Sylan Shores Health and Wellness

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #3 and Resident #6) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #3's fall on 10/09/2025 and Resident #6's fall on 11/07/2025 were in their respective care plan s. This failure placed residents at risk of not receiving appropriate care and interventions to meet their needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 111 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from sexual abuse when Resident #1's was kissed by CNA A and her hand came in to contact with CNA A's penis on 7/13/25. The noncompliance was identified as Past Non-Compliance immediate jeopardy (IJ). The IJ began on 7/13/25 and ended on 7/17/25. The facility corrected the noncompliance before the survey began. This failure placed facility residents at risk of experiencing abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives an accurate assessment reflecting the resident's status for 3 of 23 residents reviewed for assessment accuracy (Residents #7, #58, #63, #99). Bed rails used for positioning and turning were coded on the MDS as physical restraints for Residents #7, #58, #63, #99. These failures placed residents at risk of having inaccurate assessments and receiving improper care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 1 medication fridges and 1 of 4 medication carts reviewed for storage. The facility failed to ensure that medication fridges and medication carts were free of expired medications. The failure could place residents at risk of receiving expired medications.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure each resident was treated with respect and dignity, and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #10) reviewed for resident's rights, in that: -Resident #10 whose bedsheet was pulled over her face during incontinence care, while she was crying, was not treated with dignity or respect in her own room. This failure placed residents who are totally dependent on staff for incontinence care, at risk for having feelings of poor self-esteem, decreased self-worth, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #15) of 5 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency, an incident of neglect regarding Resident #15, after she had an unwitnessed fall in her room with a possible injury to her hip that occurred on 6/21/24. The unwitnessed fall later revealed through x-ray, Resident #15 had a left femur fracture, and it was not reported to the state until 06/25/2024 which was four days after the incident occurred. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 18 residents (Resident #66) reviewed for their right to voice grievances to the facility. The facility failed to report and document Resident #66's complaint about her hearing aids that stopped working after a shower. This failure could place residents at risk for harm by not having their grievances addressed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #6, #61 and #66) of 24 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #6 was coded in the MDS for a fall. The facility failed to ensure Resident #61 was coded correctly in the MDS for a fall. The facility failed to accurately assess Resident #66 for her cognitive patterns (mental capacity) on her admission MDS assessment. These failures could place residents at risk of not having all medical needs assessed and met. Findings Included: Resident #6 Record review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 2 errors out of 25 opportunities which resulted in an 8% error rate involving 1 of 4 residents (Resident #89) and 1 of 3 employees (MA A) observed during medication administration reviewed for medication error, in that: -MA A gave Resident #89 an incorrect dose of her Famotidine and antacid and antihistamine medication. -MA A gave Resident #89 an incorrect dose of her Tylenol a pain relieving and fever reducing medication. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 4 of 13 residents (Resident #6, Resident #72, Resident #78, and Resident #105) reviewed for pharmacy services. MA A failed to administer Morphine, a pain medication, to Resident #6 within the scheduled administration window. The facility failed to ensure the Medication Room did not contain expired IV medications for Residents #78 and #105. The facility failed to ensure the 400 hall nursing cart did not contain expired Insulin and supplements for Resident #72. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 22 percent based on 8 errors out of 36 opportunities, which involved 4 of 8 residents (Resident #24, Resident #39, Resident #60 and Resident #69) reviewed for medication errors. - MA B failed to administer medication as ordered to Resident #60 by administering Artificial Tears containing Glycerin, Hypromellose and Polyethylene Glycol instead of Artificial Tears containing Carboxymethylcellulose. - MA B failed to administered medication as ordered to Resident #24 by administering Lidocaine 4% Patch, a patch used for pain, instead of Lidocaine 5% and applied the patch to the right knee instead of right rib cage. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (400 Hall Nursing Cart and 200 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 400 Hall Nursing Cart did not contain insulin pens with no open date - The facility failed to ensure the 200 Hall Nursing Cart did not contain insulin pens with no pharmacy labels. This failure could place residents at risk of adverse medication reactions. Findings Included: 400 Hall Nursing Cart Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, a [AGE] year-old male admitted on [DATE] with diagnoses which included: [...]

Inspectors wroteintake ID # 418120\TX00452588 Based on interview and record review, the facility failed to coordinate the PASRR assessment for specialized services for 1 of 4 resident reviewed for PASRR coordination and assessment. (Resident #75) The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #75's OT, PT, and ST specialized services by a specific deadline. This failure could place residents with intellectual and developmental disabilities at risk for not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for 1 of 14 residents (Resident #61) reviewed for professional standards: The facility failed to ensure Resident #61 had an active physician order for her Wander guard device. A Wanderguard is a safety device placed on an individual who is high risk for unsafe wandering that alerts the responsible party when that individual attempts to exit a building/designated area. This failure to meet professional standards of entering and following physician orders could place residents at risk for inadequate care or inadequate monitoring.

Inspectors wroteIntake ID #418036\TX00453051 Based on observation, interview, and record review, the facility failed to provide supervision to each resident to prevent accidents for 1 of 6 residents (Resident #61) reviewed as part of sample. The facility failed to ensure that all facility exit doors were secured to prevent unsupervised wandering of residents out of the facility. This failure could place wandering residents at risk for being lost or harmed.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 15 residents (Resident #6) whose records were reviewed. - MA A failed to document administration of Morphine ER 15 mg, an opioid used to treat pain, until 1 hour and 20 minutes after administration. These failures could place residents at risk for inadequate errors leading to medication errors and adverse reactions. Findings Included: Record review of Resident #6's Face Sheet dated 04/12/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: motor and sensory neuropathy (nerve pain), opioid dependence, legal blindness and absence of right and left leg below the knee. [...]