Thalia Gardens Rehabilitation and Nursing

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and facility document review, it was determined that facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across 3 of the facility's 3 units, constituting substandard quality of care (SQC).

Inspectors wroteBased on staff interview, clinical record review, and review of facility documents, the facility staff failed to provide a drug regimen review that was reviewed monthly by a licensed pharmacist for 6 of 63 residents (Resident #2, #10, #11, #23, #6, and #107), in the survey sample.

Inspectors wroteBased on staff interview and facility documentation review, the facility failed to ensure the implementation of policies regarding the management and operations of the facility potentially affecting all residents in the facility.

Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to implement and maintain an effective Quality Assurance Performance Improvement (QAPI) Program/Plan for three of four quarters reviewed, affecting all residents in the facilityThe

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure implementation of a comprehensive QAPI (Quality Assurance Performance Improvement) Program/Plan included performance improvement projects potentially for three of four quarters affecting all residents in the facility

Inspectors wroteBased on information obtained during the Infection Control task, the facility staff failed to document each staff member's COVID-19 information.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to develop, implement, and maintain an effective training program for all staff, including training on QAPI (Qualiity Assurance Performance improvement) for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA)

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to develop, implement, and maintain an effective training program for all staff, including training on behavioral health care and services for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA)

Inspectors wroteBased on resident and staff interviews and a review of clinical records, the facility staff failed to assist the resident to maintain personal belongings for 1 of 63 residents (Resident #101) in the survey sampleThe

Inspectors wroteBased on observation, resident interview, staff interview and clinical record documentation review, the facility staff failed to ensure accommodation of needs for 4 residents (Resident # 97, # 21, #26 and # 5) in a survey sample of 63 residents.

Inspectors wroteBased on information obtained during the resident group meeting and a review of facility documents, the facility staff failed to ensure that 5 of 5 residents in the group meeting knew where the survey results binder was located without having to ask someone.

Inspectors wroteBased on a review of facility documents and staff interviews, the facility staff failed to thoroughly investigate prospective employees' histories before hiring.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure that one (1) resident (Resident #16) and their family members were able to attend their person-centered care plan meetings, and the facility staff failed to review and revise a care plan for one (1) resident (Resident #11) of 63 residents in the survey sample.

Inspectors wroteBased on observation and staff interview, the facility staff failed to provide a resident environment free of accident hazards.

Inspectors wroteBased on observation, staff interview, resident interview and facility documentation, the facility staff failed to ensure staffing information was posted daily at the receptionist's desk and/or on three of three units in a prominent place and readily accessible to all residents, staff and visitors.

Inspectors wroteBased on observation and Staff interview the facility staff failed to discard 2 bottles of expired insulin from 2 out of 3 medication carts.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure QAPI (Quality Assurance Performance Improvement) meetings were conducted quarterly for 3 of 4 quarters sampled.

Inspectors wroteBased on observation and staff interview the facility's staff failed to have a functional emergency call system (Emergency Pull cord) available for a resident who ambulates to the bathroom frequently For 1 of 63 residents (Resident #16), in the survey Resident #16 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: Type 2 Diabetes without complications and Alzheimer's Disease. The quarterly revision Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/13/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated that Resident #16's cognitive abilities for daily decision-making were severely impaired. [...]

Inspectors wroteThe facility staff failed to maintain an effective pest control program. Residents during the group meeting with the inspectors that represented all three nursing units, were in consensus that roaches were identified in their rooms.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to develop, implement, and maintain an effective training program for all staff, including training on Communication for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA)

Inspectors wroteBased on resident interviews, staff interviews, and clinical record reviews, the facility staff failed to ensure language interpreter services were available to allow effective communication for a Spanish-speaking resident for for 1 resident of 63 residents (Resident #16) in the survey sample.

Inspectors wroteBased on information obtained during the resident group meeting, and a review of facility documents, the facility staff failed to ensure that 5 of 5 residents in the group meeting knew the location of the list of contact names, addresses, and phone numbers of the State agencies, ombudsman and adult protective services.

Inspectors wroteBased on observations, staff interviews, and a review of facility documentation, the facility staff failed to inform the resident's representative of a change in condition and failed to update the resident representative's phone numbers for 1 of 63 residents (Resident #99) in the survey sample.

