Pennsylvania Department of Health
SILVER LAKE HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SILVER LAKE HEALTHCARE CENTER
Inspection Results For:

There are 209 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SILVER LAKE HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to two complaints completed on July 23, 2024, it was determined Silver Lake Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:
Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of a misappropriation of medication to rule out neglect for one of 3 residents (Resident R1).

Findings include:

Review of facility policy "Pennsylvania Abuse, Neglect and Misappropriation" undated, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress".

Review of the clinical record indicated Resident R1 was admitted to the facility on June 22, 2023, with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome; difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, indicated has a Brief interview for mental status (BIMS) indicated a score of 15 - cognition intact.

On July 23, 2024, at 9:15 a.m. interview with Resident R1 reveal that on June 15, 2024, the medications Keppra (seizure medication) and Depakote were given which did not belong to Resident R1.

A review of the progress note dated June 15, 2024 stated by licensed nurse, Employee E9 "medication error noted. Resident received 100 mg of Keppra meant for another resident. Resident being monitored Q (every) shif x 48 H (hours), BP (blood pressure) 128/68 HR (heart rate) 66 T (temperature) 97.5. All parties notified". A further review of the clinical record did not indicate that the medication Depakote was given to Resident R1.

On July 23, 2024, at approximately 11:30 a.m. an interview with the Assistant Director of Nursing, Employee E2 confirmed that there was no investigation conducted.

On July 23, 2024, at 12:17 p.m. an interview with the Nursing Home Administrator, Employee E1 confirmed that the facility failed to conduct a thorough investigation regarding the medication error.

28 Pa Code: 201.18 (e)(1)(2) Management

28 Pa Code: 201.29 (a )(c)(d) Resident Rights

28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of truth of facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
Investigation of medication error for R1 was initiated and reported to the department of health on 7/23/2024.
All residents have the potential to be affected by the same deficient practice. All medication errors occurring within the past 6 months will be audited by 8/16/2024 to ensure a full investigation was completed. Any medication errors found to have not been fully investigated will be immediately investigated.
DON/designee will educate all licensed nurses on the medication errors and completing a proper investigation immediately following any reported medication error by 8/16/2024.
All medication errors will be audited weekly X 4 weeks, then monthly until substantial compliance is received.
All initial and ongoing audits will be reported to the QAPI committee for review and further action of indicated.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and interventions to promote the healing of pressure ulcers for one of three sampled residents with pressure ulcers. (Resident 1)

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on June 22, 2023, with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome (condition characterized by chronic pain following back surgery); difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact.

Continued review Resident R1's clinical record revealed that the resident developed a right heel suspected deep tissue injury on January 31, 2024. Review of wound tracking documentation dated July 17, 2024, revealed that right heel wound was assessed at a Stage 4 pressure ulcer (ulcer involving loss of skin layers, exposing muscle).

Review of the progress note of the License Nurse Practitioner, Employee E10 on May 1, 2024, revealed a recommendation to "Float heels while in bed with use of heel boots."

On July 23, 2024, at 9:15 a.m. interview with Resident R1 while resident was in bed revealed no heel boots in place. Resident R1 reported that his physician permitted either a pillows around his right ankle or a boot heel. Resident R1 prefers pillows and there were no pillows around the right heel.

On July 23, 2024, at 9:23 an interview with the License nurse, Employee E3 confirmed that Resident R1's heels were not floated in bed with pillows or the use of a heel boots.

Continued review of Resident R1's clinical record revealed a Skin Assessment dated May 10, 2024 revealed that the resident was identified with a skin tear on the left thigh .

Review of physician order dated May 23, 2023 revealed an order to "clean skin alteration to left posterior thigh with ns (normal saline solution), apply Santyl and cover with bordered gauze daily and pm every evening shift."

Review of wound tracking documentation dated July 17, 2024, indicated the skin tear developed into a unstageable pressure ulcer.

The Resident's July 2024 Treatment Administration Record was reviewed on July 23, 2024 at 4:30 p.m. with Licensed nurse, Employee E11. On July 4, July 9, July 12, July 13, 2024 it was coded "9- see nursing note" related to the administration of the treatment to the left thigh pressure ulcer.

Review of nursing notes for the dates noted above revealed no note related to the treatment administration.

In an interview on July 23, 2024, at 4:35 p.m. with Assistant Director of Nursing, Employee E2 and Administrator, Employee E1 confirmed that the wound care had not been completed on July 4, July 9, July 12, July 13, 2024, as per the physician order.

