Villages At Historic Silvercrest The

Based on record review and interview, the facility failed to ensure residents were treated with dignity and respect for 1 of 12 residents reviewed for dignity. (Resident 52) Findings include:The record for Resident 52 was reviewed on 7/25/2025 at 9:56 a.m. The resident's diagnoses included, but were not limited to, arthrodesis status, cervical disc disorder with myelopathy of the cervical region, spondylosis with radiculopathy of the lumbar region, spinal stenosis of the lumbar region with neurogenic claudication, stage 3 chronic kidney disease, pulmonary fibrosis, severe morbid obesity, and anxiety disorder. The care plan, dated 6/2/25, indicated the resident was at risk for pain related to spinal stenosis, cervical fusion, and radiculopathy. The interventions, dated 6/2/25, included, but were not limited to, administer medications as ordered and notify the physician for any side effects observed or the lack of effectiveness, attempt non-pharmacological interventions, notify the physician of increased pain, observe for and record verbal and non-verbal signs of pain, and reposition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure narcotics were administered by physician's order, to obtain nursing permission, or document the narcotic count was accurate for 1 of 25 residents reviewed for medication administration. (Resident 52) Findings include:The record for Resident 52 was reviewed on 7/25/2025 at 9:56 a.m. The resident's diagnoses included, but were not limited to, arthrodesis status, cervical disc disorder with myelopathy of the cervical region, spondylosis with radiculopathy of the lumbar region, spinal stenosis of the lumbar region with neurogenic claudication, stage 3 chronic kidney disease, pulmonary fibrosis, severe morbid obesity, and anxiety disorder. The care plan, dated 6/2/25, indicated the resident was at risk for pain related to spinal stenosis, cervical fusion, and radiculopathy. The interventions, dated 6/2/25, included, but were not limited to, administer medications as ordered and notify the physician for any side effects observed or the lack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment, related to the ovens, were properly cleaned and maintained to prevent a fire from occurring. This deficient practice had the potential to affect 36 of 36 residents currently residing on the skilled nursing units. Findings include: Review of the State Complaint Report, dated 4/3/25, indicated at 5:00 a.m., a fire occurred in the right-side oven in the first-floor main kitchen. A hand-held fire extinguisher was utilized by the cook and the fire was put out. The local Fire Department arrived a few minutes later. Upon inspection of the oven, it was clean, but the Director of Food Services discovered a panel in the bottom of the oven that could be removed and cleaned. Some grease was seen on the panel and the bracket which held the panel. During an interview, on 4/15/25 at 9:45 a.m., the [NAME] 1, who was also present the day of the fire, indicated the fire happened the day after all the big storms at around 5:15 a.m. Due to the storms, the convection ovens and range hood were not able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to identify an abnormal bowel pattern for a resident (Resident B) with a previous diagnosis of C-diff for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 10:03 a.m. The resident's diagnoses included, but were not limited to, irritable bowel syndrome and a history of C-diff (Clostridium difficile). The progress note, dated 9/15/24 at 3:10 p.m., indicated the resident was confused with incoherent speech. The nurse practitioner was notified with a new order given for a urine dispstick. The dipstick results were communicated to the nurse practitioner with new orders for Macrobid (antibiotic for urinary tract infections) 100 mg (milligrams) twice daily for 5 days and Rocephin (antibiotic for urinary tract infections) 1 gram intramuscularly once. The progress note, dated 9/18/24 at 2:12 p.m., indicated the nurse practitioner reviewed the final urinalysis. New orders were obtained to discontinue the Macrobid and to Start Ciprofloxacin 1,000 mg daily for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the kitchen equipment was clean and free from grease and food particles for 3 of 3 kitchen observations. This deficient practice had the potential to affect 46 residents currently residing on the 200 and 300 Halls. Findings include: During an initial tour of the kitchen on 7/15/24 at 9:28 a.m., the following was observed: -A saucer sized whitish/yellow unknown mound was observed on the floor behind the double door heating oven. -Aluminum foil was in the drip pan under the stove top. - The stove top burners had a buildup of black charcoal, which had crackled on the surface area in the back of the burners. -The grill had black grease on