Deficiency Records for Complete Care at Silver Lake LLC
Updated as of August 01, 2021
This is not the most recent data for Complete Care at Silver Lake LLC. For the most recent information, click here.
A list of the most recent deficiencies for Complete Care at Silver Lake LLC. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-29 | 2021-04-27 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-02-11 | 2021-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-11 | 2021-03-04 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-07-15 | 2020-08-03 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-22 | 2019-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-22 | 2019-09-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-22 | 2019-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-22 | 2019-09-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-22 | 2019-09-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-08-22 | 2019-09-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-22 | 2019-09-30 | N |
| 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. | Health | 2019-08-22 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-22 | 2019-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-22 | 2019-09-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-25 | 2019-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-25 | 2019-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-03-25 | 2019-04-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-25 | 2019-04-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-18 | 2018-11-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-10-18 | 2018-11-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-18 | 2018-11-19 | 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 | 2018-10-18 | 2018-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-18 | 2018-11-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-10-18 | 2018-11-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-18 | 2018-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-18 | 2018-11-19 | N |
| 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 | 2018-10-18 | 2018-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-18 | 2018-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-10-18 | 2018-11-19 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-18 | 2018-05-30 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2017-10-31 | 2017-12-04 | N |
| 1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions. | Health | 2017-10-31 | 2017-12-04 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-10-31 | 2017-12-04 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-31 | 2017-12-04 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-31 | 2017-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-10-31 | 2017-12-04 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-31 | 2017-12-04 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-31 | 2017-12-04 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-10-31 | 2017-12-04 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-31 | 2017-12-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-11-03 | 2017-11-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-11-03 | 2017-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-11-03 | 2017-11-28 | N |
