Sylvia G Thompson Residence Center, Inc

Inspectors wroteBased on interview and record review, facility staff failed to ensure five nurse aides ((NA) NA A, NA B, NA C, NA D, and NA E) out of six sampled NA's, completed the nurse aid training program within four months of their facility hire date. The facility census was 116.1. Review of the facility provided policies did not contain a policy to direct staff on timeframe for the completion of nurse aide training program.2. Review of NA A's personnel file showed a hire date of 11/01/25. The file did not contain documentation NA A completed the nurse aide training program. During an interview on 04/29/26 at 2:42 P.M., NA A said he/she has worked as an NA since 2025. He/She said he/she is supposed to be done with the CNA class now but waiting on an email to be able to take the test. He/She said that he/she works the floor by himself/herself and performs resident cares.3. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow their Facility Assessment to ensure the facility staffed enough staff to meet the needs of the residents. Staff failed to provide a sufficient number of direct care staff members to ensure call lights were answered in timely manner. The facility census was 112. 1. Review of the facility assessment tool, dated 08/28/25, showed: -Average census of 117 residents;-Goal staffing is one to eight ratio for Certified Nursing Assistants (CNAs), the day-to-day average is one to ten for CNAs;-Days: Five Registered Nurses (RNs), two Licensed Practical Nurses (LPNs), and 17 CNAs;-Evenings: One RN, one LPN, and 14 CNAs;-Nights: Two LPNs and eight CNAs;-Weekend days: One RN, one LPN, and other direct care hours remain the same.2. Review of the facility census sheet, dated 08/30/25, showed the facility census at 117. [...]

