Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Thomson Health And Rehabilitation during CMS and state inspections, most recent first.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors found unlabeled and undated food items in resident refrigerators, including partially used chicken salad and a chicken dinner without a name or date. They also observed extensive sanitation problems in the main kitchen, including peeling and cracked surfaces, dried stains on walls and ceilings, dust, grease, debris, and a Dietary Aide washing dishes and handling clean racks while wearing the same gloves. The DM verified the findings, and the RD said she had been reporting the poor kitchen condition monthly for the past 12 months.
A sit-to-stand lift used for residents on two units was observed with missing leather on the knee rest cushion, exposed foam, and debris on the footplate. An LPN and a CNA confirmed the lift was not in good condition, and the CNA stated no work order had been completed for the damaged knee rest. The Maintenance Director said he had not been aware of the condition and had not received a work order, while the HS and a FT gave conflicting statements about who was responsible for cleaning the lifts.
Failure to Complete Timely Admission MDS Assessment: A resident’s comprehensive admission MDS was not entered, completed, or transmitted on time. The resident had only an Entry assessment accepted into the CMS system, while an admission MDS was opened and then struck out as incorrect documentation. The MDSC acknowledged the assessment was not completed, the DON said she expected to be notified if assessments were behind, and the Administrator was unaware the MDSC was behind on MDSs.
Quarterly MDS assessments were not completed for two residents. EMR review showed the MDSC entered and then removed quarterly assessments, leaving them overdue, and the MDSC stated she did not know all the MDS rules and was unable to complete all of the assessments. The DON said the MDSC was expected to report if she was getting behind, and the Administrator was unaware the MDSs were overdue.
A facility failed to ensure accurate MDS coding for two residents. One resident’s quarterly MDS incorrectly showed weight loss even though weight records and the resident’s statement reflected overall weight gain, and the DM could not explain the error. Another resident’s quarterly MDS incorrectly coded an incident as a fall with major injury, although the incident report showed a CNA tripped over trash bags and another resident fell into the resident’s chair, causing a left tibia fibula fracture.
The facility failed to maintain the ice machine in a sanitary condition, as a black substance was observed on its plastic lining. The ice machine had not been cleaned since the previous month, contrary to the facility's sanitation policy. The Dietary Manager confirmed the lapse in monitoring, which posed a potential health risk to 103 residents consuming an oral diet.
The facility failed to provide written hospital transfer notices for three residents who were hospitalized for various medical reasons, including a swollen scrotum, unstable vitals, and unresponsiveness. The facility's policy did not specify that residents or their representatives would receive a copy of the transfer information, and there was no evidence in the EMR that such notices were provided. The administrator confirmed the lack of documentation.
The facility failed to provide written bed hold notices to three residents during hospital transfers, as required by their policy. This deficiency was identified through staff interviews and record reviews, revealing that the residents or their representatives did not receive the necessary notices, potentially causing confusion about bed hold charges and availability upon their return.
Two residents in an LTC facility were served meals on styrofoam with plastic utensils, and assisted with eating while staff stood, contrary to the facility's policy on dignity. One resident, with an eating disorder, was observed spitting food, while another, with dementia, was assisted while seated in a geri chair. Staff acknowledged the oversight, citing a chaotic environment.
A facility failed to honor a resident's right to vote, as guaranteed by Federal and State laws. Despite having intact cognition, the resident was not assisted in voting, either in person or via absentee ballot. Interviews revealed a lack of coordination and communication among staff regarding the voting process, leading to the resident's disappointment at not being able to participate in the voting process.
