Inspection Reports for SilverSpring Health and Rehabilitation Center
TX, 79601
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
309% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Jun 25, 2025
Visit Reason
The visit was initiated due to an Immediate Jeopardy situation identified on 6/23/25 related to failure to provide safe and appropriate pain management for a resident who required such services, specifically Resident #1 who sustained a fall and was not properly assessed or managed for pain.
Findings
The facility failed to ensure that Resident #1's pain was recognized, properly assessed, and managed according to professional standards. Staff moved the resident after a fall without nurse assessment, failed to communicate the fall and pain properly, and did not complete a full pain assessment before administering medication. An Immediate Jeopardy was identified but later removed after corrective actions were implemented including staff in-services and monitoring.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide safe, appropriate pain management for a resident who requires such services. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure licensed nurses and nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed for pain management: 8
Residents affected: 1
Residents affected: 87
Staff interviews: 5
Monitoring frequency: 2
Monitoring duration: 6
Plan of Removal acceptance date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Did not complete mobility/safety section of Resident #1's admit form and failed to assess resident after fall |
| PT E | Physical Therapist | Witnessed resident pain after fall and reported to nurse |
| CNA B | Certified Nursing Assistant | Witnessed fall and resident pain but failed to immediately report to nurse |
| CNA C | Certified Nursing Assistant | Witnessed fall and assisted resident but did not report pain immediately |
| DON | Director of Nursing | Provided in-services and oversaw corrective actions after Immediate Jeopardy |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy and involved in Plan of Removal |
| Medical Director | Medical Director | Reviewed and agreed with Plan of Removal |
| ADON | Assistant Director of Nursing | Participated in in-services and interviews regarding falls and pain management |
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including environmental conditions, resident assessments, medication storage, food safety, and infection control.
Findings
The facility was found deficient in maintaining a clean environment, completing timely resident assessments, securing medication carts, properly discarding spoiled food, and ensuring proper infection prevention practices during care. These deficiencies posed minimal harm or potential for actual harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 resident rooms observed; specifically, blinds were dusty causing resident discomfort. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete quarterly assessments for 3 of 18 residents reviewed, risking inaccurate assessments and lack of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication cart Hall 500 was locked and secured when unattended, risking medication misappropriation or harm. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly discard spoiled food items in the kitchen, risking foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection prevention and control program; staff failed to perform proper hand hygiene and wound care, risking infection transmission. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for assessments: 18
Residents affected by assessment deficiency: 3
Medication carts reviewed: 3
Medication cart unlocked: 1
Residents affected by infection control deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Responsible for medication cart Hall 500 found unlocked | |
| CNA-E | Certified Nursing Assistant | Failed to perform proper hand hygiene during peri-care for Resident #33 |
| LVN-F | Licensed Vocational Nurse | Failed to perform proper wound care for Resident #33, contaminated gloves during procedure |
| HK DM | Housekeeping Director Manager | Stated expectation for cleaning blinds and acknowledged failure due to staff rushing |
| ADMN | Administrator | Provided statements on housekeeping, medication cart security, and food safety expectations |
| DON | Director of Nursing | Provided statements on MDS assessment responsibilities and infection control expectations |
| DM | Dietary Manager | Responsible for ensuring spoiled food was discarded |
| MDS Coordinator | Responsible for ensuring timely completion of MDS assessments |
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including housekeeping, resident assessments, medication storage, food safety, and infection control.
Findings
The facility was found deficient in maintaining a clean environment, completing timely resident assessments, securing medication carts, properly discarding spoiled food, and ensuring proper infection prevention practices by staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 resident rooms observed; specifically, blinds were dusty causing resident discomfort. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete quarterly assessments for 3 of 18 residents reviewed, placing residents at risk for inaccurate assessments and lack of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication cart Hall 500 was locked and secured when unattended, risking medication misappropriation or harm. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly discard spoiled food items in the kitchen, risking foodborne illness to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection prevention and control program; staff failed to perform proper hand hygiene during peri-care and wound care, risking infection transmission. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for assessments: 18
Residents affected by assessment deficiency: 3
Medication carts reviewed: 3
Medication cart with deficiency: 1
Residents affected by housekeeping deficiency: 1
Residents affected by infection control deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Responsible nurse for medication cart Hall 500 left it unlocked | |
| CNA-E | Failed to perform proper hand hygiene during peri-care for Resident #33 | |
| LVN-F | Performed wound care with contaminated gloves for Resident #33 | |
| HK DM | Housekeeping Director Manager | Stated expectations and responsibility for housekeeping cleanliness and dusting |
| ADMN | Administrator | Provided statements on housekeeping, medication cart security, and food safety expectations |
| DON | Director of Nursing | Provided statements on MDS assessment responsibilities and infection control expectations |
| MDS Coordinator | Responsible for ensuring timely completion of MDS assessments | |
| DM | Dietary Manager | Responsible for ensuring spoiled food was discarded |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 22, 2024
Visit Reason
The inspection was conducted following a complaint regarding the unauthorized disclosure of a resident's private medical information to a notary during an ongoing court case.
