Thomas Hospitals Skilled Nursing Unit

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.