Silver Bluff

In the surveyor’s words

From the most serious findings on record at Silver Bluff, in the surveyor’s own words.

• Immediate jeopardy, isolatedF561Jun 12, 2023

  Based on record review, observation, resident, staff, and family interviews, the facility failed to honor a resident's (Resident #49) right to choose their preferred method of bathing and the resident's right to refuse a shower. On 4-22-23, Resident #49 had refused her shower three times and on the third refusal Nurse #1 was informed of Resident #49's refusal to take a shower. Nurse #1 informed Nursing Assistant (NA) #1 and NA #2 that the resident had to take a shower regardless of Resident #49's refusal. Nurse #1 and 5 NAs (NA #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and stating she did not want to get out of bed and have a shower, out of the bed, into a shower chair and into the shower. […]

• Immediate jeopardy, isolatedF600Jun 12, 2023

  Based on record review, staff, family and resident interviews, the facility failed to protect Resident #49's right to be free from physical and emotional abuse for one of two sampled residents reviewed for abuse. On 4-22-23 Resident #49 had refused a shower three times and on the third refusal, six staff members (Nurse #1, Nursing Assistant (NA) #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and pushing staff away, out of bed and into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the high likelihood of suffering other serious physical and psychosocial harm. […]

• No harm, potential for more than minimal, patternF812Jan 8, 2026

  Based on observations and staff interviews, the facility failed to dispose of food stored past the use by date in 1 of 3 refrigerators (walk-in refrigerator). Furthermore, the facility failed to maintain clean air vents located directly above the kitchen's tray line free from gray debris and practice hand hygiene during tray line service for 1 of 4 kitchen staff (Kitchen Staff #1) observed in the kitchen. The deficient practice had the potential to affect food served to residents. Findings included:a. On 1/5/26 at 10:34 AM an observation was conducted in the walk-in refrigerator with the Dietary Manager. An opened 1-gallon container of soy sauce was observed on the top shelf of a storage rack. The container contained a written date 6/11 -12/11. […]

• No harm, potential for more than minimal, patternF761Nov 7, 2024

  Based on observation, staff interviews and record reviews, the facility failed to secure an unopened vial of inhaler and an opened tube of ointment in the medication cart for 1 of 1 room (room [ROOM NUMBER]), failed to date an opened bottle of eye medication and 7 opened pens of insulin for 3 of 6 medication carts (200 halls, 300 halls, and 400 halls), and failed to lock 1 of 6 medication carts during observations for medication storage audits (300 halls). The findings included: a. During a medication storage audit conducted on 11/04/24 at 10:51 AM, 1 vial of unopened ipratropium-albuterol (DuoNeb) solution and an opened tube of zinc oxide ointment were found sitting on Resident #73's bedside table and ready to be used. […]

• No harm, potential for more than minimal, isolatedF686Jan 8, 2026

  Based on observation, record review, and interviews with the Wound Care Nurse Practitioner (NP), Medical Director (MD) and staff, the facility failed to follow up when a Wound Care NP recommended the staff contact the primary care provider about the condition of the wound and if antibiotics needed to be ordered for a resident who showed symptoms of a wound infection. This deficient practice affected 1 of 2 residents reviewed for pressure ulcers (Resident #11).Findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, type-2 diabetes mellitus, hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following a cerebral infarction affecting… […]