Silver Oaks Health and Rehabilitation

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for 3 (Resident #47, #10, and #87) of 5 residents reviewed for accuracy of MDS assessments.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined that the facility did not ensure proper hand hygiene was used during medication administration for 1 (Resident #238) of 3 residents observed for medication administration, 1 (Resident #39) of 1 resident observed for proper incontinent care technique, and feeding assistance for 1 of 2 meal services observed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility did not ensure that incontinence care was provided in a manner that promotes cleanliness and/or prevent infections for 1 (Resident #39) of 3 sampled residents reviewed for activities of daily living, and the facility did not ensure standards of practice were followed for 1 (Resident #39) of 2 sampled residents reviewed that received enteral feedings. Specifically, the head of Resident #39 ' s bed was lowered while the resident received enteral nutrition.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure staff provided incontinence care in a timely manner to prevent 3 (Residents #7, #8, and #9) of 3 residents sampled for incontinence care from lying in a bed or sitting in a chair saturated with urine.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the freezer were covered and dated, failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, the door frames, and ceiling tiles were free of chipped, holes, paint peeling, rust, stains. dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 89 residents who received meals from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and to care for each resident in a manner and in an environment that promoted the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #5) of 4 sampled residents reliant on staff for incontinence assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had a safe, clean, and/or comfortable environment for 2 (Residents #5, #15) sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a narcotic box located in the refrigerator in the medication storage room was permanently affixed in 1 of 1 facility and the facility failed to ensure expired medications in 1 of 1 medication room and in 1 medication cart (100 Hall) of 4 (100, 200, 300 and 400 Hall) medication carts.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 10 residents who received pureed diets.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure clean linens were stored away from dirty items to prevent the spread of infection, failed to ensure the Treatment Nurse followed the facility guidelines when performing wound care; failed to ensure a clear bag of clean linens were not placed directly on the floor before being placed on a bedside table and a resident bed; and failed to ensure hand hygiene was performed during incontinence care for 1 (Resident #15) of 3 sampled residents.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview and record review, the facility failed to evaluate and determine if a resident was mentally and physically able to self-administer medication for 2 (Residents #33 and #44) of 2 sampled residents who had medications left at the bedside.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure privacy curtains were provided for 1 (Resident #51) sampled resident residing in a semi-private room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #194) of 7 (Residents #43, #48, #66, #77, #79, #92 and #194) sampled residents who were on Eliquis and failed to ensure the MDS assessment accurately reflected the resident's status for 1 (Resident #92) of 1 sampled resident who had been discharged from the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/31/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff sat at the resident's eye level and did not stand over them while assisting them with eating to promote dignity and respect for 1 (Resident #74) of 8 (Residents #4, #13, #34, #35, #63, #73, #74 and #79) sampled residents who required assistance with eating in the main Dining Room.

Inspectors wroteBased on observation, record review and interview, the facility failed to establish/maintain ongoing communication and collaboration with the Dialysis Facility for 1 (Resident # 50) of 2 (Residents #38 and #50) sampled residents who received End Stage Renal Disease services.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a treatment cart remained locked when not attended by nursing staff in accordance with State and Federal laws to prevent potential access by residents. This failed practice had the potential to affect 17 self-mobile residents who resided on the 100 Hall as documented on a list provided by the Assistant Director of Nursing (ADON) on 03/29/23 at 3:11 PM.