Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thomasville Vistas Of Journey Llc during CMS and state inspections, most recent first.
Unsanitary food storage and kitchen conditions: Surveyors found multiple unlabeled, undated, and expired food items stored in freezers, coolers, and on a shelf, along with a dirty fan, a greasy and sticky kitchen floor with missing tiles, and dietary aides without hair coverings. An ice machine used for residents also had a black/brown substance inside and was dripping water, and the RD and Administrator confirmed the kitchen cleanliness and food-handling concerns.
Unsanitary Dumpster Area: The facility failed to keep the outdoor dumpster area sanitary when surveyors observed scattered trash, including paper, plastic, and food container waste, around the dumpster on multiple observations. Wooden pallets were also seen leaning against the fence surrounding the dumpster, and the Administrator confirmed the condition and stated that trash is picked up three times a week and can get spilled.
Unauthorized medications were found stored at the bedside for multiple residents without documented self-administration assessments or orders. One resident with little to no cognitive impairment had Flonase and zinc oxide cream on the bedside table, another resident had an OTC nasal spray in the room and said it was being used without staff supervision, and two other residents had OTC products such as zinc oxide cream, cough drops, and vapor rub in open view. The DON and an LPN confirmed the medications were in the rooms and that the residents had not been assessed to self-administer medications.
Incomplete Care Plans for Nail Care and Pain Management: Surveyors found that care plans were not fully developed or implemented for three residents. Two residents with severe cognitive impairment had care plans for nail care or ADL support, yet their fingernails were repeatedly observed long and dirty, and both stated they wanted them trimmed. Another resident with rib fractures had a PRN tramadol order for pain, but the care plan had no pain management or controlled medication interventions documented.
Failure to provide needed nail care for two residents. One resident with severe cognitive impairment and diagnoses including hemiplegia, Alzheimer's disease, and PVD had long fingernails with a black substance under the tips despite a care plan for shower and nail care, and the resident said the nails should be trimmed and cleaned. Another resident with severe cognitive impairment, DM2, a stage four sacral pressure ulcer, and other diagnoses had long, dirty fingernails on repeated observations and stated a desire for them to be cut; staff, including the CNA, WCN, Unit Manager, and DON, confirmed the nails were long and dirty.
A resident with moderate cognitive impairment and an order for PRN tramadol had a controlled substance discrepancy when the narcotic count did not match the tablets remaining in the medication card. An LPN reported that the night shift nurse said she gave the medication, but there was no matching entry in the narcotic log, MAR, or progress note. The Unit Manager and DON confirmed the count was wrong, and the Pharmacist Consultant stated he was not notified of the discrepancy.
Medication pass errors resulted in an 8.33% error rate. An LPN gave a resident sucralfate while the resident was eating breakfast instead of on an empty stomach, and also administered only one 10 mg buspirone tablet and one 100 mg sertraline tablet when the orders required double those doses. The LPN confirmed the medications were not given according to the MAR and medication card directions, and the Medical Director, Pharmacist Consultant, and DON confirmed the ordered doses and timing.
Staff failed to follow infection control practices for two residents in the same room and for a room under airborne precautions. A housekeeper, an LPN, and a CNA entered the airborne-precaution room wearing surgical masks instead of N95 respirators, and the LPN left the door open while preparing meds outside the room. In addition, the WCN/Infection Preventionist changed gloves during wound and g-tube care without hand hygiene between tasks, did not change her gown between residents, and confirmed the missed hand hygiene and gown change.
Two residents with documented allergies to fish and shellfish were served meals containing these allergens. One resident was given a crab cake despite a shellfish allergy, realized the error after tasting, and did not experience a reaction. Another resident with a fish allergy reported repeatedly receiving fish and returning it. Staff interviews confirmed that both dietary and nursing staff were responsible for checking meal trays for allergens, but these checks failed to prevent the errors.
Staff did not follow infection control protocols during wound and perineal care for a resident with a pressure ulcer. A CNA and an LPN both provided direct care without wearing protective gowns as required by enhanced barrier precautions, and wound care supplies were placed on an unsanitized bedside table. Staff interviews indicated gowns had not been available for a month, despite being present in the supply room.
A facility failed to obtain ordered lab tests for a resident, leading to actual harm. The resident, with multiple health conditions, had a physician order for a CBC every three months, which was not completed for March and June. In September, a critically low hemoglobin level was discovered, resulting in the resident being hospitalized for iron deficiency anemia and receiving a blood transfusion.
The facility failed to provide full RN coverage for eight hours on multiple occasions due to an automatic time clock deduction for breaks, resulting in discrepancies in the PBJ Staffing Data Report. Despite scheduling efforts, the RNs did not meet the required hours, affecting the facility's compliance with staffing regulations.
