Silver Pines Nursing and Rehabilitation Center

Inspectors wroteBased on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident , encouraging both independence and interaction in the community for two of five residents (Resident #7 and Resident #10 reviewed for activities. The facility failed to provide Resident #7 and Resident #10 in room activities on the dates of 05/01/2025 thru 05/13/2025. This failure could place residents at risk for boredom, depression, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, 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 3 (Resident #56,Resident #22, and Resident #293) of 5 residents reviewed for infection control practices, in that: The facility failed to: 1. Ensure CNA B changed dirty gloves when handling clean items while providing peri care to Resident #56 2. Ensure MA E sanitized blood pressure monitor in between Resident #22 and Resident #293 while obtaining blood pressure. These failures could place residents at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #193) of three residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #193. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 of 4 residents (Resident #27, Resident #74 and Resident #45) reviewed for quality of care. The facility failed to ensure Resident #27, Resident #74 and Resident #45's nebulizing mask and tubing, that were observed on 06/03/25, were bagged for sanitation when not in use. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (200 Hall Med Aide Cart) reviewed for medication storage . The facility failed to ensure that the 200 Hall Med Aide Cart did not contain personal belongings of MA E, along with the medications for residents. This failure could place residents at risk for contamination and medication errors through confusion and distraction among the medication administration staff .

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary [NAME] changed her gloves during food preparation after touching a bread bag and a piece of paper. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide maintenance services necessary to maintain a safe, orderly, and comfortable homelike environment for five (room [ROOM NUMBER], 451, 460, 461, and 463) of twelve rooms reviewed in the facility's secure unit for environmental conditions. The facility failed to cut down and cap the two mounting bolts that secure the toilet's base to the floor, which ensures that the toilet does not move or leak in room [ROOM NUMBER], 451, 460, and 463. The facility failed to ensure that room [ROOM NUMBER]'s bathroom walls were painted after having two portions of drywall repaired. These failures could place residents at risk of living in an unsafe, unhomelike, and uncomfortable environment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all PASARR- Level I positive residents diagnosed with mental illness were provided with a PASARR- Level II Screening for 1 of 3 residents (Resident #70) reviewed for mental illness, intellectual disability, or developmental disability. The facility failed to ensure Resident #70 received a PASARR Level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services and causing a possible decline in mental health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to properly label food and store food by not sealing/covering food items. in one of one walk in refrigerators and dry storage shelves located in the kitchen. 2. The facility failed to ensure a visitor wore a hair net and a beard guard when he entered the kitchen from the exit side door leading to the outside near parking area. These failures placed residents at risk for health complications and foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections. AD and CNA I failed to use proper hand hygiene techniques when assisting 2 unidentified residents each (4 residents total) to eat during lunch meal service. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 dining room reviewed for environment. The facility failed to ensure the dining room was free of flies during the resident meal services. These failures could place residents at risk for infection and not receiving a home free of pest or comfortable environment to live. Findings Included: In an observation on 05/21/24 at 12:14 PM multiple flies were seen in and around residents' food throughout the dining room during meal service. A staff member was heard saying to an unidentified resident eat your food the flies are eating it all. AD and CNA I were observed swatting flies as they assisted in feeding 2 unidentified residents each. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure each resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility for two (Resident #57 and Resident #66) out of seven residents reviewed for dignity. 1. The facility failed to treat Resident #57 with respect and dignity by providing privacy during care when Resident #57 was left exposed after a fall and incontinent episode. 2. The facility failed to treat Resident #66 with respect and dignity when he was left with long untrimmed fingernails which could cause skin breakdown, damage and become a source of infection. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS system for a subset of items upon a resident's discharge from the facility for one (Resident #88) of eight residents reviewed for encoding and transmitting resident assessments. The facility failed to complete, encode, and submit a Discharge MDS Assessment for Resident #88. This failure to place discharged residents at risk of not having a proper discharge and not receiving services post discharge.

