Inspection·August 30, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who were unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene for 1 of 28 residents reviewed for ADL care. (Resident #15) Residents Affected - Few The facility did not shave Resident #15's upper lip and chin hairs. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of psycho-social well-being. Findings included: Record review of physician's orders dated August 2023 indicated Resident #15 was admitted to the facility on [DATE], was an [AGE] year old female, and had diagnoses of anxiety, muscle weakness and macular degeneration. Record review of the most recent MDS dated [DATE] indicated Resident #15 was alert and, oriented with a BIMS of 13 (score of 13 to 15 indicates the resident is cognitively intact) and required extensive assistance of one person for personal hygiene. Record review of a care plan updated 06/11/23 indicated Resident #15 had ADLs and preferences that needed staff attention, understanding, and possible assistance for her deficits. The care plan indicated the resident required extensive assistance with ADL care needs. The goal was to maintain the resident's dignity and needs. There was no care plan to indicate the resident resisted care or refused care. During observation and interview on 08/28/23 at 8:52 a.m., revealed Resident #15 was lying in bed. The resident had multiple hairs on her upper lip and chin approximately 3/4 inch in length. She said the facility staff usually shaved her but had not shaved her recently. She said she wanted to keep the facial hair shaved. She denied concerns related to dignity. During observation and interview on 08/28/23 at 12:15 p.m., revealed Resident #15 had multiple hairs to upper lip and chin approximately ¾ inch in length. During observation and interview on 08/29/23 at 12:26 p.m., revealed Resident #15 had long hairs to her upper lip approximately ¾ inch in length. HerThe chin had been shaved. The resident said one of the staff shaved her chin but did not shave her upper lip. She said she wanted her upper lip shaved but did not feel it was a dignity issue. CNA A entered the resident's room. She said (continued on next page) 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 6 Event ID: 676008 Printed: 05/15/2026 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 676008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656 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)