Silver Ridge Healthcare Center

Inspectors wroteBased on observation, interviews, record reviews, and document reviews, the facility failed to ensure a resident was protected from physical abuse for 1 of 29 sampled residents (Resident 13). The deficient practice had the potential to cause emotional and physical harm to the residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to implement Enhanced Barrier Precautions (EBP) and the required use of personal protective equipment (PPE) in accordance with current infection prevention and control guidance for 1 of 29 sampled residents (Resident #22). This deficient practice had the potential to increase the risk of transmission of multidrug-resistant organisms (MDROs), expose residents and staff to infectious pathogens, and contribute to preventable healthcare-associated infections.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a safe environment was provided to residents and staff when an unauthorized male intruder entered the facility and stole the personal belongings of 1 of 29 sampled residents (Resident 94) and a staff member. The deficient practice had the potential to cause physical harm to residents and staff members.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored in a sanitary manner when perishable items in the walk-in refrigerator were not stored within the safe temperature range of 35-41 degrees Fahrenheit (F). The deficient practice had the potential to cause food-borne illness in all residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to comply with the prescribed meal consistency and dietary preferences for 1 of 28 sampled residents (Resident #13). The deficient practice had the potential to disregard resident autonomy and preference, negatively impacting meal satisfaction, leading to reduced appetite, and increase meal refusal that could have affected the resident's nutritional intake and quality of life.

Inspectors wroteBased on interview, record review and document review, the facility failed to notify the physician regarding resident post fall behavior and refusal of care for 1 of 28 sampled residents (Resident 126). The deficient practice had the potential for not exploring other physician interventions for resident care needs.

Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence wound care treatments were provided per the physician's order for 1 of 28 sampled residents (Resident 42). The deficient practice had the potential to place the resident at risk for delayed healing of a wound.

Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure the water bag used for gastrostomy feeding hydration and the tubing system were properly dated upon initiation of use for 2 of 28 sampled residents (Resident #68 and #70). This deficient practice had the potential to compromise patient safety by increasing the risk of contamination and infections, and improper hydration management, potentially leading to adverse health outcomes.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to remove expired medications from two of three medication rooms and one of five medication carts. This deficient practice had the potential to compromise patient safety by contributing to the risk of medication errors.

Inspectors wroteBased on interview and document review, the facility failed to ensure mandatory training which included abuse, fire, disaster, and dementia training was provided to 1 of 2 sampled Certified Nursing Assistants (Employee 10). The deficient practice placed residents at risk for inappropriate care.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a baseline care plan was developed for a resident who was admitted with an infected left foot and was assessed to be at risk for developing pressure ulcers and other skin impairments for 1 of 4 sampled residents (Resident 1). The deficient practice potentially resulted in delayed interventions for the resident's skin impairments.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a care plan was developed and implemented for a resident who was assessed to be at risk for developing pressure ulcers for 1 of 4 sampled residents (Resident 1). The deficient practice potentially resulted in delayed identification and interventions resulting in multiple areas of skin breakdown.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident's left foot which was being treated for cellulitis (infection) was assessed and monitored in a timely manner for 1 of 4 sampled residents (Resident 1). The deficient practice potentially resulted in complications to the resident's left foot resulting in hospitalization.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure weekly skin assessments were not missed or late for a resident who was assessed to be at risk for developing pressure ulcers for 1 of 4 sampled residents (Resident 1). The deficient practice potentially contributed to the resident's facility-acquired pressure ulcer and a delay in necessary interventions to prevent and treat the resident's pressure sore.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) elopement measures were effectively executed for 2 of 5 sampled residents (Resident 1 and 2), and 2) elopement risk assessment tool intervention recommendations were implemented for 1 of 5 sampled residents (Resident 2). The deficient practice had a potential for residents to elope from the facility that could lead to resident's harm.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure handwashing stations were properly controlled to provide hot water, food items were labeled and dated after opening, and maintain a clean and sanitary environment in the kitchen. The 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. On 04/23/2024 at 8:05 AM, the initial tour of the kitchen was completed with the following

Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 29 sampled residents (Resident 67). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services.

