Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Cross Health & Rehab during CMS and state inspections, most recent first.
Missing Dining Room Floor Tiles: Chipped and partially missing floor tiles were repeatedly observed in a high-traffic dining room common area over several days. The Maintenance Director said the tiles could create a tripping hazard and was unaware of the issue because no work order had been submitted, while the DON acknowledged staff could have reported it and the NHA confirmed there was no formal policy for environmental safety hazards such as damaged flooring.
Expired food items were found in the dry storage area during a kitchen tour, including an opened bottle of honey, multiple bottles of lemon juice, and gallons of Italian dressing past expiration. The facility’s FIFO policy required product rotation and removal of food past its use or expiration date. The DM stated the cook was responsible for pulling expired food and that staff should rotate stock, while the NHA stated staff were expected to monitor daily and remove all expired foods.
Failure to maintain resident dignity during staff communication. An LPN was reported by residents and another LPN for speaking in a loud, gruff tone and arguing with a resident during care and communication. The resident said the LPN did not speak respectfully or with dignity, and another resident described repeated loud exchanges when the resident used pet names. The DON confirmed a complaint had been investigated, and the LPN acknowledged being in-serviced about tone and redirecting residents to use her name.
Failure to Evaluate Safe Self-Administration of Medication: A resident with moderately impaired cognition and diagnoses including vascular dementia and glaucoma kept Vapor Rub at bedside and used it on his own, stating staff did not know when he used it. The DON confirmed the resident should not have the product at bedside, that multiple assessments are required before self-administration is allowed, and that no self-administration assessments had been completed; there was also no MD order for the Vapor Rub.
A resident with Type 2 DM had inaccurate and incomplete advance directive documentation in the admission record. The signed acknowledgment form stated that an advance directive had been formulated before admission, but it did not identify the type of directive and also included an X indicating the resident declined to formulate one. The Admissions Coordinator could not locate any advance directive on file, and the DON stated the form had been corrected and that the resident did not have an advance directive.
Failure to follow the care plan for a resident’s hearing and ADL needs. The resident wanted regular shaving and reported facial hair was not being addressed, while a CNA confirmed she had not been shaved in days. The resident also needed new hearing aids after an audiology visit noted impacted wax and further evaluation, but the facility did not follow up on the visit summary or coordinate the documented hearing care needs.
A resident with intact cognition and diagnoses including depression and R shoulder OA was observed with a moderate amount of facial hair and stated she did not like it and preferred shaving every other day. A CNA confirmed the resident had not been shaved in several days and had requested shaving, while the DON stated the resident should be shaved as needed and that staff were expected to provide daily ADL care. The record did not document refusal of care when shaving was not provided.
Failure to follow up on a resident’s hearing needs: A cognitively intact resident reported needing new hearing aids and had been sent to a hearing aid supplier, but the facility did not obtain or act on the appointment summary. The summary showed the resident’s aids were packed with wax, were cleaned and adjusted, and that further evaluation was needed because the ears were impacted. Interviews with the SW, DON, and CNA/Transportation Aide confirmed there was no clear process or assigned person to ensure the results were received and followed up.
Unordered Zinc Oxide was applied during wound care for a resident with a Stage 3 coccyx pressure ulcer. The ordered treatment called for normal saline cleansing, Medi-Honey, calcium alginate, and a border foam dressing, but an RN added Zinc Oxide around the wound edges even though it was not on the MAR. The DON confirmed that the addition did not align with the wound care plan.
PEG tube care was performed improperly for a resident with hemiplegia and dysphagia. An RN cleaned the PEG site with the same gauze in a circular motion multiple times instead of discarding and replacing the gauze with each wipe, contrary to infection control standards and the resident’s PEG care orders. The RN acknowledged the error, and the DON stated the repeated wiping could cause infection, skin irritation, and discomfort.
Infection control practices were not maintained during PEG tube med administration for a resident with Parkinson's disease and mild cognitive impairment. An LPN placed the syringe plunger on the bedside table without a barrier or disinfection, then rinsed the syringe with water and returned it to the resident's bag for later use. The LPN, Infection Preventionist, and DON all stated the syringe should not have been handled that way because the surface was contaminated and the item should have been cleaned or replaced.
