Silver Stream Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF755Aug 26, 2022

  Based on review of facility document, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that medications were delivered and by the contracted pharmacy to be administered to a newly admitted resident (Resident R1) resulting in Resident R1 experiencing an uncontrollable seizure requiring transfer via emergency medical services and hospitalization into the intensive care unit for the treatment of seizures. This failure resulted in an Immediate Jeopardy situation for one of five residents reviewed (Resident R1). […]

• Immediate jeopardy, isolatedF760Aug 26, 2022

  Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to ensure that seizure medications were administered as ordered by the physician to Resident R1, resulting in a significant medication error causing Resident R1 to experience an uncontrollable seizure, requiring transfer via emergency medical services and hospitalization into the intensive care unit for the treatment of seizures. This failure resulted in an Immediate Jeopardy situation for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Administering Medications, not dated, revealed medications shall be administered in a safe and timely manner, as prescribed. […]

• Actual harm, isolatedF689Jun 13, 2022

  Based on clinical record review and interviews with staff, it was determined that the facility failed to supervise and monitor a resident with a known history of self-harm when he cut himself with a razor blade which caused harm to a resident (Resident R59) and the facility failed to supervise a resident with a history of wandering for one of thirty-three sampled residents (Resident R232). Findings include: A review of Resident R59's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis that included [CONDITION(S)] ([CONDITION(S)]), Impulsive disorder (inability to control urges), Major Depressive disorder (persistent feelings of sadness), [CONDITION(S)] (hallucinations, delusions and disorganized thoughts), [CONDITION(S)] disorder (combination of… […]

• No harm, potential for more than minimal, widespreadF908Dec 12, 2024

  Based on observations of the Food and Nutrition Services Department, interviews with residents and staff, reviews of clinical records and policies and procedures, it was determined that essential pieces of food service equipment used for the transportation, holding and delivery of hot foods from the dietary services department to the nursing units, resident rooms and dinning areas were not in use, to ensure consistently safe and satisfactory food temperatures of foods for the residents. […]

• No harm, potential for more than minimal, widespreadF812Feb 27, 2024

  Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The undated Policy: Food Storage Policy, states, he Food Service Director and/or Cook(s) will insure that all food items are stored properly, covered containers must be airtight, labeled and dated using a two date system (prepared date and use by date). An initial tour of the Food Service Department was conducted on February 21, 2024, at 9:15 a.m. […]