Silver Heights Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Silver Heights Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF677Feb 3, 2022

  Based on observations, record review and interviews the facility failed to provide four (#3, #5, #6, #15) of five residents the necessary services to maintain good nutrition, grooming and personal hygiene out of 20 sample residents. Specifically, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) assistance and needed two person assistance, were provided these services to ensure residents appearances were maintained, and the residents were presentable. Resident #3, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was totally dependent on one person for eating assistance. […]

• Actual harm, isolatedF550May 6, 2021

  Based on observations, record review and interviews, the facility failed to provide care in manner which promoted dignity and respect for one resident (#48) of two reviewed out of 32 sample residents. Resident #48 was dependent on staff for toileting. Resident #48 was left soiled with bodily fluids for over 15 hours when her bed broke and staff failed to perform incontinence care, a human right. The delay in care left the Resident #48 feeling anxious (requiring a breathing treatment), distressed, fearful and undignified. She had to eat breakfast and lunch while sitting in urine socked brief and sheets with fecal matter (see resident interview below). The resident said she felt like she was treated like an animal by the staff the way she had been left. […]

• Actual harm, isolatedF600May 6, 2021

  Based on observation record review and interviews, the facility failed to ensure all residents were free from abuse, neglect, and exploitation, for one (#48) of two residents out of 32 sample residents. Resident #48 was dependent on staff for toileting. The facility failed to implement all possible interventions to prevent a neglectful situation where Resident #48 was left soiled with bodily fluids for over 15 hours when her bed broke and staff failed to perform incontinence care, resulting in wound injuries to the skin (see physician's wound care note 5/6/21), pain and short-term emotional distress. […]

• Actual harm, isolatedF684Mar 9, 2021

  Based on record review and interviews, the facility failed to ensure treatment and care were provided in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents choices for one (#1) out of five sample residents. The facility failed to ensure Resident #1 received a needed anticoagulant medication which was discontinued by a nurse practitioner without reason or notification. Due to the facility failures, it led to Resident #1 developing a [MEDICAL CONDITION] embolism which required hospitalization (see hospital records under record review). Findings include: I. Facility policy and procedure The Physician Services policy, dated April 2013, was provided by the nursing consultant (NC) on 3/9/21 at 12:30 p.m. […]

• No harm, potential for more than minimal, widespreadF880Oct 19, 2023

  Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included in the facility's water management plan. Findings include: I. […]