Inspection Reports for
Silver Oaks Health and Rehabilitation
1875 Old Wire Road, Camden, AR, 71701
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
156% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 2
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with standards of care related to incontinence care and enteral feeding practices for residents, specifically focusing on Resident #39.
Findings
The facility failed to ensure incontinence care was provided in a manner that promotes cleanliness and prevents infections, and did not follow standards of practice for enteral feeding by lowering the head of Resident #39's bed while enteral nutrition was being administered, posing a risk of aspiration.
Deficiencies (2)
Incontinence care was provided improperly by wiping from back to front, risking infection.
The head of Resident #39's bed was lowered during enteral feeding without pausing the feeding pump, increasing aspiration risk.
Report Facts
Residents reviewed for activities of daily living: 3
Residents reviewed for enteral feedings: 2
Residents affected: 1
Assessment Reference Date: May 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #4 | Observed providing improper incontinence care | |
| Certified Nursing Assistant (CNA) #3 | Observed lowering the head of Resident #39's bed during feeding | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding proper procedure for feeding pump care | |
| Director of Nursing (DON) | Interviewed regarding proper incontinence care and feeding pump procedures | |
| Administrator | Interviewed regarding proper wiping technique during incontinence care |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess the accuracy of Minimum Data Set (MDS) assessments, proper care practices including incontinence care, enteral feeding procedures, infection prevention, and hand hygiene compliance at Silver Oaks Health and Rehabilitation.
Findings
The facility failed to ensure accurate MDS assessments for multiple residents, proper incontinence care techniques, safe enteral feeding practices, and adequate hand hygiene during medication administration and resident care. Several staff members were observed not following infection control protocols, and discrepancies were found in resident documentation and care plans.
Deficiencies (4)
Failure to ensure Minimum Data Set (MDS) assessments were completed accurately for 3 of 5 residents reviewed.
Failure to provide incontinence care in a manner that promotes cleanliness and prevent infections for 1 of 3 residents reviewed.
Failure to ensure proper treatment and care according to orders and resident preferences related to enteral feeding and positioning.
Failure to provide and implement an infection prevention and control program, including proper hand hygiene during medication administration and resident care.
Report Facts
Residents reviewed for accuracy of MDS assessments: 5
Residents affected by MDS deficiency: 3
Residents reviewed for incontinence care: 3
Residents reviewed for enteral feeding standards: 2
Residents observed for medication administration: 3
Staff involved in deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed inaccuracies in MDS assessments for Residents #47 and #10; stated staff should follow hand hygiene protocols. | |
| Director of Nursing | DON | Confirmed MDS inaccuracies; stated proper incontinence care and hand hygiene procedures; commented on feeding pump protocols. |
| Licensed Practical Nurse #1 | LPN | Observed placing medication in Resident #238's mouth with unclean hands. |
| Certified Nursing Assistant #4 | CNA | Observed providing incontinence care improperly wiping from back to front. |
| Certified Nursing Assistant #5 | CNA | Observed poor hand hygiene during meal assistance and incontinence care. |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care standards related to incontinence care and enteral feeding practices for Resident #39, focusing on infection prevention and aspiration risk.
Findings
The facility failed to ensure incontinence care was provided in a manner that promotes cleanliness and prevents infections, as CNA wiped from back to front. Additionally, the facility did not follow standards for enteral feeding care by lowering the resident's bed while the feeding pump was infusing, increasing aspiration risk.
Deficiencies (2)
Incontinence care was provided by wiping from back to front, increasing infection risk.
Head of bed was lowered while enteral feeding was in progress, risking aspiration.
Report Facts
Residents reviewed for activities of daily living: 3
Residents reviewed for enteral feeding: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #4 | Observed wiping from back to front during incontinence care | |
| Certified Nursing Assistant (CNA) #3 | Observed lowering head of bed during enteral feeding | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about proper procedure to pause feeding pump before lowering bed | |
| Director of Nursing (DON) | Interviewed about proper incontinence care and feeding pump procedures | |
| Administrator | Interviewed about proper wiping direction during incontinence care |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess the accuracy of Minimum Data Set (MDS) assessments, proper care practices including incontinence care, enteral feeding procedures, infection prevention, and hand hygiene compliance at Silver Oaks Health and Rehabilitation.