The facility failed to follow recipes for pureed carrots and chicken, affecting the nutritional value for residents on a pureed diet. Staff added water during the pureeing process, which was not in the recipe, and used an incorrect scoop size, providing less than the recommended protein portion. Interviews revealed staff were unaware of correct portion sizes and scoop measurements.
The facility failed to properly label and date food items, discard expired foods, and maintain the cleanliness of the ice machine. Observations revealed multiple unlabeled and undated food items, some past expiration, and an ice machine with chalky and black substances. Interviews confirmed lapses in adherence to policies for food handling and ice machine maintenance.
Two residents with indwelling urinary catheters were observed with uncovered catheter bags visible from their rooms, violating the facility's policy on maintaining resident dignity. Despite care plans in place, the catheter bags were not covered, which was confirmed as a dignity issue by nursing staff.
A facility failed to obtain a concurring physician's signature on a DNR order for a resident with severe cognitive impairment and no documented POA or guardian. The DNR was signed by an unauthorized person, and the resident's code status was changed to Full Code. Interviews confirmed the absence of a healthcare agent, and family members stated no legal guardianship existed.
The facility failed to provide a home-like environment, with observations of missing floor tiles, peeling paint, rust on equipment, and persistent odors in resident areas. Staff acknowledged these issues, noting offensive urine odors and rust on toilet seats and shower chairs. The Maintenance Director was unaware of needed repairs.
A facility failed to monitor a resident's dialysis access site and ensure communication with the dialysis center. The resident, with conditions like diabetes and end-stage renal disease, had no orders for site care. Staff interviews and observations confirmed lapses in documentation and communication, with missing or incomplete Dialysis Communication Sheets.
A facility failed to complete and transmit a discharge MDS assessment within 14 days for a resident who was admitted with multiple diagnoses and discharged against medical advice. Interviews revealed no discharge assessment or documentation was completed, contrary to facility policy.
A resident with end-stage renal disease did not receive proper monitoring and documentation for hemodialysis care as outlined in their care plan. The facility's records lacked consistent documentation of ongoing monitoring and communication with the dialysis center. Staff interviews confirmed missing and incomplete dialysis communication sheets, indicating a failure to adhere to the care plan.
An unsecured oxygen cylinder was found on the floor of a resident's room, posing a potential hazard. The resident, diagnosed with acute hypoxemic respiratory failure, was receiving oxygen therapy. Staff interviews revealed a lack of awareness about the danger of an unsecured cylinder, with a housekeeper, LPN, CNA, and RN failing to secure it. The LPN removed the cylinder upon discovery, and the RN expected CNAs to ensure cylinders were secured, indicating a lapse in adherence to safety protocols.
A resident with a history of urinary tract infections and sepsis had an indwelling catheter without a physician's order. The catheter tubing was frequently observed in improper positions, such as coiled, touching the floor, or obstructed by the chair's armrest, potentially impeding urine flow. Staff confirmed the absence of an active order and improper tubing positioning, despite being informed about correct procedures.
A resident receiving oxygen therapy was administered oxygen at a rate below the physician's order, and the facility failed to place required oxygen warning signage on the resident's door. The LPN and RN were unaware of these deficiencies until informed by the surveyor.
A resident with multiple diagnoses, including mood disorder and anxiety, was administered Haloperidol for agitation without prior alternative interventions. Staff interviews revealed the resident was restrained during medication administration, despite not acting out. A recommendation for Ativan as an alternative was not followed, contributing to the deficiency.
A facility failed to report an incident where a resident was allegedly restrained by the DON and LPNs during medication administration, despite the resident not acting out. The resident, with multiple health conditions, was calm and wanted to discuss the confiscation of his vape pen. The incident was not reported to the State Agency due to unfamiliarity with the process, and the Administrator was initially unaware of the situation.
A facility failed to comply with regulations for PRN antipsychotic medications. A resident returned from the ER with a PRN Haldol order, which was extended without a required physician re-evaluation. The resident received Haldol beyond the 14-day limit without proper documentation. A behavioral consultant recommended Ativan and Haldol, but there was no physician documentation for continued PRN use.
A resident with multiple health conditions was not provided with recommended restorative services after being discharged from skilled physical therapy. Communication breakdowns between the Physical Therapy Assistant, LPN, and DON led to a delay in implementing the restorative program, which included ambulation, range of motion, and transfer activities.
