Thornton Care Center

In the surveyor’s words

From the most serious findings on record at Thornton Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 20, 2024

  Based on observations, record review, and interviews, the facility failed to provide four of four residents (#3, #4, #5, and #12) out of 12 sample residents, with the necessary treatment and services to manage pressure injuries and minimize pressure injury risks. RESIDENT #3 Record review and interview revealed Resident #3 was hospitalized seven times and readmitted to the facility six times between January and June 2024. During this time, the resident developed pressure injuries to his sacrum, ischium, left and right heels, left ankle, and scrotum which ranged from stage 2 (partial thickness skin loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), as well as osteomyelitis (inflammation of the bone due to infection) of the sacral wound. […]

• Immediate jeopardy, isolatedF689Jul 21, 2022

  Based on observations, interviews, and record review, the facility failed to ensure seven residents (#55, #45, #5, #1, #71, #21, and #130), out of a total sample of 47 residents, received adequate supervision and assistive devices to prevent accidents. Specifically: The facility failed to take steps to ensure the safety of three residents identified at risk for elopement and/or to require a WanderGuard (#55, #45, and #5) after Resident #55 eloped from the facility. Specifically: -Resident #55 eloped from the facility undetected on 7/10/22, and was discovered a block away from the facility by the police. Resident #55 wore a WanderGuard device, an electronic monitoring system that triggered should he exit the facility through a door armed with the WanderGuard system. […]

• Actual harm, isolatedF689Sep 2, 2025

  Based on observations, record review and interviews, the facility failed to ensure two (#1 and #4) of five residents reviewed for accident hazards received adequate supervision out of 14 sample residents.Resident #1 was admitted to the facility with diagnoses of neurocognitive disorder, brain injury with loss of consciousness and arthritis. According to documentation, Resident #1 had four falls from 6/6/25 to 7/9/25. Two falls required evaluation and treatment at the hospital emergency department. The fall on 6/21/25 caused a pelvic fracture, and after a fall on 7/9/25, the resident was monitored and was allowed to go on an activity trip to a local restaurant for lunch on the same day. […]

• Actual harm, isolatedF600Jun 20, 2024

  Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#7, #8, #9 and #10) of four residents reviewed for abuse out of 12 sample residents. Resident #7 was admitted to the facility on [DATE] with diagnoses that included a history of mood disorder, depression and alcohol abuse. On 3/9/24 Resident #7 called certified nurse aide (CNA) #1, who was an agency CNA, a racial slur. CNA #1 went to Resident #7's bed, placed his forearm across the resident's left side and leaned on top of the resident. CNA #1 repeatedly told Resident #7 he needed to apologize for calling him a racial slur. CNA #1 then left the room. Resident #7 reported he cried out in pain all night following the incident. […]

• Actual harm, isolatedF600Oct 26, 2023

  Based on record review, and interviews, the facility failed to ensure two (#61 and #53) out of three residents reviewed out of 33 sample residents, as well as other facility residents, were protected from resident-to-resident abuse by Residents #54, #120, and #31. Residents #54 and #61 According to a sexual abuse investigation dated 8/8/23, Resident #61 reported Resident #54 had sexually assaulted her. Resident #54 had a known history of child abuse, was on the sex abuse registry due to an assault of an elderly person, and had recently gotten off parole for crimes he had committed in the past. A 4/12/23 behavioral assessment documented that facility staff reported Resident #54 had made inappropriate sexual comments since his admission on 3/23/23. […]