Findings
The facility failed to ensure accurate MDS assessments for several residents, proper incontinence care techniques, correct handling of feeding tubes, and adherence to hand hygiene protocols during medication administration and resident care. Multiple deficiencies were observed related to care practices and documentation accuracy, all with minimal harm or potential for actual harm.
Deficiencies (4)
Failure to ensure Minimum Data Set (MDS) assessments were completed accurately for 3 of 5 residents reviewed.
Incontinence care was not provided in a manner that promotes cleanliness and/or prevents infections for 1 of 3 residents reviewed.
Standards of practice were not followed for enteral feedings; specifically, the head of the resident's bed was lowered while feeding was infusing.
Improper hand hygiene was observed during medication administration, incontinence care, and feeding assistance for multiple residents.
Report Facts
Residents reviewed for accuracy of MDS assessments: 5
Residents affected by MDS inaccuracies: 3
Residents reviewed for incontinence care: 3
Residents reviewed for enteral feeding standards: 2
Residents observed for medication administration: 3
Residents observed for feeding assistance: 2
Staff Assessment of Mental Status score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed inaccuracies in MDS assessments and proper care procedures during interviews on 06/04/2025 and 06/05/2025. | |
| Director of Nursing | DON | Confirmed inaccuracies in MDS assessments and proper care procedures during interviews on 06/04/2025 and 06/05/2025. |
| Licensed Practical Nurse #1 | LPN | Observed placing medication in resident's mouth without hand hygiene; admitted hands were not clean. |
| Certified Nursing Assistant #4 | CNA | Observed providing incontinence care incorrectly and lowering bed head while feeding was infusing. |
| Certified Nursing Assistant #5 | CNA | Observed poor hand hygiene during meal assistance and incontinence care. |
| Licensed Practical Nurse #2 | LPN | Stated staff should notify nurse to pause feeding pump prior to lowering bed head. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide timely and appropriate incontinence care to residents, specifically Residents #7, #8, and #9.
Complaint Details
The complaint investigation found substantiated issues with incontinence care. Video footage and interviews revealed rounds were not performed as ordered every two hours, leading to residents being left in wet conditions. The Administrator acknowledged the findings.
Findings
The facility failed to ensure staff provided incontinence care in a timely manner, resulting in residents lying or sitting in urine-saturated bedding or chairs. Observations, interviews, and record reviews confirmed multiple instances of wet linens and inadequate rounds as ordered.
Deficiencies (1)
Failure to provide timely incontinence care to Residents #7, #8, and #9, resulting in urine-saturated bedding and chairs.
Report Facts
Residents sampled for incontinence care: 3
Incontinence checks documented: 6
Survey visit date: Mar 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed providing incontinence care and interviewed regarding wet linens | |
| Certified Nursing Assistant (CNA) #2 | Observed providing incontinence care and interviewed regarding wet linens | |
| Certified Nursing Assistant (CNA) #3 | Interviewed about wet linens and incontinence care | |
| Licensed Practical Nurse (LPN) #4 | Interviewed regarding staff instructions for rounds every two hours | |
| Administrator | Interviewed and acknowledged findings about rounds and incontinence care |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with providing appropriate incontinence care to residents, specifically focusing on timely care to prevent residents from lying or sitting in urine-saturated bedding or chairs.
Findings
The facility failed to ensure timely incontinence care for three sampled residents (#7, #8, and #9), resulting in residents being found with wet briefs, bedding, and furniture. Observations, interviews, and record reviews confirmed lapses in care rounds and timely response to residents' needs, potentially leading to skin breakdown.
Deficiencies (1)
Failure to provide timely incontinence care to residents, resulting in urine-saturated bedding and furniture.
