention and Control Program with a revision date of 2/17/25 revealed this facility has established and maintains 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 as per accepted national standards and guidelines .11. Equipment Protocol: a. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review the facility failed to ensure the comprehensive care plan interventions was implemented for a resident who was dependent for Activities of Daily Living (ADL) care for one (1) of 15 sampled residents. Resident #44.

Inspectors wroteBased on observation, interviews, record reviews and facility policy review, the facility failed to revise comprehensive care plan interventions for falls for one (1) of two (2) residents reviewed for accidents. (Resident #9)

Inspectors wroteBased on staff and resident interviews, record reviews, and facility policy review, the facility failed to ensure dependent residents received the necessary services to maintain oral hygiene for one (1) or 15 sampled residents. Resident #44.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure treatment of pressure ulcers was provided in a manner to prevent cross contamination and promote healing, as evidenced by failure to change gloves and perform proper hand hygiene during wound care for one (1) of two (2) residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interviews, facility policy review, and record review, the facility failed to maintain a medication error rate below 5 percent (%) for two (2) of 25 medication opportunities, resulting in an 8% medication error rate.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to remove expired Pneumovax-23 (pneumococcal vaccine polyvalent) vials from the medication storage refrigerator for one (1) of one (1) medication rooms observed.