Inspectors wroteBased on observation and interview facility staff failed to ensure two of three ice machines, used to supply ice to residents, drained through an air gap to prevent cross-contamination. Facility staff failed to ensure one ice machine was free of materials to prevent ice contamination. The facility census was 112.1. Observation on 10/08/25, during the Life Safety Code tour showed:-the ice machine located in the clean utility room contained two small white plastic tubes which drained from the rear of the ice machine into a larger white plastic floor drain and did not contain an air gap. Observation showed the white plastic above the ice storage bin contained a black speckled substance;-the nurse station 2 dining room ice machine contained a black drain hose which ran into a white plastic drain and did not contain an air gap. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to meet professional standards of care when they failed to document they administered treatments for three residents (Resident #46, #110, and #112) of 28 sampled resident treatments. The facility census was 112.1. Review of the facility's policy titled, Wound Care, revised October 2010, showed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information is be recorded in the resident's medical record:-The type of wound care given;-The date and time the wound care was given;-If the resident refused the treatment and the reason(s) why;-Staff are directed to notify the supervisor is the resident refuses the wound care. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a safe mechanical lift transfer for two residents (Resident #21 and #90) when staff failed to open the legs of the mechanical lift during transfers and failed to position the resident's wheelchair to prevent bumping the mechanical lift during the transfer. The facility census was 112. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to assess residents for the use of bed rails on a quarterly basis for six residents (Resident #2, #3, #10, #11, #29, and #112) of 28 sampled residents. The facility census was 112. 1. Review of the facility's policy titled, Bed Safety and Bed Rails, dated August 2022, showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, and resident assessment.2. Review of Resident #2's Quarterly minimum data (MDS), a federally mandated assessment tool, dated 09/26/25, showed staff assessed the resident as follows:-Severe cognitive impairment;-Required substantial/maximal assistance with toileting, showering, personal hygiene; -Bed rails not used as a restraint in bed. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure Nurse Aide's ((NA) NA H, NA J, NA P, NA Q, and NA S) of 24 completed the nurse aide training program within four months of his/her employment in the facility. The census was 112.1. Review of the facility's Nurse Aide Qualifications and Training Requirements policy, revised 08/2022, showed nursing assistants failing to successfully complete the required training program within the first four (4) months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services.2. Review of NA H's CNA report, showed a hire date of 03/24/25. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program.3 Review of NA J's CNA report, showed a hire date of 04/28/25. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than five percent (5%) out of 25 opportunities observed, nine errors occurred, resulting in a 36% error rate, which affected two residents (Resident #48 and #62) out of seven sampled residents. The facility's census was 112.1. Review of the facility's policy titled, Administering Medications, revised April 2019, showed staff: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to label and store medications in a safe and effective manner in one of two sampled medication storage rooms and one of two sampled medication carts. Staff failed to ensure medications were properly stored during medication administration to residents. The facility census was 112.1. Review of the facility's policy titled, Storage of Medication, revised 11/2020, showed:-The facility stores all drugs and biologicals in a safe, secure, and orderly manner;-Drug containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing;-Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed;-Schedule II-V (two to five) controlled medications are stored in separately locked, permanently affixed compartments. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide appropriate care and services per facility policy to maintain the highest practicable physical and psychosocial well-being for one resident (Resident #1) when staff failed to safely administer a warm pack for pain, which resulted in a burn injury to the resident's left arm and shoulder area. The facility census was 115.1. Review of the facility's Policy and Procedure for Using a Warm and Cool Pack, dated 08/2024, showed if a resident requests a warm or cool pack, one will be provided that will return to room temperature without intervention. This would consist of rice packs, gel packs, or warm/cool cloths that will return to room temperature on their own. Warm packs are not to be microwaved unless manufacturer recommends. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to review and revise the plan of care to address individualized physical and functional care needs for three residents (Resident #1, #2, and #3) out of four sampled residents. The facility's census was 115.1. Review of the facility's Comprehensive Care Plans Policy, revised 03/2022, showed a comprehensive, person-centered care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents' condition change. Review showed the policy did not address timeframes for revising a resident's care plan after an injury or change in functional care needs. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from July 1, 2024 through September 30, 2024. The facility census was 116. 1. Review of the facility policy titled, Reporting Direct Staffing Information (Payroll-Based Journal), Revised August 2022, showed: -Complete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS; -Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly; -Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: --Fiscal Quarter 1: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to verify medications to the Medication Administrator Record (MAR) for two (Resident #90 and #50) of three sampled residents. The facility census was 116. 1. Review of the facility's policy titled Administering Medications, revised April 2019, showed: -Medications are administered according to prescriber orders; -Verify the resident's identity before giving medication by checking photo attached to the medical record; -Check the medication three times to verify the right resident, right medication, right dose, right time, and right route of administration before giving the medication; -The individual administering the medication initials the MAR after giving each medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide safe mechanical transfers for two residents (Resident #51, and #39). Facility staff failed to safely store hazardous materials in three shower rooms and one storage area and failed to ensure medications were safely stored. The facility census was 116. 1. Review of the facility's Using a Mechanical Lifting Machine policy, dated July 2017, showed staff were directed: -Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility; -Clear an unobstructed path for the lift machine. Review of the mechanical lift operating instructions, dated 2018, showed the legs of the lift must be opened to the widest position when transferring a resident. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than five percent (%). Out of 41 opportunities observed, three errors occurred, resulting in a 7.32% error rate, which affected two residents (Resident #45, and #5) out of 10 sampled residents. The facility census was 116. Review of the American Academy of Allergy Asthma and Immunology recommendations titled Tips for Administering Eye Drops, dated 08/2010, showed close the eyelids and apply pressure for one to two minutes over the point where the eyelid meets the nose (nasolacrimal duct) after administering eye drops. 1. Review of the facility's policy titled Administering Medications, revised 04/2019, showed: -Medications are administered according to prescriber orders; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner in two of two medication rooms and failed to discard expired medications in one two medication carts. The Facility census was 116. 1. Review of the facility's policy titled Controlled Drug Policy and Procedure, revised 08/2024, showed a separate compartment for controlled drugs is provided in a locked cabinet inside the medication room or locked medication cart. The compartment has a special lock and key, and must be kept locked at all times. 2. Observation on 01/21/25 at 10:00 A.M., showed the Nurse's station one's medication room contained an unlocked refrigerator. Observation showed two opened bottles of liquid Ativan (a controlled drug). Observation showed the unlocked narcotic cabinet contained one opened four opened bottles of liquid morphine. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs, when staff failed to provide portions as directed in standardized recipes. This affected all residents who received their meals from the facility's kitchen. The facility census was 116. 1. Review of the facility's standardized menu for 01/20/25 (Week 4 - Day 23), showed staff were directed to serve the residents eight ounces of beef goulash and eight ounces of tossed salad. Observation on 01/20/25 at 12:52 P.M., showed [NAME] M served the residents one, #6 (5.33 ounces) scoop of goulash (2.66 ounces less than directed) and a four-ounce spoodle of salad (four ounces less than directed). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow infection control practices during medication administration for five (Resident #109, #45, #110, #5, & #120) out of 24 sampled residents. The facility census was 116. 1. Review of the facility's policy titled Administering Medications, revised 04/2019, showed staff are directed to follow facility infection control procedures (hand washing, antiseptic technique, gloves, etc.) for the administration of medications. Review of the facility's policy titled Handwashing and Hand Hygiene, revised 08/2019, showed: -All staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other staff, resident, or visitors; -Use an alcohol-based had rub for the following situations; -Before and after coming in contact with a resident; -Before preparing or handling medications; [...]

Inspectors wroteBased on interview and record review, facility staff failed to report to the Department of Health and Senior Services (DHSS) two allegations of resident abuse with three residents (Resident #1, Resident #2, and Resident #4) out of four sampled residents within the required two hour timeframe. The facility census was 120. 1. Review of the facility's Abuse Prohibition Policy, dated August 4, 2023, showed it is the policy of the facility to investigate any incident or allegation of suspected abuse, injury of unknown origin, neglect or misappropriation of resident's property. The facility will not permit residents to be subjected to abuse by anyone, to include staff members, other residents, consultants, volunteers, staff of other agencies that serve the resident, family members, legal guardians, sponsors, friend, or other individuals. [...]