A resident with an ADL self-care performance deficit did not receive the necessary assistance with oral care as outlined in their comprehensive care plan. Despite the resident's dependence on staff for personal hygiene, interviews revealed that oral care was not provided on multiple occasions. A CNA confirmed the lack of assistance, and an RN emphasized the importance of the care plan in guiding personalized care. The resident's medical history includes lack of coordination, muscle weakness, and hemiplegia following a cerebral infarction.
A facility failed to update a resident's fall prevention care plan, leaving outdated interventions unaddressed. Despite a policy requiring regular review and revision, the resident's care plan included interventions from 2020 that were not implemented. Observations showed missing safety features in the resident's room and wheelchair. Interviews with staff confirmed the lack of updates and visual inspections. The resident, cognitively intact with a history of falls, had a diagnosis of unspecified lack of coordination.
A facility failed to provide necessary oral hygiene assistance to a resident with muscle weakness and lack of coordination, despite policy requirements. The resident, who was cognitively intact and required supervision for oral care, reported not receiving help with brushing her teeth. Interviews with staff confirmed the oversight, highlighting a deficiency in adhering to the facility's ADL care policy.
A facility failed to maintain proper infection control during wound care for a resident with a Stage 4 pressure ulcer. An LPN did not change gloves or perform hand hygiene before applying a clean dressing, which was confirmed as an infection control issue by both the LPN and the DON.
Missing Dining Room Floor Tiles
Penalty
Summary
The facility failed to maintain a safe, functional, and homelike environment in the dining room when chipped and partially missing floor tiles were observed in the front right section of the room and remained unrepaired over four consecutive days of survey. The dining room was identified as a high-traffic common area, and the missing tiles were repeatedly seen during observation on 12/08/2025, 12/09/2025, 12/10/2025, and 12/11/2025. During interview, the Maintenance Director stated that chipped tiles could cause a tripping hazard and that he glues tiles down as needed when he notices they are loose or missing, but he was unaware of the missing tiles in the dining room and no work order had been submitted. The DON stated the area could pose a tripping hazard and acknowledged that CNAs and nurses are routinely present in the dining room during meals and could have submitted a work order. He also stated the area was typically covered by a long table and may have only recently been visible due to the placement of a Christmas tree. The NHA stated the Maintenance Supervisor provides new staff orientation on submitting work orders for environmental concerns, but confirmed there was no formal policy in place to address environmental safety hazards such as chipped or missing flooring.
Expired Food Left in Dry Storage
Penalty
Summary
Food items were not stored under sanitary conditions because expired products were left in the dry storage area. During an initial kitchen tour, surveyors found one opened 5-ounce bottle of Honey grade A with an expiration date of 10/10/25, five bottles of lemon juice that expired on 4/5/25, and two gallons of Monarch Italian dressing that expired on 10/2/25. The facility’s undated FIFO policy stated that product rotation is important for quality and safety, that the first batch product prepared in storage should be used first, and that food past its manufacturer’s use or expiration date should be thrown out. In interview, the Dietary Manager stated the cook was responsible for pulling expired food, staff should rotate items when putting up stock, and it was her responsibility to make sure staff did their job. The Nursing Home Administrator stated he expected staff to monitor daily and pull all expired foods.
Failure to Maintain Resident Dignity During Staff Communication
Penalty
Summary
The facility failed to ensure that one sampled resident, Resident #25, was treated with dignity and respect by staff during care and communication. The facility Resident's Rights policy stated that residents have the right to be treated with respect and dignity. During an interview, LPN #4 stated there had been concerns about LPN #3's interactions with multiple residents, including Resident #25 and Resident #11, and described the issue as involving tone and arguing with residents. Resident #25 stated that LPN #3, who works the night shift, spoke to him in a loud and gruff tone that he compared to a police officer, and that she did not speak to residents in a respectful or dignified manner. Resident #11 also stated that LPN #3 often argued with Resident #25 and raised her voice, especially when the resident called her baby, and that she would respond loudly and tell him not to call her that. The DON confirmed a recent complaint had been investigated regarding LPN #3, although it was unsubstantiated, and stated her tone was structured with no formal complaints related to her communication style. LPN #3 stated she had been in-serviced recently regarding tone because residents could not hear her, and acknowledged redirecting residents who used pet names by asking them to use her name instead. Resident #11 had diagnoses including hemiplegia and hemiparesis and a BIMS score of 14, and Resident #25 had chronic diastolic CHF and a BIMS score of 15.