the front surface of the grill grates and there was a buildup of black charcoal chunks between the grates. -The deep fryer had food particles on the front edge counter of the grease basin. -The vents had dust hanging down between the stove top and the steam table and preparation area. There were black areas in the vent holes above the area between the grill, stove, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor and appropriately document observation of the resident's urinary output for 1 of 2 residents reviewed for bladder incontinence. (Resident 11) Findings include: The record for Resident 11 was reviewed on 7/21/24 at 1:30 p.m. The diagnoses included, but were not limited to, sepsis, urinary tract infection, acute kidney failure, overactive bladder, and dementia. The care plan, dated 5/6/24, indicated the resident experienced episodes of incontinence. The interventions included, but were not limited to encourage fluids unless contraindicated, observe for signs and symptoms of UTI (Urinary Tract Infection) and notify the physician as needed, observe skin and report any signs of breakdown as needed, offer and assist with toileting as needed and/or per request, provide incontinence care as needed, and provide incontinence products as needed. The physicians' orders, dated 5/6/24, indicated to monitor urinary output due to the removal of the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure staff to resident neglect did not occur for 1 of 3 residents reviewed for abuse. (Resident C) Findings include: The clinical record for Resident C was reviewed on 12/14/23 at 1:51 p.m. The diagnoses included, but were not limited to, left patella fracture, rheumatoid arthritis and anxiety. The incident report, dated 11/18/23 at 9:01 p.m., indicated Resident C voiced care concerns and called her family member with her personal cell phone. The family member called the facility and spoke with LPN (Licensed Practical Nurse) 4 whom worked the floor. CNA (Certified Nursing Aide) 3 was removed from her care. The care plan, dated 11/13/23, indicated the resident required staff assistance with activities of daily living and to assist with toileting as needed and/or per request. On 12/14/23 at 1:15 p.m., the resident was observed resting in bed with her eyes open. left knee immobilizer in place and her call light in reach. The resident indicated, on 11/18/23, she had to go to the bathroom and turned her call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to notify the physician of a critical laboratory result for 1 of 3 residents reviewed for Notification of Change. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/26/23 at 10:30 a.m. The diagnoses included, but were not limited to, presence of cardiac pacemaker, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, heart failure, long term (current) use of anticoagulants, and chronic atrial fibrillation. The Annual MDS (Minimum Data Set) assessment, dated 3/23/23, indicated the resident was cognitively intact. The physician's orders, dated 4/10/23, 4/11/23 and 4/14/23 indicated the resident was to have a PT/INR (Prothrombin ratio and international normalized ratio) per coagulation machine. If the INR was greater than 8.0 staff were to obtain a laboratory blood draw. The resident was on Warfarin 3 mg (milligram) once a day for atrial fibrillation with a start date of 2/5/23. The care plan, dated 8/29/17 and last revised 3/29/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to ensure a resident received adequate supervision and interventions were properly implemented to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The record for Resident B was reviewed on 9/26/23 at 10:30 a.m. The diagnoses included, but were not limited to, presence of cardiac pacemaker, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, heart failure, long term (current) use of anticoagulants, and chronic atrial fibrillation. The Annual MDS (Minimum Data Set) assessment, dated 3/23/23, indicated the resident was cognitively intact. The physician's order, dated 2/6/23, indicated the resident was to have two staff assistance during toileting; and dated 7/29/21, the resident was to have two staff assistance if the resident has periods of weakness. The care plan, dated 8/29/27 and revised on 3/29/23, indicated the resident was at risk for falls related to decreased mobility, weakness, medications, edema, pain, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident's blood sugar levels were tested at the appropriate time sequence as ordered by the physician, related to every two hours for three days, for 1 of 12 residents reviewed for quality of care. (Resident 32) Findings include: The clinical record for Resident 32 was reviewed on 6/9/23 at 9:54 a.m. The diagnosis included, but was not limited to, Diabetes Mellitus type 1. The Quarterly MDS (Minimum Data Set), dated 4/17/23, indicated the