Silver Lake Specialized Rehabilitation and Care Ce

In the surveyor’s words

From the most serious findings on record at Silver Lake Specialized Rehabilitation and Care Ce, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure each residents received adequate supervision to prevent accidents. This was evident for one (1) (Resident #105) of four (4) residents reviewed for accidents out of 35 total sampled residents. Specifically, on 06/04/2025, Resident #105, who had severe cognitive impairment and had a history of multiple falls, had an unwitnessed fall from a wheelchair when the resident was left in the hallway without supervision. Resident #105 sustained a head laceration and was transported to the hospital and subsequently diagnosed with a cervical fracture. […]

• No harm, potential for more than minimal, patternF584Apr 16, 2026

  Based on observation, record review, and interviews, the facility failed to provide a clean, comfortable, and homelike environment for the residents. Specifically, housekeeping and maintenance services were not maintained in four (4) (Units 1A, 3A, 3B, and 4A) of seven (7) resident units.The findings include: The following were observed from 04/09/2026 through 04/15/2026:1. The wallpapers in room [ROOM NUMBER]-A, 103-B, and 105-B were peeling from behind the headboard.2. There was a hole on the wall behind the bed in room [ROOM NUMBER]-A.3. The light fixture in the residents' shower room on the 4th Floor Unit 4-B was hanging from the ceiling. […]

• No harm, potential for more than minimal, patternF656Apr 16, 2026

  Based on record review and interviews, the facility failed to ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs were created and implemented for each resident. This was evident for one (1) of five (5) residents reviewed for Unnecessary Medications, and two (2) of two (2) residents reviewed for Care Planning out of 35 total sampled residents. Specifically, Resident #187, Resident #41, and Resident #92 were taking anticoagulant or antiplatelet medications that carried an increased risk of bleeding and comprehensive care plans were not implemented to address the risk of bleeding associated with the medication use.The findings include:The facility policy and procedure… […]

• No harm, potential for more than minimal, patternF657Apr 16, 2026

  Based on observation, record review and interviews, the facility failed to ensure that residents' Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, and revised based on changing goals, preferences, and needs of the resident. This was evident for one (1) of four (4) residents reviewed for Respiratory Care, and one (1) of two (2) residents reviewed for Falls out of 35 total sampled residents. Specifically, 1.) Resident #91's Respiratory Care Comprehensive Care Plan was not updated after their Quarterly Minimum Data Set Assessment, and 2.) Resident #105's Falls Comprehensive Care Plan interventions were not reviewed and updated after enduring multiple falls in the facility. […]

• No harm, potential for more than minimal, patternF887Apr 16, 2026

  Based on observation, record review, and interviews, the facility failed to ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases. Specifically, the facility failed to provide documentation of screening, administration or declination, and education of the COVID-19 vaccination for nine (9) of ten (10) staff members reviewed for COVID-19 vaccinationsThe findings include:The facility's policy and procedure titled Immunization Recommendation for Health Care Professions with a reviewed date of 01/2026 documented that up-to-date COVID-19 vaccinations are recommended by the Centers for Disease Control but are not mandatory.During the Recertification Survey, the facility failed to provide documentation that COVID-19… […]