Inspectors wroteBased on observation, interviews, record review, and document review, the facility failed to ensure a baseline care plan was developed within 48 hours for the use of a leg brace following admission for 1 of 29 sampled residents (Resident 189). This deficient practice could have the potential to result in further injury, delayed recovery, or increased risk of falls, compromising the resident's overall safety and well-being.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a care plan for range of motion was updated to include a physician's order for a cervical collar for 1 of 29 residents (Resident 82). The deficient practice may have resulted in a delay in the use of the cervical collar potentially causing increased discomfort to the resident due to poor alignment and positioning of the head and neck.

Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure a resident who was identified as having a very high risk of developing a pressure ulcer was turned and repositioned per policy and provided with a cushion while seated in the Geri-chair as care planned for 1 of 29 sampled residents (Resident 191). These deficient practices have the potential to reopen previously healed pressure ulcers, develop new pressure ulcers, and compromise skin integrity.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a physician's order was followed for use of a cervical collar for 1 of 29 residents (Resident 82). The deficient practice may have resulted in increased discomfort to the resident due to poor alignment and positioning of head and neck.

Inspectors wroteBased on observation, interviews, record review, and document review, the facility failed to ensure the use of a full-length knee brace or immobilizer was identified, assessed, monitored, and care orders were obtained for 1 of 29 sampled residents (Resident 189). This deficient practice could have led to increased risk for falls, improper usage, or misuse of the knee brace, and compromise the resident's over all safety and well-being.

Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure: 1) The tube feeding (TF) (enteral nutrition via a tube to the stomach) was administered as ordered for 1 of 29 sampled residents (Resident 191), and 2) The head of bed was elevated during the TF administration, and the TF bottle had been in use for no longer than 24 hours per policy for 1 of 29 sampled residents (Resident 54). These deficient practices could pose risks such as malnutrition, dehydration, aspiration, and the potential exacerbation of underlying health conditions.

Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure Oxygen (O2) was administered as ordered for 2 of 29 sampled residents (Residents 4 and 131). This deficient practice could have led to serious health complications, including hypoxemia (low level of O2), O2 toxicity, and respiratory failure.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident's infection status was communicated with the dialysis provider for 1 of 29 sampled residents (Resident 99). The deficient practice placed dialysis staff members and patients at risk for transmission of Candida auris (C. auris).

Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure the pest control program was effective. The deficient practice had the potential of leading to a widespread infestation and having a negative impact on the residents of the facility. On 04/23/2024 at 8:05 AM during the initial tour of the kitchen, ants were discovered in large quantity on the side wall next to the dishwasher. The ants were in a line from a small hole in the kitchen wall near a seam and moving back and forth along the wall from the opening to the end of the wall by the food preparation station. On 04/23/2024 at 8:20 AM, the dietitian and maintenance director confirmed the presence of ants. On 04/26/2024 at 10:56 AM, the Dietary Manager indicated the maintenance director was responsible for the pest control program at the facility. [...]

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure the resident environment was free of accident hazards and there was adequate supervision to prevent accidents for two sampled residents (Resident 4, and Resident 9). The deficient practice resulted in injury to the residents.

Inspectors wroteBased on record review, interview, and document review, the facility failed to ensure a guardianship process was initiated for a resident with dementia and severely impaired cognitive skills for 1 of 10 sampled residents (Resident #6). This deficient practice could potentially deprive the resident's right to receive treatment and care for a dignified existence.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to provide documented evidence personal belongings of a discharged resident were returned to the resident's representative for 1 of 10 sampled residents. The deficient practice placed other discharged residents and resident representatives at risk for not recovering personal items.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure a care plan was revised after a fall incident for 1 of 10 sampled residents (Resident 5). The deficient practice had the potential to place the resident at risk for inappropriate care, supervision, and accidents.

Inspectors wroteBased on record review, interview, and document review, the facility failed to ensure a resident with severe cognitive impairment had a companion during an outpatient medical appointment for 1 of 10 sampled residents (Resident #6). The deficient practice had the potential to place the resident at risk for accident, injuries, or abuse.

Inspectors wroteBased on interview and document review the facility failed to follow physician's orders for 1 of 10 sampled residents (Resident 2). The deficient practice had the potential to adversely affect the resident's health and well-being.