Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide services as outlined by the comprehensive care
plan, to meet professional standards of quality for consultation with the resident's physician when there was
a significant change in the resident's condition or a need to alter treatment significantly for 1 (Resident #13)
of 29 residents reviewed for following physician's orders.
Residents Affected - Few
The facility failed to implement Resident #13's care plan when the blood pressure and/or heart rate was
below prescribed parameters and did not notify the physician in October 2024. (10/07, 10/8, 10/15, 10/16,
10/21, 10/23, 10/25, 10/26, and 10/28).
Th failure placed residents, who required blood pressure and heart rate monitoring, at risk for complications
due to delayed physician intervention.
Findings included:
Record review of Resident #13's clinical record indicated she was admitted on [DATE], was [AGE] years old
with diagnosis which included hypertension (high blood pressure).
Record review of the quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS score of
08 which indicated cognition was moderately impaired. She had a diagnosis of hypertension.
Review of Resident #13's care plan dated 07/02/24 indicated the resident had diagnosis of hypertension
and was at risk for decreased cardiac output (a state in which your heart does not pump enough blood to
supply your organs and tissues with adequate oxygen), activity intolerance from weakness, and ineffective
coping. The interventions included administering anti-hypertensive medications as ordered. Monitor for side
effects such as orthostatic hypotension (a sudden drop in blood pressure when you stand from a seated or
prone position) and increased heart rate and effectiveness.
Record review of physician orders dated October 2024 indicated Resident #13 was prescribed carvedilol
12.5 mg (used to lower blood pressure) twice daily for hypertension. Hold for blood pressure less than
110/60; and hold for heart rate below 60.
Record review of the MAR dated October 1 - 29, 2024 indicated on the following dates at 8:00 a.m. and at
5:00 p.m., Resident #13's carvedilol 12.5 mg was held and there was no indication in the electronic clinical
record the physician had been notified :
10/07/24 at 5:00 p.m., B/P (blood pressure) was 94/54,
(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 5
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
10/30/2024
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)
F 0658
10/08/24 at 8:00 a.m., B/P was not recorded but coded as held,
Level of Harm - Minimal harm
or potential for actual harm
10/14/24 at 5:00 p.m., B/P was 100/56,
10/15/24 at 8:00 a.m., B/P was not recorded but coded as held,
Residents Affected - Few
10/16/24 at 8:00 a.m., B/P was not recorded but coded as held,
10/16/24 at 5:00 p.m., B/P was 116/56,
10/21/24 at 8:00 a.m., B/P was not recorded but coded as held,
10/23/24 at 5:00 p.m., B/P was 120/47,
10/25/24 at 5:00 p.m., B/P was 117/56,
10/26/24 at 8:00 a.m., B/P was 113/46, and
10/28/24 at 5:00 p.m., B/P was 113/56 and heart rate was 56.
Record review of the nurse's notes for Resident #13 dated October 3 through October 29, 2024, gave no
indication of notifying the physician of the blood pressure medication being held for 11 of 57 opportunities.
During an interview on 10/30/24 at 9:00 a.m., MA B said she would obtain resident vital signs prior to blood
pressure medication administration, and if medication were held due to being outside prescribed
parameters, she would alert the charge nurse. MA B said the charge nurse would then assess residents
and recheck their blood pressure with a manual cuff.
During an interview and record review on 10/30/24 at 8:40 a.m., LVN A reviewed Resident #13's current
electronic MAR and acknowledged the B/P medication was held on multiple occasions in October due to
B/P being out of parameters prescribed by the physician. LVN A said the nurses were responsible for
notifying the physician after B/P medication was held 3 times or more. She added the DON and ADON
were responsible for ensuring the physician had been notified. Nurses were educated to notify physicians
when medications were held. LVN A said Resident #13's had been overlooked and she would notify
immediately. The risk was medication may not be therapeutic if physician not notified when held so
adjustments may be made to dosages.
During an interview and record review on 10/30/24 at 9:00 a.m., the DON said her expectations were for
residents with prescribed parameters for administration of medications to have documentation of those vital
signs. She added she will conduct weekly chart audits, and it was her responsibility to assure accuracy of
resident's clinical records. She acknowledged Resident #13's October MAR indicated B/P medications were
held on multiple occasions. She said the physicians or Nurse Practitioners visited facility weekly or
bi-weekly and were made aware of any concerns with residents during their visits unless there was an
emergency.
