Thalia Gardens Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Thalia Gardens Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 9, 2022

  Based on observations, staff interviews, and clinical record review, the facility staff failed to provide services to prevent development of a pressure ulcer for a resident with a known moderate risk for pressure ulcer development and to identify the left heel pressure ulcer prior to progression to a stage three (3) which measured 4 centimeters by 4 centimeters by 0.1 centimeters, and presenting with 40 percent slough and 60 percent of dermis, for 1 of 5 residents (Resident #50), with facility acquired pressure ulcer, which constituted harm. The findings included: Resident #50 was originally admitted to the facility 4/15/2022 and had not been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF584Apr 28, 2026

  Based on observations, resident and staff interviews, clinical record review, and facility document review, it was determined that facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across 3 of the facility's 3 units, constituting substandard quality of care (SQC).The findings include:On 4/22/26 at 11:00 AM, a Resident Council meeting was held with the President and four other residents who regularly attend the group meeting. All attendees agreed that the facility was not a safe, clean, comfortable, and homelike environment. 1. Resident #22 was admitted to the facility on [DATE]. The residents' diagnoses included high blood pressure and asthma. […]

• No harm, potential for more than minimal, widespreadF756Apr 28, 2026

  Based on staff interview, clinical record review, and review of facility documents, the facility staff failed to provide a drug regimen review that was reviewed monthly by a licensed pharmacist for 6 of 63 residents (Resident #2, #10, #11, #23, #6, and #107), in the survey sample.The findings included:1. Resident #2 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included fracture of unspecified part of neck of right femur, alcoholic cirrhosis of liver without ascites, essential hypertension, and depression. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/14/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 09 out of a possible 15. […]

• No harm, potential for more than minimal, widespreadF837Apr 28, 2026

  Based on staff interview and facility documentation review, the facility failed to ensure the implementation of policies regarding the management and operations of the facility potentially affecting all residents in the facility.The findings included:For all residents in the facility, the governing body failed to ensure that the facility had an effective QAPI Quality Assurance Performance Improvement program. The facility had multiple areas in which deficient practices were identified, including environmental services, sanitary, clean-and-safe building, infection control practices, medication storage, and administration. These issues affected the residents' quality of life in the facility.During the survey, investigations revealed the facility had issues involving multiple systems. […]

• No harm, potential for more than minimal, widespreadF865Apr 28, 2026

  Based on observation, staff interview and facility documentation review, the facility staff failed to implement and maintain an effective Quality Assurance Performance Improvement (QAPI) Program/Plan for three of four quarters reviewed, affecting all residents in the facilityThe Findings included: During the survey, investigations revealed the facility had issues involving multiple systems. There was no documentation of the issues being discussed during QAPI meetings. These issues affected the quality of life of the residents in the facility.The facility failed to maintain an effective QAPI (Quality Assurance Performance Improvement) program. […]