Inspection Reports for
Thornton Care Center
501 THORNTON PKWY, THORNTON, CO, 80229-2101
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
208% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 2, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to respond to resident grievances about uncomfortable and hot room temperatures, and to assess the facility's compliance with safety and medical record-keeping standards.
Complaint Details
The complaint investigation was substantiated. The facility failed to respond to grievances about hot room temperatures and failed to provide adequate supervision to prevent falls, resulting in actual harm to residents. Documentation deficiencies were also found in medication administration records.
Findings
The facility failed to promptly address grievances from residents about high room temperatures and failed to maintain adequate supervision to prevent falls, resulting in actual harm to some residents. Additionally, the facility did not maintain complete and accurate medication administration documentation for one resident.
Deficiencies (3)
F 0585: The facility failed to respond to grievances from three residents regarding uncomfortable and hot room temperatures, with temperatures recorded as high as 94 degrees Fahrenheit in resident rooms.
F 0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in multiple falls for Resident #1 and a fall with injury for Resident #4, with inadequate care plan updates and safety evaluations.
F 0842: The facility failed to maintain complete and accurate medication administration records for Resident #1, with missing documentation for administration of levetiracetam on two dates.
Report Facts
Room temperatures: 94
Number of residents reviewed for grievances: 14
Number of residents reviewed for accident hazards: 14
Number of falls for Resident #1: 4
Medication administration dates with missing documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication administration documentation deficiency and interviewed regarding room temperature and fall supervision. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding fall supervision and resident care. |
| Director of Nursing | Director of Nursing | Interviewed regarding fall reviews, care plan updates, and medication documentation. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding grievance policies, room temperature issues, and fall reviews. |
| Activities Director | Activities Director | Interviewed regarding resident outing during which a fall occurred. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
The inspection was conducted to investigate allegations of sexual abuse involving residents at Thornton Care Center, specifically concerning incidents reported by Resident #2 and Resident #5 involving Resident #3.
Complaint Details
The complaint investigation involved allegations that Resident #3 exposed himself to Residents #2 and #5 multiple times. The facility's investigation was unsubstantiated due to no witnesses and Resident #3's denial, but interviews with victims and staff confirmed ongoing incidents. The facility delayed reporting and failed to implement effective interventions.
Findings
The facility failed to protect residents from sexual abuse by another resident and did not ensure timely reporting of the incidents. The investigation was unsubstantiated due to lack of witnesses, but multiple residents reported repeated exposure incidents by Resident #3, and the facility lacked effective interventions to prevent this behavior.
Deficiencies (1)
F 0600: The facility failed to protect residents from sexual abuse by Resident #3 and did not ensure staff reported the incidents in a timely manner. Resident #3 had a history of exposing himself, and the facility lacked person-centered interventions to prevent this behavior.
Report Facts
Residents reviewed for abuse: 6
BIMS cognitive scores: 13
BIMS cognitive score: 12
Dates of incidents: 2025
Inspection Report
Routine
Deficiencies: 19
Date: Dec 19, 2024
Visit Reason
Routine state inspection survey of Thornton Care Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to honor resident shower preferences, delayed payment for resident work, inadequate management of personal funds, unsafe and unclean environment, incomplete abuse investigations, improper discharge procedures, inadequate assistance with activities of daily living, failure to provide personalized activities, medication errors, improper medication storage, poor food quality and variety, infection control lapses, and ineffective quality assurance program.
Deficiencies (19)
F 0561: Facility failed to honor resident shower preferences for five residents, resulting in missed showers and lack of documentation for missed showers.
F 0566: Facility failed to ensure timely payment for Resident #13's participation in the therapeutic stipend program.
F 0567: Facility failed to ensure residents had access to personal funds during weekends and after hours, limiting resident financial autonomy.
F 0584: Facility failed to provide a safe, clean, comfortable and homelike environment including clean towels, timely cleaning of Resident #6's closet with feces, and timely cleaning of a clogged toilet.
F 0610: Facility failed to thoroughly investigate allegations of verbal abuse for Residents #37 and #21, lacking documentation of investigations and interviews.
F 0622: Facility failed to provide Resident #216 with an appropriate discharge process and failed to reassess resident status before discharge.
F 0626: Facility failed to permit Resident #216 to return to the facility after a hospital transfer and failed to reassess resident status post-transfer.
F 0677: Facility failed to provide care and assistance for activities of daily living for Residents #32 and #48, including missed showers and inadequate meal assistance for a blind resident.
F 0685: Facility failed to ensure Resident #23 received new eyeglasses in a timely manner after prescription.
F 0689: Facility failed to ensure residents were free from accident hazards including failure to use fall mats, wheelchair foot pedals, gait belts during transfers, and safe smoking assessments.