The facility failed to create comprehensive care plans for two residents, leading to unmet needs. One resident with an eating disorder exhibited behaviors like spitting food and self-induced vomiting, which were not addressed in the care plan. Another resident with dementia and on hospice care showed significant changes in mobility and behavior, but the care plan did not reflect these changes. Staff shortages contributed to these deficiencies.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food items in the kitchen and resident pantries were properly dated and stored, and it also failed to maintain sanitary conditions in the kitchen and properly clean and sanitize dishes. During observations, surveyors found a partially used 2.07-pound container of chicken salad in the residents' refrigerator in the 400-medication room without a date of opening, and a chicken dinner containing a chicken breast, greens, pasta, and pudding in the residents' refrigerator in the 100-medication room without a name or date. The Dietary Manager verified both findings and stated the chicken salad would be removed and discarded. Surveyors also observed multiple sanitation concerns in the main kitchen, including a peeling, cracked, and flaking cardboard-like cover around the kitchen hood system near the oven, a peeling cork bulletin board above the foil wrapping paper area, dried brown and red liquid stains on the wall between the sinks, holes in the wall above the sinks, dried stains below the coffee machine/preparation area, a brown substance and hanging dust on the ceiling, a large split and peeling area in the ceiling near the stove, thick black marks on the door to the dry food storage area, and a debris- and grease-filled electrical outlet near the toaster. In addition, a Dietary Aide was observed washing dishes and placing pans and drink trays through the dishwasher while wearing the same gloves and then removing the clean racks and stacking them in the final cleaning area. The Administrator stated they were unaware of the condition in the main kitchen, while the Registered Dietitian stated she had been reporting the poor condition of the kitchen monthly over the past 12 months.
Sit-to-Stand Lift Not Clean and Not in Good Repair
Penalty
Summary
The facility failed to ensure one of two sit-to-stand lifts was clean and in good repair. During observation on 02/11/2026, an LPN and a CNA confirmed that the lift on the 500 unit had several exposed foam areas where the leather was missing from the knee rest cushion and that the footplate had debris on it. The CNA stated the lift was used for residents on the 500 and 600 units and acknowledged that the knee rest was damaged and the footplate was dirty. The facility policy titled Work Orders, Maintenance stated that maintenance work orders shall be completed to establish priority of maintenance service and must be filled out and forwarded to the Maintenance Director. The CNA stated floor techs cleaned the lift and maintenance was responsible for replacing the knee rest, but she had not completed a work order for the replacement even though she was aware of the damage. The Maintenance Director stated he was not aware the knee rest cushion was not in good repair or that the footplate was not clean, and he had not received a work order for the knee pad replacement. The Housekeeping Supervisor stated she was not aware floor techs were responsible for cleaning the sit-to-stand lifts, while a floor tech stated he did not clean the lifts and was not trained to do so. The Administrator stated floor techs were responsible for cleaning the lifts and maintenance staff were responsible for repairs, and that lifts should be cleaned twice a month and maintenance should replace parts identified during quarterly inspections.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a comprehensive admission MDS assessment for one resident, R99, in a timely manner. Review of the facility policy titled Comprehensive Assessments stated that a comprehensive assessment for a new resident must be completed by the end of day 14, and the RAI Manual stated the admission MDS completion date must be no later than 13 days after the entry date. R99 was admitted to the facility and had an Entry assessment completed, transmitted, and accepted into the CMS system, but no other assessments were completed. Record review showed that an admission MDS had been opened for R99 but was later struck out, with the status listed as SO (struck out) - incorrect documentation. The MDS tracking record showed the full admission assessment was 154 days overdue. During interview, the MDS Coordinator acknowledged that R99 did not have an admission MDS entered, completed, or transmitted and stated, "I removed it, but I do not know why. Maybe I was going to put it back in, but I forgot. I do not know what happened." The DON stated she expected the MDS Coordinator to notify her if assessments were getting behind or could not be completed on time, and the Administrator stated she was not aware that the MDS Coordinator was behind on the MDSs.
Quarterly MDS Assessments Not Completed
Penalty
Summary
The facility failed to complete quarterly MDS assessments at least once every three months for two residents, R30 and R77, out of six residents reviewed for assessment accuracy. The facility policy titled Resident Assessments stated that OBRA-required MDS assessments, including quarterly assessments, must be completed at least every 92 days following the previous OBRA assessment. Review of the EMR showed that R30 had an annual MDS completed with a quarterly assessment due later, but no quarterly assessment was present in the system. The incomplete assessment showed the MDSC had entered the quarterly assessment, then removed it and struck it out as incorrect documentation. The tracking sheet showed the quarterly assessment was 61 days overdue, and the MDSC stated she removed it, did not know why, and was not able to do them all. R77 had an admission MDS completed with quarterly assessments due later, but no quarterly assessments were in the EMR. The incomplete assessment showed the MDSC had entered the quarterly assessment multiple times and then removed and struck them out as incorrect documentation. The tracking sheet showed the quarterly assessment was 188 days overdue. The MDSC stated that R77 had multiple discharges with anticipated returns and reentry, which prevented her from completing the quarterly assessments, and also stated she did not know all the rules on the MDS and how to do it. The DON stated the MDSC was expected to notify her if she was getting behind or unable to complete assessments on time, and the Administrator stated she was not aware the MDSC was behind on the MDSs.