Findings
The facility failed to protect Resident #1's privacy by disclosing her BIMS score and medical diagnosis to a notary who was not authorized to receive this information. Additionally, the facility failed to develop a baseline care plan for Resident #2 within 48 hours of admission.
Complaint Details
The complaint involved a notary attempting to obtain Resident #1's signature on documentation and receiving unauthorized medical information during an ongoing court case. The facility administrator admitted to disclosing Resident #1's BIMS score and diagnosis to the notary to calm the situation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to keep residents' personal and medical records private and confidential, resulting in unauthorized disclosure of Resident #1's BIMS score and medical diagnosis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a baseline care plan for Resident #2 within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for privacy: 5
BIMS score: 10
Residents reviewed for baseline care plan: 2
Hours for baseline care plan completion: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Admitted to disclosing Resident #1's BIMS score and diagnosis to the notary | |
| MDS C | Interviewed regarding Resident #2's baseline care plan | |
| DON | Stated baseline care plan should be completed within 48 hours of admission |
Inspection Report
Routine
Deficiencies: 3
Jan 26, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage and labeling regulations in the facility's medication carts, specifically focusing on proper labeling, storage, and security of drugs and biologicals.
Findings
The facility failed to ensure medication carts were locked when unattended and medications were properly stored and labeled. Loose medications were found stored in medication cups without proper labeling, and pre-popped medications were left unsecured on medication carts, placing residents at risk of harm or medication errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication cart #1 was not locked when unattended by nurse. | Level of Harm - Minimal harm or potential for actual harm |
| Medications stored in Hall 600 and Hall 700 medication carts were not properly stored or labeled, including loose pills in medication cups without labels. | Level of Harm - Minimal harm or potential for actual harm |
| Medication carts contained pre-popped medications left unsecured on top of the cart. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Loose pills: 10
Medication cups: 7
Pills in medication cups: 4
Pills in medication cups: 5
Pills in medication cups: 6
Pills in medication cups: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Stored loose pills in medication cart on 700 hall | |
| RN B | Stored loose medications in medication cups on 600 hall medication cart | |
| RN C | Nurse responsible for medication cart #1, admitted to pre-popping medications and leaving cart unlocked | |
| DON | Director of Nursing | Interviewed about medication storage policies and monitoring |
Inspection Report
Routine
Deficiencies: 11
Oct 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, abuse prevention, accurate assessments, PASRR coordination, discharge summaries, medication administration, food safety, call light systems, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights regarding smokeless tobacco, incomplete criminal background checks for employees, inaccurate resident assessments, failure to follow PASRR Level II recommendations, lack of discharge summaries, medication errors involving insulin and aspirin, serving food at unsafe temperatures, improper food storage, malfunctioning call light systems, and unsafe and unsanitary environmental conditions in resident rooms and hallways.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to preserve resident right to make choices about smokeless chewing tobacco for Resident #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement policies and procedures to prevent abuse, neglect, and theft; failed to perform initial criminal and EMR/NAR checks for CNA-P. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate resident assessment; incorrect discharge status entered for Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to incorporate Level II PASRR recommendations and follow up with local authority for Resident #13. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure discharge summary was completed for Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5%; wrong dose of Aspirin given to Resident #125 and wrong insulin administered to Resident #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors; Resident #31 received wrong insulin medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide food that was palatable and served at a safe and appetizing temperature; hamburger served at 106°F. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, seal, and date food items properly; disposed of food items past expiration date; multiple unsealed and unlabeled food items found in kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure working call system in resident bathrooms and bathing areas; call lights for two resident rooms did not connect to hallway lights. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe, functional, sanitary, and comfortable environment; holes in drywall, scuffed paint, broken blinds, broken light strings, missing toilet covers, and toilets without flushing handles found in resident rooms and hallways. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.41
