VI at Silverstone, a VI and Plaza Companies Commun

Inspectors wroteNumber of residents sampled: 2 Number of residents cited: 2 Based on observation, staff interviews, clinical record review, review of facility's documents and policy, the facility failed to ensure that its medication error rate was not greater than 5 percent. Observed 2 medication errors out of 25 which resulted in an 8 percent error rate. The deficient practice could result in residents receiving medications inappropriately and could place the residents at risk for health illnesses.

Inspectors wroteNumber of residents sampled: facility staffNumber of residents cited: facility staff Based on staff interviews and review of facility documentation and policy, the facility failed to ensure that 3-staff members (#44, #168, #182) received training on emergency preparedness. The deficient practice could result in staff inappropriately trained regarding emergency preparedness and could place the residents and other individuals at risk for their health and safety.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to ensure that 3-staff members (#44, #168, #182) received annual training on resident rights. The deficient practice could result in staff inappropriately trained regarding resident rights and could place the residents at risk for their safety.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to ensure that 2-staff members (#44, #182) received annual training on abuse, neglect and exploitation. The deficient practice could result in staff inappropriately trained regarding abuse, neglect and exploitation and could place the residents at risk for their safety.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to ensure that 4-staff members (#44, #92, #168, #182) received annual training on infection control. The deficient practice could result in staff inappropriately trained and could place the residents at risk for infection.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to ensure that 3-staff members (#44, #168, #182) received annual training on behavioral health training related to dementia care. The deficient practice could result in staff inappropriately trained regarding behavioral health training related to dementia care and could place the residents at risk for their health and safety.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, facility documentation, and policies and procedures, the facility failed to develop and implement a care plan for one resident (#5) regarding rehabilitation services. The deficient practice could result in the residents' care and services not being met according to their assessed needs so that the resident can attain or maintain his or her highest practicable physical, mental and psychosocial well-being. The universe was 18 and the sample size was 1.

Inspectors wroteBased on review of the clinical record, resident and staff interviews, observations, facility documentation, and policy and procedure, the facility failed to ensure the comprehensive care plan for one resident (#5) was reviewed and revised to meet the resident's needs regarding occupational therapy services. The deficient practice could result in care or services that do not meet residents' needs. The universe was 18 and the sample size was 1.

Inspectors wroteBased on record review, resident and staff interviews and observations, the facility failed ensure proper nail care was provided for one resident (5). The deficient practice could result in grooming and hygiene needs not being met. The universe was 18, and the sample size was 1.

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#5) was provided with occupational therapy treatment and services per physician orders in accordance with professional standards of practice. The deficient practice could result in care or services resulting in an actual or potential decline in residents' physical, mental, and/or psychosocial well being. The universe was 18 and the sample size was 1.

Inspectors wroteBased on clinical record review, staff interviews, observations, facility documentation, and policy and procedure, the facility failed to ensure rehabilitation services were provided as ordered for one resident (#5). The deficient practice could result in residents not receiving therapy services to maintain function and prevent further decline. The universe was 18 and the sample size was 1.

Inspectors wroteNumber of residents sampled: 1 Number of residents cited: 1 Based on record review, staff interviews, review of facility documents and policy, the facility failed to maintain accurate documented medical records for 1 resident's advance directives (#3) in accordance with accepted professional standards and practice. The deficient practice could result in residents' medical records not having accurate documents.

Inspectors wroteBased on observations, record reviews, staff interviews, and review of facility policy and procedures, the facility failed to ensure a blood pressure cuff and monitor were properly sanitized after each resident use. The deficient practice could result in transmission of infection in the facility.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure discharge MDS assessment was completed for one sampled resident #12. The deficient practice could result in not having resident specific information for payment and quality measures purposes.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure that medications were discarded according to the standard of practice. The deficient practice could result in medication misappropriation, medications being used by other residents or staff.

Inspectors wroteBased on clinical record review, staff and resident interviews, and observation of current practice the facility failed to ensure resident #1 was free from abuse from an employee. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse.