Thomasville Health & Rehab, Llc

F-F698

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 36377

Residents Affected - Few Based on observation, staff interviews, record review, and the facility policy titled, Oxygen Concentrator, the facility failed to ensure an environment free from potential accident hazard by failing to ensure an oxygen cylinder was secure in a cylinder holder for one resident (R), Resident R20 out of ten residents receiving oxygen therapy.

Findings include:

Record review of the facility policy titled Oxygen Concentrator stated 2. Oxygen is administered under orders of the attending physicians, except in the case of an emergency. 6. Oxygen warning signs must be placed on

the door of the resident 's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility Oxygen Safety Policy.

Observation on 8/9/2024 at 9:33 am pm revealed an unsecured oxygen cylinder sitting on the floor of Resident R20's room in front of an adjoining bathroom door. If the bathroom door was open the oxygen cylinder tank could have easily been tipped over. At the time of the observation, Resident R20 was observed lying in bed in his room and receiving oxygen via a nasal cannula.

Record review of Resident R20's medical record revealed the following diagnoses but not limited to acute hypoxemic respiratory failure.

Record review of Resident R20's Physician Order Form (POF) revealed an order dated 7/14/2024 which stated 02 via N/C (oxygen by nasal cannula) Simple Mask @ 2-4 LPM PRN (at 2-4 liter per minute as needed) for 02 Sat < than 90% or SOB (less than 90 percent short of breathe) every 2 hours as needed.

Interview with Housekeeper Supervisor on 8/9/2024 at 9:33 am, she reported entering the resident room to clean the room and observing the oxygen cylinder tank on the floor.HK Supervisor reported not considering free standing oxygen as a risk.

Interview at the time of observation on 8/9/2024 at 9:34 am with Licensed Practical Nurse (LPN), LPN II confirmed that the oxygen cylinder was sitting on the floor. She removed the cylinder from the room immediately. LPN II confirmed that this is considered a hazardous situation, because if tipped over (referring to the oxygen cylinder) it could result in an explosion injuring residents and others. She reported that oxygen cylinder was placed in the resident's room on Monday by the Hospice Nurse, due to expected inclement weather from an upcoming storm in the area. She reported entering the resident's room earlier this morning with the nightshift nurse at the change of shift. LPN II reported that she did not observe the cylinder in the room at that time.

Interview on 8/9/2024 at 9:36 am, Certified Nursing Assistant (CNA) FF reported feeding the resident breakfast and providing Activities of Daily Living Care (ADL) to Resident R20. She reported observing the O2 tank sitting in the room. She reported being unaware of the danger of not having the oxygen cylinder tank freely standing and not in a cylinder holder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Interview on 8/9/2024 at 2:01 pm with Registered Nurse (RN) BB who reported being unaware of the oxygen cylinder being left free standing by staff. She reported that her expectation is that all CNAs remove any Level of Harm - Minimal harm or unused oxygen cylinder out of the resident room. She further stated that any oxygen cylinder tank in resident potential for actual harm room for resident use should be placed in a holder.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36377

Residents Affected - Few Based on observations, staff interviews, record review, the facility failed to have a Physician's order for one resident (R,) Resident R20, of eight residents with indwelling catheters. In addition, the facility failed to ensure that Resident R20's catheter tubing was not coiled and correctly position to prevent obstruction of urinary flow.

Findings include:

Record review of Resident R20's medical record revealed the following diagnoses but not limited to retention of urine unspecified and chronic kidney disease. Record review revealed that resident has a history of urinary tract infections and sepsis.

Record review did not reveal an active order for an indwelling catheter.

Record review of Significant Change Minimum Data Set (MDS) dated [DATE REDACTED] revealed a Brief Interview Mental Status Score (BIMS) that indicated severe cognitive impairment. Section H revealed an assessment for catheter use.

Observation on 8/9/2024 at 8:10 am revealed Resident R20 lying in bed with catheter attachment and tubing touching

the floor.

During a secondary observation on 8/9/2024 at 2:44 pm Resident R20's tubing was coiled and the catheter bag was hanging on the arm rest of the chair obstructing urine flow.