Inspectors wroteBased on interview and record review, facility staff failed to thoroughly investigate two allegations of resident abuse with three residents (Resident #1, Resident #2, and Resident #4). The facility census was 120. 1. Review of the facility's Abuse Prohibition Policy, dated August 4, 2023, showed it is the policy of the facility to investigate any incident or allegation of suspected abuse, injury of unknown origin, neglect or misappropriation of resident's property. The facility will not permit residents to be subjected to abuse by anyone, to include staff members, other residents, consultants, volunteers, staff of other agencies that serve the resident, family members, legal guardians, sponsors, friend, or other individuals. [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop interventions for comprehensive care plans for four residents (Residents #1, #2, #3 and #4) out of four sampled residents. 1. Review of the facility's Care plan policy, revised November 2019, showed staff are directed to: -Define the problems: identify the behavioral implications of the problem; -Identify the relationships between risk factors, triggers, and problems; -Distinguish between causes and consequences; -Look for common causes of multiple issues; -Determine whether the problem needs interventions, -Design interventions that address causes not symptoms; -Include specific interventions, including recommendations for monitoring and follow ups. [...]

Inspectors wroteBased on interview and record review, facility staff failed to properly assess two residents', (Resident #1 and #2) capacity to consent to sexual activity and failed to ensure residents with severe cognitive impairment remained free from sexual abuse when staff found Resident #2 holding Resident #1's hand to perform a sexual act. The facility census was 117. The administrator was notified on 3/22/24 at 5:09 P.M., of an Immediate Jeopardy (IJ) which began on 3/19/24. The IJ was removed on 3/29/24 as confirmed by the surveyor's onsite verification. Review of the facility's Abuse Prohibition Policy, dated August 4, 2023, showed it is the policy of this facility to investigate any incident or allegation of suspected abuse, injury of unknown origin, neglect or misappropriation of resident's property. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete neurological checks for 72 hours for two of four sampled residents (Resident #1 and #3) who had unwitnessed falls, as directed by the facility policy. The facility census was 117. 1. Review of the facility's Falls and Fall Risk, Managing Policy, undated, showed a fall defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. If a resident has a fall or other accident or incident the staff are expected to assess if the resident hit their head. If so, neurological checks will be initiated at the time of the fall, every 15 minutes for one hour, every 30 minutes for one hour, and then every shift for three days. [...]

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 117. 1. Review of the facility's Dietary Services Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, dated November 2022, showed: -Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Employees must wash their hands: *after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); *whenever entering or re-entering the kitchen; *before coming in contact with any food surfaces; *after handling soiled equipment or utensils; [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to screen six of 10 sampled newly hired staff (Registered Nurse (RN) A, RN B, Licensed Practical Nurse (LPN) C, Certified Medication Technician (CMT) D, CMT E and Certified Nurse Aide (CNA) F) for tuberculosis (TB), in accordance with the facility policy. The facility census was 117. 1. Review of the facility's policy, titled Employee Screening for Tuberculosis, dated March 2021, showed staff were directed to do the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to include a requirement to check the Nurse Assistant (NA) Registry in the facility ' s policy to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) and failed to implement their written policies and procedures to prevent abuse, neglect, exploitation and misappropriation of resident property when the staff failed to request a criminal background check (CBC) prior to contact with residents for three of 10 new hired staff (RN A, RN B and Certified Nurse Assistant (CNA) F). The facility census was 117. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure five residents (Residents #24, #70. #76, #89, #373), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 117. 1. Review of the policies provided by the facility showed no policy for ADLs. 2. Review of Resident #24's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/30/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required moderate assistance from staff for eating, toilet hygiene and bathing; -Occasionally incontinent of bowel and bladder; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel two residents (Resident's #51 and #80) in wheelchairs. The facility census was 117. 1. Review of the facility's policy titled, Assistive Devices and Equipment, dated January 2020, showed staff were directed to do the following: -Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include (but are no limited to) mobility devices (wheelchairs, walkers and canes); -Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents; [...]

Inspectors wroteBased on interview and record review, facility staff failed to document of the type of pneumocococcal (lung inflammation caused by bacterial or viral infection) vaccine or date the resident received the pneumococcal vaccine for one resident (Resident #28) and failed to offer two residents (Resident #67 and #84) a pneumococcal conjugate vaccine. The facility census was 117. 1. Review of the facility's policy, titled Pneumococcal Vaccine, dated March, 2022, showed staff were directed to do the following: -All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #103) remained free from physical abuse when Certified Nursing Assistant (CNA) CC placed his/her arms around the resident and forced the resident to walk from the common area to his/her room. The facility census was 117. The administrator was notified on 11/02/2023 of past Non-Compliance which occurred on 10/26/23. On 10/26/23 CNA CC placed his/her arms around Resident #103 and carried the resident from the common area to his/her room. Upon discovery, the Administrator watched the video, then contacted the resident's responsible party, physician and the Adult Abuse and Neglect Hotline, interviewed staff, including CNA CC, and resident's and conducted an in-service with the memory care staff members. CNA CC was terminated on 10/27/23. Staff corrected the deficient practice on 10/28/23. 1. [...]