Silver Heights Skilled Nursing and Rehabilitation

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Egress Deficiencies

Meet other general requirements.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Egress Deficiencies

Provide large enough exits.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.The building is a one-story wood-framed structure, Type V (000) (VA), with no attic, and a partial bas.. K-916STANDARD not met based on observation and staff interviews during the survey. It was determined that the facility failed to maintain emergency power systems under Section 9.1.3 of the Life Safety Code and the referenced .. STANDARD is not met as evidenced by: Based on observation and staff interviews during the survey, it was determined that the fire resistance rating of smoke barrier walls was not maintained per the Life Safety Code Section 19.3.2.1Th.. STANDARD is not met as evidenced by: Based on record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 and Life Safety Code 101.Records indicate that the fire extingu.. STANDARD is not met, as evidenced by: Based on record review during the generator' s testing, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code .. STANDARD is not met, as evidenced by: Through observation during the survey, it was determined that the facility failed to provide no-smoking signs in areas where smoking is prohibited per NFPA 101 Life Safety Code, Section 19.7... STANDARD not met as evidenced by: Based on observation and staff interview during the facility tour, it was determined that the facility failed to continuously maintain the exit discharge and access means of egress to full use .. STANDARD not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain corridor doors per the Life Safety Code Section 19.3.6.3. The doors in resid.. STANDARD not met as evidenced by: Based on observation during the tour of the facility, it was determined that the facility failed to arrange the exit access so that exits are always readily accessible by Life Safety Code 101 Section 19.. STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. The .. STANDARD not met: Through observation and discussion during the facility tour, it was determined that the facility failed to install and maintain the kitchen-hood-exhaust system as required by NFPA 96 (Chapter 7, Section 7.8.2). Th.. STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected areas by Life Safety Section 19.3.2.5.Doors were used as protective.. STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain the marking of means of egress per the 20212 Life Safety Code 101- Section 7.10. The .. The standard is not met based on a review of records and discussions during the survey. It was determined that the facility failed to inspect and test the fire alarm system as required by NFPA 101, Chapter 9 (Section 9.6, Paragraph 9..

A recertification survey with complaint #CO39067 and Incident #39070 was completed on 3/31/25 to 4/3/25. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 3/31/25 to 4/3/25. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards in one of one medication storage rooms.Specifically, the facility failed to ensure Tubersol (tuberculin purified protein derivative), Hepatitis B vaccine, Prevnar (pneumococcal vaccin.. Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for eight of 36 rooms.Specifically, the facility failed to provide residents with hand towels on a daily basis.Findings include:I. Facility policy and procedureThe Homelike Environment policy and procedure, revised February 2021, was provided b.. Based on observations, record review and interviews, the facility failed to ensure one (#12) of one resident with limited range of motion received appropriate treatment and services out of 30 sample residents.Specifically, the facility failed to:-Develop a comprehensive care plan for Resident #12' s left hand contracture (a condition of shorteni.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities for one (#24) of three residents out of 30 sample residents. Specifically, the facility failed to provide timely .. Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units.Specifically, the facility failed to:-Ensure hand hygiene was performed during woun.. Based on record review and interviews, the facility failed to assist residents to obtain routine or emergency dental services, as needed, for one (#12) of one resident reviewed for ancillary services out of 30 sample residents.Specifically, the facility failed to ensure a dental referral was followed upon timely for Resident #12.Findin.. Based on record review and interviews, the facility failed to ensure one (#259) of three residents reviewed for accidents out of 30 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to identify the root cause of Resident #259' s falls and implement effective person-centered interventions.Findi.. Based on record review and interviews, the facility failed to ensure three (#259, #15 and #10) of five residents reviewed out of 30 sample residents were free from unnecessary medications as possible.Specifically, the facility failed to:-Ensure the facility had proper justification for the implementation of an antipsychotic medication (Seroque.. Based on record review and interviews, the facility failed to ensure two (#15 and #42) of five residents out of 30 sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #15 was kept free from physical abuse by Resident #13; and,-Ensure Resident #42 was kept free from physical abuse by Resident #58.Findings.. Based on record review and interviews, the facility failed to implement policies and procedures related to influenza and pneumococcal vaccines for two (#26 and #43) of five residents reviewed for immunizations out of 30 sample residents.Specifically, the facility failed to:-Document the influenza vaccine was offered annually for Resident #26 a..

A complaint survey, prompted by #CO37588, #CO37998, #CO38053 and Incident #CO38057 was conducted on 11/5/24 to 11/7/24. Five deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#10 and #16) of four residents reviewed out of 18 sample residents. Specifically, the facility failed to:-Provide Resident #10 and Resident #16 with timely incontinence care; and, -Provide the necessary assistance for Resident #10, who required physical assistance and encouragement with meals.Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADLs), Supporting policy, undated, was provided by the director of nursing (DON) on 11/7/2.. Based on observations, record review and interviews, the facility failed to take steps to protect one (#1) of five residents reviewed for abuse out of 18 sample residents.Specifically, the facility failed to ensure Resident #1 was kept free from physical abuse by Resident #2. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 11/6/24 at 1:49 p.m. It read in pertinent part, "It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit an.. Based on record review and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of one (#18) of three residents out of 18 sample residents.Specifically, the facility failed to follow procedures to prevent the drug diversion of Resident #18' s Ativan (a Schedule IV controlled substance medication for treatment of anxiety).Findings include:I. Professional referenceAccording to Leslie S Treas, Karen L Barnett, Mable H Smith (2022). Basic Nursing third addition, "Controlled substances are drugs considered to have either limited medical use or high p.. Based on record review and interviews, the facility failed to maintain accurately documented medical records for two (#4 and #12) of four residents reviewed out of 18 sample residents.Specifically, the facility failed to ensure nursing staff documented skin assessments accurately for Resident #4 and Resident #12.Findings include:I. Facility policy and procedureThe Charting and Documentation policy and procedure, undated, was provided by the director of nursing (DON) on 11/7/24 at 11:22 a.m. It read in pertinent part,"All services provided to the resident, progress toward the care plan goals and any changes in the resident' s medical, physical, functional or psychosocial condition, shall be doc.. Based on record review and interviews, the facility failed to notify the physician timely for one (#15) of three residents reviewed out of 18 sample residents.Specifically, the facility failed to ensure Resident #15' s physician was notified when the resident consistently refused her anticoagulant medication (medication used to decrease the risk of stroke and blood clots). Findings include:I. Resident #15A. Resident statusResident #15, age 65, was admitted on 4/16/24. According to the November 2024 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, end-stage renal disease, atrial fibrillation (irregular hear..