Report Facts
Residents affected: 3
Incontinence checks documented: 6
Rounds observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed providing incontinence care and interviewed regarding wet briefs and linens for Residents #7, #8, and #9. |
| CNA #2 | Certified Nursing Assistant | Observed providing incontinence care and interviewed regarding wet briefs and linens for Residents #7 and #9. |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding wet linens for Resident #8. |
| LPN #4 | Licensed Practical Nurse | Interviewed about staff instructions to perform rounds every two hours and check Resident #9's incontinence. |
| Administrator | Facility Administrator | Interviewed regarding staff instructions for incontinence care rounds and expectations about wet bedding. |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 18, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident dignity, medication administration, privacy, environment, food safety, infection control, and wound care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, improper medication self-administration practices, lack of privacy curtains, unsanitary resident environments, expired and improperly stored medications, poor food preparation and kitchen sanitation practices, and inadequate infection control including improper hand hygiene and wound care practices.
Deficiencies (8)
Failure to treat resident with respect and dignity, including exposure of incontinence briefs and lack of privacy during care.
Failure to evaluate and determine if residents were able to self-administer medications and medications left at bedside.
Failure to provide privacy curtains in a semi-private room for a resident.
Failure to ensure a safe, clean, and comfortable environment; presence of urine odor and flies in resident rooms.
Failure to ensure narcotic box was permanently affixed and expired medications were present in medication room and carts.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency.
Failure to ensure food items were properly covered, dated, and kitchen environment was sanitary; failure of dietary staff to wash hands appropriately.
Failure to ensure clean linens were stored away from dirty items, failure to follow wound care guidelines, failure to perform hand hygiene during incontinence care, and improper handling of linens.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication carts: 4
Residents affected: 10
Residents affected: 89
Residents affected: 3
Pressure ulcers: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in dignity and medication self-administration findings |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Named in dignity, infection control, and linen handling findings |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Named in dignity findings |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity, privacy, medication, and infection control |
| Licensed Practical Nurse Treatment Nurse | Licensed Practical Nurse | Observed and interviewed regarding wound care deficiencies |
| Dietary Employee #1 | Dietary Employee | Observed failing to wash hands during food handling |
| Dietary Employee #2 | Dietary Employee | Observed failing to wash hands during food handling |
| Dietary Employee #3 | Dietary Employee | Observed failing to wash hands during food handling |
| Laundry Worker #1 | Laundry Worker | Interviewed regarding linen storage practices |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication self-administration, privacy, environment cleanliness, medication storage, food safety, infection control, and wound care at Silver Oaks Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, improper medication self-administration practices, lack of privacy curtains, unsanitary resident environments, expired medications and unsecured narcotics, improper food preparation and storage practices, and inadequate infection prevention and control measures including improper wound care and hand hygiene.
Deficiencies (8)
Failure to treat Resident #5 with respect and dignity, including exposure of incontinence briefs and lack of privacy during care.
Failure to evaluate and determine if residents #33 and #44 were able to self-administer medications appropriately.
Failure to provide privacy curtains for Resident #51 in a semi-private room.
Failure to ensure a safe, clean, and comfortable environment for Residents #5 and #15, including strong urine odor, flies, and wet floors.
Failure to ensure narcotic box was permanently affixed and expired medications were removed from medication storage and carts.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure food items in the kitchen were properly covered, dated, and stored; failure to maintain sanitary kitchen environment; and failure of dietary staff to wash hands appropriately.
