Complete Care at Silver Lake LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Silver Lake LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 23, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent residents from sustaining injuries from falls and/or a burn from hot water for three (Residents (R) 40, R96, and R38) of eight sampled residents reviewed for accidents out of a total sample of 32. R40 was assessed to require two staff members for bed mobility; however, the resident was repositioned by one staff member and slid out of bed, which resulted in actual harm of bilateral femur fractures. R96 suffered actual harm of second degree burns when water, which had been heated in the microwave for three to four minutes, spilled on her. […]

• Actual harm, isolatedF684Dec 9, 2022

  Based on interview, record review, and review of other documentaion as indicated, it was determined that for one (R211) out of one resident sampled for hospitalization , the facility failed to complete a comprehensive respiratory assessment, monitor, and provide respiratory interventions for a resident recognized as having an acute change in respiratory status. R211 was caused further distress when she remained without supplemental respiratory interventions (oxygen) until EMS (Emergency Medical Services) implemented interventions upon arrival at the facility. […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, interview, document review, and policy review, the facility failed to ensure chicken salad sandwiches were served at the proper temperature. This deficient practice had the potential to affect 112 out of 114 residents.Findings included:During the second kitchen observation and interview on 01/22/26 from 11:54 AM to 12:15 PM, the following were made with the Dietary District Manager (DDM):A steam table pan was observed on the counter at the left end of the steam table. The steam table pan contained approximately 20 chicken salad sandwiches, stacked one on top of one another. At 12:05 PM the chicken salad sandwiches were being served on the tray line for room trays. […]

• No harm, potential for more than minimal, widespreadF925Jan 23, 2026

  Based on observation, interview, and policy review, the facility failed to ensure the kitchen area was free from fruit flies. The facility failed to keep the kitchen clean and ensure bait boxes remained under the three compartments sink to deter pests as recommended by their pest control provider. This created the potential for the harborage of insects and vermin which had the potential to affect 114 out of 114 residents.Findings included:1. During the initial kitchen observation and interview on 01/20/26 from 9:30 AM to 9:54 AM, the following observations were made with the Dietary Manager (DM):a. The smaller three compartment sink in the corner of the kitchen, near the hand-washing sink, had approximately 15-20 fruit flies near the floor on the right side of the sink. […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2025

  Based on observation, interviews, and facility policy review, the facility failed to ensure cold storage units contained interior temperature gauges, kitchen floors and walls were kept clean and in good repair, and leftovers were cooled down correctly, in one of one kitchen. This deficient practice had the potential to affect 107 of 107 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness. Findings include: Review of the facility's policy titled, Sanitation Inspection, revised 03/29/23, revealed It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 1. […]