Inspection Reports for
The Villages at Historic Silvercrest

The complaint involved Resident 52 reporting that QMA 5 mocked her and administered incorrect medication. The claim of mocking was not substantiated by witnesses, but the medication error was confirmed. QMA 5 was suspended pending investigation and corrective actions were implemented.

The facility failed to ensure residents were treated with dignity and respect and failed to properly administer narcotic medications according to physician orders and documentation requirements. The investigation found that QMA 5 mocked Resident 52 and administered incorrect medication doses, leading to suspension and corrective actions.

This Federal tag relates to Complaint IN00456878. The complaint was substantiated as the fire was confirmed to have started by oil or grease on the bottom tray of the oven.

The facility failed to ensure kitchen equipment, specifically the ovens, were properly cleaned and maintained to prevent a fire. A fire occurred due to grease buildup on a removable oven panel, potentially affecting 36 residents on the skilled nursing units.

Complaint IN00456878 was substantiated with a federal/state deficiency cited at F812 related to food procurement and kitchen safety. The fire occurred on 4/3/25 in the kitchen oven due to grease buildup. The facility corrected the deficiency by 4/7/25 with a systemic plan including staff education and cleaning schedule monitoring.

The facility failed to ensure kitchen equipment related to the ovens was properly cleaned and maintained, which led to a fire in the kitchen oven. The fire was extinguished without resident harm, and the facility implemented corrective actions including staff education and enhanced cleaning schedules.

Complaint Number IN00456847 was substantiated with federal/state deficiencies cited at tags K324 and K711 related to fire safety and emergency preparedness.

The facility was found not in compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness. Deficiencies included failure to ensure staff were instructed in the proper use of the UL 300 hood fire suppression system in the kitchen and failure to have an accurate fire safety plan addressing all required elements for kitchen staff protection.

This citation relates to Complaint IN00448119. The facility was found deficient in monitoring and managing a resident's abnormal bowel pattern associated with C-diff infection.

The facility failed to identify an abnormal bowel pattern for Resident B, who had a history of C-diff infection. The resident exhibited multiple episodes of loose stools with foul odor and mucous, and the facility did not have a policy on bowel and bladder management.

Complaint IN00448119 was substantiated with a federal/state deficiency cited at F684 related to quality of care.

The facility failed to identify an abnormal bowel pattern for a resident with a previous diagnosis of C-diff. The resident had multiple loose stools and was eventually hospitalized and treated for UTI and sepsis. The facility lacked a policy on bowel and bladder management and did not consistently monitor or notify providers of abnormal bowel movements.

The facility was found in substantial compliance with emergency preparedness and life safety requirements, but several deficiencies were identified including unsecured fire alarm annunciator panel, lack of proper sprinkler wrench, incomplete fire hydrant and fire pump inspections, ceiling penetrations, uninspected fire extinguishers, corridor doors not latching properly, and incomplete electrical receptacle testing documentation.

The facility was found deficient in monitoring and documenting urinary output for one resident with bladder incontinence, and in maintaining kitchen equipment cleanliness and sanitation, which had the potential to affect all residents receiving food from the kitchen.

The facility failed to properly monitor and document urinary output for one resident with bladder incontinence, leading to potential health risks. Additionally, the kitchen equipment was found to be unclean with grease and food particle buildup, posing a risk to resident safety.

Complaint IN00435536 - No deficiencies related to the allegation cited. Complaint IN00435798 - No deficiencies related to the allegations cited. Complaint IN00434496 - State deficiency related to the allegation cited at R241.

No deficiencies were cited related to complaints IN00435536 and IN00435798. A state deficiency related to complaint IN00434496 was cited at R241. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the investigated nursing home complaints.

The complaint was substantiated. The investigation found that a CNA disconnected the call light cord for Resident C, causing a delay in assistance for over 40 minutes. The facility took corrective actions by 11/22/23.

The facility failed to prevent staff neglect for one resident when a CNA disconnected the resident's call light, causing a delay in assistance. The facility corrected the deficiency by implementing a systemic plan including call light checks, staff education, and monitoring for burnout.

Complaint IN00420694 was investigated and found to have no deficiencies related to the allegations. The cited deficiency was unrelated to the complaint. The complaint involved concerns about neglect related to call light functionality and response time.

No deficiencies related to the complaint allegations were cited; however, an unrelated deficiency was cited involving staff neglect of a resident, specifically failure to ensure the resident's call light was functional and timely response to the resident's needs.

This Federal tag relates to Complaint IN00412995. The complaint involved failure to notify the physician of critical lab results and inadequate supervision to prevent falls for Resident B.

The facility failed to notify the physician promptly of critical PT/INR laboratory results for one resident and failed to ensure adequate supervision and proper interventions to prevent accidents for the same resident. Both issues were supported by record reviews and staff interviews.

Complaint IN00412995 was substantiated with federal/state deficiencies cited at F580 and F689. Complaints IN00412762 and IN00416511 had no deficiencies related to the allegations.

The facility failed to notify the physician of a critical laboratory result for one resident (Resident B) and failed to ensure adequate supervision and proper implementation of interventions to prevent accidents for the same resident. Resident B was discharged from the facility. The facility provided plans of correction including education and ongoing monitoring to ensure compliance.

The facility was found in substantial compliance with Emergency Preparedness requirements and Life Safety Code standards, but deficiencies were cited related to expired inspection certificates for fuel-fired water heaters and lack of current documentation for reliable fuel source for emergency generators.

This Federal tag relates to Complaint IN00406418. The investigation included review of records, observations, and interviews related to complaints about blood sugar monitoring, catheter care, respiratory emergency supplies, expired food service, and electrical safety.

The facility was found deficient in multiple areas including failure to test a resident's blood sugar at ordered intervals, improper catheter maintenance with tubing on the floor, lack of emergency respiratory supplies for a resident with a tracheostomy, serving expired foods, and unsafe electrical outlets in the laundry room.

Complaint IN00406418 - Federal/State deficiency related to the allegation is cited at F812 and State deficiency related to the allegation is cited at R0273.

The facility was found deficient in multiple areas including failure to test blood sugar levels as ordered for one resident, improper catheter maintenance for another resident, lack of emergency respiratory supplies for a resident with a tracheostomy, expired food items in the kitchen, and unsafe electrical outlets in the laundry room.

Complaint IN00406418 triggered the inspection related to expired foods and electrical outlet safety issues.

The facility failed to ensure expired foods were removed from service, potentially affecting 46 of 48 residents on regular diets. Additionally, the facility failed to maintain an electrical outlet in a safe, functioning manner in the laundry room, potentially affecting all 48 residents.