Silsbee Oaks Health Care LLP

In the surveyor’s words

From the most serious findings on record at Silsbee Oaks Health Care LLP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision after a resident expressed suicidal ideations (she wanted to die). The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions for suicidal thoughts and attempts which could lead to residents sustaining serious injury or harm. […]

• Immediate jeopardy, isolatedF580Feb 3, 2023

  Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was an accident which resulted in injury and required physician intervention for 1 of 10 residents (Resident #1) reviewed for change of condition. Resident #1 was on an anticoagulant therapy and the facility did not: *consult with the physician when Resident #1 fell and hit her head sustaining a laceration to her head on [DATE] at 2:00 p.m. *consult with the physician when Resident #1 began vomiting at approximately 5:00 p.m. […]

• Immediate jeopardy, isolatedF684Feb 3, 2023

  Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 10 residents (Resident #1) reviewed for treatment and services. The facility did not consult with the physician or provide interventions when Resident #1 fell and hit her head and began vomiting approximately 3 hours after the fall on [DATE]. The resident was on anticoagulant therapy and was admitted to the hospital with a diagnosis of intracranial bleed on [DATE]. Resident #1 was admitted to Hospice services and died on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] The IJ template was provided to the facility on [DATE] at 5:35 p.m. […]

• No harm, potential for more than minimal, patternF640Jan 28, 2026

  Based on record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 3 of 3 residents reviewed for MDS transmission. (Resident #s #3, #87, and #98) The facility failed to complete and transmit a Discharge MDS assessment for Resident #3 within 14 days of completion.The facility failed to initiate and complete Discharge MDS assessments for Resident #s #87 and #98 within 14 days of discharge. These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.Findings included:1. […]

• No harm, potential for more than minimal, patternF908Jan 28, 2026

  Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.Findings included: During an observation and interview on 01/26/26 at 9:30 a.m., DM turned on the burners on the stove. 2 of 10 burners (front left first burner and the back third burner) did not light using their pilot lights. The stove did not have an odor of escaping gas. DM said sometimes the 2 burners were slow to light but had been lighting and she turned the 2 burners off. […]