Thornapple Manor

In the surveyor’s words

From the most serious findings on record at Thornapple Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 4, 2025

  This citation pertains to Intake # 2605454.Based on interview, and record review, the facility failed to implement care plan interventions to ensure safety and thoroughly document/investigate a fall in 1 of 4 residents (Resident #102) reviewed for safety and fall prevention, resulting in a fall with a right fibula fracture for Resident #102, and the potential for additional falls/injuries.Findings include:Resident #102Review of an admission Record revealed Resident #102 was a female, with pertinent diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), Alzheimer's disease, dementia, depression, osteoporosis (a condition in which the bones become weak and brittle), and arthritis.Review of a Minimum Data Set (MDS) assessment for Resident #102,… […]

• Actual harm, isolatedF689Dec 7, 2023

  This citation pertains to MI00141167. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with major injury, and ensure that assistive devices (a gait belt) were used according to the care plan during a transfer for 1 (Resident #103) of 3 residents reviewed for falls, resulting in major injury when Resident #103 sustained a fall with a head laceration, multiple rib fractures, right scapular fracture, and an ADL (activities of daily living) decline. Findings include: .A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2024

  Based on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure general repair of kitchen areas; 3. Ensure proper working order of dish machines; and 4. Use sanitizer in a manner that minimizes the risk of contamination. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 142 residents who consume food from the kitchen. Findings Include: 1. During a tour of the facility, at 10:15 AM on 1/31/24, an interview with Director of Dining Services (DDS) R found that the slicer gets used a couple times a week for slicing up meats. […]

• No harm, potential for more than minimal, widespreadF812Dec 8, 2022

  Based on observation, interview, and record review the facility failed to: 1. Properly date mark potentially hazardous foods; 2. Have the means to test sanitizer and use approved sanitizing products; 3. Store raw animal product in a manner to reduce the risk of contamination; 4. Clean food and non-food contact surfaces to sight and touch; and 5. Ensure proper working order of a dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 128 residents who consume food from the kitchen. Findings Include: 1. During a tour of the walk-in cooler #3, at 9:20 AM on 12/6/22, it was observed that a two gallon container of ham was open and dated 11/28 to 12/28. […]

• No harm, potential for more than minimal, widespreadF812Aug 18, 2021

  Based on observation, interview, and record review the facility failed to: 1. Thoroughly clean food and non-food contact surfaces; 2. Maintain sanitizer buckets in the required concentration; 3. Properly thaw frozen food products; and 4. Wash hands after contamination and minimize barehand contact with ready to eat foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 129 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 9:57 AM on 8/16/21, it was observed that dried yellow food debris was evident on the backside top portion of the meat slicer. […]