The Lilac at Silver Palms

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure medications and biologics were properly stored in two out of two medication rooms (First floor and Second floor medication rooms). As evidenced by: Expired saline and sterile water on the second-floor treatment cart, eye drops observed at Resident # 5's bedside; ointment and medications observed in residents' rooms at bedside (Resident #7, Resident # 15, Resident #31, Resident #60, Resident #76 and Resident #108). Expired Intravenous (IV) start kits and alcohol pads found in the first-floor medication room, expired liquid Lansoprazole for Resident#4 in the second-floor medication room and expired insulin for Resident # 68 found in the first-floor medication cart. There were 94 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor residents right to a dignified experience for one (Resident #29) out of one sampled resident with an indwelling cholecystostomy drainage device as evidenced by observation of Resident # 29 receiving physical therapy and the cholecystostomy drainage collection bag was not inside a privacy bag and visible. There was one resident with a cholecystostomy drainage device residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect residents' personal information on one out of four medication carts as evidenced by: 1) facility's staff left paperwork with residents' personal medical information unattended on top of medication cart. 2) Facility's staff failed to close a computer screen before walking away and resident information visible on the second-floor nursing unit. There were three nursing units in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (Resident #68) out of one sampled resident receiving insulin injections as evidenced by documentation indicating expired insulin found on the first-floor medication cart was administered to Resident # 68.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure an environment free of accident hazards as evidenced by razor observed in Resident #7's room, 2) Resident #107 observed with heating pad; 3) Overfilled sharps container in Resident #29's room and 4) Unsecured door with interior lock on second floor south hallway. There were 94 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly position indwelling urinary catheter's tubing in a manner to promote free flow of urine for two ( Resident #29 and Resident #76) of two sampled residents with an indwelling urinary catheter as evidenced by: 1)Resident # 29's indwelling urinary tubing observed extending down and up through pants with urine in the tubing. 2) Resident # 76's indwelling urinary catheter tubing observed coiled with urine in the tubing. This deficient practice prevented urine from freely flowing, increasing the risk for catheter-associated urinary tract infections and other serious medical issues.

Inspectors wroteBased on observations, interviews and record review the facility failed to store food under sanitary condition and to ensure resident's food items were dated and labeled in the nourishment refrigerator on the Second Floor North Wing. This has the potential to affect 31 out of 35 residents who eat orally residing on the Second Floor North Wing out of 94 residents in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to collaborate and coordinate with hospice representative for one (#5) out of one sampled resident receiving hospice services as evidenced by: facility staff failed to obtain and keep nursing notes in the hospice folder for Resident#5 since December 2025 when Resident started with hospice. There were seven residents receiving hospice care residing in the facility at the time of survey.

Inspectors wroteBased on interview and record review, the facility failed to demonstrate effective plans of action were implemented to correctly identify repeated deficient practices in the problem areas of F880 Infection Prevention & Control, F689 Free of Accident hazards/Supervision/Devices, and F761Medication Storage. These deficient practices have the potential to affect 168 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow infection control protocol when storing medical equipment for two (#38, #46) out of two sampled residents as evidenced by: 1) Observation of an incentive spirometer not stored in a dated plastic bag. 2) Observation of an enteral syringe dated 2/16/26 stored at the bedside of Resident#46 for two days. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record reviews and interviews the facility failed to develop a comprehensive care plan for one (Resident #2) and failed to implement care plan for two (Resident # 6 and Resident # 7) out of seven sampled residents. As evidenced by a fall care plan was not developed for Resident #2 who is at high risk for falls; and staff failed to implement Care Plan interventions to prevent worsening of wounds for Resident # 6 and Resident #7.

Inspectors wroteBased on Observation and interview, the facility failed to implement infection control standards and procedures related to Soiled Utility Rooms. As evidenced by during focused observations the three Soiled Utility rooms in the facility were found to be unlocked. There were 98 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an environment free from accidents for Resident #24, as evidenced by, observations of electric and hand razors on the Resident # 24's nightstand. There were 98 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for one Resident (Resident #27) out of 25 sampled residents. As evidenced by, during several observations, Resident #27's oxygen was being administered via nasal cannula at the incorrect rate. There were 98 residents residing at the facility at the time of the survey.

Inspectors wroteBased on observation and interview, the facility failed to ensure the proper rotation of Dietary Medication supplements. As evidenced by, during observation of first floor's Medication Storage Room, two nutritional supplements were found to be expired. There were 98 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident #13) out of 16 sampled residents was not verbally abused by facility staff.

Inspectors wroteBased on record review and interview, the facility failed to provide bed hold policies upon discharge to the hospital for three Residents (Residents #4, #13 & #25) out of 16 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1) Hand hygiene was conducted between residents during dining and 2) The food service staff were wearing hair restraints properly. The certified nursing aide (CNA) was observed passing breakfast trays to residents without practicing hand hygiene and a Food Service Worker was serving on the lunch tray line without the hair net covering the entire head. This has the potential to affect fifty three residents out of fifty eight residents who eat orally residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewed, informed the residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements.

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewe. The binding arbitration agreements did not provide for the selection of a neutral arbitrator agreed upon by both parties.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident's dignity and respect for one (Resident #15) out of 16 sampled residents. As evidenced by a facility staff person standing while feeding a resident and calling residents who need assistance with eating, feeders.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for one (Resident #13) out of four residents whose clinical records were triggered and reviewed for written evidence of provision of information regarding formulating an advanced directive. There were 58 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure two residents (#12 & #301) out of 16 sampled residents were free from the use of physical restraints. As evidenced by resident's bed positioned in a concave position ( the head and foot of the bed were elevated) and one bedside chair was positioned on each side of the bed preventing the resident from getting out of the bed without assistance. There were 58 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the Quarterly Minimum Data Set (MDS) assessment was accurate related to Ostomy (including urostomy, ileostomy, and colostomy), for one (Resident #12) out of 16 residents sampled.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an enteral feeding was administered as prescribed and dated correctly for one (Resident #46) out of 16 sampled residents.