Thomas Hospitals Skilled Nursing Unit

Based on record review, staff interviews, and observation, the facility failed to develop and implement person-centered, comprehensive care plans that included individualized activities for 9 of 16 residents reviewed (Residents #30, #29, #6, #1, #32, #27, #37, #38, and #23). This failure resulted in residents, including those with low BIMS scores and those who remained in their rooms, lacking documented activity interventions tailored to their needs and preferences. Resident Identifier: #30, #29, #6, #1, #32, #27, #38, and #23 Facility Census: 16a) On 07/30/2025 at 12:00 PM, a review of 16 resident records revealed that nine (9) lacked individualized activity care plans or interventions, despite cognitive or physical limitations requiring modified or room-based activities.Resident #30 had a low BIMS score and remained in their room and had no documented activity plan or evidence of room-based engagement effort.On 07/30/25 at 12:30 PM, during an interview with the Activities Director (AD) revealed she was unaware of how to create or update activity care plans in the facility's…

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, observations, and record reviews, the facility failed to ensure residents maintained the highest practicable mental and psychosocial well-being. The facility did not provide individualized activities and meaningful engagement for residents who remain in their rooms, failing to implement sensory stimulation or one-on-one interventions. In addiiton they failed to offer weekend activity programming for all residents. Facility Census: 16. a) On 07/30/25 The facility reported that it does not provide outings or opportunities for community involvement.On 07/31/25 The facility was unable to provide specific programming for one-on-one or sensory stimulation residents who are either unable or unwilling to leave their rooms.During record review on 07/30/25 at 12:00 PM a review of 16 resident care plans for activities revealed nine (9)lacked individualized activity care plans/interventions, particularly for residents who remain in their rooms or have low BIMS scores.An Interview on 07/30/25 with the Activities Director (AD) revealed that she was unaware of how to create or…

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 record review, interviews, and observations, the facility failed to provide an ongoing activities program that met the individual needs, interests, and abilities of residents in accordance with their comprehensive assessments and care plans. Specifically, the facility failed to offer room-based or sensory stimulation activities for residents who did not leave their rooms, failed to develop individualized care plans for activities for most sampled residents, and did not offer weekend activities. These systemic failures had the potential to negatively impact the residents' quality of life and psychosocial well-being. Facility census: 16.a) During the survey on 07/30/25, the following concerns were identified:Facility staff reported that there were no community outings or external engagement opportunities offered to residents.Staff stated they did not provide one-on-one or sensory stimulation activities for residents who are room-bound or chose not to leave their rooms.14 of 16 resident care plans reviewed showed no individualized activities interventions for 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 observation, and staff interviews, the facility failed to date and safely store open and prepared food items in multiple refrigeration units; maintain cleanliness of kitchen equipment and surfaces; and implement effective systems to prevent contamination or spoilage of food, including food that may be consumed by residents. These practices created a risk of foodborne illness. Facility Census: 16.On 07/30/2025 at 11:48 AM, the following was observed in the kitchen areas:Walk-In Cooler:A canister of chopped garlic was observed with no open or discard date.Walk-In Freezer:A bag of chicken tenders was stored outside of the original box, open and without a date.An open box of fish filets was observed without an open date and not sealed, exposing contents to possible contamination.Reach-In Cooler:The following perishable food items were observed undated and unsealed:OnionsCheeseLettuceSliced tomatoesSalad mixDishwashing Area:The floor under the dishwasher was visibly soiled with build-up.Racks and surrounding walls were observed to be unclean, indicating a lack of proper…

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 observation, resident interview, and staff interview, the facility failed to have an ongoing activity program that included group activities. This was true for six (6) of six (6) anonymous residents reviewed for the care area of activities during the long - term care survey process. This had the potential to affect more than a limited number of residents. Facility census: 17. Findings included: a) Resident interviews Anonymous interviews with residents during the initial phase of the survey on 10/10/22 found the unit has no group activities scheduled. One resident said, If they ever had any bingo, I would probably go. At 12:20 PM on 10/11/22, the activities coordinator (AC) #14 said, We have not had any group activities since COVID started, we have not been released to have group activities. Review of the August, September, and October activities calendar with AC #14 confirmed the unit has no group activities listed on the calendar. The AC was asked if residents who were not in isolation and did not have COVID could attend group activities with masks and social distancing?…

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 observation and staff interview, the facility failed to ensure food items were stored, prepared, distributed and served in accordance with professional standards for food service safety. Meats were stored above vegetables and fruit in kitchen refrigeration's. The cook in the kitchen did not have a hair restraint. In addition, the facility failed to ensure residents personal snacks in the pantry refrigerator on the unit were labeled and dated as to when they were prepared and when to discard. This had the potential to affect more than a limited number of residents. Resident identifier: #66. Facility census: 17. Findings included: a) Tour of the kitchen The initial tour of the kitchen with the Dietary Operations Manager (DOM) #6 began at 11:25 AM on 10/10/22 and ended at 11:40 AM on 10/10/22 found the following: --Observation of 1 refrigerator found an unsliced section of roast beef which had not been prepared stored above an open box containing watermelon. --Observation of a second refrigerator found sliced ham and a unsliced section of ham stored above an open box…