F 0698: Facility failed to ensure Resident #1's dialysis care was consistent with professional standards including incomplete dialysis communication forms and inconsistent documentation of post-dialysis weights.
F 0760: Facility failed to ensure residents were free from significant medication errors including administration of incorrect medication to Resident #6 and excessive acetaminophen dosage to Resident #44.
F 0761: Facility failed to ensure proper storage and labeling of medications including expired medications, unlabeled opened medications, and lack of temperature logs in medication refrigerators.
F 0800: Facility failed to provide residents with nourishing, palatable, well-balanced diets meeting nutritional and special dietary needs, including failure to provide preferred menu items and variety.
F 0804: Facility failed to ensure food was palatable in taste, texture, appearance and temperature, with observations of overcooked, bland, cold and repetitive meals.
F 0812: Facility failed to store, prepare, distribute and serve food in a sanitary manner including improper dish sanitization and unsafe storage of food items in walk-in refrigerator.
F 0849: Facility failed to ensure hospice agency notes were accessible to staff to coordinate care for Resident #9 receiving hospice services.
F 0867: Facility failed to operate an effective quality assurance program to identify and address quality of care concerns across multiple domains.
F 0880: Facility failed to maintain an infection control program including failure to wear appropriate PPE during enhanced barrier precautions, incomplete water management program, poor hand hygiene and sanitation of shared equipment, and failure to offer hand hygiene at meals.
Report Facts
Shower opportunities: 16
Acetaminophen dosage: 4300
Acetaminophen dosage: 5300
Medication doses: 3
Temperature: 40
Temperature: 99
Temperature: 119.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Identified medication error with Resident #6 |
| RN #1 | Registered Nurse | Interviewed regarding hospice care and medication errors |
| RPH | Registered Pharmacist Consultant | Interviewed regarding medication errors and acetaminophen dosing |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including shower care, medication errors, infection control |
| DOCS | Director of Clinical Services | Interviewed regarding multiple deficiencies including medication errors, infection control, quality assurance |
| DM | Dietary Manager | Interviewed regarding food quality and menu concerns |
| NHA | Nursing Home Administrator | Interviewed regarding quality assurance and food quality |
| SSC | Social Services Consultant | Interviewed regarding eyeglasses and abuse investigations |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding shower care and medication storage |
| CNA #7 | Certified Nurse Aide | Observed and interviewed regarding infection control and enhanced barrier precautions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to administer pain medications in a timely manner to residents as per physician orders.
Complaint Details
The complaint investigation was substantiated, finding that Residents #1, #2, and #3 experienced late administration of pain medications despite formal grievances and facility follow-ups.
Findings
The facility failed to ensure timely administration of pain medications for three sampled residents, resulting in delayed medication delivery beyond the allowed administration windows. Staff interviews confirmed inconsistent medication timing and lack of physician notification for late administrations.
Deficiencies (1)
F 0658: The facility failed to administer pain medications timely per physician orders for Residents #1, #2, and #3, with multiple documented late doses beyond the allowed medication administration windows.
Report Facts
Medication late administration instances: 26
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 20, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of physical abuse and failure to provide appropriate pressure ulcer care at Thornton Care Center.
Complaint Details
The complaint investigation substantiated multiple incidents of physical abuse by staff and residents, including a staff member sitting on a resident causing multiple rib fractures and pneumothorax, and resident-to-resident physical altercations causing injuries. The investigation also found failures in pressure injury care leading to serious harm and immediate jeopardy.
Findings
The facility failed to protect residents from physical abuse by staff and other residents, resulting in actual harm including multiple rib fractures and skin injuries. Additionally, the facility failed to provide adequate pressure injury care, including timely assessment, monitoring, and treatment of wounds, leading to serious harm and immediate jeopardy to resident health.
Deficiencies (3)
F0600: The facility failed to protect residents from physical abuse by staff and other residents, resulting in actual harm including multiple rib fractures, pneumothorax, eye injury, and skin injuries.
F0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in immediate jeopardy to resident health or safety.
F0867: The facility failed to implement an effective quality assurance program to identify and address compliance concerns, including abuse prevention and pressure injury care.
