Silver Bluff

Based on observations and staff interviews, the facility failed to dispose of food stored past the use by date in 1 of 3 refrigerators (walk-in refrigerator). Furthermore, the facility failed to maintain clean air vents located directly above the kitchen's tray line free from gray debris and practice hand hygiene during tray line service for 1 of 4 kitchen staff (Kitchen Staff #1) observed in the kitchen. The deficient practice had the potential to affect food served to residents. Findings included:a. On 1/5/26 at 10:34 AM an observation was conducted in the walk-in refrigerator with the Dietary Manager. An opened 1-gallon container of soy sauce was observed on the top shelf of a storage rack. The container contained a written date 6/11 -12/11. On 1/5/26 at 10:43 AM the Dietary Manager stated the soy sauce useful date range was 6 months after it was opened on 6/11/25. The soy sauce should have been disposed after 6 months (12/11/25).b. On 1/7/26 at 11:31 AM during tray line service Kitchen Staff #1 was observed removing his hat and rubbing his hair with his bare hands. The Kitchen…

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 observation, record review, and interviews with the Wound Care Nurse Practitioner (NP), Medical Director (MD) and staff, the facility failed to follow up when a Wound Care NP recommended the staff contact the primary care provider about the condition of the wound and if antibiotics needed to be ordered for a resident who showed symptoms of a wound infection. This deficient practice affected 1 of 2 residents reviewed for pressure ulcers (Resident #11).Findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, type-2 diabetes mellitus, hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following a cerebral infarction affecting left non-dominant side.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment. The MDS showed that she required substantial/ maximal assistance with upper body dressing…

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, observations and interviews with staff, resident, Nurse Practitioner and Pharmacist, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication ordered not to be crushed was administered crushed and medication omissions (3 medication errors out of 34 opportunities), resulting in a medication error rate of 8.82% for 1 of 3 residents (Resident #116) observed during medication pass.The findings included:Resident #116 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia (condition where the prostate gland enlarges) and age-related bilateral cataract.a. The Physician's Orders in Resident #116's electronic medical record indicated an active order dated 11/2/24 for Oxybutynin Chloride XL oral tablet extended release 24 hour 5 milligrams (mg) - give 1 tablet by mouth one time a day for bladder spasms/urgency. Do not crush.On 1/7/26 at 9:04 AM, Medication Aide (MA) #1…

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, observations and staff interviews, the facility failed to date an opened insulin pen and discard an expired stock medication available for use in 1 of 5 medication carts (500 hall long-side medication cart). Additionally, the facility failed to store a heparin flush syringe in a locked cart instead of leaving it unsecured on a resident's bedside table (Resident #8).The findings included: 1. An observation of the 500 hall long-side medication cart with Nurse #1 on 1/8/26 at 10:24 AM revealed an opened and undated Novolog flex pen available for use in the top drawer of the medication cart. The insulin pen had a pharmacy label indicating it was filled by the pharmacy on 11/10/25. A review of the manufacturer's instructions for Novolog pen indicated that it lasted 28 days after its first use. The observation further revealed an open bottle of Acidophilus tablets with manufacturer's expiration date of 11/25. There were approximately 40 tablets left in the bottle. Acidophilus is probiotic…

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 Payor source: MedicaidBased on record review, and resident and staff interviews, the facility failed to hold aspirin (an antiplatelet medication that helps prevent blood clots) which resulted in Resident #55 not being able to have an ordered tooth extraction in November 2025 for 1 of 1 resident reviewed for providing dental services (Resident #55). Findings included:Resident #55 was admitted to the facility on [DATE] with diagnoses of severe protein-calorie deficiency and heart disease.A physician's order for one Aspirin Oral Tablet Chewable 81 milligrams at bedtime was ordered on 4/9/25.Resident #55 was care planned on 4/10/25 for dental health problems related to broken teeth and poor repair. The care plan included Resident #55 had recent tooth pain related to abscess and recurring abscesses. The care plan intervention included reporting bleeding gums and complaints of mouth or tooth pain.Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded him as cognitively intact, received 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record reviews, the facility failed to secure an unopened vial of inhaler and an opened tube of ointment in the medication cart for 1 of 1 room (room [ROOM NUMBER]), failed to date an opened bottle of eye medication and 7 opened pens of insulin for 3 of 6 medication carts (200 halls, 300 halls, and 400 halls), and failed to lock 1 of 6 medication carts during observations for medication storage audits (300 halls). The findings included: a. During a medication storage audit conducted on 11/04/24 at 10:51 AM, 1 vial of unopened ipratropium-albuterol (DuoNeb) solution and an opened tube of zinc oxide ointment were found sitting on Resident #73's bedside table and ready to be used. An attempt to interview Resident #73 on 11/04/24 at 10:52 AM was unsuccessful. She was unable to answer questions. During an interview conducted on 11/04/24 at 10:54 AM, Unit Manager #1 acknowledged that the vial of DuoNeb solution and the tube of zinc oxide ointment should not be left unattended…