Failure to Evaluate Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that one resident assessed as moderately cognitively impaired was properly evaluated for safe self-administration of medication. The facility policy stated that residents may self-administer medications only with approval of the interdisciplinary or care planning team, and that a self-administration evaluation should be completed in the EHR. Resident #8, admitted with diagnoses including vascular dementia, anxiety, and primary open-angle glaucoma, had a BIMS score of 10, indicating moderately impaired cognition. During observation and interview, Resident #8 had a 3.5-ounce jar of Vapor Rub on the bedside table and stated he used it as needed, brought it from home, and rubbed it under his nose. He said staff did not know when he used it. The DON later observed the Vapor Rub still at bedside and stated the resident should not have it there, that multiple assessments are required for self-administration of medication, and that the resident could have inhalation issues by using it on his own and breathing it into his nares. The DON confirmed that no self-administration of medication assessments had been completed, and the resident’s physician orders contained no order for Vapor Rub.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation of advance directive status for one resident who was admitted with diagnoses including Type 2 Diabetes Mellitus. The admission record included an Acknowledgement of Advance Directives Decisions, Rights, and Information signed by the resident representative and dated 3/25/25, which stated that an advance directive had been formulated before admission, but the form did not identify what type of advance directive had been completed and also contained an X indicating the resident declined to formulate an advance directive at that time. During interview, the Admissions Coordinator/Staff Scheduler stated she searched for any advance directive provided to the facility but could not find a copy and believed the resident representative initialed the form indicating an advance directive was formulated in error. The DON later stated the form had been corrected and that the resident did not have an advance directive.
Failure to Follow Care Plan for Hearing and ADL Needs
Penalty
Summary
The facility failed to implement the care plan interventions for one resident’s hearing needs and ADL needs. The resident’s comprehensive care plan included referrals to audiology for a hearing consult and assistance with all ADLs and personal hygiene needs every shift and as needed. During observation, the resident was noted to have a moderate amount of gray hair under her chin and upper lip, and she stated she did not like the facial hair and wanted to be shaved every other day. A CNA confirmed the resident had a moderate amount of facial hair and had not been shaved in days, and the DON stated the resident should be shaved when needed and that ADL care was expected daily. The resident also reported needing new hearing aids after being seen by a hearing provider months earlier, but she still did not have them. The social worker confirmed the resident was sent for a hearing evaluation in June and did not have the visit summary, and the DON acknowledged no one had followed up to obtain it. The appointment summary from the hearing aid supplier documented that further evaluation was needed because the resident’s hearing aids were impacted with wax; the aids were cleaned and changed, and the note stated the resident would return after her ears were cleaned out. The resident’s record showed she was admitted on 10/16/24 and had a BIMS score of 14, indicating she was cognitively intact.
Failure to Provide Requested Facial Shaving
Penalty
Summary
The facility failed to ensure grooming needs were met in accordance with a resident’s preferences and needs for one of three residents reviewed for activities of daily living. The resident, who was cognitively intact with a BIMS score of 14, had diagnoses including depression unspecified and primary osteoarthritis of the right shoulder. During observation, the resident had a moderate amount of grey hair under her chin and upper lip and stated that she did not like the hair on her face. She reported that if she was lucky, staff would shave her twice a week, that she had been shaved early the prior week, and that her preference was to be shaved every other day. An interview with a CNA confirmed that the resident had a moderate amount of facial hair, had not been shaved in several days, and had expressed dissatisfaction with the facial hair and requested to be shaved. The facility’s policy stated that care and services would be provided for grooming and that a resident unable to carry out ADLs would receive necessary services to maintain grooming and personal care. The DON stated the resident should be shaved as needed and that staff were expected to provide ADL care on a daily basis. The record review did not show documentation of refusal of care when shaving was not provided.
