Harborview Thomasville

Inspectors wroteBased on observations, staff interviews, record review, and facility policy titled Elopement and Wandering Residents, the facility failed to follow the care plan for one resident (R) (R1) of three sample residents related to a non-functioning wander guard bracelet. This deficient practice places residents at risk for elopement and potential injury or harm.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Date marking for food safety, Food safety requirements, and Dietary sanitation, the facility failed to ensure that food was properly labeled, stored, and prepared in a sanitary condition to prevent foodborne illness, and failed to ensure the cleaning of appliances (ovens, griddles, fryers), countertops, food preparation areas, floors, ceiling tiles, vents, and fans. The deficient practice had the potential to affect 59 out of 61 residents receiving an oral diet.

Inspectors wroteBased on observation, interviews, and review of the facility's policy titled, Medication Storage, the facility failed to ensure that medications, biologicals and supplies was stored properly following manufacturers recommendations or those of the supplier including expiration dates for one of one medication storage room.

Inspectors wrote3. Observations on 6/23/2025 at 10:01 am, 6/24/2025 at 12:26 pm, and 6/26/2025 at 4:01 pm of room [ROOM NUMBER] on Wing W revealed short privacy curtains for Bed A , Bed C and Bed D which prevented the residents from receiving full visual privacy during patient care services. An interview was conducted on 6/26/2025 at 4:05 pm with R5 (who resided in room [ROOM NUMBER] Bed C on Wing W), the DON and Registered Nurse (RN) Supervisor regarding the short privacy curtains. R5 reported that curtain was too short. Residents in Bed A and Bed D was non interviewable. Both the DON and RN Supervisor reported being unaware of the condition of the short privacy curtains which prevented full visual privacy. [...]

Inspectors wroteBased on interviews, record reviews, and review of the facility's and policy titled Abuse, Neglect and Exploitation, the facility failed to ensure one out of 31 sampled residents (R) (R35) was free from abuse. Specifically, R35 was hit with by R60 on two different incidents.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy titled, Reporting Reasonable Suspicion of a crime, the facility failed to report abuse to Law Enforcement after one Resident (R) (R60) struck (R35) on two different incidents. The sample size was 31 residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure a Preadmission Screening and Resident Review (PASSAR) Level I assessment was accurately completed for one out of six residents (R) R14 with a PASSAR Level II.

Inspectors wrote2. Review of R17's electronic health record (EHR) revealed the following diagnoses but not limited to dementia acquired absence of right leg above knee and contracture of right hand Review of R17's Annual MDS dated [DATE] revealed a BIMS score of seven for moderate cognitive impairment. The resident functional level was assessed as nonambulatory with a physical impairment on one side for upper extremities for range of motion (ROM) and requiring substantial maximum assist for bed mobility. Observation of R17 's room on 6/24/2025 at 12:10 pm to 3:32 pm and 6/25/2025 at 8:01 am to 10:00 am revealed R17 lying in bed awake with head of bed elevated at the highest level. Continued observation revealed quarter bed rails raised in an upward position and bed mat on one side of the bed. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide the resident who was unable to carry out ADLs the necessary services to maintain good nutrition for one out of 31 sampled residents (R) (R14). Specifically, R14 who is legally blind and has left side hemiparesis was not assisted with meals and was eating food with his hands.

Inspectors wrote2. Review of R17's electronic health records (EHR) revealed the following diagnoses but not limited to dementia, anxiety disorder, psychotic disorder and mood disorder, hearing loss, acquired absence of right leg above knee and contracture of right hand. Review of R17's Annual MDS dated [DATE] revealed a BIMS score of seven for moderate cognitive impairment. The resident functional level was assessed as nonambulatory with a physical impairment on one side for upper extremities for range of motion (ROM) and requiring substantial maximum assist for bed mobility. Observation of R17 's room on 6/24/2025 at 12:10 pm to 3:32 pm and 6/25/2025 at 8:01 am to 10:00 am revealed R17 lying in bed awake with head of bed elevated at the highest level. Review of R17 's Activities of Daily Living (ADL) care plan (revised 11/13/2024) listed an intervention bed in lowest position. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's titled Preventative Maintenance Program, the facility failed to ensure one of 10 residents (R) (R42) reviewed for safety of bed rails, that the bed rails were maintained in a safe and operable manner to ensure a secure tight fit to prevent risk of falls and injury.

Inspectors wroteBased on observation, staff interview, record review and review of the facility's policy titled Medication Administration, the facility failed to ensure that the medication error rate was less than five percent. 38 opportunities were observed for five residents (R) with two errors noted resulting in an error rate of 5.26 percent.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Disinfection of and storage of non-critical resident care items, the facility failed to ensure resident's personal care items were stored in a manner to prevent cross-contamination in four of 31 bathrooms (Wing S in rooms [ROOM NUMBERS], and Wing W in room [ROOM NUMBER] and 2). The deficient practice had the potential to increase the probability of the spread of infection in the resident's living area.

