Resident #259 was prescribed Seroquel 50 milligrams nightly in March following falls that left him with a large hematoma on his forehead and skin tears on his hands. But a review of his medical records revealed no behavioral concerns or hallucinations until after the falls occurred.
The March 12 physician's note described the resident as "confused and pleasant, ambulatory and seemed fairly steady" when seen in the hallway. Staff reported no issues beyond a fall with skin tears the night before.
The next evening, staff found Resident #259 lying on the floor in the hallway, unable to explain what happened. A hematoma covered the left side of his forehead, and small skin tears marked both hands. The facility contacted his physician to review medications for "restlessness and agitation."
Three days later, he fell again. Staff discovered him lying beside his wheelchair in the hallway at 11:55 p.m., reporting a skin tear to his right forearm. Two staff members helped him back to his wheelchair and took him to the nursing station to watch television under supervision.
The hospice team suggested Seroquel following the second fall, and the facility started the antipsychotic medication on March 20. The interdisciplinary team review noted "increased restlessness and agitation" as justification.
But inspectors found the facility had not identified what caused the resident's restlessness. No non-pharmacological interventions were attempted before starting the medication. The care plan contained no documentation of hallucinations or behavioral concerns that would warrant immediate use of an antipsychotic drug.
Certified nurse aide #1 told inspectors on April 3 that Resident #259 required maximum assistance with transfers because he couldn't maintain his balance. The aide said the resident was usually unable to get up by himself, though occasionally managed without help. He believed the falls occurred because the resident "wanted and needed to move."
Staff kept the door to his room open as much as possible to monitor him, the aide said.
Registered nurse #1, an agency worker, said she was unaware the resident had sustained recent falls or that he was considered a fall risk. Though she knew he had dementia, she had never witnessed hallucinations or problematic behaviors. She was unfamiliar with any fall interventions for the resident.
The director of nursing and nursing home administrator, interviewed together, acknowledged they could not find documentation that the facility had determined the root cause of the resident's restlessness. The director of nursing said she was unaware of any hallucinations or psychosis before or after the falls, and could not locate records showing non-pharmacological interventions were tried before prescribing Seroquel.
The medication storage problems extended beyond inappropriate prescribing. Inspectors found vaccines and insulin stored at 50 degrees Fahrenheit in the medication refrigerator, well above the safe range of 36 to 46 degrees required by manufacturers.
Tuberculin skin test solution, hepatitis B vaccine, pneumococcal vaccine, influenza vaccine, COVID-19 vaccine and Basaglar insulin pens were all stored at the improper temperature. According to the Centers for Disease Control, improper storage can cause vaccines to lose potency and become unusable.
The director of nursing, who also served as infection preventionist, acknowledged the refrigerator should maintain temperatures between 36 and 46 degrees. She said night shift nurses were supposed to check the temperature but had not documented doing so. The facility lacked a temperature log and she didn't know how long the refrigerator had been running too warm.
The maintenance director planned to order a new medication refrigerator since the current one wasn't holding proper temperature.
Infection control failures pervaded the facility across three units. The director of nursing violated basic sterile technique during wound care for three residents, placing clean supplies on contaminated surfaces and failing to change gloves after touching soiled dressings.
During care for Resident #40's left foot wound, she placed clean dressing supplies on the bedside table without establishing a sterile field, then placed a disposable pad on the bed directly on top of the old, soiled dressing. She applied new dressing without changing gloves after handling the contaminated material.
Similar violations occurred during wound care for two other residents. She failed to perform hand hygiene before putting on gloves, didn't change gloves between treating different wound sites on the same patient, and consistently failed to maintain sterile fields for clean supplies.
A housekeeper cleaned a shared room using the same disinfectant rag for both residents' bedside tables and windowsills, violating protocols requiring separate cleaning supplies for each resident area. She mopped the entire room with one mop head instead of changing equipment between resident zones, and failed to clean high-touch surfaces like light switches and door handles.
The maintenance director, who supervised housekeeping, said the facility's disinfectant required one minute of contact time to be effective. He acknowledged that high-touch areas should be included in room cleaning but admitted the observed practices created potential for cross-contamination.
In the laundry area, staff reused protective gowns for up to a week without washing them between uses. Multiple cloth gowns hung on hooks behind the sorting room door, touching each other and creating contamination risks. The laundry aide also reused hair ties to secure oversized gown sleeves, never cleaning them between uses.
Residents' toothbrushes sat unlabeled in shared rooms, making it impossible to prevent cross-contamination. Inspectors found unlabeled toothbrushes, mouthwash and deodorant on vanities in multiple shared rooms over several days.
The director of nursing said the facility previously used labeled covers for toothbrushes but had thrown them away over time. She promised to obtain new covers and proper labeling.
Dental care suffered similar neglect. Resident #12, a 66-year-old woman with bipolar disorder and left-side paralysis from a stroke, waited nearly five months for a surgical referral. The facility dentist recommended an alveoloplasty procedure in November 2024 to reshape her painful lower jaw ridge, but staff never followed up.
The resident told inspectors in April that she had experienced jaw pain for a long time and was still waiting for an appointment. She had received no communication about when the dental work would be scheduled, though she remained able to eat despite the discomfort.
The nursing home administrator said the social services department was responsible for coordinating dental referrals, but the facility was in the process of hiring social services staff. She couldn't find documentation that the November referral had been processed and said she would contact the dentist to determine where the resident should be sent for the procedure.
Vaccination policies also failed residents. Two residents never received required annual offers of influenza vaccine, and one resident who consented to pneumonia vaccination in February 2023 never received the shot.
The facility's own policy required offering vaccines annually unless medically contraindicated, and documenting administration details including site, date, lot number and expiration date. But Resident #26's records showed only a 2022 refusal with no evidence of subsequent annual offers. Resident #43 signed consent for pneumonia vaccine in 2023 but never received it, despite records incorrectly indicating he had declined.
The director of nursing said many residents declined immunizations because they "did not trust the government," but acknowledged the facility should offer vaccines annually and document residents' responses properly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Silver Heights Skilled Nursing and Rehabilitation from 2025-04-03 including all violations, facility responses, and corrective action plans.
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