Failure to Follow Up on Hearing Evaluation and Hearing Aid Needs
Penalty
Summary
The facility failed to ensure timely follow-up and coordination of care for a resident’s hearing needs. Resident #10, who had a BIMS score of 14 and was cognitively intact, stated she needed her new hearing aids and reported that she had gone to a doctor about five months earlier but still did not have them. She also reported that she had been taken to a Miracle Ear physician in a nearby city. The resident had been admitted with diagnoses including Encounter for Prophylactic Measures, Unspecified, and Vitamin D Deficiency Unspecified. A record review of the hearing aid supplier’s appointment summary showed that the resident’s hearing aids were stopped up with wax, the aids were cleaned and the domes changed, and the resident was hearing better, but the outcome also stated that further evaluation was needed because the ears were impacted and she would need her ears cleaned out before returning. Interviews with the SW, DON, and CNA/Transportation Aide showed the facility did not have the appointment summary at first, had no specific person assigned to obtain it, and had not followed up on the evaluation results. The DON confirmed no one had followed up to obtain the physician summary, and the CNA stated she was not given the summary or made aware of the follow-up appointment.
Unordered Zinc Oxide Applied During Pressure Ulcer Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not followed when wound care for Resident #38’s Stage 3 coccyx pressure ulcer was administered. The physician’s order dated 12/10/25 directed staff to cleanse the wound with normal saline, pat dry, apply Medi-Honey to the wound bed, place calcium alginate over the honey, and cover with a border foam dressing daily. During observed wound care, RN #1, assisted by LPN #1, completed the ordered treatment and then applied Zinc Oxide ointment around the edges of the wound. RN #1 later confirmed that Zinc Oxide was not listed as an active order on the MAR, and the DON confirmed that medical orders must be followed as written and that adding Zinc Oxide without a physician’s order did not align with the established wound care plan. Resident #38 was admitted with diagnoses including cerebral infarction, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left dominant side, and a Stage 3 pressure ulcer of the sacral region; the resident’s BIMS score was 15, indicating cognitive intactness.
PEG Tube Care Performed Improperly
Penalty
Summary
Facility staff failed to follow professional nursing standards during PEG tube care for one resident. During an observation on 12/10/2025 at 10:00 AM, RN #1 provided PEG tube care to Resident #44 and cleaned the PEG site with a gauze soaked in wound cleaner. She used the same gauze in a circular motion four times without discarding it and replacing it with a new gauze for each wipe, as required by infection control standards. Resident #44 was admitted on 1/5/24 with diagnoses of hemiplegia and hemiparesis following a nontraumatic intracranial hemorrhage affecting the right dominant side and dysphagia following a non-traumatic intracranial hemorrhage. The resident’s physician orders directed staff to cleanse the PEG tube site with wound cleanser, pat dry, apply sure prep topically under and around the PEG tube, cover with a drain sponge, and secure with paper tape as needed. RN #1 stated she should have discarded the gauze and used another one while cleaning the site, and the DON stated the nurse should have wiped once and discarded the gauze with each wipe.
Infection Control Lapse During PEG Tube Medication Administration
Penalty
Summary
Infection prevention and control practices were not maintained during PEG tube medication administration for one resident. During observation, an LPN administered PEG tube meds and took the syringe apart to drain the medication into the stomach by gravity. The nurse placed the syringe plunger on the bedside table next to household items without using a clean barrier or disinfecting the surface. After completing the task, the nurse rinsed the syringe with water, patted it dry, and returned it to the resident's zip lock bag on the bedside pole before leaving the room. During interview, the LPN stated a barrier should have been used to prevent spreading infections to the resident and acknowledged that rinsing the syringe without soap and water was not sufficient. The Infection Preventionist stated the syringe plunger should not have been placed on the bedside table because it was a contaminated surface and could spread infection, and the syringe should have been replaced rather than returned for later use. The DON also stated a barrier should have been used and the syringe should have been properly cleaned or disposed of because it was contaminated. The resident had Parkinson's disease and a BIMS score of 10, indicating mild cognitive impairment.
