Silver Pines Nursing And Rehabilitation Center

Based 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. In an observation on 05/22/24 at 12:20 PM in the dining room multiple flies were observed again during meal services. The DON and SNA were observed swatting flies that were landing on food and flying around as they assisted in feeding two unidentified residents . In an interview on 05/21/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the Face Sheet for Resident #57 reflected he was admitted on [DATE] with diagnosis of: COPD, a single Pulmonary Nodule, Atrial Fibrillation, Heart Failure, Type 2 Diabetes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Closed record review of Resident #88's Face Sheet, dated 05/23/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged from the facility on 02/19/2024 with the following diagnoses: Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and Vascular Dementia (changes to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the Face Sheet for Resident #57 reflected he was admitted on [DATE] with diagnosis of: COPD, a single Pulmonary Nodule, Atrial Fibrillation, Heart Failure, Type 2 Diabetes, Morbid Obesity, Major Depressive disorder, acute and chronic respiratory failure with hypoxia, and obstructive uropathy. Review of the MDS assessment for Resident #57 dated 3/18/24 reflected a BIMS score of 15 indicating normal cognitive function. His physical assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the Face Sheet for Resident #57 reflected he was admitted on [DATE] with diagnosis of: COPD, a single Pulmonary Nodule, Atrial Fibrillation, Heart Failure, Type 2 Diabetes, Morbid Obesity, Major Depressive disorder, acute and chronic respiratory failure with hypoxia, and obstructive uropathy. Review of the MDS assessment for Resident #57 dated 3/18/24 reflected a BIMS score of 15 indicating normal cognitive function. His…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident # 54's face sheet dated 05/22/2024 reflected a [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with a diagnoses of pain in the right foot (a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort), need for assistance with personal care (anything that a person needs to maintain hygiene, well-being, self-esteem, and dignity), essential hypertension (is often due to obesity, family history, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the face sheet for Resident #71 reflected he was admitted to the facility on [DATE] with diagnoses of: Unspecified Dementia, High Blood Pressure, Chronic Atrial fibrillation, and Bilateral Osteoarthritis of hips. Review of the quarterly MDS assessment for Resident #71 dated 3/04/24 reflected a BIMS score of 5 indicating severe cognitive impairment. His physical assessment reflected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #1's face sheet, dated 02/29/2024, revealed Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had the following diagnoses: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a mental illness or disorder that causes disturbances in though, perception, and behavior, and makes it hard to distinguish reality from imagination. It may involve hearing voices, having false beliefs, or showing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Therefore, the findings are of past noncompliance. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, need for assistance with personal care, drug induced, subacute, dyskinesia, insomnia, dementia, major depressive disorder, and generalized anxiety disorder. Review of the quarterly MDS assessment for Resident #1 dated 09/15/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebrovascular Disease (group of conditions that affect blood flow and the blood vessels in the brain), Muscle wasting and atrophy (thinning or loss of muscle tissue leading to loss of strength), and Type 2 Diabetes (chronic condition that affects the way he body processes blood sugar, glucose) with Diabetic Neuropathy (nerve damage cause by Diabetes which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: 1. Review of Resident #76's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), Muscle wasting and Atrophy (decrease in size and strength of muscles), repeated falls, unspecified lack of coordination, Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) with Diabetic Neuropathy (nerve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. She also stated she would notify dietary staff before the meeting not to come out of the kitchen until after the resident group meeting. Record review on 03/27/2023 at 8:30 AM of the Resident Council…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Citation 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. Findings included: Observation on 03/25/2023 at 11:45 AM there were medication carts in front of the postings for staff and residents in the display case. The medication carts blocked the postings in the display case except for one posting located at the very top in large print. In an interview on 03/27/2023 at 9:30AM during a confidential resident group meeting held in the dining room with seven residents revealed the residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: In a confidential group interview on 03/27/2023 at 9:30 AM through 10:00 AM, seven residents stated they did not know where or how to access survey results in the facility. Several of the residents stated they would like to have access to this information, because the staff did not tell them anything about visits from the state. Two of the residents stated they did not know the state sent a report to the facility of any type of visits. The other four residents agreed. They all stated it would be great if they knew the results of the surveys. All the residents stated if they were informed at the time of admission they did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These failures put residents at risk for poor hygiene, dignity issues and decreased quality of life. 1. Review of Resident #198's undated Face Sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: 1. Review of Resident #62's face sheet revealed Resident #62 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), high blood pressure, epilepsy and arthritis. Review of Resident #62's significant change MDS assessment dated [DATE] revealed Resident #62 had a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Observation and Iinterview on [DATE] at 11:55 AM, of the nurse medication cart for Hall 100 revealed the second drawer of the cart had a sticky yellow/brown/black substance with hairs and loose pills stuck to it. Medication bottles were observed sitting in the sticky substance.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Citation 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. Findings included: 1. Review of Resident #147's undated Face Sheet reflected she was an 83 -year-old female admitted to the facility on [DATE] 00/00/00 with diagnoses of Pressure Ulcer of right hip Stage 4 (ulcer extending into the muscle, tendon, ligament, cartilage and possibly exposing bone), Neuromuscular Dysfunction of Bladder (lack of bladder control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Record review of Resident # 197's face sheet, dated 03/28/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included pain in right upper arm ( often due to muscle , tendon- cord-like tissue that connects muscle to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #148's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Amyotrophic Lateral Sclerosis (progressive nervous system disease that weakens muscles and impacts physical function), Lyme Disease (tick borne illness that causes fatigue and flu-like symptoms), Neoplasm Unspecified (abnormal growth in some part of the body), Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #7's face sheet dated 03/28/2023 revealed Resident #7 was an [AGE] year old female admitted to the facility on [DATE] with a diagnoses of a history of stroke with left upper limb partial paralysis (lack of oxygen to the brain causing immobility to the left upper limb), chronic obstructive pulmonary disease (lung disease which causes difficulty breathing), congestive heart disease (chronic condition in which the heart doesn't pump blood as well as it should),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.