Inspectors wroteBased on the record review, staff interviews, and the facility policy Abuse, Neglect and Exploitation, the facility failed to report that one resident (R2) with suicidal ideations of seven sample residents used a call light cord and/or a bed remote cord in an attempt to harm himself. On 11/18/2024 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Regional Director of Operation, Administrator, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 11/18/2024 at 10:07 am. The noncompliance related to the IJ was identified to have existed on 9/27/2024 when R2 was found with the call light cord wrapped around his neck. The IJ is outlined as follows: [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans and the Care Plans, Comprehensive Person-Centered policy, the facility failed to implement care plan interventions to monitor the safety of one of seven sampled residents (R2), who had wrapped his call light and/or bed remote cord around his neck.

Inspectors wroteBased on record review and staff interviews, and the facility's policy Accidents and Supervision, the facility failed to ensure a safe environment for one Resident (R2) of seven sampled residents. Specifically, the facility failed to remove the call light cord and/or bed remote cord from the resident's room and failed to adequately supervise the resident with a history of suicide attempts/ideations.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled Behavioral Health Services, the facility failed to ensure one resident (R2) of seven residents received necessary behavior health services to address significant worsening behaviors that include safety concerns with call light cord and/or bed remote cord wrapped around his neck. On 11/18/2024 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Regional Director of Operation, Administrator, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 11/18/2024 at 10:07 am. The noncompliance related to the IJ was identified to have existed on 9/27/2024 when R2 was found with the call light cord wrapped around his neck. [...]

Inspectors wroteBased on record review, staff interview, and the facility job description for the Administrator and Director of Nursing, the facility failed to provide supervision and oversight of one resident (R2) with suicidal ideations behaviors to ensure R2's environment was free of choke hazards; failed to ensure interventions were put in place to maintain the safety of the resident. On 11/18/2024 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Regional Director of Operation, Administrator, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 11/18/2024 at 10:07 am. The noncompliance related to the IJ was identified to have existed on 9/27/2024 when R2 was found with the call light cord wrapped around his neck. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that two Residents (R4 and R5) of seven sampled Residents' call lights were within reach while in bed or in their room.

Inspectors wroteBased on observations, and staff interviews, the facility failed to maintain a clean and homelike environment for seven of 33 rooms (W2, W4, W6, W7, W9, W10, and W11). Specifically, the facility failed to ensure residents rooms were free from cracking wall molding, missing floor tiles, broken or missing toilet paper holders, missing ceiling tile pieces, holes in walls, black scuff marks on the walls, and a dirty pillowcase.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Resident Personal Funds, the facility failed to ensure that two Residents (R) R4, R8 of five whose accounts were reviewed, were paid their final refund for account reconciliation within 30 days after discharge from the facility.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Transfer and Discharge (including AMA), the facility failed to ensure that a facility-initiated transfer or discharge for one resident (R) R4 of 10 sampled residents, who did not receive a 30-day notice discharge. The facility census was 63 residents.

Inspectors wroteBased on observations, staff interviews, and a review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure that opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry. In addition, the facility failed to ensure that the oven and fan were clean. This deficient practice had the potential to affect 61 of the 63 residents who were served food from the kitchen.

Inspectors wroteBased on observations, staff interviews, and a review of the facility's policies titled, Department Environmental Services: Laundry, and Infection Prevention and Control Program, the facility failed to ensure infection control policies were followed for handling, storage, and processing of linens, cleaning of lint traps, and food along with personal items in the clean storage laundry. These deficient practices had the potential to spread infection.

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, the facility failed to ensure resident's received an accurate assessment that reflected the resident's status at the time of the assessment for two of 27 sampled residents (R) (#49 and R#32) reviewed for accuracy of assessments related to Pre-admission Screening and Resident Review (PASRR). This failure had the potential to cause the resident's medical record to reflect inaccurate data related to disposition. Findings Include: A review of the policy titled, Certifying Accuracy of the Resident Assessment with revised date November 2019 revealed: Policy statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 1. [...]

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to ensure that a resident's nails were trimmed for one of 27 sampled residents (R) (#53). This failure had the potential to negatively impact resident's quality of life and decrease functional status.

Inspectors wroteBased on resident and staff interviews, record review, and review of the policy titled, Advanced Directives, the facility failed to ensure a Physician's Order was received to implement resident's Do Not Resuscitate (DNR) code status and failed to clarify the code status for one of 27 sampled residents (R#46).

Inspectors wroteBased on resident and staff interview, record review, and review of the policy titled, Comprehensive Care Plan, the facility failed to develop a person-centered care plan with interventions for Do Not Resuscitate (DNR) that agreed with resident's wishes for code status for one of 27 sampled residents (R#46).