Sylvia G Thompson Residence Center, Inc

In the surveyor’s words

From the most serious findings on record at Sylvia G Thompson Residence Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 29, 2024

  Based on interview and record review, facility staff failed to properly assess two residents', (Resident #1 and #2) capacity to consent to sexual activity and failed to ensure residents with severe cognitive impairment remained free from sexual abuse when staff found Resident #2 holding Resident #1's hand to perform a sexual act. The facility census was 117. The administrator was notified on 3/22/24 at 5:09 P.M., of an Immediate Jeopardy (IJ) which began on 3/19/24. The IJ was removed on 3/29/24 as confirmed by the surveyor's onsite verification. […]

• Actual harm, isolatedF689Aug 26, 2025

  Based on observation, interview and record review, facility staff failed to provide appropriate care and services per facility policy to maintain the highest practicable physical and psychosocial well-being for one resident (Resident #1) when staff failed to safely administer a warm pack for pain, which resulted in a burn injury to the resident's left arm and shoulder area. The facility census was 115.1. Review of the facility's Policy and Procedure for Using a Warm and Cool Pack, dated 08/2024, showed if a resident requests a warm or cool pack, one will be provided that will return to room temperature without intervention. This would consist of rice packs, gel packs, or warm/cool cloths that will return to room temperature on their own. […]

• Actual harm, isolatedF600Apr 13, 2023

  Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free from physical abuse, when another resident (Resident #1) pushed the resident down and caused him/her to fracture his/her hip. The facility census was 109. 1. Review of the facility's Abuse and Neglect Clinical Protocol Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised March 2018, showed: -Abuse, Neglect, Misappropriation of Patient Property and Exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor of any other individual in this center. […]

• No harm, potential for more than minimal, widespreadF725Oct 9, 2025

  Based on interview and record review, the facility staff failed to follow their Facility Assessment to ensure the facility staffed enough staff to meet the needs of the residents. Staff failed to provide a sufficient number of direct care staff members to ensure call lights were answered in timely manner. The facility census was 112. 1. Review of the facility assessment tool, dated 08/28/25, showed: -Average census of 117 residents;-Goal staffing is one to eight ratio for Certified Nursing Assistants (CNAs), the day-to-day average is one to ten for CNAs;-Days: Five Registered Nurses (RNs), two Licensed Practical Nurses (LPNs), and 17 CNAs;-Evenings: One RN, one LPN, and 14 CNAs;-Nights: Two LPNs and eight CNAs;-Weekend days: One RN, one LPN, and other direct care hours remain the same.2. […]

• No harm, potential for more than minimal, widespreadF812Oct 9, 2025

  Based on observation and interview facility staff failed to ensure two of three ice machines, used to supply ice to residents, drained through an air gap to prevent cross-contamination. Facility staff failed to ensure one ice machine was free of materials to prevent ice contamination. The facility census was 112.1. Observation on 10/08/25, during the Life Safety Code tour showed:-the ice machine located in the clean utility room contained two small white plastic tubes which drained from the rear of the ice machine into a larger white plastic floor drain and did not contain an air gap. […]