28 Pa. Code 211.10 (c) Resident care policies

28 Pa. Code 211.12 (d)(1) Nursing services

Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of truth of facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
A full skin assessment was completed for R1 on 8/8/2024 to ensure all skin alterations were identified and appropriate treatments and interventions are in place to promote proper healing.
All residents will be assessed to ensure any skin areas are documented and all skin areas have appropriate treatments and interventions in place to ensure proper healing by 8/24/2024.

DON/Designee will educate all licensed nurses on proper wound care for residents including but not limited to physical interventions are ordered and in place, appropriate treatments are in place for any skin condition and all treatments are completed per physician order by 8/17/2024.
DON/designee to audit of 5 residents to ensure treatments are completed as ordered and interventions in place 5 times a week for 2 weeks and then 3 times a week for 2 weeks
All initial and ongoing audits will be reported to the QAPI committee for review and further action if indicated

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on reviewof clinical record, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that hospital recommendation were address for one of three clinical records reviewed. (Resident R1)

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on June 22, 2023, with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome (chronic pain following back surgery); difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact.

Continued review Resident R1's clinical record revealed that the resident developed a right heel suspected deep tissue injury on January 31, 2024. Review of wound tracking documentation dated July 17, 2024, revealed that resident's right heel wound was assessed at Stage 4 pressure ulcer (ulcer involving loss of skin layers, exposing muscle).

Review of hospital records dated April 2, 2024, indicated that Resident R1 was prescribed a Rom Knee Brace.

Further review of discharge hospital record dated July 17, 2024 indicated to schedule a "cardiologist appointment with in two weeks".

On July 23, 2024, at 9:23 an interview with the license nurse, Employee E3 confirmed that Resident R 1 did have a Rom Knee Brace in place.

On July 23, 2024, at 4:15 p.m. an interview with the Assistant Director of Nursing, Employee E2 and Administrator, Employee E1 confirmed that Resident R1 should have had the physician orders per the nurse practitioner's recommendation and per the hospital record for the Rom Knee Brace and there should have been a cardiologist appointment scheduled.

28 Pa. Code 211.10 (c) Resident care policies

28 Pa. Code 211.12 (d)(1) Nursing services

Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of truth of facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
Order reconciliation for R1 was completed on 8/8/2024 to ensure all appropriate orders present at time of hospitalization have been re-ordered by physician following re-admission to the facility. A cardiology appointment was scheduled for 2/04/2025.

All re-admissions to the facility over the last month will be audited to ensure appropriate orders are in place and follow up appointments scheduled after the hospitalized resident returned to the facility by 8/24/2024. Any discrepancies will be reported to the physician for immediate follow-up.

DON/designee will educate all licensed nurses on the admission process and ensuring all appropriate orders are in place and follow up appointments scheduled following admission from the hospital by 8/17/2024

DON/designee will audit all readmissions weekly x4 weeks to ensure appropriate orders are in place and appointments scheduled

All initial and ongoing audits will be reported to the QAPI committee for review and further action if indicated.

51.3 (f) LICENSURE NOTIFICATION:

51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations:

Based on interview with resident and staff, it was determined the facility failed to report to State Licensing Agency, PA Department of Health, Division of Nursing Care Facilities an event as required.

Findings include:

On July 23, 2024, at 9:15 a.m. interview with Resident R1 reveal that "months ago a black male nurse gave his insulin. Nurse came check my sugar which was 61, came back with 5cc insulin and place it my arm". The insulin belonged to his roommate. Resident R1 is nondiabetic and should not have received insulin medication.

There was no evidence to indicate that the facility notified Department of Health of a situation which could compromise resident health and safety related to the administration of insulin to the wrong resident.

An interview with the Administrator, Employee E1 on July 23, 2024, at approximately 10:00 a.m. confirmed that facility received an anonymous complaint on July 2, 2024, through their facility compliance line that in June 2024 a nondiabetic resident received an insulin which belong to his roommate. There was no resident identified. Facility conducted an internal investigation and did not notify the Department of Health via the Event Reporting System (ERS).

Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of truth of facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Insulin Medication Error investigation was immediately completed and reported to the Department of Health on 7/23/2024.

All medication errors in the last 6 months will be audited by 8/17/2024 to ensure any medication error that should be reported to DOH have been reported. Any reportable medication errors that were not reported appropriate will immediately be reported to the department of health.

Executive Director and DON will be educated by Regional Director of Clinical Operations on reporting requirements to the Department of Health by 8/17/2024.

ED/designee will audit of all medication errors to ensure any medication errors required to be reported to the department of health have been reported weekly x 4 weeks.
All initial and ongoing audits will be reported to the QAPI committee for review and further action of indicated

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