Thorne Crest Retirement Center

In the surveyor’s words

From the most serious findings on record at Thorne Crest Retirement Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Oct 15, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 11, 2024

  Based 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. […]

• Actual harm, isolatedF689Dec 26, 2025

  Based 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). Findings include: R1's face sheet dated 12/18/25, identified diagnoses of neurocognitive disorder with Lewy Bodies dementia with anxiety, and history of falling. […]

• No harm, potential for more than minimal, widespreadF725Jan 27, 2026

  Based 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. Findings include: Refer to F676- Based 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. […]

• No harm, potential for more than minimal, widespreadF726Jan 27, 2026

  Based 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.Findings include: Refer to F760: Based on observation, interview and document review, 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… […]