Inspectors wroteBased on resident interview, it was determined that facility staff failed to ensure a grievance was filed on missing items for 1 of 63 residents in the survey sample, Resident #12. The finings included: Resident #12 was originally admitted to the facility 2/14/25 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Malignant Neoplasm of the colon. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/17/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #12's cognitive abilities for daily decision making were moderately impaired. [...]

Inspectors wroteBased on clinical record review and staff interviews, the facility's staff failed to ensure that 1 of 63 residents (Resident #11) did not have as needed Lorazepam ordered for use for greater than 14 days.

Inspectors wroteBased on staff interviews, facility document review, and resident interviews, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for 1 of 63 residents in the survey sample, Resident #12.

Inspectors wroteBased on family and staff interviews and a review of the clinical record, the facility staff failed to provide discharge information for 2 of 63 residents in the survey sample (Residents #114 and #120).

Inspectors wroteBased on a review of the clinical record and staff interviews, the facility staff failed to ensure that the Minimum Data Set (MDS) assessment was accurately completed for 1 of 63 residents (Resident #39) in the survey sample.

Inspectors wroteBased on observations and staff interviews, the facility's staff failed to ensure that 1 of 63 residents (Resident #11), who were unable to perform activities of daily living (ADL), received all necessary services.

Inspectors wroteBased on observation, resident and staff interviews, and clinical record review, the facility staff failed to follow the physician's order for the oxygen flow rate for 1 of 63 residents (Resident # 99) in the survey sample.

Inspectors wroteBased on observation, staff interviews, and a review of the clinical record, the facility staff failed to ensure proper technique was utilized to achieve the ordered dose of medication for 1 of 63 residents (Resident 23) in the survey sample.

Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to provide services to prevent development of a pressure ulcer for a resident with a known moderate risk for pressure ulcer development and to identify the left heel pressure ulcer prior to progression to a stage three (3) which measured 4 centimeters by 4 centimeters by 0.1 centimeters, and presenting with 40 percent slough and 60 percent of dermis, for 1 of 5 residents (Resident #50), with facility acquired pressure ulcer, which constituted harm.

Inspectors wroteBased on observation, staff interview and facility policy, the facility staff failed to maintain an effective pest control program.

Inspectors wroteBased on observations, a resident council meeting, staff interviews and facility document review the facility staff failed to provide an environment for resident, staff and visitors that was safe, sanitary and comfortable.

Inspectors wroteBased on resident interviews, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide evidence that two out of 51 residents were invited to attend a care plan meeting, Resident #68 and Resident #59.

Inspectors wroteBased on observation, resident interview, and staff interviews the facility staff failed to treat a resident's clothing with respect and dignity for 1of 51 residents (Resident #48), in the survey sample with laundry concerns.

Inspectors wrote3. For Resident #68 the facility staff failed to execute the opportunity to provide an advance directive. Resident #68 was originally admitted to the facility 3/30/2017 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Major Depressive Disorder and Anxiety Disorder. The Quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/10/22 coded the resident coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #68 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two person for bed mobility and toileting. Requiring extensive assistance of one person with eating. [...]

Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure 1 of 3 residents reviewed for Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued the notices per the requirement.

Inspectors wroteBased on observation, resident interview, staff interview and facility document review, it was determined that facility staff failed to ensure a clean comfortable and homelike environment for 1 of 51 residents in the survey sample, Resident #8.

Inspectors wroteBased on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 51 residents (Resident #79 and Resident #36) in the survey sample.

Inspectors wroteBased on information obtained during a closed record review, staff interviews, and a clinical record review, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 51 residents (Resident #103 and #10), in the survey sample.

Inspectors wroteBased on observations, clinical record review, resident interviews, staff interviews and facility document review the facility staff failed to ensure that 2 of 51 residents in the survey sample who were unable to carry out grooming activities of daily living (ADL) were provided showers, Resident #37 and Resident # 69. 1. The facility staff failed to ensure Resident #37 who was unable to carry out activities of daily living was offered and received a scheduled twice-weekly shower to maintain good personal hygiene since admission. Resident #37 was admitted to the facility on [DATE] with diagnoses to include but not limited to Stroke, Left Hemiparesis, Hypertension and Depression. Resident #37's most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 3/24/22. [...]