Unsanitary food storage and kitchen conditions
Penalty
Summary
The facility failed to label, date, store, prepare, and discard food under sanitary conditions, and failed to maintain cleanliness of the kitchen floors and equipment used for residents. During an initial kitchen observation with the RD and dietary staff, surveyors found a stand-up fan with dirt and dust on the blades and grill, a kitchen floor under the sinks with missing tiles and a buildup of grease, dirt, and a sticky substance, and multiple food items in three freezers and two coolers that were either unlabeled, undated, or expired. These items included hashbrowns, hot dogs, cheese pizza, fries, breaded cheese sticks, chicken tenders, cheese slices, coleslaw, cabbage, greens, and multiple bags of pasta with various use-by or expiration dates, including expired pasta stored on a shelf across from the freezers. During the same tour, dietary aides were observed without hair coverings, and the RD confirmed the staff needed a lot of education on labeling, dating, and discarding items. The RD removed and discarded most of the identified food items as they were found and stated the kitchen was due for a deep cleaning and she did not know when it was last cleaned. On a later observation, the ice machine in the break room off the dining room used for residents contained a black/brown substance on the inside ceiling and was dripping water. The RD verified the substance and dripping water, and the Administrator stated she did not know when the ice maker was last cleaned and confirmed the kitchen concerns identified during the survey.
Unsanitary Dumpster Area
Penalty
Summary
Disposal of garbage and refuse was not maintained in a sanitary manner because the outdoor dumpster area had trash scattered on the ground, including paper, plastic, and food container waste products, during multiple observations. The facility policy required outside refuse containers and dumpsters to be kept covered when not being loaded and the surrounding area to be kept clean to minimize debris and insect or rodent attractions. Surveyors observed trash on the ground outside the dumpster on 12/16/2025, 12/17/2025, and 12/18/2025, and also observed wooden pallets leaning against the wooden fence surrounding the dumpster. The Administrator confirmed the trash on the ground and the pallets leaning against the fence, and stated that trash is picked up three times a week, trash gets spilled, and the Maintenance Director leans the pallets against the dumpster fence and discards them himself.
Unauthorized Medications Stored at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure unauthorized medications were not stored at the bedside for four residents. The facility policy titled Resident Self-Administration of Medication stated that a resident may only self-administer medications after the interdisciplinary team determines which medications may be safely self-administered, that the assessment results are recorded on a self-administration form in the medical record, and that bedside storage is only permitted if it does not present a risk to other residents and is stored to prevent access by other residents. The Director of Nursing stated that residents should be assessed to self-administer medications and that medication should not be stored at the bedside. For one resident, the quarterly MDS showed a BIMS score of 14 with little to no cognitive impairment and diagnoses including diabetes mellitus, depression, knee pain, digestive surgery, atrial fibrillation, and hypertension. The record did not contain an IDT self-administration assessment or physician order to self-administer medications. Observations in the resident’s room showed Flonase on the bedside table, and later Flonase and zinc oxide cream remained on the bedside table within view of other residents and visitors. An LPN confirmed the medications were present and stated the resident had not been assessed to self-administer medications and should not store medication at the bedside. For another resident, an OTC nasal spray was observed on the bedside stand and the resident stated it was being used without staff supervision. The resident’s EHR showed diagnoses including paroxysmal atrial fibrillation and respiratory infections, and the MDS showed a BIMS score of 14. There was no documented order for the nasal spray, no order for self-administration of medications, and no self-administration assessment or care plan. For two additional residents, zinc oxide cream, cough drops, and a jar of vapor rub were observed on bedside tables or in open view in the room. Their records also showed no active order for the observed OTC medications and no self-administration assessment or care plan. The DON and nurse supervisor confirmed the medications were in the rooms and removed them, and the DON stated the residents had not been assessed to self-administer medications.
Incomplete Care Plans for Nail Care and Pain Management
Penalty
Summary
The facility failed to develop and/or implement a comprehensive person-centered care plan related to nail care and pain management for three residents. The facility policy titled Comprehensive Care Plans required measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs, but the care plans reviewed did not reflect the needed care or were not followed as documented in the record and observed by surveyors. R35 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, gastrostomy status, hypertension, anxiety disorder, peripheral vascular disease, Alzheimer’s disease, and major depressive disorder. The annual MDS showed severe cognitive impairment and dependence on staff for personal hygiene. Although the care plan directed staff to provide shower and nail care per schedule and when needed, surveyors observed on multiple occasions that R35’s fingernails were long and had a black substance underneath, and R35 stated he wanted his nails trimmed and cleaned. The DON and MDS Coordinator confirmed the care plan was not being implemented. R42 also had severe cognitive impairment and diagnoses including right great toe amputation, neuromuscular bladder dysfunction, protein-calorie malnutrition, depression, urethritis, stage four sacral pressure ulcer, and type 2 diabetes mellitus. The care plan addressed ADL self-care deficits, but surveyors observed long, dirty fingernails on two occasions, and R42 stated she did not want her nails that long and wanted them cut. For R24, who was admitted with multiple left rib fractures and had a physician order for tramadol 50 mg every eight hours as needed for pain, the comprehensive care plan contained no problem or interventions for pain management or controlled medication use.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to provide ADL care services for two residents related to nail care. The facility policy titled Activities of Daily Living stated that care and services would be provided for bathing, dressing, grooming, and oral care, and that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene. For one resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, Alzheimer's disease, peripheral vascular disease, anxiety disorder, and major depressive disorder, the annual MDS showed severe cognitive impairment and dependence on staff for personal hygiene. The care plan directed staff to provide shower and nail care per schedule and when needed, yet observations on multiple dates showed long fingernails with a black substance under the tips, and the resident verbally stated a desire for the nails to be trimmed and cleaned. For the second resident, the quarterly MDS showed severe cognitive impairment and diagnoses including right great toe amputation, neuromuscular dysfunction of the bladder, protein-calorie malnutrition, depression, stage four sacral pressure ulcer, and type two diabetes mellitus. The care plan identified an ADL self-care performance deficit at risk of not having needs met in a timely manner. Observations showed long and dirty fingernails on multiple dates, and the resident stated a desire for the nails to be cut. Staff interviews showed the CNA, WCN, Unit Manager, and DON all confirmed the fingernails were long and dirty, and the DON stated CNA staff were responsible for maintaining fingernails during bath time; however, the nails remained unaddressed during the observations.