Report Facts
Residents reviewed for abuse: 12
Residents hospitalized: 7
Pressure injury stages: 4
Dates of survey completion: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in physical abuse finding for sitting on Resident #7 causing rib fractures and pneumothorax. |
| RN #1 | Registered Nurse | Interviewed regarding Resident #7's pain and oxygen saturation levels. |
| NHA | Nursing Home Administrator | Conducted investigations and interviews related to abuse and pressure injury care. |
| DON | Director of Nursing | Interviewed about wound care policies, assessments, and failures. |
| RDCS | Regional Director of Clinical Services | Provided facility policies and interviewed about wound care and abuse prevention. |
| MD | Medical Director | Interviewed about facility conditions and recent staffing changes. |
| CNA #3 | Certified Nurse Aide | Reported missed dressing changes for Resident #3. |
| WCRN | Wound Clinic Registered Nurse | Interviewed about Resident #3's wound care and treatment failures. |
Inspection Report
Routine
Deficiencies: 11
Date: Oct 26, 2023
Visit Reason
Routine inspection of Thornton Care Center to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to compensate residents fairly for work, lack of privacy curtains, failure to prevent resident-to-resident abuse, inadequate nursing assessments after falls, medication administration errors, inconsistent personal care, fall prevention failures, transportation assistance deficiencies, improper food portioning, poor food palatability, and unsafe food handling practices.
Deficiencies (11)
F 0566: The facility failed to ensure Resident #14 was paid fairly for therapeutic work, lacked a care plan for the work program, had a contract that did not match workload, and allowed work without a signed contract.
F 0583: The facility failed to provide a privacy curtain for Resident #170 to ensure personal privacy while in bed.
F 0600: The facility failed to protect residents from resident-to-resident abuse involving Residents #53, #61, and others, including failure to implement effective interventions for Resident #54, a registered sex offender.
F 0658: The facility failed to have a registered nurse assess Resident #1 after a fall and failed to administer pain medications on time to Resident #53.
F 0677: The facility failed to provide consistent bathing to maintain good personal hygiene for Residents #6 and #15, despite care plan requirements.
F 0689: The facility failed to ensure the resident environment was free from accident hazards and failed to implement effective fall prevention interventions and neurological checks for Resident #15 after multiple falls.
F 0761: The facility failed to label insulin pens with open dates and store them according to manufacturer recommendations in two medication carts.
F 0774: The facility failed to assist Residents #52 and #53 with transportation arrangements for outside medical appointments.
F 0803: The facility failed to follow correct portion sizes for meals, serving inadequate amounts of food to residents, including those on renal and dysphagia diets.
F 0804: The facility failed to ensure food was palatable in taste, texture, and appearance, with multiple resident complaints and observations of bland, unappetizing food.
F 0812: The facility failed to ensure safe food handling practices, including appropriate glove use and hand hygiene by dietary staff during food preparation and service.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Medication carts inspected: 4
Residents affected: 2
Residents affected: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding resident abuse, fall investigations, and work program deficiencies |
| Certified Nurse Aide #2 | CNA | Interviewed regarding resident abuse, falls, bathing, and medication administration |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding falls, bathing, medication administration, and resident care |
| Dietary Manager | DM | Interviewed regarding food portioning, palatability, and food safety practices |
| Dietary Aide #1 | DA | Observed and interviewed regarding food service and glove use |
| Dietary Aide #2 | DA | Observed and interviewed regarding food service and glove use |
| Registered Dietitian | RD | Interviewed regarding importance of correct food portioning |
| Social Service Assistant | SSA | Interviewed regarding transportation assistance failures |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 26, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident care, safety, nutrition, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide consistent bathing and personal hygiene for residents, inadequate fall prevention and investigation practices, failure to assist residents with transportation arrangements, failure to follow correct portion sizes in meal service, serving unpalatable food, and improper food handling practices in the kitchen.
Deficiencies (6)
F 0677: The facility failed to provide consistent bathing to maintain good personal hygiene for Residents #6 and #15, including failure to document shower preferences and refusals.
F 0689: The facility failed to ensure the resident environment was free from accident hazards and failed to implement effective fall prevention interventions and timely neurological checks for Resident #15 after multiple unwitnessed falls.
F 0774: The facility failed to assist Residents #52 and #53 with transportation arrangements for outside medical appointments, resulting in residents managing their own transportation.
F 0803: The facility failed to follow correct portion sizes during meal service, serving less than the prescribed amounts of food to residents requiring renal and dysphagia diets and those ordered large or double portions.
F 0804: The facility failed to ensure food was palatable in taste, texture, and appearance, with multiple residents reporting bland, salty, or unappetizing meals and observations confirming poor food quality.
F 0812: The facility failed to ensure proper kitchen sanitation practices, including inappropriate glove use by dietary staff leading to potential contamination of ready-to-eat foods.
Report Facts
Residents sampled: 41
Showers received: 4
Bed baths: 3
Falls: 5
Portion size: 4
Resident interviews: 7
Inspection Report
Deficiencies: 20
Date: Jul 21, 2022
Visit Reason
The inspection was conducted as a recertification and complaint investigation survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, care planning participation, accommodation of resident needs, abuse prevention, pressure ulcer care, elopement prevention, medication administration, infection control, and quality assurance. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (20)
F0550: The facility failed to ensure Resident #42 was treated with respect and dignity by other residents, including failure to prevent Resident #55 from entering Resident #42's room and urinating on the floor.