Failure to Implement Comprehensive Care Plan for Resident's ADL Needs
Penalty
Summary
The facility failed to implement the comprehensive care plan interventions for a resident who was dependent on staff for Activities of Daily Living (ADL) care. The facility's policy requires a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's needs. However, the care plan for the resident, who has an ADL self-care performance deficit, indicated that the resident is totally dependent on 1-2 staff for personal hygiene and oral care. Despite this, the resident expressed a desire to brush her teeth and mentioned that she had previously informed the staff about it, but could not recall the last time she did so. Interviews with the resident and staff revealed that the resident had not received assistance with oral care on multiple occasions. A Certified Nursing Assistant (CNA) confirmed that she had not assisted the resident with oral care on the previous day and had not done so on the day of the interview. The CNA acknowledged that oral care should be performed daily before breakfast. Additionally, a Registered Nurse (RN) stated that the comprehensive care plan is intended to guide personalized care, including oral care as part of ADL care. The resident's admission record indicated diagnoses of unspecified lack of coordination, muscle weakness, and hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side.
Failure to Update Fall Prevention Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan interventions for falls for a resident, despite having a policy that mandates the review and revision of care plans by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The resident, who had a history of frequent falls, had several interventions listed in their care plan dating back to 2020, which were not updated or implemented. Observations revealed that many of these interventions, such as a cup holder attached to the bed rail, a TV remote attached to the bedside table, and a mirror mounted near the bed, were not present in the resident's room. Additionally, the resident's wheelchair lacked several safety features that were supposed to be in place, such as an anti-rollback device, colored tape for identification, a reacher, and dycem material on the cushion. Interviews with the RN responsible for care plans and the CNA assigned to the resident confirmed that the interventions were outdated and not reconciled with the resident's current needs. The RN admitted to not conducting visual inspections to ensure the interventions were being provided, and the CNA noted that some items had not been present for a long time. The Director of Nursing acknowledged that the care plan should have been revised to reflect the resident's current needs, especially after a fall that required a change in interventions. The resident was cognitively intact, as indicated by a BIMS score of 15, and had a diagnosis of unspecified lack of coordination.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to ensure that dependent residents received necessary services to maintain oral hygiene, specifically for one resident. The facility's policy on Activities of Daily Living (ADL), revised in September 2022, mandates that residents unable to perform ADLs independently should receive assistance to maintain personal and oral hygiene. However, interviews and record reviews revealed that Resident #44, who was admitted in May 2023 and diagnosed with muscle weakness and lack of coordination, did not receive assistance with oral care. Despite being cognitively intact and requiring supervision or assistance with oral hygiene, the resident reported not receiving help with brushing her teeth, which she had previously done twice daily. Interviews with staff, including a CNA and the Director of Nurses (DON), confirmed that oral care is part of ADL care and should be provided every shift. The CNA admitted to not assisting the resident with oral hygiene on the days in question, while the DON emphasized the importance of oral care in preventing oral infections. The Task List Report for the resident indicated that personal hygiene tasks were to be performed by a CNA every shift and as needed, yet the resident's oral care needs were not met, leading to the identified deficiency.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control during wound care for a resident with a pressure ulcer. During an observation, an LPN did not remove her soiled gloves, perform hand hygiene, and apply clean gloves before applying alginate to the wound bed and covering it with a border dressing. The LPN confirmed in an interview that she forgot to change her gloves and perform hand hygiene, acknowledging that her actions could lead to contamination of the wound. The Director of Nurses also confirmed that the LPN should have changed gloves and performed hand hygiene, recognizing this as an infection control issue. The resident involved was admitted to the facility with a diagnosis of a Stage 4 pressure ulcer in the sacral region.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Brookhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Brookhaven | 0.2 mi | ★★★★★ | 9 | 0 |
| Trend Health And Rehab Of Brookhaven | 0.2 mi | ★★★★★ | 6 | 0 |
| Haven Hall Health Care Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Pine Crest Guest Home Inc | 19.7 mi | ★★★★★ | 0 | 0 |
| Lawrence Co Nursing Center | 21.1 mi | ★★★★★ | 3 | 0 |
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