Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  79 surveys for this facility. Please select a date to view the survey results.

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a Complaint completed on January 17, 2020, it was determined that Silver Stream Nursing and Rehabilitation 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.

 Plan of Correction:

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

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide wound care treatment in accordance with physician's orders for one of five sampled residents. (Resident 2).

Findings include:

Clinical record review revealed that Resident 2 had diagnoses that included diabetes, chronic pain, and peripheral vascular disease (a condition that affects blood circulation to the limbs). A physician's order dated November 20, 2019, directed staff to cleanse the residents' left heel ulcer and cover with a dry sterile dressing once daily. Observation on January 17, 2020, at 9:05 a.m., revealed that Resdient 2 had a white bandage on his left foot that was dated January 14, 2020. Staff failed to clean and change the dressing for two days (January 15, and January 16, 2020).

In an interview on January 17, 2020, at 9:05 a.m., Resident 2 stated "they have not changed the dressing or cleaned my foot since the fourteenth."

In an interview on January 17, 2020, at 2:20 p.m., the Director of Nursing confirmed that the left foot heel dressing had not been cleansed and changed as per the physician order since January 14, 2020 at 2:30 p.m.

28 Pa. Code 211.12 (a)(1)(5) Nursing Services
Previously cited 5/31/19, 4/6/19, 11/2/18

 Plan of Correction - To be completed: 02/18/2020

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.


Resident(R2) dressing was changed
Current residents with wound care orders will be reviewed by DON/Designee to ensure treatment is being done in accordance with doctor's orders
Licensed nurses will be reeducated by DON/Designee on following wound care orders
DON/Designee will audit monthly x 3
Audit results will be reported to the QA committee for further recommendation

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