Observation on 8/10/2024 at 9:50 am revealed Resident R20 sitting in a geriatric chair with catheter attachment. Resident R20 was observed sitting on the tubing and tubing positioned on the arm rest of the chair (above waist). Continued review revealed no flow of urine in a downward position (obstruction of urine flow).

Interview on 8/10/2024 at 9:11 am, with Registered Nurse (RN) DD revealed confirmed no order for the catheter. She reported that resident was readmitted to the facility after a hospital stay with the catheter.

Interview on 8/10/2024 at 9:15 am, Licensed Practical Nurse (LPN) II confirmed no active order for catheter.

She reported that the catheter order per record review was put in place on 7/9/2024 and discontinue by error

on 7/10/2024. She reported that the positioning of the tubing is important to prevent the risk for possibility of urinary tract infection and sepsis.

8/10/2024 at 9:59 am Resident R20 was observed sitting in his Geri chair and tubing on the floor and cord underneath

the Geri Chair, wheel of the chair on the cord. RN DD repositioned the tubing by removing the tubing. RN DD reported that the risk is that the tubing can dislodge from the resident. She reported that she would re-educate the assigned certified nursing assistant (CNA) about the correct positioning of the tubing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Surveyor returned to resident room at 8/10/2024 at 2:00 pm and 3:00 pm, each time the resident was observed with the catheter hanging on the arm rest of the chair and sitting on the tubing. The MDS Level of Harm - Minimal harm or Coordinator was summoned to the room by the surveyor to observe the deficient practice. The MDS potential for actual harm Coordinator repositioned the catheter and repositioned the resident to prevent the resident from sitting on the tubing. Residents Affected - Few

Observation of Resident R20 with RN BB and Unit Manager LPN CC on 8/11/2024 at 9:01 am, both staff observed Resident R20 sitting in an upright position in his geriatric chair with the catheter tubing cord hanging on the arm rest of

the chair. Continued observation revealed Resident R20 sitting on the catheter tubing. LPN CC reported being upset about the positioning of the resident. LPN CC stated that the CNA was informed not to do this anymore. Both staff immediately began to reposition the resident.

Interview with 8/11/2024 at 10:01 am, CNA FF confirmed receiving inservice about the positioning of the catheter and the tubing. However, she reported being unaware that hanging the catheter tubing on the arm rest of the chair could obstruct urine flow. She reported failing to observe Resident R20 sitting on the catheter tubing.

Interview on 8/11/2024 at 10:03 am, RN BB revealed that her expectation is for the licensed nurse to review

the hospital record at the time of the resident's admission and contact the physician if there is not order for a catheter. She reported being unaware of Resident R20 not having an order for a catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36377 potential for actual harm Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Residents Affected - Few Oxygen Concentrator, the facility failed to ensure oxygen (O2) was administered in accordance with the physician order for one of eight residents (R) Resident R20 receiving oxygen therapy. In addition, the facility failed to ensure that oxygen signage was placed on the resident 's door. The deficient practice had the potential for respiratory difficulty for Resident R20.

Findings include:

Record review of the facility policy titled Oxygen Concentrator stated 2. Oxygen is administered under orders of the attending physicians, except in the case of an emergency. 4. Use of the Concentrator (a). The nurse shall verify physician 's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula).

6. Oxygen warning signs must be placed on the door of the resident 's room where oxygen is in use.

8. Storage of oxygen shall be in accordance with the facility Oxygen Safety Policy.

Record review of Resident R20's medical record revealed the following diagnoses but not limited to acute respiratory hypoxemic.

The Significant Change Minimum Data Set (MDS) dated [DATE REDACTED] assessed a Brief Interview Mental Status Score of unable to tract. A score of 0 out of 15 indicates severe cognitive impairment. Section O assessed oxygen therapy.

Review of orders listed an active order dated 7/14/2024 for O2 via for N/C/Simple Mask @ 2-4 LPM PRN for O2 Sat < than 90% or SOB every 2 hours as needed (oxygen by nasal cannula with simple mask at two to four liters per minute as needed for O2-oxygen saturation less than 90 % every two hours or shortness of breath).

Observation on 8/9/2024 at 8:10 am revealed Resident R20 lying in bed receiving oxygen by oxygen concentrator and via nasal cannula at 1.5 LPM (liters per minute). Resident stated that he is not feeling well. No signage on door indicating oxygen usage.

Observation on 8/9/2024 12:48 pm, revealed Resident R20 lying in bed and being fed by Certified Nursing Assistant (CNA) LL. Surveyor observed Resident R20 receiving oxygen by via nasal cannula at 1.5 at LPM while being assisted with his meal.

Interview at the time of observation on 8/9/2024 at 12:51 pm with Licensed Practical Nurse (LPN), LPN II. LPN II reviewed record with surveyor and confirmed that O2 should be set at 2-4 LPM. She reported that she was prn nurse and was not aware until brought to her attention by the surveyor. She adjusted the O2 Sat

Observation on 8/10/2024 at 8:19 am and 10:36 am, revealed Resident R20 lying in bed receiving oxygen by oxygen concentrator and via nasal cannula at 2 LPM. No signage on door indicating oxygen usage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview at the time of observation on 8/10/2024 at 10:36 am with Register Nurse (RN), RN DD no signage on door to indicate oxygen usage was confirmed. She reported being unaware of this deficient Level of Harm - Minimal harm or practice until brought to her attention by the surveyor. She reported that she would now instruct the potential for actual harm Maintenance Director to put a sign on the door. RN DD reported that the importance and purpose of the oxygen sign is to prevent risk of visitors smoking in the room while the resident is using oxygen. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42463 potential for actual harm Based on observations, record review, staff interviews, and review of the facility's policy titled, Hemodialysis, Residents Affected - Some the facility failed to provide evidence of ongoing monitoring and care of a dialysis access site and failed to ensure ongoing communication and collaboration with the dialysis center for one of one resident (R) (Resident R31) reviewed for dialysis services. This deficient practice had the potential to place Resident R31 at risk for medical complications, unmet needs, and a diminished quality of life.

Findings include:

A review of the facility's policy titled Hemodialysis, dated 2/12/2022, under the section titled Policy revealed,

This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis. Under the section titled Purpose revealed, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include:

The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Under the section titled Compliance Guidelines revealed, number 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications.

Review of Resident R31's Face Sheet revealed diagnoses that included but not limited to type two diabetes mellitus with other diabetic kidney complication, end stage renal disease, and anemia in chronic kidney disease.

Review of Resident R31's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Section O (Special Treatments and Programs) documented that Resident R31 received hemodialysis while a resident.

Review of Resident R31's Electronic Medical Record (EMR) revealed a physician's order dated 9/5/2023 that read, Resident will have dialysis with [Name of dialysis facility] M/W/F (Monday, Wednesday, and Friday). Further

review of physician orders revealed there were no orders for ongoing monitoring and care for Resident R31's dialysis access site.

Review of Resident R31's Administration Record dated 8/1/2024 - 8/31/2024 revealed, there were no orders for ongoing monitoring and care for Resident R31's dialysis access site.

Review of the Resident R31's Progress Notes from 9/5/2023 through 8/9/2024 revealed, the lack of consistent documentation and proof of ongoing monitoring for Resident R31's dialysis access site in addition to not communicating and collaborating with the dialysis center on the resident's scheduled dialysis days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 During an interview on 8/10/2024 at 8:31 am with Registered Nurse (RN) DD and Licensed Practical Nurse (LPN) EE Resident R31's medical records were reviewed, which revealed there were no physician orders that Level of Harm - Minimal harm or addressed the monitoring and care for the resident's dialysis access site. RN DD revealed that she and the potential for actual harm charge nurses were responsible for monitoring the dialysis site each shift ensuring that it remained dry and intact. LPN EE revealed the dialysis staff access Resident R31's dialysis port, and should the facility nurses need to Residents Affected - Some do anything with it they would call the doctor and get an order.

During an interview on 8/10/2024 at 8:36 am with RN BB, Resident R31's medical records were reviewed. RN BB verified there were no orders that addressed nursing care and monitoring for the resident's dialysis port. RN BB stated that it was the responsibility of the nurses at the facility to ensure the dressing at the dialysis access site was dry and intact every shift and as needed.

Observation on 8/10/2024 at 8:40 am with RN BB of Resident R31 revealed the resident had a dialysis port that was intact to the right chest wall with a dry dressing covering it. RN BB confirmed there should have been dialysis orders written to address monitoring and care for the dialysis port.

Interview on 8/10/2024 at 10:58 am with LPN Unit Manager (UM), CC revealed that her expectations of nurses were to make sure orders were in place for dressing changes and to monitor dialysis access sites for residents on dialysis.

During an interview on 8/11/2024 at 8:30 am with RN BB, a record review of the Dialysis Communication Sheets for Resident R31 that was kept in the book at the nurses' station revealed missing and incomplete dialysis communication sheets ranging from 9/11/2023-8/2/2024. RN BB confirmed some of the dialysis communication sheets were missing and/or were not completed. She revealed that the facility nurses were to complete the pre-dialysis information and send the form with Resident R31 to dialysis and that the dialysis staff were to complete the post dialysis information and send it back with the resident, but they had not been sending

this information back. She reported that most of the time, the facility nurse would call the dialysis center to get a report on the resident. When questioned why the post dialysis information reported from the dialysis center was not documented, she stated she was not sure why. She reported receiving training on dialysis care and understands the importance of communication and collaboration between the facility and dialysis staff.

Interview on 8/11/2024 at 9:07 am with LPN Unit Manager (UM), CC stated her expectations of nurses were to complete the dialysis communications sheet and to make sure that Resident R31 returned with the dialysis communication sheet with the post dialysis information completed. She revealed if the post-dialysis sheet was not returned or completed, they were to call and get a report and document this on the communication sheet and/or nurse notes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 42463

Residents Affected - Many Based on record review, staff interviews, and review of the Payroll-Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31), the facility failed to provide Registered Nurse (RN) coverage for 8 hours within a 24-hour period on 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024. The facility census was 40 residents.

Findings include:

Review of the most recent PBJ Staffing Data Report CASPER Report 1705D FY Quarter 2 2024 (January 1 - March 31) revealed the facility triggered for No RN Hours which indicated four or more days within the Quarter with no RN hours for the following dates: 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024.

Review of the form titled, [Facility Name] Daily Nursing Sheet, dated 1/7/2024 revealed, there was not a registered nurse scheduled on the 1st, 2nd, or 3rd shifts. Further review revealed on 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024, and 3/31/2024 there was RN coverage eight hours on 1st shift.

Review of the form titled, Daily Staffing Schedule dated 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024 revealed, RN HH was scheduled to work on 1st shift.

Review of the payroll Timecard Report for RN HH revealed, the total number of hours worked on 1/7/2024 (7. 67 hours),1/21/2024 (8.22 hours), 2/4/2024 (7.55 hours), 2/18/2024 (7.47 hours), 3/3/2024 (7.80 hours), 3/17/2024 (7.43 hours) and 3/31/2024 (7.68 hours).

Interview on 8/10/2024 at 10:05 am with the Business Office Manager (BOM) revealed, she was responsible for human resources and payroll. She confirmed there was no RN coverage for eight full hours for the following dates (1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024) indicated on

the PBJ report. The BOM revealed they had RN coverage scheduled on those days however the time clock system automatically deducted 30 minutes for lunch. She stated they were aware that RN HH who worked

on those dates did not work the full eight hours and that this had been addressed with the Administrator. She reported they try to staff at least two RNs daily to meet the requirements.

Interview on 8/10/2024 at 2:00 pm with the Administrator revealed, she was aware of the discrepancy with

the RN hours indicated on the PBJ report. She revealed that she knew it would potentially trigger the report.

She revealed the facility staff are required to take 30 minute lunch breaks and two 15 minute breaks during

an eight hour period. She revealed she had discussed this with corporate so that they could produce a resolution. She reported she was aware that there should be RN coverage a full eight hours within a 24 hour period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Interview on 8/10/2024 at 3:22 pm with Licensed Practical Nurse (LPN) Unit Manager revealed, that she was responsible for staffing RN coverage for eight hours per day. She reported that the new time clock system Level of Harm - Minimal harm or automatically clocks them out regardless of whether the nurse took the lunch or not. LPN Unit Manager potential for actual harm stated her expectations of the RNs was to work at least 8.5 hours to ensure a full eight hours daily as required. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41914

Residents Affected - Few Based on staff interviews and record review, the facility failed to ensure laboratory orders were obtained as ordered by the physician for one of 13 residents (R) (Resident R21). This failure resulted in actual harm on 9/19/2023 when Resident R21 was admitted to the local hospital and required a blood transfusion after the facility failed to obtain ordered labs for March 2023 and June 2023 facility received lab results on September 19, 2023, indicating Resident R21 had a hemoglobin level of 5.9 g/dl (grams per deciliter) normal range was 13.5 - 17.5 g/dl.

Findings:

Record review revealed Resident R21 was admitted to the facility with the diagnosis of but not limited to, Idiopathic gout, cerebral infarction, aphasia, hemiplegia, Diabetes mellitus, chronic systolic congestive heart failure, hypertensive heart disease, hypercholesterolemia, angina pectoris, major depressive disorder, and epilepsy. Physician order dated 3/7/2023 indicated to collect labs CBC (complete blood count) w (with) diff Q (every) three months March/June/September/December. There was no indication the ordered labs were obtained for March 2023 and June 2023.

Review of the laboratory results dated [DATE REDACTED] revealed a CBC was obtained with a result of Hemoglobin (HGB) 5.9 g/dl.

Review of Resident R21 progress notes dated 9/19/2023 revealed resident has a critical lab with a hemoglobin of 5.9 (--) on call for Medical Director (MD) wanted to send to emergency room (ER) notified family member and called report to ER was transported by Emergency Medical Service (EMS).

Interview on 8/10/2024 at 2:37 pm with Unit Manager revealed that Resident R21 received the diagnosis of Iron Deficiency anemia after he was admitted to the hospital and received two units of blood for a hemoglobin of 5.9. The order to collect the CBC was a routine blood draw that the facility physician would order for all residents. The results for the CBC that was ordered for March 2023 and June 2023 were not completed, and results were unable to be located in the electronic Laboratory system or in the Resident R21 medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 41914 potential for actual harm Based on observation, staff interviews, and review of facility documents, the facility failed to ensure recipe for Residents Affected - Many puree carrots and chicken were followed to preserve nutritional value of food for residents receiving a pureed diet. The facility also failed to ensure residents consuming a puree diet were served the recommended three ounces (oz) of protein during meal service.

Findings:

Review of the untiled document submitted by the Dietary Manager with scoop number, diameter capacity (in ounces) and color (color of scoop handle) revealed the number 16 scoop that was used to measure the puree foods had the following: Number 16 -Diameter 2 1/4 inches/5.72 cm (Centimeters), Capacity - 2 3/4 0z. The number 16 scoop did not provide the needed three ounces of protein per resident.

Review of the document titled, Quantified Recipe (Recipe #220) for baked chicken revealed the following: portion size: number 8 scoop, serving utensil #8 scoop, baked chicken 30z SCR. 1. Prepare according to ground recipe. Stock Chicken/soup base for thinning. Recipe #249 Seasoned carrots, portion size #16 scoop (1/2 cup), serving utensil #16 scoop.1. Prepare according to regular recipe. There was no indication to add any type of liquids during the puree process

Puree observation on 8/10/2024 at 10:45 am revealed [NAME] AA poured measured carrots into food processor and began blending food. During blending staff member went over to the vegetable sink next to blending station and retrieved tap water from the sink faucet and proceeded to add to the carrots during the mixing process. This step was repeated one more time until desired consistency was met. After carrots were completed [NAME] AA proceeded to prepare the diced chicken for the puree residents in the same manner of adding water to the mixture until desired consistency was met.

Interview on 8/10/2024 at 11:00 am with [NAME] AA revealed that the facility currently had three residents that were on puree diets. It was reported that the recipe for pureeing foods is in the menu book that is kept

on the shelf above the milk cooler. During the interview staff member was asked how many ounces (oz) of protein should each resident on a puree diet receive and staff member was unable to verbalize the amount needed for each resident to receive to ensure the appropriate nutritional value was met. [NAME] AA stated,

The puree residents have a divided plate and I just make sure that one of the squares is full when I scoop

the food into the plate, and sometimes I will put a little more in it. Further interview also revealed that [NAME] AA stated that she uses the number 16 scoop to measure the portions before pureeing the food but was unable to verbalize what the measurement of the scoop used was.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Interview on 8/10/2024 at 11:30 am with the Dietary Manager revealed that there are recipes that are to be followed that are located in the kitchen, but the staff that is currently working in the kitchen have been there Level of Harm - Minimal harm or for a while and are aware of which scoop to use for measuring foods to ensure nutritional value is met. potential for actual harm During interview, the Dietary Manager was asked how the staff know which scoop to use and she stated that

the scoops are color coded and there use to be a guide posted on the wall in the kitchen that indicates the Residents Affected - Many amount in ounces of each scoop by the color of the handle. Further interview also revealed that sometimes

during the puree process the cooks will add water or milk to ensure the right consistency is obtained. Dietary Manager confirmed the scoop used by [NAME] AA was not the correct scoop to obtain the recommended three ounces of vegetables and protein for residents consuming a puree diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41914

Residents Affected - Many Based on observations, staff interviews, and review of the facility policy titled, Used By Dating Guideline, the facility failed to ensure food items were properly labeled and dated, failed to discard expired foods by expiration date, and failed to ensure ice machine was kept clean and free of lime and calcium buildup. The deficient practice had the potential to affect 36 of 40 residents receiving an oral diet.

Findings:

Review of the facility policy titled, Used By Dating Guideline Dated [DATE REDACTED] revealed under Section 1: foods that have been mixed with other ingredients, prepared in any way, or portioned out include, but are not limited to juices, thickened beverages, canned fruit, unused portions, prepared salads, cut fruits/vegetables, roasted/sliced meats use by date-three days after preparation.

Observation on [DATE REDACTED] at 7:50 am revealed in the reach in cooler located to the right of the main kitchen a small steamtable pan of tuna salad that was unlabeled and dated, a bag of cooked macaroni noodles that were not label or dated, 16 oz (ounce) bottle of opened Zesty Italian dressing that was not labeled or dated, 22 oz bottle of opened strawberry syrup not labeled or dated.

Observation on [DATE REDACTED] at 7:51 am revealed on the steel table at the back of the main kitchen in a large gray plastic container was an opened half bag of brown sugar that was not labeled or dated, a bag of unknown substance that was wrapped in plastic wrap unlabeled and undated, a opened half bag of fried onions with a use by date of [DATE REDACTED].

Observation on [DATE REDACTED] at 7:53 am revealed in the reach in cooler located to the left of the kitchen by the steam table a large chef salad unlabeled with no expiration date, chef salad in a small white bowl unlabeled and not dated, medium size steamtable pan of macaroni salad with the expiration date of [DATE REDACTED], half a bag of shredded white cheese not labeled or dated, half a bag of opened cheese cubes unlabeled and undated.

Observation on [DATE REDACTED] at 11:10 am revealed the facility ice machine located in the staff break area there were white chalky streaks noted streaming down the back, front and side of the machine, there was also a thick layer of white chalky substance that was noted in right upper crevices on the front side of the machine.

Observation on the inside of the ice machine also revealed a thin layer of black substance on the plastic white panel on the inside of the machine.

Interview on [DATE REDACTED] at 11:15 am with the Administrator revealed the ice machine should be cleaned by the dietary staff daily and maintenance cleans the filter and the motor parts quarterly. A further interview also revealed that the expectation is that the machine is cleaned at least monthly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 115427 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115427 B. Wing 08/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Thomasville Care Center LLC 120 Skyline Drive Thomasville, GA 31757

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Interview on [DATE REDACTED] at 11:25 am with Dietary Manager revealed that she will wipe down the ice machine daily but has been on vacation for the last week. Maintenance is responsible for cleaning the inside of the Level of Harm - Minimal harm or machine to include the white plastic panel on the inside of the machine. Further interview also revealed that potential for actual harm all foods should be labeled and dated when put in the cooler and any leftover food should be discarded after three days. The Dietary Manager also confirmed all unlabeled and expired foods as well as the ice machine Residents Affected - Many that were observed during the initial tour.

Interview on [DATE REDACTED] at 11:57 am with the Maintenance Director revealed that he was responsible for cleaning the ice machine quarterly and the last time it was cleaned was in [DATE REDACTED]. A further interview revealed that the last quarter's cleaning was not completed, and the machine is currently being cleaned.

During the interview it was also revealed that when the machine is cleaned the ice bin is emptied, the filters are cleaned, and the outside of the machine is de limed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 115427