The Lilac at Silver Palms

In the surveyor’s words

From the most serious findings on record at The Lilac at Silver Palms, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 6, 2023

  45019 Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of three residents sampled with exit seeking behaviors. This deficient practice led to Resident #1 exiting the facility undetected at approximately 5:45AM on 5/22/23. The facility's lack of adequate supervision and failure to ensure an adequate and effective alert monitoring system was in place enabled the resident to elope undetected by staff on 5/22/23 at approximately 5:45 AM. The resident was located at approximately 7:23 AM on 5/22/23 by law enforcement at a local high school 1.7 miles away from the facility. […]

• Immediate jeopardy, isolatedF835Jun 6, 2023

  Based on observations, record reviews and interviews, the facility's administration failed to implement, provide and to ensure effective and efficient preventative measures were in place to prevent the elopement of one resident (Resident #1) out of three residents sampled who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure an emergency exit door was able to be opened by staff promptly, ensure the exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to implement the assigned level of supervision for resident #1 who was a high risk for elopement. […]

• Actual harm, isolatedF600Sep 14, 2023

  Based on observation, interview and record review, the facility failed to ensure one (Resident #13) out of 16 sampled residents was not verbally abused by facility staff. The findings included: Record review of the facility's Abuse, Neglect and Exploitation Policy and Procedure dated 10/1/2022 included, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. […]

• No harm, potential for more than minimal, patternF761Feb 20, 2026

  Based on observations, record review, and interviews, the facility failed to ensure medications and biologics were properly stored in two out of two medication rooms (First floor and Second floor medication rooms). As evidenced by: Expired saline and sterile water on the second-floor treatment cart, eye drops observed at Resident # 5's bedside; ointment and medications observed in residents' rooms at bedside (Resident #7, Resident # 15, Resident #31, Resident #60, Resident #76 and Resident #108). Expired Intravenous (IV) start kits and alcohol pads found in the first-floor medication room, expired liquid Lansoprazole for Resident#4 in the second-floor medication room and expired insulin for Resident # 68 found in the first-floor medication cart. […]

• No harm, potential for more than minimal, patternF880Jan 30, 2025

  Based on Observation and interview, the facility failed to implement infection control standards and procedures related to Soiled Utility Rooms. As evidenced by during focused observations the three Soiled Utility rooms in the facility were found to be unlocked. There were 98 residents residing in the facility at the time of the survey. The findings included: On 01/28/25 at 10:09 AM Focus tour with the surveyor and Registered Nurse Infection Control Preventionist -The two soiled utility rooms on the second floor and the soiled utility room on the first floor were observed to be unlocked. […]