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Deficiency Records for Silver Stream Nursing and Rehabilitation Center
A list of the most recent deficiencies for Silver Stream Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Silver Stream Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-18 | 2024-04-10 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-03-18 | 2024-04-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-27 | 2024-04-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-02-27 | 2024-04-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-27 | 2024-04-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-02-27 | 2024-04-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-02-27 | 2024-04-01 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2024-02-27 | 2024-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-27 | 2024-04-01 | N |
| Provide appropriate foot care. | Health | 2024-02-27 | 2024-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-27 | 2024-04-01 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-02-27 | 2024-04-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-27 | 2024-04-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-27 | 2024-04-01 | N |
| 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. | Health | 2024-02-27 | 2024-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-27 | 2024-04-01 | N |
| 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. | Health | 2024-02-27 | 2024-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-27 | 2024-04-01 | N |
| Dispose of garbage and refuse properly. | Health | 2024-02-27 | 2024-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-27 | 2024-04-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-27 | 2024-04-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-27 | 2024-04-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-03-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-25 | 2024-03-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-22 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-22 | 2023-07-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-22 | 2023-07-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-06-22 | N |
| 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. | Health | 2023-05-04 | 2023-06-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-04 | 2023-06-22 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-04 | 2023-06-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-04 | 2023-06-22 | N |
| Provide or obtain dental services for each resident. | Health | 2023-05-04 | 2023-06-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-04 | 2023-06-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-04 | 2023-06-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-04 | 2023-06-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-04 | 2023-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-06-22 | N |
| Keep all essential equipment working safely. | Health | 2023-05-04 | 2023-06-22 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-05-04 | 2023-06-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-20 | 2023-04-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-06 | 2023-03-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-06 | 2023-03-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-19 | 2023-01-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2023-01-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-26 | 2022-09-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-26 | 2022-09-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-26 | 2022-09-15 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Use approved construction type or materials. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-13 | 2022-07-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-13 | 2022-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-13 | 2022-07-26 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-13 | 2022-07-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-13 | 2022-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-13 | 2022-07-26 | N |
| Dispose of garbage and refuse properly. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-01 | 2022-06-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-01 | 2022-06-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-01 | 2022-06-29 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-16 | 2022-03-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-31 | Not Fixed | Y |
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