F 0578
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
Based on record review and staff interview, the facility failed to designate a single code status in the
medical record for 1 of 1 residents sampled for Advance Directives. (Resident #44)
Residents Affected - Few
The findings include:
On 2/7/24, a record review was conducted for Resident #44. The resident's record contained an active
order for a Full Code dated 8/21/23 and an additional active Do Not Resuscitate (DNR) order dated
8/15/23.
On 2/7/24 at approximately 1:17 PM, an interview was conducted with the Director of Nursing (DON). The
DON was asked who is responsible for entering the code status into the medical record. The DON indicated
that the admitting nurse is responsible for entering the initial code status during admission and Social
Services is responsible for verifying and updating the code status if necessary.
On 2/7/24 at approximately 2:56 PM, an additional interview was conducted with the DON regarding active
advance directive orders for Resident #44. The DON retrieved the medical record hard copy chart and
reviewed the DNR yellow State of Florida form executed on 2/23/23. The DON indicated that Resident #44
is currently a DNR. The DON indicated the Full Code physician order should have been made inactive
when Resident #44's code status changed from full code to DNR.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105612
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105612
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Silvercrest Health and Rehabilitation Center
910 Brookmeade Drive
Crestview, FL 32539
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, and policy review, the facility failed to ensure staff perform
appropriate hand hygiene in accordance with facility policy during 1 of 1 wound care observations.
(Resident #101)
Residents Affected - Few
The findings include:
An observation of wound care for Resident #101 was conducted on 2/7/24 at 10:35 AM with the Assistant
Director of Nursing (ADON). The ADON was observed to don a disposable gown, wash her hands, and
apply clean gloves. She then removed the soiled dressing from the resident's sacrum and disposed of the
dressing. She then cleansed the wound with the same gloves she used to remove the soiled dressing. She
then washed her hands, applied new gloves, and applied the new wound dressing. Employee A did not
wash or sanitize her hands after removing the soiled dressing and before cleansing the wound.
An interview was conducted with the ADON on 2/7/24 at 11:37 AM. She stated she should have washed
her hands and changed gloves after removing the soiled dressing and before cleansing the wound.
Review of the facility policy for Non-Sterile Dressings (April 2019) revealed staff should wash or sanitize
hands with alcohol based hand rub (ABHR), put on disposable exam gloves, loosen tape and remove
soiled dressing, pull glove over dressing and discard into appropriate receptacle, wash hands or sanitize
hands with ABHR (if not visibly), put on clean gloves, observe the wound and surrounding skin, cleanse the
wound, use dry gauze to pat the wound dry, wash hands or sanitize hands with ABHR and apply new
gloves, apply the ordered dressing and secure with tape.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105612
If continuation sheet
Page 2 of 2