Inspectors wroteBased on observations, record review, and interviews the facility failed to update one (Resident #57) out of seven residents reviewed for care plan in relation to changes in health, changes in behavior and significant changes. The facility failed to update Resident #57's care plan and adjust it r/t physician orders or behaviors. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, record review, and interviews the facility failed to update the Resident's (#57) care plan in relation to changes in health, changes in behavior and significant changes for one (Resident #57) out of 8 residents reviewed. The facility failed to update Resident #57's care plan and adjust it in relation to physician orders. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have all residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, for 1 of 3 (Resident # 54) residents reviewed for edema care. The facility failed to follow physician orders, the comprehensive care plan, and provide treatment for Resident #54's edema. This failure could place residents at risk for untreated medical issues and diminished quality of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the environment remains as free of hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #71) out of eight residents reviewed. The facility failed to safely and securely store mouthwash and hand sanitizer in Resident #71's room. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's IV was inappropriately placed on a IV Pole. This failure could result in residents experiencing accidents, injuries, loss of dignity , and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff did not use physical abuse or corporal punishment on a resident for 1 of 13 residents (Resident #1) reviewed for abuse in that: CNA A slapped Resident #1 on her hand while providing assistance with dressing. This failure could place residents at risk of fear and physical/psychosocial injury. Noncompliance existed from 09/24/23 to 09/29/23, but the facility corrected the noncompliance through training, reviews of clinical information, revision of processes, and the QAPI process.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 10 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 was provided assistance with nail care as documented in her plan of care and MDS. This failure could place residents at risk of scratches, infection, and poor self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 4 of 10 Rresidents (#76, #148, #147 and #49) reviewed for call lights in that: Residents #76, #148, #147 and #49 were observed in their rooms with their call lights not in reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on interview and observation, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for seven of sevenresidents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private without uninvited staff being present. Findings Included: In an interview on 03/26/2023 at 1:30 PM, the Activity Director stated the Resident Council meetings were held in the dining room. She stated there was not another area for the residents to meet in private. She stated she would place signs on the doors and have someone to stand at each door to prevent any staff from entering the dining room. [...]

Inspectors wroteCitation Text for Tag 0574, Regulation FF12 [NAME], [NAME] Based on interview and record review the facility failed to ensure the location of the state agency phone number was reviewed with the residents and ensure information was discussed on how to file a complaint with the state agency with seven residents reviewed for resident council. The facility failed to ensure the residents was aware the location in the facility of the phone number for the complaint hotline with the state agency. This failure could prevent residents from calling state agency to voice concerns about their care.

Inspectors wroteBased on interviews, the facility failed to post a notice and inform residents of availability to the results of the most recent survey. The facility failed to inform residents by verbally informing residents or by posting a sign letting the residents know the location of the most recent survey. This failure placed residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 of 20 residents (Residents #198, #88, #36 and #197) reviewed for quality of care. 1. The facility failed to ensure Resident # 198's facial hair was shaved, his nails were trimmed and cleaned, and his adult brief was changed every two hours. 2. The facility failed to ensure Resident #88's mustache was trimmed. 3. The facility failed to ensure Resident #36 received showers on his preferred shower days, failed to trim and clean his fingernails and failed to shave his face. 4. The facility failed to ensure Resident #197 received showers or baths, failed to trim and clean his fingernails, and failed to wash his hair and shave his facial hair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for three (Resident #62, #88, #65) of 16 residents reviewed for nutrition on pureed diets. The facility failed to ensure Resident #62, #88, and #65 whose diet order was for pureed diet maintained acceptable parameters of nutritional status and prevented weight loss with effective interventions. This failure put residents at risk for malnutrition, weight loss and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 of 2 nurse medication carts (Hall 100) and 1 of 1 Medication storage rooms reviewed for drug storage. The nurse medication cart for Hall 100 had a sticky substance in the cart with loose pills and hair stuck in it. Two bottles of a diabetic nutritional oral supplement with expiration dates of 08/2022 were found in the cart. Three bottles of a diabetic nutritional oral supplement with an expiration date of 08/2022 were found stored in the medication storage room This failure placed residents at risk of receiving contaminated medications and expired oral supplements.

Inspectors wroteCitation Text for Tag 0557, Regulation FF12 May, [NAME] L. Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 2 of 2 residents (Residents #147, and #148) reviewed for dignity. 1. Residents #147's urinary catheter bag was uncovered with dark yellow urine visible from the entrance to her room. 2. Residents #148's urinary catheter bag was uncovered with yellow urine visible upon entering her room. This failure could affect residents by putting them at risk for loss of self-worth and a decline in their psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care and failed to ensure a care plan was developed within 48 hours of a resident's admission for two of eight residents (Resident # 197 and Resident # 148) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident # 197 and Resident #148 within the required 48-hour timeframe. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 2 residents (Residents #148 and #147) reviewed for oxygen therapy. The facility failed to ensure Resident #148's oxygen tubing and humidifier were dated. The facility failed to ensure Resident #147's oxygen tubing was dated. This failure placed residents at risk of respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for one resident (Resident #7) of five residents reviewed. The facility failed to provide Resident #7's physician ordered independent mug with lunch. This failure put residents at risk for decreased fluid intake, dehydration and decreased quality of life.