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 staff interviews and review of time card, the facility failed to have an Infection Control Preventionist (IP) at least part time. This failed practice had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Facility census: 17. Findings included: a) Infection Control Preventionist On 10/12/22 at 10:00 AM in an interview with the IP regarding the hours the IP worked in the facility, the IP stated that she worked at the facility approximately 4-6 hours per month. She further stated that she was shared with a sister hospital as well as with the Skilled Care Unit and the rest of the hospital. In addition, she stated she depends on the unit management to complete infection control audits and monitor infection control practices. An attempt was made to obtain the IP's time card to review the hours worked on the Skilled Care Unit. During the interview on 10/12/22 at 10:00 AM, the IP stated she was salaried and therefore did not clock in and/or out so there were no records of the hours she worked in any facility. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of nine (9) residents reviewed during the long - term care survey process had a chair in the room to accommodate her needs and personal preferences. This was a random opportunity for discovery. Resident identifier: #62. Facility census: 17. Findings included: a) Resident #62 On 10/10/22 at 12:18 PM, the resident said she needs a chair so she can get up out of bed. She said, it needs to be a chair that would allow me to prop up my right leg. The residents' husband was visiting in the room and occupying the only chair in the room which was a hard back chair with arms. The residents' husband added, it could even be a wheelchair with an extension because she has a fractured leg. When asked if she had asked staff for a chair, the resident replied, I did but they told me all the reclining chairs are in use. Observation revealed no other chairs or wheelchairs were present in the residents' room. Review…

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 record review and staff interview, the facility failed to update the resident's care plan after the resident experienced a fall. This was true for one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process. Resident identifier: #55. Facility census: 17. Finding included: a) Resident #55 Review of the medical record revealed the resident fell at 4:30 AM on 10/05/22. At 0430 Nursing Assistant entered patient's room. Patient was found on the floor. Notified nursing supervisor and (name of physician.) (Name of physician was apprised of patient hitting her head and the presence of a hematoma. Doctor's order was to continue to monitor patient Patient complained of hitting her head and shoulder on the right side. Placed patient back in bed; applied ice pack to forehead; noted bruise to left arm. Will continue to follow. At 8:12 AM on 10/05/22 the physician documented the resident had a traumatic hematoma of the forehead. On 10/05/22 at 1:20 PM, an x-ray report noted the resident had a minimally displaced fracture of the right…

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 record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Neurological checks were not started after the resident had a fall, hit her head, resulting in a hematoma. Resident identifier: #55. Facility census: 17. Finding included: a) Resident #55 Review of the medical record revealed the resident fell at 4:30 AM on 10/05/22. At 0430 Nursing Assistant entered patient's room. Patient was found on the floor. Notified nursing supervisor and (name of physician.) (Name of physician was apprised of patient hitting her head and the presence of a hematoma. Doctor's order was to continue to monitor patient Patient complained of hitting her head and shoulder on the right side. Placed patient back in bed; applied ice pack to forehead; noted bruise to left arm. Will continue to follow. At 8:12 AM on 10/05/22 the physician documented the…

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 observation and staff interview, the facility failed to ensure medications were properly stored for Resident #57. This was a random opportunity for discovery. Resident identifier: #57. Facility census: 17. Findings included: a) Resident #57 On 10/12/22 at 10:34 AM during medication pass, observed Registered Nurse (RN) #1 remove a cup of medications from the back pocket of her uniform. When asked why the prepoured medications were stored in her uniform, RN #1 explained the medications were poured and found Resident #57 was not available to take the medications. An interview with the Unit Manager (UM) #15 on 10/12/22 at 10:34 AM regarding RN #1 putting poured medications in uniform pocket stated that the medications should have been placed in the locked box outside Resident #57's room and not in RN #1's uniform. .

Based on review of record review and interview, the facility failed to ensure the employee, who was designated as the Infection Preventionist for the unit, had completed specialized training in infection prevention and control. Additionally, the facility failed to ensure the Infection Preventionist was a member of the Skilled Nursing Unit Quality Assessment and Assurance Committee and reported on the infection control program, to the committee, on a regular basis . This practice had the potential to affect all residents in the facility. Facility census: 11. Findings included: a) Infection Preventionist training An interview, with the Infection Preventionist, on 07/13/21 at 3:05 PM, revealed the employee had not completed a specialized training in infection prevention and control. A review of the information provided for review, dated 2019, provided no evidence of a specialized training. Training included reporting and data collection with no specified length of event, and educational activity for continuing education. An interview with the DON, on 07/13/21 at 07:50 AM, revealed the…

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 facility documentation review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that consisted of the minimum required members. The facility failed to ensure the Administrator, Owner or a Board member participated and was included as a member of the Skilled Nursing Unit (SNU) quarterly QAA committee. The failed practice had the potential to affect more than unlimited number of residents on the SNU. Facility census: 11. Findings included: a) Skilled Nursing Unit QAA Committee A facility document titled Health Facility Key Personnel was reviewed, on 07/13/21 at 10:46 AM. The document was provided by the Director of Nursing DON and listed the SNU QAA Committee members. The Health Facility Key Personnel form excluded the Administrator as a member of the SNU QAA Committee. The SNU QAA Committee members were as followed: Director of Nursing DON Minimum Data Set MDS Coordinator Social Worker Activities Director Lead Physical Therapist Occupational Therapist Medical Director Dietician An additional facility document titled, SNU…

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 observation, record review and interview, the facility failed to accurately ensure a resident's advance directive was correct on the information board at the nurses' desk. The facility failed to ensure the advance directive was completed and documented in the resident's electronic medical record (EMR). This was true for one (1) of 11 residents reviewed for advance directives. Resident identifier: #7. Facility census: 11. Findings included: a) Resident #7 A record review, on 07/13/21 at 8:15 AM, revealed a Skilled Nursing Unit admission Communication form in the medical record that stated, Do Not Resuscitate DNR. An interview with Registered Nurse (RN) #1, on 07/13/21 at 8:25 AM, revealed the Information board located at the Nurses' desk was color coded as to a resident's current resuscitation status. RN #1 stated, if the Resident is a full code their name would be written in black on the information board and if the resident is a DNR their name would be written in red on the board. An observation of the information board, on 07/13/21 at 8:30 AM, revealed Resident #7's name…

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.