Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Silsbee Oaks Health Care Llp during CMS and state inspections, most recent first.
Failure to Timely Complete and Transmit Discharge MDS Assessments: The facility did not complete or transmit required discharge MDS assessments for three residents. One resident with acute respiratory failure and morbid obesity had a completed discharge assessment that was not sent to CMS, and two residents with diagnoses including Alzheimer's disease, diabetes mellitus, osteoporosis with femur fracture, and muscle weakness had discharge MDSs due after discharge but still not completed. The DON said the MDS coordinator was responsible and that role changes likely contributed to the missed submissions.
Gas Stove Burners Failed to Light Properly: A kitchen gas stove was found with 2 of 10 burners not lighting with their pilot lights during observation. The DM said the burners were sometimes slow to light and turned them off, and later the burners were not being used during meal prep. The maintenance supervisor said the pilot lights may need cleaning, and the Administrator stated the stove should light with the pilot light and that equipment problems should be reported immediately.
Incomplete DNR Forms for Two Residents: Two residents with DNR status had incomplete OOH-DNR forms. One resident’s form was missing the physician’s license number and POA signature, and another resident’s form was missing a witness date and printed name. Both residents were documented as DNR, and both stated they did not want CPR.
A resident with anxiety disorder, muscle weakness, moderate cognitive impairment, and a history of multiple falls did not have the ordered fall mat in place beside the bed during observation. The care plan listed the bedside fall mat as an intervention, but an LVN said the mat had been removed for cleaning and was not returned, and the DON and Administrator stated it should have been bedside for the resident.
A resident with heart failure and an order for oxygen at 2 L via NC was found more than once with a soiled oxygen concentrator filter covered in a thick grayish/white powdery substance. Staff gave conflicting accounts of who was responsible for cleaning the filter, and an LVN stated she overlooked it. Facility records required weekly cleaning of oxygen concentrator filters, but the filter was not cleaned as scheduled.
A resident with dementia, generalized weakness, bladder and bowel incontinence, a history of UTI, and EBP for a gastric tube and wound received incontinent care from two CNAs who did not follow hand hygiene and supply-handling procedures. One CNA removed gloves and did not wash or sanitize hands before putting on clean gloves, and the other CNA placed the resident’s wipes in the supply closet instead of leaving them in the room. Staff interviews confirmed the hand hygiene and supply practices were not followed.
A resident with hypertension had their blood pressure medication held multiple times due to low readings without notifying the physician, contrary to facility policy. The resident's condition included moderately impaired cognition and risk for decreased cardiac output. Interviews revealed that the responsibility to notify the physician was not fulfilled, leading to a deficiency in meeting professional standards of care.
A resident with missing teeth and dental decay did not receive necessary dental services due to a lack of communication and follow-up by the facility staff. Despite the resident's cognitive intactness and expressed need for a dental appointment, the social worker was not informed, and the resident's dental needs were not assessed as required by the facility's policy.
Failure to Timely Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS system within 14 days after completion of the resident assessments for 3 of 3 residents reviewed. Resident #3, a male admitted with diagnoses including acute respiratory failure and morbid obesity, had a Discharge assessment marked return not anticipated dated 08/30/2025 that had been completed but was not transmitted to CMS as of 01/28/2026. The facility also failed to initiate and complete Discharge MDS assessments for Resident #87 and Resident #98 within 14 days of discharge. Resident #87, a male with diagnoses including Alzheimer's disease and diabetes mellitus, was discharged to a private home with home health services on 09/29/2025, and the MDS tracking tab showed a Discharge MDS due with an ARD of 9/29/2025, but no Discharge assessment had been completed as of 01/28/2026. Resident #98, a female with diagnoses including osteoporosis with fracture to the left femur and muscle weakness, was discharged to a private home with no home health services on 11/05/2025, and the MDS tracking tab showed a Discharge MDS due with an ARD of 11/05/2025, but no Discharge assessment had been completed as of 01/28/2026. During interview, the DON stated the MDS coordinator was responsible for completing and transmitting assessments and said role changes over the prior year likely contributed to the assessments not being completed or transmitted as required.
