Thornton Terrace Health Campus

Based on observation, record review, and interview, the facility failed to ensure the kitchen equipment was clean, sanitary and the removal of expired food items during 3 of 3 kitchen observations. This deficient practice had the potential to affect 45 of 45 residents who received meals in the facility.Findings include:1. During an observation of the kitchen, on 9/03/25 at 9:25 a.m., the following concerns were identified:-On the floor between the fryer and stove were food debris and a bug trap. There was a yellowish-brown greasy substance running down the right side of the stove. -There were three brown colored burnt areas on the back panel behind each burner of the stove top.-The drip pan under the stove top had a foil liner that was 100% covered with a tan substance and food debris.-The grill top to the left of the stove had a black build-up on the griddle irons.-The drip pan under the grill had a torn foil liner with a half inch of a brown liquid substance with a heavy coverage of food debris.-Dried food debris was observed on a large, slotted spoon hanging from the overhead…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident had an order to self administer medications related to medications left at the bedside for 1 of 4 residents reviewed for self-administration of medication. (Resident 31)Findings include:An observation, on 9/3/25 at 10:01 a.m., indicated Resident 31 had multiple medications in a medicine cup sitting on the resident's bedside table. No staff members were present or near the resident's room. The medications were due between 8:00 a.m. and 10:00 a.m. There was an open inhaler sitting next to the medicine cup on the bedside table. The resident was asleep and did not observe the medications sitting next to her breakfast bowls. During an interview, on 9/3/25 at 10:03 a.m., Licensed Practical Nurse (LPN) 9 looked at the orders and indicated there was no order for the resident for self-administration. She indicated the following medications were in the medication cup on the resident's bedside table: Tart cherry supplement; Potassium; metoprolol; Hair, Skin, and Nails vitamins; Lysine; Allopurinol;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the accuracy of skin assessments (Residents 2 and 23) and failed to ensure accurate coding of the Minimum Data Set assessments (Resident 11) for 3 of 6 residents reviewed for assessments. Findings include:1.The record for Resident 2 was reviewed on 9/7/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation The care plan, dated 11/2/21 and revised 7/9/25, indicated the resident was at risk for skin breakdown related to impaired mobility, type II diabetes, nutritional status, hand contractures, noncompliance with wearing a stump shrinking device. The interventions included, but were not limited to, floating the heels as needed, pressure reducing cushion to his chair, using moisture barrier to the perineal area as needed, a pressure reducing mattress to the bed, avoid shearing skin during positioning, turning, and transferring, encourage and provide assistance to turn and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure care plans were revised and implemented with interventions for 2 of 12 residents review for care plan revision. (Residents 2 and 23)Findings include:1.The record for Resident 2 was reviewed on 9/7/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation. The care plan, dated 11/2/21 and revised 7/9/25, indicated the resident was at risk for skin breakdown related to impaired mobility, type II diabetes, nutritional status, hand contractures, noncompliance with wearing a stump shrinking device. The interventions included, but were not limited to, floating the heels as needed, pressure reducing cushion to his chair, using moisture barrier to the perineal area as needed, a pressure reducing mattress to the bed, avoid shearing skin during positioning, turning, and transferring, encourage and provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure resident's wounds had accurate documentation for size, staging, and treatment for 2 of 2 residents reviewed for non pressure wounds.Findings include:1.During an observation of the resident on 9/8/25 at 1:21 p.m., the resident was sitting on his left hip in his recliner. The resident was asleep. The Infection Control Infection Tracker Event Report, dated 9/2/25, indicated Resident 23 had Cellulitis/Soft Tissue/Wound to the buttocks with light green drainage. This was a healthcare-associated infection. The signs and symptoms of the cellulitis/soft tissue/wound infection was redness, tenderness, and purulent drainage. The interventions were to give medications as prescribed for the infection, encourage fluids, monitor for effectiveness of the antibiotic, and monitor for signs and symptoms of the infection. The care plan, dated 5/2/24 and reviewed 9/3/25, indicated Resident 23 had moister associated skin damage (MASD. The interventions,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident received medications as ordered for 1 of 5 residents reviewed for pharmacy services. (Resident 34) Findings include: The record for Resident 34 was reviewed on 8/16/24 at 9:32 a.m. The resident's diagnoses included, but were not limited to, anxiety disorder and depression. The care plan, dated 7/4/24, indicated the resident had a diagnosis of anxiety and demonstrated anxiousness, restlessness, agitation, and aggressive behaviors. The interventions included, but were not limited to, encourage the resident to voice the cause for his anxiety and problem solve ways to resolve stressors, identify and avoid triggers whenever possible, provide consistency and routine, monitor for increased signs and symptoms and resolve the concerns when possible. The Quarterly MDS (Minimum Data Set) assessment, dated 6/24/24, indicated the resident was moderately cognitively intact. The resident had physical behavioral symptoms directed toward others. The nurse's notes, dated 6/5/24 at 12:02 a.m., indicated the CNA (Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure influenza vaccinations were monitored for expiration dates and disposal of the expired medication for 1 of 4 observations of medication storage. (Medication