Inspection Reports for
Thorne Crest Retirement Center

The facility had multiple deficiencies including failure to timely notify providers and implement wound care orders, inadequate assistance with personal hygiene and toileting, medication administration errors, insufficient staffing leading to delayed care and long call light response times, poor infection control practices including laundry handling and wound care, lack of comprehensive staff orientation, incomplete medication reconciliation and disposal, delayed initiation of physical therapy, persistent odors in hallways and resident rooms, and ineffective quality assurance and performance improvement processes.

The investigation was complaint-driven based on reports of insufficient staffing causing delayed resident care, long call light response times, missed meals, and inadequate orientation of agency and facility nursing staff. Substantiation is implied by the detailed findings of deficiencies affecting many residents.

The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed assistance, missed meals, and long call light wait times for many residents. Additionally, the facility did not ensure proper orientation and training for agency and employed nursing staff, which compromised resident care and safety.

The complaint investigation was triggered by an incident where resident R1 rolled out of bed onto a heater causing second degree burns. The resident had severe cognitive impairment and a history of falls. The investigation substantiated the complaint, finding the facility had not maintained safe bed placement relative to heaters.

The facility failed to ensure beds were placed a safe distance from wall heaters, resulting in a resident sustaining second degree burns. Corrective actions were implemented prior to the survey, including moving beds away from heaters, applying floor markings, auditing heater temperatures, staff education, and policy creation.

The complaint investigation substantiated that the facility failed to notify the resident's representative of a change in condition, failed to monitor infection signs and symptoms, failed to safely transport the resident, delayed medication administration, and failed to follow infection prevention protocols.

The facility failed to notify the resident's representative of a change in condition, failed to monitor infection signs and symptoms consistently, failed to safely transport a resident using a manual wheelchair without proper assessment, delayed medication administration contrary to provider orders, and did not ensure staff followed infection prevention protocols including proper use of PPE and hand hygiene.

The complaint investigation was triggered by an incident on 12/7/24 when resident R1 eloped from the facility through an unlocked door and was found outside with hypothermia and injuries. The immediate jeopardy began on 12/7/24 and was removed on 12/8/24 after the facility implemented corrective actions including locking doors, 15-minute checks, re-assessment of residents, and staff re-education.

The facility failed to maintain adequate supervision and safety measures to prevent elopement and accidents for resident R1. The resident exited the building unnoticed through an unlocked door, resulting in serious injury and hospitalization. The facility lacked proper communication and implementation of safety interventions despite identifying R1 as an elopement and fall risk.

The complaint was substantiated. The investigation found that resident R31 did not have water within reach, leading to dehydration risk. Staff interviews revealed inconsistent policies and practices regarding water pitcher placement and refilling.

The facility failed to ensure that resident R31 had water within reach, resulting in dehydration risk. Observations and interviews confirmed that water pitchers were often placed out of reach, and staff did not consistently ensure water was accessible to the resident.

The investigation was complaint-driven, focusing on hydration concerns for resident R31. The complaint was substantiated as the facility failed to maintain water pitchers within reach and refill them consistently according to policy.

The facility failed to ensure that resident R31 had water within reach while in bed, resulting in dehydration risk. Staff interviews and observations confirmed inconsistent placement and refilling of water pitchers, despite facility policy requiring water pitchers to be within easy reach and changed each shift.

The complaint investigation was substantiated. The facility failed to protect residents from sexual abuse by R1 and failed to timely report the incidents to the State Agency and law enforcement. Immediate jeopardy was identified and later removed after corrective actions.

The facility failed to immediately implement appropriate interventions to protect residents from sexual abuse by R1, who had a history of inappropriate sexual behaviors. The immediate jeopardy was removed after corrective actions, but noncompliance remained at a lower severity level. The facility also failed to timely report the abuse incidents to the appropriate authorities.

The facility failed to ensure proper hand hygiene during personal cares and wound care for two residents observed. Staff did not perform hand hygiene at required times, increasing the risk of infection transmission.

The facility was found deficient in multiple areas including failure to document and communicate resident transfer information, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, missing advanced directives documentation, inadequate hearing services, insufficient fall prevention interventions, failure to follow catheter care orders, lack of trauma-informed care planning, and inaccurate payroll-based journal staffing data submissions.