Thomson Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and facility policy reviews, the facility failed to ensure that food items in the kitchen and resident pantries were properly dated and stored. In addition, the facility failed to ensure sanitary conditions in the kitchen and properly clean and sanitize dishes. The deficient practices had the potential to place the 103 residents who received meals from the dietary department at increased risk of foodborne illness.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Work Orders, Maintenance, the facility failed to ensure one of two sit-to-stand lifts was clean and in good repair. This deficient practice had the potential to place residents at risk of living in a non-home-like environment.

Inspectors wroteBased on record review, staff interview, review of the facility's policy titled Comprehensive Assessments, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system in a timely manner for one resident (Resident (R) 99) out of six residents reviewed for accurate assessments in the sample of 37. This deficient practice prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysis.

Inspectors wroteBased on record review, staff interview, and review of the facility's policy titled Resident Assessments, the facility failed to complete quarterly Minimum Data Set (MDS) Assessments not less that once every three months, for two resident (Resident (R) 30 and R77) out of six residents reviewed for accuracy of assessments in the sample of 37. This deficient practice prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysis.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Resident Assessments, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment that reflected the resident's status at the time of the assessment for two (Residents (R)8 and R59) of six residents reviewed for accuracy of assessments in the sample of 31 residents. This failure had the potential to affect nutritional assessments and dietitian evaluations, as well as fall precautions and care planning.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Sanitation, the facility failed to maintain the ice machine in a clean and sanitary manner. The deficient practice had the potential to cause illness to 103 out of 105 residents who consumed an oral diet.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Transfer Agreement, the facility failed to provide written hospital transfer notices for three of three Residents (R) (R11, R12, and R43) reviewed for hospitalization out of a total sample of 33 residents. The failure had the potential to cause residents to not fully understand the purpose of the hospital transfer.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Bed-Holds and Returns, the facility failed to provide written bed hold notices for three of three Residents (R) (R11, R12, and R43) reviewed for hospitalization out of a total sample of 33 residents. The failure had the potential to cause confusion as to what the charge would be after the bed hold expired or if they would have a bed when they returned to the facility.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy and procedure titled Resident Rights, the facility failed to provide a dignified dining experience for two of 33 sampled Residents (R) (R24 and R100) by serving meals on styrofoam with plastic utensils and standing to assist with meal intake. This failure created the potential for the residents to be treated in an undignified manner.

Inspectors wroteBased on staff and resident interviews, record review, and review the facility's policy titled Resident Rights, the facility failed to honor the resident's right to vote for one of two Residents (R) (R83) who were reviewed for choices out of a total sample of 33 residents. This had the potential for the resident not to be able to make choices that could impact the resident's life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy and procedure titled Care Plans, the facility failed to develop a person centered, comprehensive care plan for two of 33 sampled Residents (R) (R24 and R100) related to meal assistance, safety needs, and ambulation which had the potential for unmet care needs.

Inspectors wroteBased on observation, staff interviews, and review of the facility policies titled, Administering Medications , Preparation and General Guidelines IIA1: Equipment and Supplies for administering Medication and Legionella Water Management Program. The facility failed to maintain infection control standard precautions during medication administration for one of four sampled residents during medication administration observation. The facility also failed to develop an updated water management plan for the prevention of Legionella for 105 of 105 residents in the facility. 1.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Dignity, the facility failed to ensure resident's dignity was maintained by not displaying confidential clinical information indicating clinical status or care needs for one resident (R) (R#95).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Maintenance Service, the facility failed to maintain a clean, comfortable, homelike, environment related to scuffed walls, holes in walls, missing baseboards, and peeling paint, in two of 18 rooms on the 400 Hall (room [ROOM NUMBER] and 412) and one of 15 rooms on the 500 Hall (room [ROOM NUMBER]).

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Care Plans, Comprehensive Person-Centered and Medication Monitoring and Management, the facility failed to develop/implement a care plan related to high-risk medications for three of seven residents (R) (R#4, R#28, and R#52).

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Care Plan, Comprehensive Person-Centered, the facility failed to update the care plan to include post operative care for one resident (R) (R#98).

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to promptly notify the ordering physician, physician assistant, or nurse practitioner of laboratory results for one of one Resident (R) R#28. Specifically, the facility failed to ensure physician was notified of lab results received on June 1, 2023.