Controlled Substance Count Not Reconciled
Penalty
Summary
The facility failed to reconcile controlled narcotic medications for one resident, R24, out of 40 sampled residents. The facility policy titled, Controlled Substance Administration and Accountability, required controlled substances obtained from a non-automated medication cart or cabinet to be recorded on the designated usage form, with the dose on the usage form or automated dispensing system matching the dose recorded on the MAR, Controlled Drug Record, or other facility form placed in the medical record. R24’s most recent MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and diagnoses including hypertension, renal insufficiency, multiple rib fractures, and a motor vehicle accident. The care plan dated 11/20/2025 did not document a problem or interventions for pain management or controlled medication use. R24 had an order for tramadol HCL 50 mg by mouth every 8 hours as needed for pain. During observation and interview, the narcotic count on the reconciliation form did not match the number of tablets remaining in the medication card. The LPN stated that the night shift nurse reported giving PRN tramadol at 12:30 a.m., but the controlled substance form showed the last documented dose as 12/15/2025. There was no documentation of that dose in the narcotic control book, MAR, or progress note. The Unit Manager confirmed the count was wrong and that the night shift LPN had not recorded the dose on the narcotic log or MAR, though it was written on the shift-to-shift communication report. The DON confirmed the discrepancy and stated nurses must document the time a narcotic is given and notify leadership when a count is wrong. The Administrator confirmed a controlled substance discrepancy, and the Pharmacist Consultant stated he had not been notified of the narcotic discrepancy.
Medication pass errors resulted in an 8.33% error rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. During observation of a medication pass, 36 medication opportunities were reviewed and three medication errors were identified for one resident, resulting in an 8.33% medication error rate. The resident had physician orders for buspirone HCL 20 mg by mouth three times daily for anxiety disorder, sertraline HCL 200 mg daily for major depressive disorder, and sucralfate 1 gram twice daily for gastro-esophageal reflux disease without esophagitis. The medication card for sucralfate included special directions to give it on an empty stomach. During the medication pass, an LPN administered sucralfate while the resident was eating breakfast rather than on an empty stomach. The same observation showed the resident received one 10 mg buspirone tablet even though the order required 20 mg, and received one 100 mg sertraline tablet even though the order required 200 mg. The LPN confirmed the medications were not administered according to the MAR and medication card directions, and the Medical Director, Pharmacist Consultant, and DON all confirmed the ordered doses and timing should have been followed.
Infection Control Failures During Airborne Precautions and Resident Care
Penalty
Summary
The facility failed to follow infection prevention and control practices for two residents in the same room and for one room on an airborne precautions hallway. During an observation, a housekeeper entered the room wearing a gown, gloves, and a surgical mask even though the door sign indicated Airborne Precautions and the resident required an N95 or higher-level respirator. A nurse later entered the same room wearing a gown, gloves, and a surgical mask, left the room door open to the hallway while preparing medications on the med cart outside the room, and exited through the adjoining room, despite the sign instructing staff to keep the door closed. A CNA also entered the room wearing a gown, gloves, and a surgical mask and confirmed that an N95 mask should have been worn for airborne precautions. The UM stated the resident in the room was on airborne precautions related to chicken pox, and the DON confirmed staff should wear a gown, N95 mask, gloves, and possibly a face shield, and that the door should remain closed. The facility also failed to maintain hand hygiene and gown/glove use during wound and g-tube care for two residents sharing the same room. The WCN/Infection Preventionist changed gloves during wound care for one resident without using hand sanitizer between glove changes, then moved to provide dressing care to the second resident in the room without cleaning her hands after removing gloves and without changing the gown. She changed gloves again and did not disinfect her hands before applying new gauze around the g-tube site. During interview, she confirmed she did not disinfect her hands between glove changes or between residents, that the hand sanitizer was across the room on the dresser rather than at the bedside, and that the gown should have been changed.