During a joint interview on 10/30/24 at 12:00 p.m., the DON and ADON said they were responsible for
ensuring the physician was notified when medications were being held. They were overlooked. They said
they would in-service staff and start running a report in the electric medical record system
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676008
If continuation sheet
Page 2 of 5
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
10/30/2024
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)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
weekly/monthly to ensure physician notification of any medication that was consistently held or refused.
She said the risk was that the medication may not be therapeutic if the physician was not notified when
held.
Record review of the policy Specific Medication Administration Procedures dated August 2019 indicated . P.
Notification of Physician/Prescriber: 2) Held medications for pulse, blood pressure, low or high blood sugar,
or other abnormal test results, vital signs, resulting in medications being held.
Event ID:
Facility ID:
676008
If continuation sheet
Page 3 of 5
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
10/30/2024
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)
F 0790
Provide routine and 24-hour emergency dental care for each resident.
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 provide or obtain from an outside source
dental service to meet the needs of 1 of 29 residents reviewed for dental services. (Resident #132)
Residents Affected - Few
The facility did not assist Resident #132, who had missing teeth and dental decay, with a dental service
consult.
This failure could place the residents at risk for not receiving care and services to maintain their highest
practicable mental, physical, and psychosocial well-being.
Findings included:
Record review of an admission record dated 10/30/24 indicated Resident #132 admitted on [DATE] and
was [AGE] years old with diagnoses of high blood pressure, diabetes (disease results in too much sugar in
the blood), and peripheral vascular disease (chronic condition when blood vessels become block).
Record review of an admission document dated 05/21/24 for Resident #132 indicated no concerns with his
teeth.
Record review of a quarterly MDS assessment dated [DATE] for Resident #132 did not indicate any
problems with his oral health. His BIMS indicated he was cognitively intact. He required set up assistance of
staff for oral care.
Record review of the care plan dated 09/05/24 indicated Resident #132 was independent with his oral care
and no mention of dental problems.
During an observation and interview on 10/28/24 at 8:53 a.m., Resident #132 said he had not seen a
dentist in a long time and needed an appointment. He opened his mouth and said, I am missing some
teeth. There were some teeth on the lower jaw that were deteriorated. He denied being in pain or difficulty
in chewing his food.
During an interview on 10/29/24 at 10:00 a.m., the SW said she was responsible for making the
appointments for the residents to see the dentist. She said Resident #132 had not complained to her and
none of the nursing staff had reported he had a need for dental consult. She said they have a dentist to
send residents too if they have dental issues. She said nurses normally let her know. She said Resident
#132 had Medicaid so she would get him an appointment.
During an interview on 10/29/24 at 10:55 a.m., the DON said Resident #132's teeth should have been
assessed on admission and quarterly. She said we should have addressed that during care plan meetings.
During an interview on 10/30/24 at 8:57 a.m., the DON said she had observed Resident #132's teeth after
surveyor intervention and said the nurses should have referred him to the social worker for missing and
deteriorated teeth.
During an interview on 10/30/24 at 10:25 a.m., LVN C said she looked at the residents' teeth while
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676008
If continuation sheet
Page 4 of 5
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
10/30/2024
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)
F 0790
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
making rounds. She said if the resident complained of issues or pain, she would refer them to the SW. She
said Resident #132 performed his own oral care himself. LVN C said she had not seen any missing teeth or
cavities but if he needed an appointment, she would tell the social worker.
During an interview on 10/30/24 at 9:30 a.m., the Administrator said her expectations were for the residents
to be referred to the dentist as needed.
Record review of the policy dated 08/14/17 titled Dental Care indicated Resident assessed and assisted
with dental care needs to help maintain their nutritional needs and promote oral hygiene. Residents will be
assessed by nursing personnel for dental care needs at admission and as needed.Referrals for
professional dental care needs will be facilitated by the facility according to resident'/ resident'
representatives' preference.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676008
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
FAQ · About this visit
Common questions about this visit
What happened during the October 30, 2024 survey of SILSBEE OAKS HEALTH CARE LLP?
This was a inspection survey of SILSBEE OAKS HEALTH CARE LLP on October 30, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SILSBEE OAKS HEALTH CARE LLP on October 30, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.