Silver Pines Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Silver Pines Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF697Apr 13, 2023

  Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 12 residents reviewed. The facility failed to ensure Resident #1 received effective treatment of pain which resulted in Resident #1 having untreated pain of 10/10. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/10/2023. […]

• Immediate jeopardy, isolatedF760Apr 13, 2023

  Based on observation, interview and record review the facility failed to ensure that residents are free from any significant medication error for one resident (Resident #1) out of 12 residents reviewed for significant medication errors. The facility failed to ensure Resident #1 received lactulose as ordered by the physician which caused a rise in ammonia levels which was exhibited by Resident #1 having increased confusion and decreased cognition. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/10/2023. […]

• Actual harm, isolatedF692Apr 13, 2023

  Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) resident of 12 residents reviewed for nutrition. The facility failed to ensure Resident #1 whose diet order was for pureed texture and required eating assistance maintained acceptable parameters of nutritional status resulting in a significant weight loss in less than one month of admission This failure put residents at risk for malnutrition, weight loss and harm. […]

• No harm, potential for more than minimal, widespreadF805Jan 20, 2022

  Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 1 meal (breakfast) reviewed for residents with a diet order for pureed texture. The facility failed to ensure the nutritional form of the pureed food when the facility used water only to puree the breakfast meat. This deficient practice could place residents who received pureed diets at-risk for poor intake and malnutrition related to decreased calorie intake. Findings included: An observation on 01/18/2022 at 7:05 AM reflected the preparation of the pureed breakfast sausage by COOK B and he used a clear measuring cup containing water. COOK B w as observed to pour the water into the blender and blend the food. […]

• No harm, potential for more than minimal, widespreadF812Jan 20, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen, dishwasher and nourishment room. -The facility failed to properly store and refrigerate food in dry storage and resident nourishment refrigerator. -The facility failed to properly clean and store mixer attachments used in food preparation. -The facility failed to ensure the dishwasher was working according to manufacturer's specifications to clean and sanitize the dishware as evidenced by the water temperature not meeting the minimum temperature guidelines of at least 125 degrees during the wash cycle. […]