Thorne Crest Retirement Center

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess and evaluate care plan interventions for effectiveness, and develop individualized repositioning program to prevent pressure ulcer development and/or deterioration for 2 of 3 residents (R1, R2) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance in a timely manner, when 15 of 47 residents (R3, R5, R7, R13, R15, R17, R22, R24, R25, R28, R34, R36, R39, R43, R47) reviewed for sufficient staffing, experienced excessively long call light wait times, and/or missed breakfast, or experienced a delay in getting to breakfast or delay in receiving care. This deficient practice had the potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 6 of 6 agency staff (nursing assistant (NA)-B, NA-C, NA-D, NA-G and registered nurse (RN)-G, RN-I) and 4 of 4 facility staff (NA-E, NA-J, RN-B, RN-J) received appropriate orientation and training prior to starting their first shift caring for residents. This had the potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure complete narcotic and controlled substance reconciliation occurred for two of two medication carts, failed to provide secure storage of disposed medications, and failed to ensure consultant pharmacist involvement and awareness of medication reconciliation and disposal processes. This practice had the potential to affect all 47 residents residing in the facility. In addition, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complications for 1 of 1 resident (R26) reviewed for medication administration.

Inspectors wroteBased on interview and document review the facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven quality assurance and performance improvement (QAPI) program. These findings had potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas, identified thorough data collection, analysis and evaluation of identified concerns during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure laundry was handled, transported, and processed in a manner that prevented the spread of infection. Specifically, soiled linens were transported unbagged from resident rooms and through hallways, and the facility failed to implement oversight, staff education, and monitoring of laundry infection control practice, further the facility failed to follow infection prevention and control practices related to enhanced barrier precautions (EBP), wound care, and appropriate use of personal protective equipment (PPE) for 1 of 1 resident (R2) reviewed for non-pressure skin concerns,, failed to identify residents who met criteria for EBP, post required signage, educate staff on EBP versus contact precautions, and ensure staff used appropriate PPE and infection control practices during wound care.

Inspectors wroteBased on interview and document review the facility failed to implement and maintain an effective Infection Prevention and Control Program specific to antibiotic stewardship. The facility did not have a system to track antibiotic use, culture results, organisms identified, or antibiotic resistance to ensure residents received appropriate treatment, this had the ability to affect all 47 residents. Findings Include:Review of the Infection Prevention and Control (IPC) case log dated 1/22/26, showed documentation included resident name, room number, onset date, current prescription, prescriber, infection type, infection site, diagnosis, and category. However, the log lacked documentation of the date cultures were obtained, organisms identified from culture results, and whether organisms were resistant to prescribed antibiotics. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary environment free from persistent odors for one of three hallways, which resulted in strong and ongoing odors of urine and bowel movements. In addition, the facility failed to ensure clean air/heating vents in common areas including two resident hallways and one day room. This had the potential to affect residents, staff or visitor who resided and/or used hallways and common areas.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the provider was timely notified and appropriate orders were obtained and implemented following a change in condition related to worsening skin integrity for 1 of one 1 resident (R2) reviewed for skin changes. This failure resulted in delayed treatment, lack of wound care orders, and inconsistent care, placing the resident at risk for infection and further skin breakdown. In addition, the facility failed to notify the resident representative when there had been a change in condition for 1 of 1 resident (R26), reviewed for notification of change.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance to complete personal hygiene care for 1 of 1 resident (R3) reviewed who needed assistance with fingernail care. R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, no rejection of care, utilized a wheelchair, required substantial/maximal assistance with personal hygiene, upper body dressing, dependent on staff for toileting hygiene and transfers; diagnoses included hemiplegia or hemiparesis, depression, dependence on renal dialysis. R3's care plan dated 1/2/26, indicated self-care: [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely toileting for 1 of 1 resident (R36) who was dependent upon staff for assistance with activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure necessary care and services were provided for 1 of 1 resident (R2) reviewed for non-pressure skin concerns, when staff failed to appropriately assess, treat, and manage bilateral lower-extremity wounds. This included failure to timely notify the provider and obtain and implement wound care orders following a change in skin condition, and failure to ensure wound care was provided as needed. These failures resulted in R2 going multiple days without wound care and placed the resident at risk for worsening skin breakdown, infection, and complications related to delayed treatment. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely toileting for 1 of 1 resident (R4) who required staff assistance with activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis communication forms were consistently reviewed, addressed, and incorporated into the resident's medical record, and failed to ensure provider orders communicated by the dialysis provider were implemented in a timely manner for 1 of 1 resident (R3) of one reviewed for dialysis. Findings Include:R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, no rejection of care, utilized a wheelchair, required substantial/maximal assistance with personal hygiene, upper body dressing, dependent on staff for toileting hygiene and transfers; diagnoses included hemiplegia or hemiparesis, depression, dependence on renal dialysis. R3's care plan dated 1/2/26, need hemodialysis r/t (related to) renal failure and interventions included: [...]