Residents Served Meals Containing Documented Allergens
Penalty
Summary
Two residents with documented allergies to fish and shellfish were served meals containing these allergens. One resident, with a history of gastro-esophageal reflux disease and vitamin deficiency, had shellfish listed as an allergy in both the admission record and active orders. Despite this, the resident was served a crab cake, took a bite, and then realized it contained shellfish, prompting her to spit it out and rinse her mouth. The incident was reported by a CNA, and it was confirmed by the Certified Dietary Manager that the resident had received the wrong tray. The resident did not experience an allergic reaction, but the event was documented in the facility's incident report. Another resident, diagnosed with adult failure to thrive and with a documented fish allergy, reported receiving fish every time it was on the menu and consistently sent it back. A CNA confirmed that the resident had been served a meal with fish and that she returned the tray to dietary for a replacement. Staff interviews revealed that both dietary and nursing staff were responsible for checking meal trays for allergens, but these checks failed to prevent the residents from being served foods to which they were allergic.
Failure to Follow Enhanced Barrier Precautions During Wound and Perineal Care
Penalty
Summary
Staff failed to follow infection control protocols during wound care and perineal care for a resident with an unstageable pressure ulcer. Specifically, a Certified Nursing Aide (CNA) provided perineal care and removed a soiled brief without wearing a protective barrier gown, and a Licensed Practical Nurse (LPN) performed wound care on the resident's right heel without donning a gown. Additionally, the LPN placed wound care supplies directly on a bedside table without sanitizing the surface or using a barrier, contrary to facility policy. Interviews revealed that gowns had not been available to staff for the past month, and staff were aware that gowns should be worn during high-contact care activities, especially for residents on enhanced barrier precautions. The Infection Preventionist confirmed that gowns should be used in these situations but was unsure why staff were not wearing them. An observation later confirmed that gowns were present in the supply room, indicating a breakdown in the process of making gowns available to staff at the point of care.
Failure to Obtain Ordered Labs Results in Harm
Penalty
Summary
The facility failed to ensure laboratory orders were obtained as ordered by the physician for a resident, resulting in actual harm. The resident, identified as R21, was admitted to the facility with multiple diagnoses, including idiopathic gout, cerebral infarction, aphasia, hemiplegia, diabetes mellitus, chronic systolic congestive heart failure, hypertensive heart disease, hypercholesterolemia, angina pectoris, major depressive disorder, and epilepsy. A physician order dated March 7, 2023, required the collection of a complete blood count (CBC) with differential every three months in March, June, September, and December. However, the facility did not obtain the ordered labs for March 2023 and June 2023. On September 19, 2023, the facility received lab results indicating that R21 had a critically low hemoglobin level of 5.9 g/dl, significantly below the normal range of 13.5 - 17.5 g/dl. This critical lab result prompted the facility to contact the medical director, who decided to send the resident to the emergency room. The resident was subsequently admitted to the hospital, diagnosed with iron deficiency anemia, and received two units of blood. An interview with the unit manager revealed that the CBC results for March and June 2023 were not completed and could not be located in the electronic laboratory system or the resident's medical record.
Failure to Provide Full RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for a full eight hours within a 24-hour period on multiple dates during the first quarter of 2024. The Payroll-Based Journal (PBJ) Staffing Data Report indicated that there were no RN hours recorded for specific dates, despite the facility's attempts to schedule RN coverage. The Business Office Manager confirmed that the time clock system automatically deducted 30 minutes for lunch, which resulted in the RN not being recorded as working a full eight hours. This issue was acknowledged by the Administrator, who was aware that the discrepancy could trigger a report. The Licensed Practical Nurse (LPN) Unit Manager, responsible for staffing RN coverage, reported that the new time clock system automatically clocks out staff for breaks, regardless of whether they were taken. This led to the RNs not meeting the required eight hours of coverage. The facility's census at the time was 40 residents, and the failure to provide adequate RN coverage was a recurring issue on several dates, as confirmed by the PBJ report and staff interviews.
Failure to Follow Puree Diet Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that the recipe for pureed carrots and chicken was followed, which compromised the nutritional value of the food provided to residents on a pureed diet. During an observation, it was noted that a staff member added tap water to the carrots and chicken during the pureeing process to achieve the desired consistency, which was not indicated in the recipe. The facility also did not ensure that residents on a pureed diet received the recommended three ounces of protein during meal service. The scoop used to measure the pureed foods was a number 16 scoop, which only provided 2 3/4 ounces, falling short of the required three ounces. Interviews with staff revealed a lack of knowledge regarding the correct portion sizes and the appropriate scoop to use for measuring food. A staff member was unable to verbalize the amount of protein needed for residents on a pureed diet and was unaware of the measurement of the scoop used. The Dietary Manager confirmed that the incorrect scoop was used and acknowledged that the guide indicating the scoop sizes by color was no longer posted in the kitchen. The Dietary Manager also mentioned that staff sometimes add water or milk during the pureeing process to achieve the right consistency, which was not part of the recipe instructions.
