Silver Hills Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was completed and failed to report an allegation of misappropriation involving a certified nursing assistant to the State Board of Nursing. The deficient practice had the potential to place all residents at risk for unreported financial exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of misappropriation involving a certified nursing assistant was reported to the State Agency within the required timeframe for 1 of 1 allegation reviewed. The deficient practice had the potential to place all residents at risk for unreported financial exploitation.

Inspectors wroteBased on observation, interview, and document review, the facility did not ensure that dishware was sanitized according to food safety protocols in the three-compartment sink area of the main kitchen. This deficient practice had the potential to cause cross-contamination and foodborne illness, affecting all residents who receive meals from the kitchen.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure psychotropic medication consent forms were obtained and/or updated for 3 out of 39 sampled residents (Resident 12, 14, and 15). The deficient practice had the potential to deny residents the right to be fully informed and to participate in decisions regarding care and treatment.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a comprehensive care plan was revised to reflect interventions following a fall incident for 1 of 39 sampled residents (Resident 9). The deficient practice had the potential to result in unmet care needs and to increase the risk of additional falls.

Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure there were physician orders for the care and maintenance of a central line (a long, flexible tube inserted in a large vein, usually the superior vena cava near the heart) and a peripheral line (a small plastic tube inserted through the skin into a vein of the arm or hand) for 1 of 30 sampled residents (Resident 153). This deficient practice had the potential for an increased risk of infection and to compromise resident health.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the temperature in a resident's personal refrigerator was monitored for 1 of 30 sampled residents (Resident 97). The deficient practice had the potential for foods to be stored at temperatures which could lead to food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records were complete and accurate for 3 of 30 sampled residents (Residents 153, 156, and 157). The deficient practice had the potential for residents not to receive timely interventions needed and for the facility missing the opportunity to identify care issues.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure 1) enhanced barrier precautions were in place for 2 of 39 sampled residents (Resident 60, and 114); 2) staff observed infection control protocols during resident care; and 3) infection prevention and control policies and procedures were reviewed and updated annually. The deficient practice had the potential to result in increased risk of transmission of infectious organisms to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure an assessment was completed for the self-administration of medication for 1 of 6 sampled residents (Resident 6). The deficient practice had the potential for the resident's unsafe administration of medication.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure an allegation of physical and verbal abuse were thoroughly investigated for 1 of the 6 sampled residents (Resident 3). This deficient practice could potentially compromise the safety and well-being of other residents.

Inspectors wrote2.) Resident 5 (R5) was admitted to the facility on [DATE], with diagnoses including partial left side paralysis due to stroke. The resident's insurance coverage ended on 01/01/2025 and the resident's discharge was to be effective 01/02/2025. The resident's medical record lacked documented evidence the facility provided discharge planning prior to the resident's discharge on [DATE]. On 02/6/2025 at 9:00 AM, Case Manager 1 (CM) indicated the discharge planning began when the insurance submits an intent to discharge. Upon admission, the CM would conduct a discharge assessment of the resident and annotate the notes from the assessment on a personal paper tracker. The notes would be kept on the CM's personal tracker until the resident's discharge which it would then be shredded. The CM indicated the notes were not scanned into the electronic medical record. [...]

Inspectors wroteBased on interview, record review and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure stored foods and cleaning agents were labeled, dated, and were stored properly and ice machines were properly cleaned in 2 of 4 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure assistance with activities of daily living (ADLs) were provided to 3 of 29 sampled residents (R225, 226, and 229). The deficient practice had the potential for the residents' further decline and compromised the residents' skin integrity.

Inspectors wroteBased on interview, document review and record review, the facility failed to follow physician's orders for one unsampled resident (Resident 276). The deficient practice had the potential to exacerbate a life-threatening medical condition.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a pain medication was administered as scheduled for 1 of 29 sampled residents (R228). The deficient practice had the potential for the resident's pain management to be ineffective and inadequate and compromised resident safety.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident's personal food items from outside or home were properly labeled and stored for 2 of 39 sampled residents (Residents #77 and #84). The failure to label, date, and store food items had the potential risk to cause psychosocial distress to the residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure standards of infection control practices were followed during medication administration for one unsampled resident (Resident 276). The deficient practice had the potential to place the resident at risk for communicable diseases from cross contamination.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure an alleged incident of neglect was reported to the state agency for 1 of 14 sampled residents (Resident 13). The deficient practice had the potential for the facility to not give the state survey agency the opportunity to investigate the alleged incident of neglect and other alleged incidents of abuse and neglect.

Inspectors wroteBased on interviews, record reviews, and document reviews, the facility failed to ensure a person-centered baseline care plan for a resident at high risk for falls had been formulated within 48 hours following admission for 1 of 14 sampled residents (Resident 1). The deficient practice resulted in inadequate management of existing fall-related injuries.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure showers were provided as scheduled for 1 of 14 sampled residents (Resident 5). The deficient practice placed dependent residents at risk for not receiving assistance with activities of daily living (ADLs).

Inspectors wroteBased on interviews, record reviews, and document review, the facility failed to ensure the resident's skin or surgical incision site had been appropriately assessed, weekly skin assessments were completed per protocol, and the resident's skin conditions pre- and post-removal of the staples were appropriately documented for 1 of 14 sampled residents (Resident 2). The deficient practice could have the potential to compromise residents' health and providing ineffective treatment.

Inspectors wroteBased on observation, interviews, record reviews, and document review, the facility failed to ensure the resident's wound had been treated as ordered and appropriately documented when the treatment had not been provided for 1 of 14 sampled residents (Resident 14). This deficient practice could have the potential to result in worsening of the wound, increased risk of infection, delayed healing, and overall deterioration of the resident's health.

Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure fall prevention interventions were implemented for 1 of 29 sampled residents (Resident 13). The deficient practice had the potential for fall with major injury impacting the quality of life of the resident.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure their arbitration agreement provided for the selection of a venue that was convenient to both parties, for three sampled residents (Resident 112, 100, 540), and 29 unsampled residents who had signed the arbitration agreement. The deficient practice had the potential to obstruct each resident's ability to make well-informed decision about signing the agreement.