Silver Oaks Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Silver Oaks Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF693Apr 18, 2024

  Based on observation, interview and record review, the facility failed to clarify orders for the correct flush amount to be administered before and after medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube to decrease the potential for harm for 1 (Resident #52) of 2 sampled residents with a PEG tube. The findings are: Resident #52 had diagnoses of dysphagia (difficulty swallowing), following cerebral infarction (disruption of blood flow to the brain) and encounter for attention to gastrostomy (a medical procedure where a tube is inserted into the stomach). […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered and dated, failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, the door frames, and ceiling tiles were free of chipped, holes, paint peeling, rust, stains. dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 89 residents who received meals from the kitchen. The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF812Oct 29, 2021

  Based on observation, record review and interview, the facility failed to ensure dietary staff and Certified Nursing Assistants washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 2 of 2 kitchens. The failed practice had the potential to affect 82 residents who received meals from the 2 kitchens (total census: 83), as documented on a list provided by the Dietary Supervisor on 10/29/2021. The findings are: 1. On 10/27/21 at 4:38 PM, Dietary Employee (DE) #1 used a knife to open a bag of Potato Crunch [NAME]. Without washing her hands, she picked up a glove from the glove box and placed it on her right hand, contaminating the glove in the process. […]

• No harm, potential for more than minimal, patternF641Jun 5, 2025

  Based on observations, interviews, record review and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for 3 (Resident #47, #10, and #87) of 5 residents reviewed for accuracy of MDS assessments. The findings include: Resident #47 Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2025, indicated Resident #47 had diagnoses which included schizophrenia, anxiety, and depression. The MDS also revealed a score of 13 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Resident #47 received an antipsychotic medication. […]

• No harm, potential for more than minimal, patternF880Jun 5, 2025

  Based on observations, interviews, record reviews, and facility policy review, it was determined that the facility did not ensure proper hand hygiene was used during medication administration for 1 (Resident #238) of 3 residents observed for medication administration, 1 (Resident #39) of 1 resident observed for proper incontinent care technique, and feeding assistance for 1 of 2 meal services observed. The findings include: On 06/02/25 at 12:30 PM, during dining observation, this surveyor observed Certified Nursing Assistant (CNA) #5 assisting residents during meal service. CNA #5 touched both residents, the table, one resident ' s wheelchair, his hair, and picked a spoon up off the floor all without washing or sanitizing his hands before assisting residents with dining. […]