Silver Oaks Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 9, 2024

  Based on observation, record review, and interview, the facility failed to prevent a fall during care that resulted in a fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: During an observation on 09/09/24 at 2:31 P.M., Resident B was lying in bed with his call light in reach. The resident was lying on an air mattress and there were no side rails or grab bars on the bed. The resident's bed was located by the door. The resident's bathroom door was located on the far side of the room by the other resident's bed. The clinical record for the Resident was reviewed on 09/09/24 at 10:33 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/17/24, indicated the resident was severely cognitively impaired. […]

• Actual harm, isolatedF687May 8, 2024

  Based on interview, observation, and record review, the facility failed to ensure a resident did not acquire a burn during care. This deficient practice resulted in Resident B sustaining a second-degree burn (a mild to moderate burn caused by heat, chemical, or light source and damages the outer and second layer of skin) on the left foot. (Resident B) Findings include: An Annual MDS (Minimum Data Set) assessment, dated 02/08/24, indicated Resident B was cognitively intact. The diagnoses included, but were not limited to, traumatic spinal cord dysfunction, quadriplegia, hypertension, and neurogenic bladder. The resident required extensive staff assistance with all ADL (Activities of Daily Living). […]

• Actual harm, isolatedF641Nov 1, 2022

  Based on record review and interview, the facility failed to accurately document a medication error in detail and the full assessment for a medication error in the resident's clinical record for 1 of 3 residents reviewed for accuracy of assessment. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/31/22 at 10:11 A.M. An Admission MDS (Minimum Data Set) assessment, dated 08/22/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, sepsis, cancer, anemia, hypertension, anxiety, depression, and respiratory failure. The resident required the extensive assistance of two physical staff for bed mobility. […]

• No harm, potential for more than minimal, patternF761Apr 14, 2023

  Based on observation and interview the facility failed to label and store and medications appropriately for 4 of 5 medication carts reviewed. (200 Hall Medication Cart, 600-1 Medication Cart, 600-2 Medication Cart, and 100 Hall Medication Cart) Findings include: 1. The 200 Hall Medication Cart was observed on 04/10/23 at 10:38 A.M., with LPN (Licensed Practical Nurse) 9 and contained the following: - a Humalog insulin vial with no opened date for Resident 102 that was 1/2 full. The Humalog vial had a received date from the pharmacy of 04/05/23. The LPN indicated the insulin pen should have had an opened date written on it, and it was good for 28 days. 2. […]

• No harm, potential for more than minimal, isolatedF558May 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure call light accessibility for a resident with a history of frequent falls for 1 of 17 residents reviewed for accommodation of needs. (Resident 61)Findings include:On 05/08/2026 at 2:20 P.M., during an observation, the resident was seated in his recliner with his eyes closed. The recliner control was next to him, but the call light was on the floor behind the wheelchair, approximately six feet away.On 05/08/2026 at 2:52 P.M., during another observation, the resident remained seated in the recliner with his eyes closed, and the call light continued to be located on the floor behind the wheelchair, six feet away. […]