resident was severely cognitively impaired. The care plan, dated 11/1/22 and revised on 5/31/23, indicated Resident 32 was at risk for hypoglycemia and hyperglycemia related to Diabetes Mellitus. The interventions included, but were not limited to, laboratory test per physician orders, medications per orders, and monitor blood sugars per physician orders. The physician's orders, dated 1/3/23, indicated staff were to obtain a blood sugar q (every) 2 hours for 24 hours a day for 3 days. Fax over the results to the physician after completed for the 3 days. Twelve times a day at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure proper maintenance of a catheter and drainage system was off the floor for 1 of 2 residents reviewed for bowel and bladder. (Resident 29) Findings include: The record for Resident 29 was reviewed on 6/7/23 at 10:14 a.m. The diagnoses included, but were not limited to bacteremia, acute kidney failure, chronic kidney disease stage 3, altered mental status, urine retention, and neuromuscular dysfunction of bladder. The care plan, dated 2/2/23, indicated the resident used a catheter due to urinary retention related to neurogenic bladder. The interventions included, but were not limited to, maintain a closed system with urinary bag below the residents bladder and cover, observe for any signs of complication such as UTI (Urinary Tract Infection), urethral trauma, strictures, bladder calculi or silent hydronephrosis, observe tubing and avoid any obstructions, and provide assistance with catheter care and change catheter per physician orders. The physician's order, dated 2/2/23, indicated the resident had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure emergency respiratory supplies were available for a resident with a tracheostomy for 1 of 2 residents reviewed for Respiratory Care. (Resident 35) Findings include: The record for Resident 35 was reviewed on 6/6/23 at 1:13 p.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), pleural effusion, chronic respiratory failure with hypoxia, chronic bronchitis, chronic cough, shortness of breath, history of COVID-19, and encounter for attention to tracheostomy. The admission MDS (Minimum Data Set) assessment, dated 3/23/23, indicated the resident was cognitively intact and required assistance with oxygen therapy, suctioning, and tracheostomy care. The care plan, initiated on 3/24/23, indicated the resident had a potential for complications related to having a tracheostomy. The interventions included, but were not limited to, assess lung sounds and report any wheezes, crackles, or decreased breath sounds; avoid unnecessary diagnostic or therapeutic procedures and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure expired foods were removed from service related to the mustard, fruit cups and mango chunks. This deficient practice had the potential to affect 46 of 48 residents receiving regular diets. Findings include: During a tour of the kitchen on 6/5/23 at 9:45 a.m., with the Dietary Manager the following was observed: -In the dry goods storage room sitting on the dry goods storage shelf was a bottle of mustard with an indicated use by date 5/10/23. -The Dietary Manager indicated there was another bottle of the mustard open in the stand-alone refrigerator. The bottle had a use by date of 5/10/23. -In the steam tables' refrigerator, there were 2 fruit cups with a use by date of 6/4/23. -In the freezer there was an open bag of mango chunks with a hand-written use by date of 1/25/23. During an interview on 6/5/23 a 2:07 p.m., Resident D indicated last week she did have one instance where she got the wrong food, and then she got a fruit cup that had a sticker with a use by date for the previous day. It was prepared 4 days prior.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure an electrical outlet was maintained in a safe, functioning manner during 2 of 2 observations of the laundry room. This deficient practice had the potential to affect all 48 residents currently residing at the facility. Findings include: During an observation of the laundry room on 6/9/23 at 12:11 p.m., the electrical outlet behind the washing machines was observed to have black scorch marks on the two bottom electrical sockets. The top two sockets were unable to be visualized as they were currently in use with the detergent dispensers plugged into them. During an interview on 6/9/23 at 12:15 p.m., Laundry Aide 11 indicated one of the detergent dispensers had shorted out and they were having to load the detergent manually into the machine. She thought there was a work order in on the outlet. She believed the top two outlets were okay to use. She thought the Director of Plant Operations (DPO) and the Housekeeping Supervisor were aware. During an interview on 6/9/23 at 12:19 p.m., the Housekeeping Supervisor indicated he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.