Room refrigerator) Findings include: During an observation on 8/16/24 at 1:01 p.m., of the 200 Hall medication storage room with RN 5, four boxes of Fluzone influenza vaccination, plus an open box with one vial of Fluzone influenza vaccination had an expiration date of June 2024. She indicated the influenza vaccinations were dated June 2024, and she would check to make sure the boxes and vial were expired. There were 10 vials of the influenza vaccine in each box for a total of 41 vials. During an interview on 8/16/24 at 2:10 p.m., the ED (Executive Director) indicated the influenza vaccinations were expired. She indicated they had not been administered since the influenza season ended. During an interview on 8/20/24 at 8:43 a.m., LPN (Licensed Practical Nurse) 4 indicated if an influenza vaccination was expired, it would go to the DON (Director of Nursing) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure resident rights related to dignity for 1 of 3 residents reviewed for resident rights. (Resident B) Findings include: The record for resident B was reviewed on 1/10/23 at 11 33 AM. The diagnoses included, but were not limited to, incomplete lesion at C5 level of cervical spinal cord, quadriplegia C5 through 37 incomplete, attention deficit hyperactivity disorder, major depressive disorder, anxiety, paraplegia, reduce mobility, lack of coordination, muscle weakness, and difficulty in walking. The quarterly MDS (Minimum Data Set) assessment, Dated 12/27/23, indicated the resident was cognitively intact. The care plan initiated on 12/26/23 and last revised on 1/3/24 indicated the resident had a history of verbal behaviors directed towards staff such as threatening their jobs, accusing them of abuse, retaliatory behaviors, inappropriate attachment to staff, and recording conversations. The interventions included but were not limited to avoiding power struggles with resident conveying attitude of acceptance to resident,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions and response for dementia related behaviors for 1 of 3 residents reviewed for dementia care. (Resident C) Findings include: During an observation on 1/10/24 at 10:35 a.m., Resident C was in his bed. He was pleasantly confused and very hard of hearing. When asked his name he indicated a name which was not his. He was not able to be interviewed. He appeared pleasantly confused and in no distress. He had no visible bruising at this time. The record for Resident C was reviewed on 1/10/24 at 11:16 a.m. The diagnoses included, but were not limited to, unspecified psychosis, hallucinations, altered mental status, visual disturbance, unsteadiness on feet, and muscle weakness. The Quarterly MDS (Minimum Data Set) assessment, dated 11/24/23, indicated the resident was rarely or never understood and was not assessed for cognitive status. The nurses note, dated 9/26/23 at 12:49 a.m., indicated the resident was being verbally and physically aggressive that night. He refused his medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure medications were appropriately labeled and discarded within appropriate time frames in 3 of 3 medication carts observed for medication storage. (200 Front Hall cart, 200 Back Hall cart, and the Memory Care unit cart) Findings include: 1. During an observation on 6/30/23 at 8:49 a.m. ,of the 200 Hall Medication Cart with LPN (Licensed Practical Nurse) 9, the following concerns were observed: a. Resident 197's albuterol pro-air HFA (hydrofluoroalkane inhaler) was stored lying down in its side in the box. The side label of the medication indicated to store with the mouthpiece down. The clinical record for Resident 197 was reviewed on 6/30/23 at 1:00 p.m. The diagnoses included, but were not limited to COPD (chronic obstructive pulmonary disease) with acute exacerbation, acute respiratory failure with hypercapnia, and acute bronchitis. The physician's order, dated 6/9/23, indicated the resident received albuterol sulfate HFA aerosol inhaler 90 mcg/act (micrograms per actuation) 2 inhalations every 6 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the physician was notified of residents change in condition for 2 of 16 residents reviewed for physician notification. (Residents 32 and 35) Findings include: 1. The record for Resident 32 was reviewed on 6/27/23 at 9:26 a.m. The diagnoses included, but were not limited to, essential hypertension and hyperlipidemia. The Quarterly MDS (Minimum Data Set) assessment, dated 5/28/23, indicated the resident was cognitively intact. The care plan, initiated on 2/23/23 and last revised on 6/5/23, indicated the resident had a potential for cardiovascular distress related to a diagnosis of hypertension. The interventions included, but were not limited to, provide medications as ordered, observe for and report side effects as needed, observe for signs/ symptoms of cardiovascular distress and report as needed, and obtain vital signs as ordered and needed. The nurse's note, dated 5/2/23 at 5:00 p.m., indicated the resident was sitting up in the dining room and stated, Can you check my blood pressure, I feel dizzy. His blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents received the appropriate perineal care related to infection control guide lines to prevent urinary tract infections for 3 of 6 residents reviewed for bowel and bladder. (Residents 3, 18, and 29) Findings include: 1. During an observation of incontinence and catheter care for Resident 3 on 6/29/23 at 9:45 a.m., CNAs (Certified Nurse Aides) 5 and 6 had the washcloths and towels set up on the bedside table. They performed hand hygiene and applied gloves. The labial area and catheter tubing were cleaned by CNA 5 and the resident was rolled onto her left side. The catheter bag was lifted above the level of the bladder and held there as CNA 5 was able to take it and place it on the left side of the bed. CNA 6 performed hand hygiene and applied gloves. CNA 6 used a folded washcloth, using a four-corner method with no rinse soap applied to each corner. CNA 6 cleaned the left buttock with 13 swipes of the same area of the washcloth corner. She folded the corner over and with 31 swipes of the same area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.