Silver Lake Specialized Rehabilitation and Care Ce

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each residents received adequate supervision to prevent accidents. This was evident for one (1) (Resident #105) of four (4) residents reviewed for accidents out of 35 total sampled residents. Specifically, on 06/04/2025, Resident #105, who had severe cognitive impairment and had a history of multiple falls, had an unwitnessed fall from a wheelchair when the resident was left in the hallway without supervision. Resident #105 sustained a head laceration and was transported to the hospital and subsequently diagnosed with a cervical fracture. This deficient practice resulted in actual harm to Resident #105 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a clean, comfortable, and homelike environment for the residents. Specifically, housekeeping and maintenance services were not maintained in four (4) (Units 1A, 3A, 3B, and 4A) of seven (7) resident units.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs were created and implemented for each resident. This was evident for one (1) of five (5) residents reviewed for Unnecessary Medications, and two (2) of two (2) residents reviewed for Care Planning out of 35 total sampled residents. Specifically, Resident #187, Resident #41, and Resident #92 were taking anticoagulant or antiplatelet medications that carried an increased risk of bleeding and comprehensive care plans were not implemented to address the risk of bleeding associated with the medication use.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that residents' Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, and revised based on changing goals, preferences, and needs of the resident. This was evident for one (1) of four (4) residents reviewed for Respiratory Care, and one (1) of two (2) residents reviewed for Falls out of 35 total sampled residents. Specifically, 1.) Resident #91's Respiratory Care Comprehensive Care Plan was not updated after their Quarterly Minimum Data Set Assessment, and 2.) Resident #105's Falls Comprehensive Care Plan interventions were not reviewed and updated after enduring multiple falls in the facility. See F-689.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases. Specifically, the facility failed to provide documentation of screening, administration or declination, and education of the COVID-19 vaccination for nine (9) of ten (10) staff members reviewed for COVID-19 vaccinationsThe

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure there was adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This was evident for four (4) of seven (7) units. Specifically, call bell systems did not function as designed and residents were given hand bells.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for one (1) (Resident #140) of two (2) residents reviewed for Urinary Catheter out of 35 total sampled residents. Specifically, Resident #140's urinary catheter tubing was exposed on multiple observations.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, to the State Survey Agency. This was evident for one (1) (Residents #105) of four (4) residents reviewed for accidents out of 35 total sampled residents. Specifically, Resident #105 had an unwitnessed fall on 06/04/2025 when they were observed on the floor with a laceration to the right eyebrow. The resident was transferred to the hospital and was diagnosed with a cervical fracture. Resident #105 was cognitively impaired and was unable to explain how the injury was sustained. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for one (1) of two (2) residents (Resident #43) reviewed for Activities out of 35 total sampled residents. Specifically, Resident #43 was not provided with television stations in their preferred language.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) (Resident #191) of one (1) resident reviewed for change in condition. Specifically, Resident #191 who had a documented allergy to Vancomycin was prescribed and administered Vancomycin for the treatment of pneumonia placing the risk at risk for an adverse allergic reaction. See F-755.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident who required respiratory care received such care, consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for one (1) of four (4) residents reviewed for Respiratory Care out of 35 total sampled residents. Specifically, Resident #91, who had a physician's order to change the oxygen tubing every three (3) days, was observed on multiple occasions between 04/09/2026 and 04/14/2026 receiving oxygen through a nasal cannula that was dated 03/27/2026.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that medications were dispensed in a safe manner and in accordance with professional standards of practice. This was evident for one (1) (Resident #191) of one (1) resident reviewed for change in condition. Specifically, the facility failed to ensure that the pharmacy identified and acted upon Resident #191's documented drug allergy to Vancomycin prior to dispensing, resulting in the delivery and administration of Vancomycin to Resident #191 with a known allergy to the medication. See F-684.

Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (2691440). the facility failed to ensure that a resident was free from abuse. This was evident for one (1) of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 12/11/2025 at 5:23:43 PM the facility's surveillance camera footage shows Certified Nursing Assistant #1 approach Resident #1 in the dayroom and pulled the dayroom table away from Resident #1's wheelchair. At 5:23:56 PM, Certified Nursing Assistant #1 was observed hitting Resident #1 on the back of their head with an open hand and Resident #1's head falls forward. At 5:24 PM, Certified Nursing Assistant #1 pushed Resident #1's wheelchair to the dayroom exit door and stop. [...]

Inspectors wroteBased on interview and record review conducted during an abbreviated survey (2691440), the facility did not ensure that an alleged violation involving abuse, neglect, mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Agency and adult protective services where state law provides for judications in long term care facilities) . This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 4 of 4 resident floors (Floors 1, 2, 3, 4) reviewed for Environment. Specifically, 1) the 1st Floor had stained walls and curtains, missing and mismatched paint, missing baseboards, torn wallpaper, , and a dirty air conditioning (AC) unit, 2) the 2nd Floor had tables with mismatched and missing paint and rust, 3) the 3rd Floor had missing baseboards, mismatched and missing paint, and chipped and missing veneer on shelves , and 4) the 4th Floor had tables with mismatched and missing paint.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during review of the kitchen. Specifically, 1) a 5-pound container of expired cottage cheese was in the kitchen refrigerator, 2) the 3rd floor pantry contained expired honey-thickened juices, and 3) the 4th floor pantry had an expired quart of milk.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #238) of 2 residents reviewed for urinary catheter out of 39 total sampled residents and the Main Dining Room (MDR). Specifically, 1) the Foley catheter (FC) tubing for Resident #238 was touching the floor, and 2) hand hygiene was not performed for multiple residents eating lunch in the MDR.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/06/2023 to 12/13/2023, the facility did not ensure that resident was cared for in a manner that maintained their dignity. This was evident for 1 (Resident #238) of 2 residents reviewed for Urinary Catheter out of 39 total sampled residents. Specifically, Resident #238 had a Foley catheter (FC) bag that was exposed and in public view.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 1 (Resident #121) of 39 total sampled residents. Specifically, Resident #121 was not invited to attend their scheduled Comprehensive Care Plan (CCP) meetings.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #68) of 39 total sampled residents. Specifically, the MDS assessment for Resident #68 did not accurately reflect the resident's use of a physical restraint.