Gas Stove Burners Failed to Light Properly
Penalty
Summary
The facility failed to maintain the kitchen gas stove in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. During an observation and interview on 01/26/26 at 9:30 a.m., the DM turned on the stove burners and 2 of 10 burners, the front left first burner and the back third burner, did not light using their pilot lights. The stove did not have an odor of escaping gas. The DM stated that sometimes the 2 burners were slow to light but had been lighting, and she turned the 2 burners off. She also said she would clean the stove that day and have maintenance check it. During later observations on 01/26/26 and 01/27/26, the 2 burners were not being used during lunch meal preparation, there was no odor of escaping gas in the kitchen, and the pilot lights were lit on all 10 burners. The stove was clean and free of spills, and the DM stated they were not using those 2 burners. On 01/28/26, the maintenance supervisor stated the pilot lights on the stove are required to be cleaned at times and said she would check the stove. The Administrator stated her expectation was for the stove to light with the pilot light, that the DM should report equipment problems immediately, and that the facility did not have a policy about equipment, although the stove should work properly. She also stated the two burners were not being used until repaired. Later that day, the Administrator stated the stove service company checked the stove and replaced 2 pilot lights, and an observation showed all 10 burners lighting promptly.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had properly completed advance directives for Do Not Resuscitate status. Resident #5, who had diagnoses including multiple pelvic fractures, osteoarthritis of the hip, and Alzheimer’s disease, was listed as DNR on the face sheet, care plan, and physician order. However, the resident’s Out-of-Hospital DNR form was incomplete because the physician’s license number was blank and the POA signature line was not signed. During interview, Resident #5 stated she was a DNR and wanted to remain that way. Resident #9, who had diagnoses including hypertension and unspecified dementia, was also listed as DNR on the face sheet, care plan, and physician order. The resident’s Out-of-Hospital DNR form was incomplete because Witness #1 did not have a signed date and the printed/typed name section was blank. During interview, Resident #9 stated she did not want anyone to do CPR on her. The social worker stated that if a DNR form was not completed correctly with accurate dates and signatures, it could be considered invalid, and acknowledged that the forms for Resident #5 and Resident #9 were not completed properly. The DON also verified that the current advance directives for both residents were not completed, noting that the documents needed to be thorough and legally binding. The Administrator stated that if a DNR form was not completed correctly, it would not be accepted and staff would be required to initiate CPR.
Failure to Maintain Bedside Fall Mat for High Fall-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and failed to ensure assistive devices were in place to prevent avoidable accidents for Resident #117, who was reviewed for falls and hazards. Resident #117 was an [AGE]-year-old male admitted to the facility with diagnoses including anxiety disorder and muscle weakness. His quarterly MDS indicated a BIMS score of 9, showing moderate cognitive impairment, and the assessment also documented falls since admission with falls triggering a care planning decision. The care plan dated 01/29/2026 identified multiple falls, including falls on 08/13/25, 11/21/25, 11/24/25, 12/30/25, and 01/19/26, and listed fall mats on the floor bedside as an intervention. During observation on 01/27/2026 at 11:15 a.m., Resident #117 had no fall mats in place beside the bed while in bed. An LVN stated the mat had been there earlier but had been removed to be cleaned and that she did not follow up to ensure it was returned. The DON and Administrator both stated the resident should have had the fall mat bedside, and the facility policy required individualized fall-risk interventions to be initiated and maintained.