Deficiencies in Food Labeling and Ice Machine Maintenance
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of food items, as well as the timely disposal of expired foods. Observations revealed multiple instances of unlabeled and undated food items in the kitchen's reach-in coolers and on a steel table. These included a pan of tuna salad, a bag of cooked macaroni noodles, bottles of Zesty Italian dressing and strawberry syrup, a bag of brown sugar, and various salads and cheese products. Additionally, some items were found to be past their expiration dates, such as a bag of fried onions and a pan of macaroni salad. These deficiencies were confirmed by the Dietary Manager, who acknowledged the expectation that all foods should be labeled and dated, and leftovers discarded after three days. The facility also failed to maintain the cleanliness of the ice machine located in the staff break area. Observations noted white chalky streaks and a thick layer of chalky substance on the machine's exterior, as well as a thin layer of black substance on the inside panel. Interviews with the Administrator and Maintenance Director revealed that the ice machine should be cleaned daily by dietary staff and quarterly by maintenance, but the last quarterly cleaning was missed. The Dietary Manager, who was on vacation, confirmed that the machine was not cleaned as expected, and the Maintenance Director admitted that the last cleaning was incomplete.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of two residents with indwelling urinary catheters, as observed by surveyors. Resident R11, who has a history of cerebral infarction, hemiplegia, hemiparesis, urinary retention, and is at risk for pressure ulcers, was found with an uncovered urinary catheter bag visible from the door on multiple occasions. Despite having a care plan in place to manage the urinary catheter and prevent infections, the catheter bag was not covered, which was confirmed as a dignity issue by a registered nurse. Similarly, Resident R20, diagnosed with chronic kidney disease and diabetes, was observed with an uncovered urinary catheter bag visible from the door. The resident's care plan included catheter care, yet the catheter bag remained uncovered during several observations. A registered nurse confirmed the lack of a dignity bag as a dignity issue. Both residents' catheter bags were not covered, contrary to the facility's policy on promoting and maintaining resident dignity.
Failure to Obtain Concurring Physician Signature on DNR Order
Penalty
Summary
The facility failed to obtain a concurring physician's signature on a Do Not Resuscitate (DNR) order for a resident, identified as R29, who was reviewed for DNR status. R29's medical record indicated diagnoses including Alzheimer's Disease, paranoid schizophrenia, and hyperlipidemia. The resident was originally admitted to the facility on May 4, 2022, and re-admitted on November 22, 2023. The medical record showed no Power of Attorney (POA) or Legal Guardian listed for R29. The Quarterly Minimum Data Set (MDS) assessments revealed severe cognitive impairment with Brief Interview Mental Status Scores (BIMS) of four and two, respectively. The DNR order for R29 was signed by an Authorized Person, purportedly a guardian, on May 4, 2022, and by one physician on May 7, 2022. However, there was no documentation confirming the existence of a guardian, POA, or healthcare agent for R29. An interview with a family member confirmed that no family member had legal guardianship or had been appointed as POA, although R29's preference was to remain a DNR. Interviews with the Unit Manager RN and LPN confirmed the absence of a healthcare agent and that R29's code status was changed to Full Code. The surveyor was unable to contact another family member to verify POA or guardianship status.