Medication errors: 2
Medication administration opportunities: 27
Residents affected by medication errors: 2
Residents affected by food temperature issue: 1
Residents affected by call light issue: 2
Residents affected by environmental deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Named in medication error finding for administering wrong dose of Aspirin | |
| LVN F | Named in medication error finding for administering wrong insulin medication | |
| ADM-C | Interviewed regarding smoking policy and discharge summaries | |
| HR-T | Human Resources | Interviewed regarding employee background checks |
| HRA-V | Human Resources Assistant | Interviewed regarding employee background checks |
| MDS coordinator B | Interviewed regarding PASRR and resident assessments | |
| DON D | Director of Nursing | Interviewed regarding MDS assessments and medication errors |
| LVN G | Interviewed regarding call light system issues | |
| LVN H | Interviewed regarding maintenance and call light system issues | |
| Dietary Manager | Interviewed regarding food temperature and storage | |
| RN L | Interviewed regarding discharge summaries | |
| SW A | Interviewed regarding PASRR and discharge planning |
Inspection Report
Routine
Deficiencies: 11
Oct 5, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident rights, abuse prevention, accurate resident assessments, PASRR coordination, discharge planning, medication administration, food safety, call light systems, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights regarding smokeless tobacco, incomplete criminal background checks for employees, inaccurate resident assessments, failure to follow PASRR Level II recommendations, lack of discharge summaries, medication errors including wrong dose and wrong medication administration, serving food at unsafe temperatures, improper food storage and labeling, malfunctioning call light systems, and unsafe and unsanitary environmental conditions in resident rooms and hallways.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to preserve resident right to make choices about smokeless chewing tobacco for Resident #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform initial criminal and EMR/NAR checks for CNA-P employee. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate resident assessment and discharge coding for Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to incorporate PASRR Level II recommendations and follow up with local authority for Resident #13. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure discharge summary was completed for Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5%; wrong dose of Aspirin given to Resident #125 and wrong insulin medication given to Resident #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors; wrong insulin administered to Resident #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide food that was palatable and served at a safe and appetizing temperature; hamburger served at 106°F. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store, seal, label, and dispose of food items past expiration dates in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure working call system in resident bathrooms and bathing areas; call lights did not connect to hallway lights in two resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, functional, sanitary, and comfortable environment; holes in drywall, scuffed paint, broken blinds, broken light strings, missing toilet covers, and toilets without flushing handles in resident rooms and hallways. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.41
Medication errors: 2
Residents affected: 6
Employees reviewed: 15
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Food temperature: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Named in medication error for administering wrong dose of Aspirin | |
| LVN F | Named in medication error for administering wrong insulin medication | |
| ADM-C | Interviewed regarding smoking policy and PASRR process | |
| MDS coordinator B | Interviewed regarding PASRR and MDS accuracy | |
| DON D | Director of Nursing | Interviewed regarding MDS assessments and medication errors |
| HR-T | Human Resources | Interviewed regarding employee background checks |
| HRA-V | Human Resources Assistant | Interviewed regarding employee background checks |
| LVN G | Interviewed regarding call light system issues | |
| LVN H | Interviewed regarding maintenance and call light system issues | |
| Dietary Manager | Interviewed regarding food temperature and storage | |
| RN L | Interviewed regarding discharge summaries | |
| LVN K | Interviewed regarding discharge summaries | |
| SW A | Interviewed regarding PASRR and discharge planning | |
| CNS-S | Interviewed regarding smoking policy |
Inspection Report
Complaint Investigation
Deficiencies: 10
Aug 7, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to notify physicians of significant changes in residents' conditions, missed wound treatments, and neglect in care for multiple residents.
Findings
The facility failed to notify physicians of significant changes in condition and missed wound treatments for multiple residents, resulting in an Immediate Jeopardy (IJ) that was later lowered but the facility remained out of compliance. Deficiencies included failure to complete skin assessments, follow physician orders, maintain accurate documentation, and ensure proper wound care and treatment.