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review the facility staff failed to provide necessary respiratory care and services for 1 of 48 residents (Resident #11), in the survey sample for the use of a BiPap machine.

Inspectors wroteThe facility staff failed to ensure RN coverage for 8 consecutive hours for 24 days.

Inspectors wroteBased on clinical record review, staff interviews and facility document review the facility staff failed to ensure the PRN (as need) psychotropic medication Lorazepam was not administered for more than 14 days for 1 of 51 residents in the survey sample, Resident #37.

Inspectors wroteBased on observations, staff interview,and in the course of a complaint investigation, the facility staff failed to maintain equipment to include an ice dispenser in the kitchen and a washing machine in safe operating conditions.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 2 (Resident #37 and 64) of 66 residents in the survey sample, to attend their person centered care plan meeting.

Inspectors wroteBased on observations, record review, complaint investigation and staff interviews the facility staff failed to ensure the environment was safe, clean and comfortable for potentially all residents in the facility and specifically for 3 of 66 residents in the survey sample, Residents #14, #40, #109).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide the required documentation upon transfer to the hospital for five of 66 residents in the survey sample, Residents #15, #78, #102, #37 and #71.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written bed hold notification upon transfer to the hospital for five of 66 residents in the survey sample, Residents #15, #78, #102, #37, & #71.

Inspectors wroteBased on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for five of 66 residents in the survey sample; Residents #67, #15, #218, #31 and #102.

Inspectors wroteBased on a complaint investigation, record review and staff interviews it was determined that the facility staff failed to ensure medications for the treatment of scabies was available from the pharmacy for 10 of 66 residents in the survey sample, Residents #43, #75, #82, #219, #56, #224, #66, #115, #92, and #22

Inspectors wroteBased on observations, and staff interview it was determined that the facility staff failed to store and prepare food under sanitary conditions.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure a complete and accurate clinical record for five of 66 residents in the survey sample, Resident #114, #418, #86, #87 and #31.

Inspectors wroteBased on observations, staff interviews, facility documentation and clinical record review, it was determined that facility staff failed to implement effective infection control practices for 4 of 66 residents in the survey sample. For Resident #31, the facility staff failed to prevent the indwelling catheter drainage bag from touching the floor. The facility staff failed to follow infection control practices as evidenced by not performing hand hygiene before and after medication administration for three residents in the medication administration observation, Resident #114, #24, and #113.

Inspectors wroteBased on observations and staff interview it was determined that the facility staff failed to maintain an effective pest control system.

Inspectors wroteBased on observations, staff interviews, and facility document review the facility staff failed to ensure 1 of 66 residents in the survey sample (Resident #78) had footwear and clothing other than the facility's hospital gowns to wear.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices were issued in accordance with applicable Federal regulations to 2 of 3 residents (Resident #7 and #93) in the survey sample.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure an accurate MDS (Minimum Data Set) assessment was completed for one of 66 residents in the survey sample, Resident #220.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility stafff failed to develop a baseline care plan for 2 of 66 residents in the survey sample, Resident #418 and #419.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed to develop the comprehensive care plan for 2 of 66 residents in the survey sample, Residents #67 and 98.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed to review and revise the care plan for two of 66 residents in the survey sample, Resident #15, and 37. 1a. For Resident #15, facility staff failed to revise his care plan after he was admitted back to the facility on 6/29/19 with a diagnosis of a urinary tract infection requiring antibiotic therapy. 1b. For Resident #15, facility staff failed to revise his care plan after a fall on 1/20/19.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility staff failed to ensure appropriate care and services were provided to 1 of 66 residents in the survey sample, Resident #86. The facility staff failed to assess the resident's self inflicted wound to the left buttock on a weekly basis and failed to apply dressing changes as ordered.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow orders and the comprehensive care plan for oxygen administration for one of 66 residents in the survey sample, Resident #114.

Inspectors wroteBased on staff interview and clinical record review, it was determined that facility staff failed to provide medically related social services following the loss of a loved one for one of 66 residents in the survey sample, Resident #64.

Inspectors wroteBased on record review and staff interview the facility staff failed to ensure one resident (Resident #110) in the survey sample of 66 residents was provided with a gradual dose reduction (GDR) of the psychotropic medication Seroquel.