Facility Fails to Maintain Home-like Environment
Penalty
Summary
The facility failed to maintain a consistent home-like environment, as evidenced by several deficiencies observed in the living conditions of residents. Observations revealed missing floor tiles, peeling paint on walls, rust on resident equipment such as raised toilet seats, and persistent odors in resident areas. Specifically, rooms on the 300 hall were noted to have various issues, including dark brown substances on the frames of raised toilet seats, missing shower fixtures, stained tiles, and strong urine odors that permeated the resident rooms. Additionally, peeling paint and dark substances were observed on walls and ceilings in certain rooms. During an environmental tour, staff, including the RN Supervisor, Maintenance Director, and Housekeeper Supervisor, acknowledged the presence of these issues. The RN Supervisor noted that the urine odor was offensive to both residents and visitors, and the Maintenance Supervisor confirmed that the odor was embedded in the bathroom tiles, which required replacement. The Maintenance Director was unaware of the needed repairs and stated that maintenance repair forms were available at nurse stations. The staff also confirmed the presence of rust on the raised toilet seat frames and shower chairs, with the Maintenance Director indicating an attempt would be made to remove the rust.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide ongoing monitoring and care for a dialysis access site and did not ensure communication and collaboration with the dialysis center for a resident receiving dialysis services. The facility's policy on hemodialysis care, dated February 12, 2022, outlined the need for ongoing assessment and communication with the dialysis center, but these were not adhered to. The resident, who had diagnoses including type two diabetes mellitus with kidney complications, end-stage renal disease, and anemia in chronic kidney disease, had no physician orders for monitoring and care of the dialysis access site. The resident's medical records from September 5, 2023, to August 9, 2024, lacked consistent documentation of monitoring the dialysis access site and communication with the dialysis center. Interviews with nursing staff revealed that there were no specific orders for monitoring the dialysis access site, and it was the nurses' responsibility to ensure the site remained dry and intact. Observations confirmed the presence of a dialysis port with a dry dressing, but no written orders for its care. Additionally, the Dialysis Communication Sheets, which were supposed to be completed and exchanged between the facility and the dialysis center, were often missing or incomplete. Staff acknowledged the importance of these communication sheets but admitted to lapses in their completion and documentation, leading to a lack of proper communication and collaboration with the dialysis center.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment within 14 days of discharge for a resident identified as R37. According to the facility's policy on Assessment Frequency/Timelines, an OBRA discharge assessment should be completed within 14 days of discharge. However, interviews with the Unit Manager and the MDS Coordinator revealed that no discharge assessment was completed for R37, and there was no documentation of the resident's stay in the facility's medical record system. R37 was admitted to the facility with diagnoses including lipoprotein deficiency, essential hypertension, low back pain, dementia, major depressive disorder, and altered mental status. The resident was admitted in February 2024 and discharged in March 2024 after being taken out of the facility against medical advice by the family. Despite the facility's policy requiring timely documentation of discharge needs and plans, there was no record of a discharge assessment or any documentation related to R37 in the facility's system.
Failure to Follow Hemodialysis Care Plan
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R31, who required hemodialysis due to end-stage renal disease. The care plan, dated June 12, 2024, specified interventions such as assessing the arteriovenous (AV) shunt for bruit and thrill every shift, maintaining communication with the dialysis center, and monitoring for signs of infection or renal insufficiency. However, a review of the administration record from August 1 to August 31, 2024, revealed no orders or documentation for ongoing monitoring and treatment of R31's dialysis access site. Additionally, progress notes from September 5, 2023, to August 9, 2024, lacked consistent documentation and proof of ongoing monitoring and communication with the dialysis center. Interviews with facility staff, including an LPN responsible for developing care plans and an RN who reviewed dialysis communication sheets, confirmed the absence of complete documentation and monitoring for R31's dialysis needs. The RN noted missing and incomplete dialysis communication sheets from September 11, 2023, to August 2, 2024. The LPN Unit Manager expressed that her expectation was for nurses to follow the care plans for residents, indicating a lapse in adherence to established protocols for R31's hemodialysis care.
Unsecured Oxygen Cylinder Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment by not securing an oxygen cylinder in a holder for a resident receiving oxygen therapy. During an observation, an unsecured oxygen cylinder was found on the floor of a resident's room, posing a potential accident hazard. The resident, who was diagnosed with acute hypoxemic respiratory failure, was receiving oxygen via a nasal cannula at the time. The facility's policy requires oxygen to be stored according to safety guidelines, which was not adhered to in this instance. Interviews with staff revealed a lack of awareness regarding the potential danger of an unsecured oxygen cylinder. A housekeeper, LPN, CNA, and RN all interacted with the resident's room but did not ensure the cylinder was secured. The LPN acknowledged the hazard and removed the cylinder upon discovery. The RN stated that her expectation was for CNAs to remove any unused oxygen cylinders from resident rooms and to ensure those in use were placed in holders, indicating a lapse in following these expectations.
Failure to Maintain Proper Catheter Care and Physician Orders
Penalty
Summary
The facility failed to have a physician's order for a resident with an indwelling catheter, identified as R20, who was one of eight residents with such catheters. R20 had a history of urinary tract infections and sepsis, and the medical record did not show an active order for the catheter. The catheter order was mistakenly discontinued shortly after being put in place. Observations revealed that R20's catheter tubing was improperly positioned, often coiled, touching the floor, or obstructed by being placed on the armrest of a chair, which could impede urinary flow. Multiple staff members, including registered nurses and licensed practical nurses, confirmed the absence of an active catheter order and acknowledged the improper positioning of the catheter tubing. Despite being informed and in-serviced about the correct positioning of catheter tubing, a certified nursing assistant was unaware that hanging the tubing on the armrest could obstruct urine flow. The facility staff, including the MDS Coordinator and unit manager, were observed repositioning the catheter tubing multiple times, indicating a repeated failure to maintain proper catheter care for R20.