Inaccurate MDS Assessments for Weight Status and Fall Coding
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents. For one resident admitted with depression, CHF, and stroke, the quarterly MDS with an ARD of 12/05/25 recorded a BIMS score of 10 out of 15 and documented a weight of 130 pounds with weight loss in the prior month or over the prior six months. However, the resident’s weight records showed 124.0 pounds on 07/02/25, 132.0 pounds on 08/07/25, 129.0 pounds on 09/02/25, 134.0 pounds on 10/07/25, 133.0 pounds on 11/04/25, and 130.0 pounds on 12/02/25, reflecting a weight gain over six months rather than the coded weight loss. The resident stated she had not lost weight and had gained weight. The MDSC stated the Dietary Manager was responsible for entering the weight and nutritional status section, and the DM stated she did not know why the MDS had been coded with weight loss because the record showed an overall weight gain. For another resident admitted with contractures, cerebral infarction, and hemiplegia/hemiparesis, the quarterly MDS with an ARD of 01/15/26 indicated the resident had sustained a fall with major injury since admission/reentry. The facility’s incident report for 01/10/26 documented that CNA 6 reported tripping over two clear plastic trash bags while pushing another resident to a room, causing that resident to fall into the resident’s geriatric chair and injure the chair and left leg. During interview, the MDSC confirmed she incorrectly coded the incident that caused the resident’s left tibia fibula fracture as a fall with major injury on the quarterly assessment and stated she had attended the morning clinical meeting when the incident was discussed. The Administrator stated she expected MDS assessments to be completed accurately and in a timely manner.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the ice machine in a clean and sanitary manner, as observed during a kitchen inspection. A black substance was found on the plastic lining inside the ice machine, indicating it had not been cleaned properly. The facility's policy on sanitation, revised in November 2022, requires that ice machines be drained, cleaned, and sanitized regularly. However, the cleaning schedule showed that the ice machine was last cleaned on October 21, 2024, nearly a month before the observation. During an interview, the Dietary Manager confirmed that maintenance was responsible for cleaning the ice machine and acknowledged that it was not clean, indicating a lapse in monitoring. This deficiency had the potential to cause illness to 103 out of 105 residents who consumed an oral diet.
Failure to Provide Written Hospital Transfer Notices
Penalty
Summary
The facility failed to provide written hospital transfer notices for three residents who were hospitalized, as required by their policy. The policy titled 'Transfer Agreement' was reviewed and found to facilitate the exchange of medical and other information necessary for the care and treatment of residents transferred between institutions. However, it did not specify that the resident or their representative would receive a copy of the information or other written notice of transfer. The Notice of Transfer/Discharge form, dated March 2017, indicated the reason, time, date, and location of the hospital transfer, as well as the amount of the bed hold, but there was no evidence that this form was provided to the residents or their representatives. The deficiency was identified through staff interviews, record reviews, and examination of the facility's policy. Three residents, identified as R11, R12, and R43, were transferred to the hospital for various medical reasons, including a swollen scrotum, unstable vitals with congested lung sounds, and unresponsiveness with slumping to one side. In each case, there was no documentation in the Electronic Medical Record (EMR) that the residents or their representatives received written notice of the hospital transfer. The facility's administrator confirmed the absence of such documentation during an interview.
Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified for three residents (R11, R12, and R43) out of a sample of 33. The facility's policy, titled Bed-Holds and Returns, mandates that residents or their representatives receive a written notice of the bed-hold policy at the time of transfer, or within 24 hours if the transfer is an emergency. However, there was no evidence in the Electronic Medical Records (EMR) that such notices were provided to the residents or their representatives during their respective hospital transfers. Resident R11 was transferred to the hospital due to a swollen scrotum and returned to the facility without receiving a bed hold notice. Similarly, Resident R12 was transferred due to unstable vitals and congested lung sounds, and Resident R43 was transferred after not responding to staff and slumping to one side. Both returned to the facility without evidence of receiving the required written notices. The facility's administrator confirmed the absence of these notices during an interview, highlighting the facility's failure to adhere to its own policy and potentially causing confusion regarding bed hold charges and availability upon the residents' return.
Undignified Dining Experience for Residents
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, R24 and R100, by serving meals on styrofoam with plastic utensils and assisting with meal intake while standing. R24, who was admitted with an eating disorder and adult failure to thrive, was observed during multiple meal times to be served meals in a styrofoam container. She was seen spitting food onto the floor, her wheelchair, and into her lap. Staff interviews revealed that styrofoam was used because R24 sometimes spits in her food and has previously smeared feces on her tray. However, it was unclear if staff attempted to remove the meal before these incidents occurred. R100, diagnosed with unspecified dementia and behavioral disturbances, was observed being assisted with meals while seated in a reclining geri chair. On two occasions, staff members assisted R100 with eating while standing, despite an offer to provide a chair for the assisting staff. The HR staff member acknowledged the oversight, noting the chaotic environment and R100's attempts to get out of the chair. These actions were inconsistent with the facility's policy on treating residents with dignity and respect.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to honor a resident's right to vote, which is a fundamental right guaranteed by Federal and State laws. The deficiency was identified through staff and resident interviews, as well as a review of the facility's policy on Resident Rights. The policy, revised on January 6, 2023, emphasizes the residents' rights to exercise their citizenship rights, including voting. The resident in question, identified as R83, had a cognitive status indicating intact cognition, as evidenced by a perfect score on the Brief Interview for Mental Status (BIMs). Despite this, the facility did not facilitate her ability to vote, either in person or via absentee ballot. Interviews with the Social Service Director (SSD) and the Activity Director (AD) revealed a lack of coordination and communication regarding the voting process for residents. The SSD, who had been employed for only a week, was unaware of any arrangements made for residents to vote and did not know if any absentee ballots were provided. The previous SSD was responsible for organizing voting assistance, but it was unclear if any actions were taken. The resident, R83, expressed disappointment at not being able to participate in the voting process, as she preferred to vote in person and had no family to assist her. The AD confirmed that voting is discussed as a resident right during council meetings, but no specific actions were taken to assist residents in voting during this period.
Deficient Care Plans for Residents with Behavioral and Mobility Needs
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for two residents, R24 and R100, which led to unmet care needs. R24, who was admitted with an eating disorder and adult failure to thrive, exhibited socially inappropriate behaviors such as spitting food and self-induced vomiting during meals. Despite these observations, the care plan for R24 did not include interventions to address these specific behaviors, focusing instead on other inappropriate behaviors like smearing feces. Interviews with staff, including an LPN and the DON, confirmed the resident's behaviors, but no specific strategies were implemented to manage the spitting and vomiting. R100, diagnosed with unspecified dementia and behavioral disturbances, experienced a significant change in condition after hospitalization for pneumonia and subsequent placement on hospice care. The resident was no longer walking independently, was unsteady, and at increased risk for falls. Observations showed R100 attempting to stand from a geri chair and becoming agitated, yet the care plan did not reflect these changes in condition. It lacked interventions for assistance with eating, supervision to prevent accidents, and adjustments for the resident's new hospice status. The MDS Coordinator acknowledged the care plan's deficiencies, citing staffing shortages as a reason for the oversight.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warrenton Woods Of Journey Llc | 9.9 mi | ★★★★★ | 2 | 0 |
| Gibson Health Opco Llc | 16 mi | ★★★★★ | 4 | 0 |
| Reserve At Appling Of Journey Llc, The | 18.1 mi | ★★★★★ | 14 | 0 |
| Pruitthealth - Evans, Llc | 22.6 mi | ★★★★★ | 0 | 0 |
| Pavilion At Brandon Wilde | 22.8 mi | ★★★★★ | 9 | 0 |
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