Soiled oxygen concentrator filter not cleaned as ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who was ordered oxygen at 2 liters per nasal cannula every shift and as needed for shortness of breath. Resident #90 had diagnoses of systolic and diastolic heart failure and a BIMS score of 10, indicating moderately impaired cognition. Her care plan included oxygen therapy for ineffective gas exchange related to shortness of breath, with an intervention to provide oxygen as ordered. During observations, the resident was found in bed with oxygen in use through a concentrator set at 2 liters per minute, and the black filter on the back of the concentrator was soiled with a thick grayish/white powdery substance. This condition was observed on more than one occasion. The resident stated that staff changed the oxygen tubing every Sunday, but she was unsure whether the oxygen concentrator filter was cleaned. Staff interviews showed that the filter had been overlooked. Staff gave differing accounts of who was responsible for cleaning and checking the oxygen concentrator filters. The LVN who worked the Sunday night shift said she was responsible for cleaning the filter and overlooked it, while other staff said hall monitors were responsible and nurses served as backup. The DON and Administrator stated that staff were expected to monitor and clean the filters routinely. Facility records showed the oxygen concentrator filters were to be cleaned weekly on Sundays, and the facility policy and in-service both directed that air filters be cleaned at least once a week.
Infection Control and Hand Hygiene Failure During Incontinence Care
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed for infection control. Resident #10 was an elderly female admitted with diagnoses including dementia and generalized muscle weakness, and her quarterly MDS indicated she required assistance of 1-2 staff for incontinence care, was always incontinent of bladder and bowels, and had memory problems. Her care plan documented bladder incontinence, a history of UTI, risk for septicemia, and Enhanced Barrier Precautions related to a gastric tube and a wound. During an observation of incontinent care, CNA A and CNA B provided care for Resident #10. CNA A used wipes for the resident’s front peri area and then used more wipes on the coccyx area, removed her gloves, and did not use hand sanitizer or wash her hands before putting on a clean pair of gloves. After care was completed, CNA B walked down the hall and placed the package of wipes in the supply closet instead of leaving them in the resident’s room. During interviews, CNA A stated she should have washed her hands before applying clean gloves, CNA B stated the wipes should have been placed in the resident’s drawer or nightstand, LVN C stated hands should be washed or sanitized after removing gloves and wipes should have remained in the resident’s nightstand, and the DON stated hands are to be sanitized before and after glove use and supplies should not be brought out of the room and used on other residents.
Failure to Notify Physician of Held Medication
Penalty
Summary
The facility failed to provide services according to the comprehensive care plan for a resident with hypertension, leading to a deficiency in meeting professional standards of quality. The resident, who had a moderately impaired cognition and was at risk for decreased cardiac output, was prescribed carvedilol to manage hypertension. However, the medication was held on multiple occasions in October 2024 due to blood pressure readings being below the prescribed parameters, without notifying the physician. This lack of communication with the physician occurred despite the facility's policy requiring notification when medications are held due to abnormal vital signs. Interviews with facility staff revealed that the nurses were responsible for notifying the physician after blood pressure medication was held three times or more, but this protocol was not followed for the resident in question. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the oversight and the absence of documentation indicating physician notification. The failure to notify the physician when the medication was held placed the resident at risk for complications due to delayed intervention.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident, identified as Resident #132, who had missing teeth and dental decay. Despite being cognitively intact and requiring only setup assistance for oral care, the resident had not seen a dentist for a long time and expressed the need for an appointment. The resident's admission records and quarterly assessments did not indicate any oral health issues, and the care plan noted the resident was independent with oral care, with no mention of dental problems. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. The social worker, responsible for making dental appointments, was not informed of the resident's condition by the nursing staff. The Director of Nursing acknowledged that the resident's teeth should have been assessed on admission and quarterly, and that the issue should have been addressed during care plan meetings. The facility's policy required nursing personnel to assess and assist with dental care needs at admission and as needed, but this was not followed in the case of Resident #132.
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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.
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Nursing homes near Silsbee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mill Creek | 1.3 mi | ★★★★★ | 7 | 0 |
| Paradigm At The Pines | 1.3 mi | ★★★★★ | 18 | 1 |
| Village Creek Rehabilitation And Nursing Center | 5.9 mi | ★★★★★ | 16 | 3 |
| Paradigm At Kountze | 9 mi | ★★★★★ | 5 | 0 |
| Jefferson Nursing And Rehabilitation Center | 15.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.