Oxygen Therapy Administration and Signage Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with the physician's order for a resident, identified as R20, who was receiving oxygen therapy. The physician's order specified that oxygen should be administered via nasal cannula or simple mask at a rate of 2-4 liters per minute as needed for oxygen saturation below 90% or shortness of breath. However, observations revealed that R20 was receiving oxygen at a rate of 1.5 liters per minute, which was below the prescribed rate. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who was unaware of the correct oxygen setting until it was pointed out by the surveyor. Additionally, the facility did not place oxygen warning signage on the resident's door, as required by the facility's policy. This was observed on multiple occasions, and the absence of signage was confirmed by a Registered Nurse (RN) who was also unaware of this oversight until informed by the surveyor. The lack of signage posed a potential risk, as it is intended to prevent visitors from smoking in the room while oxygen is in use.
Failure to Use Alternative Interventions Before Administering Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Haloperidol without attempting other interventions to manage the resident's behaviors. The resident, who had multiple diagnoses including mood disorder and anxiety disorder, was administered Haloperidol on several occasions for agitation and combative behavior. However, there was no documentation of alternative interventions being attempted prior to the administration of the medication. On one occasion, the resident was agitated and threw objects, leading to the administration of Haloperidol without any prior intervention attempts. Interviews with staff revealed that the resident was held down by staff members during the administration of Haloperidol, despite not acting out at the time. The resident expressed feeling overmedicated and reported being restrained by staff. Additionally, a Nurse Practitioner recommended an alternative medication, Ativan, for agitation, but there was no evidence that this recommendation was followed or that the order was initiated. The lack of documented interventions and the use of physical restraint during medication administration contributed to the deficiency identified in the report.
Failure to Report Alleged Restraint of Resident
Penalty
Summary
The facility failed to ensure that staff reported an allegation of restraining a resident during the administration of medication. The incident involved a resident with multiple diagnoses, including chronic obstructive pulmonary disease, hypertension, and anxiety disorder, who was reportedly agitated and received Haldol. According to a Certified Nurse Aide, the Director of Nursing (DON) and two Licensed Practical Nurses (LPNs) were involved in holding the resident down while the medication was administered, despite the resident not acting out at the time. This incident was not reported immediately to the Administrator or designee as required by the facility's policy. Further interviews revealed that another LPN observed the DON restraining the resident during a separate incident, where the resident was calm and wanted to discuss the confiscation of his vape pen. The LPN did not report the incident to the State Agency due to unfamiliarity with the reporting process. The Administrator was not initially aware of the restraint incident and later received a denial from the DON regarding the use of restraint. The failure to report these incidents promptly and appropriately constitutes a deficiency in the facility's adherence to its abuse and neglect policy.
Non-compliance with PRN Antipsychotic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN antipsychotic medications, specifically Haldol, for a resident. The resident was sent to the emergency room and returned with a PRN order for Haldol, which was entered into the electronic medical record as indefinite. This order was supposed to have an end date of 14 days later, but a new order was entered by an LPN extending the PRN Haldol without a face-to-face re-evaluation by a physician, as required. The resident received a dose of PRN Haldol beyond the 14-day period without the necessary physician evaluation and documentation. Additionally, a behavioral consultant recommended Ativan and Haldol for the resident's agitation, and while the physician and family were informed, there was no documentation from the physician indicating a continued need for the PRN medication. An interview with the physician confirmed that no progress note was made for the renewal of the PRN Haldol, highlighting a lapse in the documentation and evaluation process required for the continuation of PRN antipsychotic medications.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide restorative services for a resident who was discharged from skilled physical therapy with a recommendation for a Restorative Program. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus, was recommended to receive restorative services for ambulation, range of motion, transfer to a wheelchair, and bed mobility. However, there was no evidence in the medical records that these restorative recommendations were implemented prior to a specified date. Interviews with staff revealed communication breakdowns that contributed to the deficiency. The Physical Therapy Assistant (PTA) indicated that the resident was discharged from skilled therapy about two weeks prior, but the necessary form for restorative services was not provided. The Licensed Practical Nurse (LPN) stated that she did not receive communication from the therapy department regarding the resident's need for restorative services until a later date. The Director of Nursing (DON) acknowledged a lack of communication from the therapy department to the restorative nurse, which resulted in the resident not receiving the recommended services.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 43 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Thomasville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Thomasville | 2.7 mi | ★★★★★ | 1 | 0 |
| Camellia Gardens Of Life Care | 3.2 mi | ★★★★★ | 0 | 0 |
| Archbold Living Thomasville | 3.7 mi | ★★★★★ | 7 | 0 |
| Archbold Living Cairo | 15.7 mi | ★★★★★ | 2 | 0 |
| Brynwood Health And Rehabilitation Center | 20.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.