E W Thompson Health & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, facility staff failed to meet professional standards of practice when staff failed to document medications as administered for two residents (Resident #1 and Resident #2) and failed to complete treatments as ordered for one resident (Resident #2). The facility census was 59.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to administer nutritional supplements as ordered by the physician for one resident (Resident #1) out of one sampled resident. The facility census was 59.1. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact. Review of the resident's Physician Order Summary (POS), undated, showed an order for meal supplement health shakes. Review of the resident's Medication Administration Record (MAR), dated 02/01/26 through 02/28/26, did not contain documentation staff administered the resident's nutritional supplemental health shake as directed on 02/01/26, 02/03/26, 04/05/26, 02/07/26, 02/08/26, 02/09/26, 02/11/26-02/15/26, and 02/19/26. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from verbal and emotional abuse when Certified Nurse Aide (CNA) B demanded multiple times for the resident to perform his/her toileting independently although he/she was unable to perform, and aggressively pulled resident under the arm to stand him/her up without a gait belt. The facility census was 60. The administrator was notified on 5/1/25 of past Non-Compliance, which occurred on 4/28/25 when staff reported the allegation. Staff immediately suspended CNA B pending the results of the investigation, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/25/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 60. 1. Review of the facility's Food and Nutrition Services Hand Washing policy, dated 01/01/07, showed the policy directed staff to wash their hands: -During food preparation; -When switching between raw food and work with ready-to-eat food; -Before donning gloves for working with food; -After handling soiled utensils or equipment; -After engaging in other activities that contaminate the hands. Review showed the procedure for handwashing listed as: -Rinse hands under clean, running, warm water; -Apply a cleaning compound; -Rub together vigorously for approximately 10 to 15 seconds; -Rinse thoroughly under clean, running, warm water; [...]

Inspectors wroteBased on interview and record review, facility staff failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data on the schedule specified by CMS from January 1, 2024, through July 31, 2024. The facility census was 60. 1. Review of the facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy, revised August 2022, showed: -Direct care staffing information is reported electronically to CMS through the PBJ; -Compete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS; -For auditing purposes, reported staffing information is based on payroll records, invoices, tied back to a contract, or other verifiable information; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5% out of 25 opportunities observed. Four errors occurred, resulting in a 16% error rate, which affected four residents (Residents #22, #36, #47 and #64) of six sampled residents. The facility census was 60. 1. Review of the facility policy titled, Insulin Administration Policy, not dated, showed nursing staff will have access to specific instructions (from manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the Insulin Aspart Injection manufacturer insert showed: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: -Turn the dose selector to select two units; -Hold the Insulin Aspart FlexPen with the needle pointing up. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 56. 1. Review of the facility's Dietician policy, dated November 2022, showed if a dietician is not employed 35 or more hours per week a director of food and nutrition services will be designated. This individual will: -be a certified dietary manger (CDM), or; -be a certified food service manager, or; -be nationally certified in food service management and safety, or; -have an associates (or higher) degree in food service management or hospitality, if the course includes food service or restaurant management from an accredited institution, or; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain proper food temperatures to prevent the spread of food borne illness. Facility staff also failed to properly clean and sanitize mechanically washed dishes to prevent cross-contamination. The facility census was 56. 1. Review of the facility's Food Preparation and Service policy, revised July 2014, showed: -the danger zone for food temperatures is between 41 degrees Fahrenheit (F) and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness; -potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese; -the longer foods remain in the danger one, the greater the risk for growth of harmful pathogens; The temperature of foods held in steam tables will be monitored by food service staff. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for four residents (Residents #4, #19, #38, and #49). The facility's census was 56. 1. Review of the facility's Bed-Holds and Returns policy showed the policy did not direct staff to provide written information regarding bed-hold at the time of transfer. 2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/01/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -discharged to the hospital from the facility on 07/15/23; -readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of care when they failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) following unwitnessed falls for three residents (Resident #32, #43, and #49), and failed to administer medications according the the facility policy for three residents (Residents #37, #45, and #25). The facility census was 56. 1. Review of the facility's Neurological Assessment policy, revised October 2010, showed it directed staff as follows: -The purpose of the procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3)subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition; [...]

Inspectors wroteBased on observation, interview, and record review staff failed to ensure medications were stored in a safe and effective manner, by not ensuring medications were properly labeled and contained in their original package until time of administration on two medication carts, failed to discard expired medications from the medication room refrigerator, failed to store time scheduled controlled medications (medications which fall under United States (US) Drug Enforcement Agency (DEA) Schedules II-V and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) in a separately locked, permanently affixed compartment and failed to ensure medications carts were locked at all times. The facility census was 56. 1. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for one resident (Resident #11), failed to ensure sanitary conditions for a catheter bag (a container to hold urine) by keeping the catheter off the floor for one resident (Resident #64), additionally staff failed to change oxygen tubing for three residents (Resident #4, #23, and #31) and failed to properly store nebulizer supplies for one resident (Resident #47). The facility census was 56. 1. Review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, showed staff were directed to the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure food temperatures remained out of the danger zone (the temperature range in which food-borne bacteria can grow, between the temperatures of 45 degrees Fahrenheit and 135 degrees Fahrenheit) during food service. The facility staff also failed to serve and store food in a manner to prevent cross-contamination and outdated use and to ensure staff used hair restraints while in the kitchen. The census was 55. 1. Review of the facility's Food Preparation and Service policy, dated 7/2014, showed: - The danger zone for food temperatures is between 41° F (degrees Fahrenheit) and 135° F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness; - Potentially hazardous foods (PHF) include milk, yogurt, and cottage cheese; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to prevent access to razors in shower rooms. Additionally, staff failed to store a bottle of antibacterial cleaning spray in a manner to prevent to access to residents. The facility census was 55. 1. Review of the facility's Hazardous Areas, Devices and Equipment Policy, dated July 2017, showed a hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: -Sharp objects that are accessible to vulnerable residents; -Open areas or items that should be locked when not in use. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to obtain informed consent for the use of side rails for eight residents (Resident #1, #20, #26, #36, #37, #40, #41 and #50) out of 15 sampled residents. The facility census was 55. 1. Review of the facility's Bed Safety Policy, dated December 2007, showed staff are directed to obtain consent for the use of side rails from the resident or the resident's legal representative prior to use. 2. Review of Resident #1's Annual Minimum Date Set (MDS), a federally mandated assessment tool, dated 3/29/22, showed staff assessed the resident as follows: -Severe Cognitive Impairment; -Diagnosis of stroke; -Totally dependent on staff for mobility, toileting, transfers, locomotion, personal hygiene, dressing, and showering; -Upper and Lower extremity impairment on both sides. [...]