Silver Tree Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide appropriate supervision for Resident #1 resulting in Resident #1 leaving the facility without the facility's knowledge on 08/28/2025 between 1:20 and 1:40 AM and being found face down on the ground in the facility parking lot. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/28/25 and ended on 08/29/25. […]

• Immediate jeopardy, isolatedF580Apr 27, 2025

  Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there was a an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention, and or a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for notification to the physician. […]

• Immediate jeopardy, isolatedF684Apr 27, 2025

  Based on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed quality of care. On 4/20/2025, early morning, LVN A failed to provide quality care for Resident #1, by not following facility protocol for an unwitnessed fall with injuries to begin neurological assessments, reporting to the physician and the residents representative, when Resident #1 was discovered on the floor by her bedside and hospitalized for chronic heart failure with fluid overload in addition to fractures to right ribs 3rd, 7th and 9th ribs, 3… […]

• Immediate jeopardy, isolatedF686Dec 22, 2023

  Based on interviews and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of pracxtice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure sores in that: The facility failed to acquire and administer treatment to resident #1's sacral wound when it deteriorated to a Stage 3 on 09/25/2023 until 10/01/2023 and did not send her out of the facility for further care when her pressure sore… […]

• Actual harm, isolatedF689Sep 15, 2021

  Based on record review, interview, and review of the facility's policy, the facility failed to safely transfer a resident (R)5 from the bed to the shower chair using a mechanical lift, which resulted in a fall from the lift that required six sutures over her eye and failed to address the potential for R4's feet to slide from the foot rest when in his wheelchair for two of four sampled residents reviewed for supervision to prevent accidents in a total sample of 12 residents. Findings include: 1. Review of the facility's document titled, Task # 774 dated 07/06/21, included general guidelines for mechanical lift inspections that included 12 areas. Item 5 of the Task included, Inspect the swivel bar, check bolts/hooks for damage or wear, check sling hooks for bends or deflection. […]