Failure to implement infection prevention and control program including improper storage of clean linens, failure to follow wound care guidelines, placing clean linens on floor and bed, and failure to perform hand hygiene during incontinence care.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication carts: 4
Residents affected: 10
Residents affected: 89
Residents affected: 3
Pressure ulcers: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident dignity and medication self-administration |
| CNA #6 | Certified Nursing Assistant | Observed providing incontinence care and handling linens improperly |
| CNA #7 | Certified Nursing Assistant | Assisted CNA #6 with incontinence care |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity, privacy, medication policies, and infection control |
| LPN Treatment Nurse | Licensed Practical Nurse | Observed performing wound care with improper infection control practices |
| Dietary Employee #1 | Dietary Employee | Observed handling food and utensils without proper hand hygiene |
| Dietary Employee #2 | Dietary Employee | Observed handling utensils without proper hand hygiene |
| Dietary Employee #3 | Dietary Employee | Observed handling utensils and blender blade without proper hand hygiene |
| Laundry Worker #1 | Laundry Worker | Interviewed about improper storage of clean linens |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 31, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare regulations and standards at Silver Oaks Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure staff assisted residents with dignity during feeding, inaccurate Minimum Data Set (MDS) assessments related to anticoagulant medication, inadequate communication with dialysis providers, unsecured treatment carts with accessible medications, and improper preparation of pureed food items.
Deficiencies (5)
Staff failed to sit at the resident's eye level while assisting with eating, standing over the resident instead, compromising dignity and respect.
The Minimum Data Set (MDS) assessment was inaccurate and incomplete regarding anticoagulant medication use and discharge status for sampled residents.
Failed to establish and maintain ongoing communication and collaboration with the dialysis facility, including lack of dialysis communication forms and lab results in the medical record.
Treatment cart drawers containing drugs and biologicals were left unlocked and accessible to residents, posing a safety risk.
Pureed food items served were not blended to a smooth, lump-free consistency, increasing risk of choking or complications for residents requiring pureed diets.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 17
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Voiced expectation that CNAs should sit while feeding residents; confirmed dialysis communication issues; confirmed treatment cart policy; provided facility policies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Responsible for treatment cart; acknowledged drawers not locking |
| Director of Nursing | Director of Nursing (DON) | Confirmed Eliquis is an anticoagulant; responsible for MDS accuracy; discussed discharge MDS responsibilities |
| Medicare Manager | Medicare Manager (LPN) | Responsible for discharge assessments; acknowledged discharge MDS inaccuracies |
| Registered Nurse #1 | Registered Nurse (RN) | Attempted to locate dialysis communication notebook |
| Dietary Employee #1 | Dietary Employee (DE) | Prepared pureed food items; described consistency issues |
| Dietary Supervisor | Dietary Supervisor | Described pureed food consistency issues |
| Dietary Employee #2 | Dietary Employee (DE) | Described pureed bread consistency as dry and thick |
| Operational Corporate RD | Registered Dietitian | Confirmed clinical RD completes nutritional assessments; nursing staff responsible for lab results |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 31, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Silver Oaks Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure staff assisted residents with dignity during feeding, inaccurate Minimum Data Set (MDS) assessments, inadequate communication with dialysis facilities, unsecured treatment carts containing medications and biologicals, and improper preparation of pureed food items.
Deficiencies (5)
Staff failed to sit at the resident's eye level while assisting with eating, compromising dignity and respect.
The Minimum Data Set (MDS) assessments were inaccurate and incomplete, failing to reflect residents' medication status and discharge information.
Failed to establish and maintain ongoing communication and collaboration with the dialysis facility, resulting in lack of dialysis lab results and treatment documentation in the medical record.
Treatment cart drawers containing medications and biologicals were left unlocked and accessible to residents, posing a safety risk.
Pureed food items served were not blended to a smooth, lump-free consistency, increasing risk of choking or complications for residents requiring pureed diets.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 17
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Voiced expectation for feeding assistance and provided facility policies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Responsible for treatment cart; acknowledged drawers not locking |
| Registered Nurse #1 | Registered Nurse (RN) | Attempted to locate dialysis communication notebook |
| Director of Nursing | Director of Nursing (DON) | Confirmed Eliquis as anticoagulant and responsible for MDS accuracy |
| Medicare Manager | Medicare Manager (LPN) | Responsible for discharge assessments and MDS modifications |
| Dietary Employee #1 | Dietary Employee (DE) | Prepared pureed food items with improper consistency |
| Dietary Supervisor | Dietary Supervisor | Described pureed food consistency issues |
| Operational Corporate RD | Registered Dietitian | Confirmed nursing staff responsible for obtaining lab results |
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