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 observations, record review, and staff interviews the facility failed to protect a resident's right to be free from physical restraint when Nurse Aide (NA) #2 held Resident #61's wrists/hands in front of her chest during incontinence care when Resident #61 started swinging her arms and kicking her legs. In addition, NA #1 and NA Student #1 observed NA #2 smacking Resident #61 with an open hand on the wrist following the completion of incontinence care. This was for 1 of 3 residents reviewed for physical restraint (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbances. The annual Minimum Data Assessment (MDS) dated [DATE] revealed Resident #61 had severe cognitive impairment. The MDS documented she had physical behaviors directed toward others 1 to 3 days and verbal behaviors directed toward others daily. She was not documented for rejection of care. Resident #61 was documented as being incontinent of bowel/…

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 observations, record review, test tray, and resident, resident representative, and staff interviews, the facility failed to provide palatable food that was appetizing in temperature for 3 of 3 residents reviewed with food concerns (Resident #42, Resident #59, and Resident #103). Findings included: a. Resident #59 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated [DATE] revealed Resident #59 had severely impaired cognition and required set up assistance with eating. An interview on 11/04/24 at 10:15 AM with Resident #59's resident representative revealed the food was often cold at lunch and dinner. b. Resident #103 was admitted to the facility on [DATE]. The annual Minimum Data Set, dated [DATE] revealed Resident #103 was cognitively intact and required set up assistance with eating. An interview on 11/04/24 at 11:08 AM with Resident #103 revealed he said the food was cold about half the time. c. Resident #42 was admitted to the facility on [DATE]. The quarterly Minimum Data…

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, staff, and family interviews the facility failed to follow their abuse policy in the areas of identification, immediately reporting an allegation of abuse to the Administrator, and reporting an allegation of abuse to the state agency within two hours. This occurred for 1 of 2 residents (Resident #49) reviewed for reporting. Findings included: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating policy and procedure revised on 9-2022 revealed in part; If resident abuse is suspected, the suspicion must be reported immediately to the Administrator. The Administrator immediately reports the suspicion to the agency within two hours of an allegation involving abuse. A telephone interview occurred with Resident #49's daughter on 6-6-23 at 11:35am. The daughter explained she had visited the resident around supper time on 4-23-23 and saw the bruise on her hand. She stated when she asked Resident #49 what had happened, the resident told her staff had held her hand down and pinched her hand on 4-22-23 because she did not want 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident and staff interviews the facility failed to provide protection for residents during the investigation of an allegation of abuse for 1 of 2 residents (Resident #18) reviewed for abuse. Findings included: A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised September 2022 revealed in part: Investigating Allegations: 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Resident #18 was admitted to the facility on [DATE] with a diagnosis of osteoarthritis (the wearing down of protective tissue at the end of bones). A review of Resident #18's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She required the extensive assistance of 2 people for bathing and dressing. A nursing progress note dated 6/2/23 at 4:53 PM written by Nurse #3 revealed she was called to Resident…

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 observations, record review, and staff interviews, the facility failed to (1) perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound, and before applying a clean dressing to a wound and (2) provide a clean field for wound care materials for 1 of 1 staff member observed for wound care (Nurse #4). Findings included: Review of a facility policy titled Wound Care revised in October 2010 read in part in steps #3 through #5 Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hand thoroughly. Put on gloves. Step #12 read in part Be certain all clean items are on clean field. An interview on 6/07/23 at 2:28 PM with Nurse #4 revealed he was the Infection Control Preventionist and Wound Treatment Nurse. An observation on 6/07/23 at 2:28 PM with Nurse #4 for wound care on Resident #82's right shin skin tear. Nurse #4 was observed to place wound care supplies on the overbed table without sanitizing it or placing a protective barrier. Nurse #4 brought wound care…

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.