Inspectors wroteBased on observation, interview and document review, and staff interview, the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan (blood pressure medication) was administered incorrectly for three months, constituting a significant medication error for 1 of 5 residents (R44) reviewed for medication administration. Findings Include:R44's Minimum Data Set (MDS) dated [DATE], indicated R44 was cognitively intact, required partial/moderate assistance with personal hygiene, and diagnoses included hypertension. R44's care plan dated 12/19/25, indicated R44 at risk cardiovascular status r/t (related to) hypertensive heart disease and atherosclerosis of aorta. R44's provider note dated 10/8/25, physician assistant (PA)-K provider note indicated decrease losartan to 25 mg (milligrams) daily. [...]

Inspectors wroteBased on observation, interview and documentation review, the facility failed to seek clarification and initiate physical therapy timely for 1 of 1 resident (R43) who had had orders for physical therapy after a fracture.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure beds were a safe distance away from a wall heater to prevent entrapment and burns for 1 of 1 resident (R1) who had severe cognitive impairment, and a history of self-transfers and falls reviewed for accidents. This resulted in actual harm when R1 rolled out of bed onto the heater which caused second degree burns to his left hip and back. The facility immediately implemented corrective action and the deficient practice was corrected on 12/19/25, prior to the start of the survey and was therefore issued as a past non-compliance (PNC).

Inspectors wroteBased on observation, interview, and document review, the facility failed to notify a resident's representative of a change in condition for 1 of 3 residents (R3) reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review the facility failed to monitor for signs and symptoms of infection for 1 of 1 resident (R1) reviewed for change in condition. In addition, the facility failed to safely transport 1 of 1 resident (R1) to an outside appointment reviewed for resident safety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R1) reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were following standard precautions by not performing hand hygiene before and after resident contact and failed to use personal protective equipment (PPE) for one of one resident (R1) that was on transmission-based precautions to reduce the risk of infection spread reviewed for quality of care. In addition, the facility failed to place the PPE cart directly outside R1's doorway to mitigate the risk for spread.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain resident supervision and safety to prevent accidents for 1 of 1 residents (R1) who was an elopement risk left the facility unsupervised through an unlocked door during the night and found outside. This resulted in an immediate Jeopardy (IJ) situation for R1. The IJ began on 12/7/24 when R1 exited the building without staff awareness through an unlocked door to a courtyard between 11:15 p.m. and 3:30 a.m. (on 12/7/24) and found on the ground at approximately 4:10 a.m. with hypothermia and minor injuries. The administrator and chief operating officer (COO) were notified of the immediate jeopardy on 12/11/24 at 3:00 p.m. The facility had implemented immediate corrective action on 12/8/24 to prevent recurrence, so the IJ was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R31) had adequate hydration and hydration within reach.

Inspectors wroteBased on observation, interview, and document review the facility failed to immediately implement appropriate interventions to protect residents from sexual abuse from R1 who sexually abused R2 in the facility and posed an ongoing risk of serious harm resulting in immediate jeopardy. The IJ began on 10/6/24, when facility failed to implement protection measures after staff observed R1 inappropriately touching R2's breast/chest area on 10/6/24. The administrator, director (DON) and assistant director of nursing (ADON) were notified of the IJ on 10/11/24 at 4:43 p.m. The immediate jeopardy was removed on 10/13/24 at 9.11 a.m. but noncompliance remained at the lower scope and severity level 2 E - pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Inspectors wroteBased on interview and document review the facility failed to timely report actual inappropriate unwanted touching and/or allegations of sexual abuse to the facility administrator/designee and to the State Agency (SA) for 6 of 6 residents (R2, R3, R4, R6, R7, R9) reviewed for abuse.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper hand hygiene during personal cares and wound care for 2 of 2 residents (R1,R2) observed for activities of daily living.

Inspectors wroteBased on interview and document review, the facility failed to accurately record weekend staffing data for fiscal year quarter 3 2023 (April 1-June 30) on the payroll-based journal (PBJ) Staffing Data Report. This deficient practice had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility to ensure continuity of care when transferred emergently to the hospital for 1 of 2 residents (R3) reviewed for hospitalizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the current status and needs for 1 of 1 resident (R9) reviewed for accuracy of the MDS.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a comprehensive care plan had been developed for 1 of 1 resident (R9) who had an impairment in range of motion (ROM) and utilized a splint.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident cardiopulmonary (CPR) life support orders were included in the medical record for 1 of 12 residents (R10) reviewed for advanced directives (AD).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate treatment and services were provided to maintain and/or improve hearing and communication for 1 of 1 resident (R3) reviewed for communication-sensory.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff were implementing fall risk prevention measures for 2 of 3 residents (R18, R31) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow physician's orders to ensure appropriate management and routine care was provided for 1 of 1 resident (R31) reviewed for urinary catheter.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R23), who had post-traumatic stress disorder (PTSD), reviewed for behavioral-emotional.