Silver Oak Nursing and Rehabilitation Center LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 22, 2024

  Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to complete accurate evaluation, failed to implement interventions and failed to prevent a staff member from allowing an exit seeking cognitively impaired resident from leaving the facility at 5:40 AM, walking down the street around the corner, down a main road 0.3 miles (1584 feet) and being outside in below freezing temperatures for 20 minutes. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The Facility reported a census of 67 Residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on February 19, 2024 on February 20, 2024 at 10:45 a.m. […]

• Actual harm, isolatedF689Oct 5, 2023

  Based on clinical record review, observation, and staff interviews, the facility failed to adequately provide supervision to keep one of three residents safe from an accident with injury (Resident #6). While providing care to a resident in bed who required extensive assistance of two persons with bed mobility, they completed the task with only one person. As they rolled Resident #6, he fell out of bed, and received a hip fracture. In addition, the facility failed to lock the medication cart while unsupervised. During the time the lock remained unlock, at least one resident sat need the medication cart. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. […]

• Actual harm, isolatedF697Oct 5, 2023

  Based on clinical record review, observations, staff and resident interviews the facility failed to provide pain medications for 1 of 10 residents reviewed (Resident #3). Resident #3 missed 14 doses of fentanyl (pain medication) patch. The documented assessments revealed that she had an increase in pain from not every day and mild to everyday and moderate. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. Resident #3 required extensive assistance with dressing and total assistance for transfers, personal hygiene, and bathing. The MDS indicated that Resident #3 did not walk and utilized a wheelchair to move about the facility. […]

• Actual harm, isolatedF684Jan 31, 2023

  Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide adequate nursing assessments for two of three residents reviewed (Residents #2 and #6). On 12/21/22, when Resident #2 admitted to the facility. On 12/23/22, Resident #2 discharged to the hospital. Between Resident #2's admission and discharge, the facility failed to complete and document assessments on his condition at the time. When Resident #2 discharge from the facility to the hospital, he got admitted to the ICU. On 1/20/23, Resident #6 dropped hot chocolate with an unknown temperature on her abdomen and thigh resulting in second to third degree burns. Following the incident, the staff reported that Resident #6 had complained of pain. […]

• Actual harm, isolatedF689Jan 31, 2023

  Based on clinical record review, facility policy review, staff, and resident interviews the facility failed to adequately supervise one of three residents (Resident #3), to prevent an elopement and a subsequent fall with injury. The facility reported a census of 52 residents. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS indicated that Resident #3 could be independent with ambulation, transfers, personal hygiene, and toilet use. The MDS included diagnoses of tobacco use, anemia, anxiety and depression. Resident #3 use an antianxiety medication for five out of the seven days in the lookback period. […]