Complaint Details
The complaint investigation revealed substantiated neglect related to failure to notify physicians, missed wound treatments, failure to follow physician orders, and inadequate skin assessments and documentation.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to notify physician of Resident #4's missed wound treatments and deterioration of pressure ulcer. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to notify physician of Resident #1's missed wound treatments and deterioration of pressure ulcer. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to notify physician of Resident #2's newly acquired pressure ulcer and missed treatments for 12 days. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to notify physician of Resident #6's left heel Deep Tissue Injury and missed treatments for 5 days. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to complete skin assessments for Resident #7 leading to development of stage 2 pressure ulcers. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to complete weekly skin assessments for Resident #8 leading to development of stage 2 pressure ulcers. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure accurate skin assessments and documentation by the Director of Nursing (DON) for Residents #1, #2, #4, #5, #7. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure wound treatments were completed and accurately documented by DON and ADON E for Residents #1, #4, #5. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to maintain accurate list of residents with pressure ulcers; skin sweep found unreported wounds for Residents #7 and #8. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure Resident #1 received proper treatment and follow-up appointments with Podiatrist/Orthopedic Surgeon post amputation, including daily dressing changes. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Days without treatment: 12
Days without treatment: 5
Residents with skin issues: 15
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 2.2
Pressure ulcer measurements: 3.2
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 0.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| TX G | Treatment Nurse | Documented missed wound treatments and was removed from treatment nurse duties due to documentation issues. |
| DON | Director of Nursing | Failed to complete accurate skin assessments and documentation; acknowledged mistakes and overwhelmed with EHR system. |
| ADON E | Assistant Director of Nursing | Performed skin sweep, acknowledged not to backdate or fill in holes in documentation; involved in wound care oversight. |
| ADON C | Assistant Director of Nursing | Performed skin sweep, stated treatment nurse responsible for skin assessments; emphasized proper documentation and timely treatment. |
| RNWS J | Weekend RN Supervisor | Responsible for skin assessments for new admissions and ensuring nurses complete charting; stated neglect if wound care or assessments not done. |
| RN OS | Registered Nurse | Expressed concerns about missed appointments and wound care for Resident #1. |
| MR | Transportation Coordinator | Responsible for transportation arrangements and appointment follow-ups. |
| CSD | Clinical Services Director | Conducted audits, reeducated staff on documentation and wound care; monitored compliance. |
| LVN B | Licensed Vocational Nurse | Described wound care and appointment scheduling responsibilities. |
| MDS H | MDS Nurse | Used skin assessments in EHR for MDS; acknowledged assessments were inaccurate. |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 27, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 4
Jun 1, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and revision of comprehensive, resident-centered care plans that address medical, nursing, mental, and psychosocial needs.
Findings
The facility failed to develop a comprehensive care plan addressing Resident #1's dialysis needs and frequent refusals to attend dialysis sessions. Additionally, the facility failed to revise care plans for Residents #2, #3, and #4 to reflect actual falls and changing needs. These deficiencies place residents at risk of unmet medical, physical, mental, and psychosocial needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive resident-centered care plan that included measurable objectives and timeframes to meet Resident #1's dialysis needs and frequent refusal to attend dialysis sessions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise Resident #2's care plan to include an actual fall on 04/27/2023. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise Resident #3's care plan to include actual falls on 05/17/2023 and 05/22/2023. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise Resident #4's care plan to include an actual fall on 05/17/2023. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dialysis sessions missed: 3
Fall dates: 4
Dialysis appointment time: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 8, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a nursing home survey conducted on 2023-03-08.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 4
Aug 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, medication storage, and environmental safety in the nursing home.
Findings
The facility failed to develop baseline care plans within 48 hours for newly admitted residents, failed to develop comprehensive person-centered care plans with measurable objectives for some residents, left medication carts unlocked and unsecured, and did not maintain a safe, clean, and comfortable environment due to unrepaired damage in resident rooms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop a Baseline Care Plan within 48 hours of admission for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive person-centered care plan with measurable objectives for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Medication cart was left unlocked and unsecured while unattended, including controlled substances not under double lock. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe, functional, sanitary, and comfortable environment due to holes and scraped paint in resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 2
Medication carts reviewed: 4
Medication carts unlocked: 1
Rooms with environmental issues: 2
Total rooms: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in medication cart unlocked finding |
| DON | Director of Nursing | Interviewed regarding baseline care plan and medication cart findings |
| Administrator | Interviewed regarding care plan development and maintenance reporting | |
| Activity Director | Member of IDT responsible for care planning activity problems | |
| Social Worker | Interviewed regarding baseline care plan responsibilities | |
| Maintenance Director | Interviewed regarding environmental maintenance issues |
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