F0553: The facility failed to invite and conduct regular care conferences to review the person-centered plan of care with seven residents, including Resident #43, #11, #48, #16, #59, #21, and #30.
F0558: The facility failed to reasonably accommodate the needs and preferences of residents, including improper wheelchair positioning for Resident #71 and providing a bed too short for Resident #21.
F0566: The facility failed to ensure Resident #43 was paid a fair and decent wage for a therapeutic work program, compensating him with a free meal or a pack of cigarettes instead of money.
F0584: The facility failed to provide a comfortable and homelike environment by not maintaining safe temperature ranges in hallways and resident rooms, with temperatures exceeding 81 degrees Fahrenheit.
F0585: The facility failed to provide prompt efforts to resolve grievances for Resident #30's missing clothing and Resident #21's missing money reported during a resident council meeting.
F0600: The facility failed to protect Resident #38 from physical abuse by Resident #45 on two occasions, including shaking Resident #38's wheelchair and punching him in the chest.
F0655: The facility failed to develop an acute/baseline care plan involving Resident #43 within 48 hours of admission, including failure to involve the resident in care planning and provide a copy of the plan.
F0676: The facility failed to ensure Residents #48 and #59 received regular bathing in accordance with their plan of care, with multiple missed showers documented.
F0677: The facility failed to provide care and assistance to Residents #39, #21, and #18 to maintain or improve activities of daily living, including missed bathing, delayed incontinent care, and lack of nail care.
F0688: The facility failed to provide appropriate care to maintain or improve range of motion for Residents #21 and #8, including failure to provide restorative therapy and passive stretching.
F0689: The facility failed to ensure safety of Residents #55, #45, and #5 at risk for elopement and/or requiring WanderGuard monitoring, including failure to investigate and educate staff after Resident #55's elopement on 7/10/22, and failure to provide adequate supervision to prevent accidents for Residents #1, #71, #21, and #130.
F0693: The facility failed to ensure Resident #130 received his tube feeding as ordered, including failure to administer the full volume of formula and failure to reconnect feeding after resident requested a pause.
F0726: The facility failed to ensure annual competency documentation for licensed practical nurse (LPN) #3.
F0744: The facility failed to provide appropriate dementia care to Resident #55, including failure to develop person-centered care plans with individualized interventions, failure to prevent wandering and elopement, and failure to provide meaningful engagement.
F0761: The facility failed to label insulin pens and eye drops with open dates in three medication carts, contrary to manufacturer recommendations.
F0781: The facility failed to assist residents in obtaining routine or emergency dental services for Residents #48, #30, and #21, including failure to follow up on dental recommendations and failure to arrange dental services.
F0808: The facility failed to provide therapeutic and mechanically altered diets consistent with physician orders for five residents, including failure to serve appropriate main dishes and prepare dysphagia advanced diet textures correctly.
F0867: The facility failed to develop, implement, monitor and reevaluate its quality assurance performance improvement program to address resident safety, staffing, and quality of care deficiencies.
F0880: The facility failed to maintain an infection control program, including failure to conduct proper hand hygiene when administering tube feeding, administer medications in a sanitary manner, and ensure oxygen tubing was clean prior to application.
Report Facts
Deficiencies cited: 22
Residents affected by dignity deficiency: 1
Residents affected by care planning deficiency: 7
Residents affected by accommodation deficiency: 2
Residents affected by abuse deficiency: 1
Residents affected by bathing deficiency: 2
Residents affected by ADL assistance deficiency: 3
Residents affected by ROM deficiency: 2
Residents affected by elopement risk: 3
Residents affected by feeding tube deficiency: 1
Residents affected by dental services deficiency: 3
Residents affected by therapeutic diet deficiency: 5
Nursing staff missing competency: 1
Medication carts with unlabeled meds: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Failed to complete annual competency and medication administration errors |
| RN #2 | Registered Nurse | Failed hand hygiene during tube feeding administration |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies and staff education |
| NHA | Nursing Home Administrator | Interviewed regarding QAPI and facility deficiencies |
| RCR #1 | Regional Clinical Resource | Interviewed regarding elopement and pressure ulcer issues |
| SSA | Social Services Assistant | Interviewed regarding dental and dementia care |
| ADON | Assistant Director of Nursing | Interviewed regarding neurological checks and infection control |
| DOR | Director of Rehabilitation | Interviewed regarding range of motion and diet texture |
| RD | Registered Dietitian | Interviewed regarding therapeutic diets and tube feeding |
| DOM | Director of Maintenance | Interviewed regarding WanderGuard system and mechanical lift |
| CNA #4 | Certified Nurse Aide | Interviewed regarding resident wandering and bathing |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication cart and WanderGuard knowledge |
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