Thornton Manor Nursing and Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF882May 7, 2026

  Based on record review, staff interviews, and policy review the facility failed to ensure the Infection Preventionist (IP) had sufficient time to perform the duties of the infection control program, when the IP worked 1 to 2 hours a week on average in the IP role while working full time as a floor nurse. During April 2026, the facility's infection logs showed that 7 of 28 residents were diagnosed with a Urinary Tract Infection (UTI) (Resident #11, #13, #35, #18, #20, #23, and #26), and the IP had not yet completed staff training or audits to address the UTI rate. The facility reported a census of 29 residents. […]

• No harm, potential for more than minimal, patternF803Apr 3, 2025

  Based on observation, policy review, document review, consulting dietician and staff interviews, the facility failed to serve approved menu substitutions of similar nutritional content. The facility identified a census of 31 residents. Findings include: On 3/31/25 (Monday) the Certified Dietary Manager (CDM) provided a copy of the Week 4 Tuesday Menu which included to provide a Mandarin spinach salad at the noon meal. The Week 4 Tuesday Noon menu lacked documentation of the substitution and reason why the substitution was needed on the actual menu. The CDM reported they had tried to serve the Mandarin spinach salad a few times and it didn't go over well. She stated she would be substituting a seven-layer salad in its place. […]

• No harm, potential for more than minimal, patternF812Apr 3, 2025

  Based on observation, policy review, and staff interview the facility failed to prevent bare hands from contacting serving utensils and failed to recognize proper cold food temperatures and served 6 of 19 residents a seven-layer salad that had temperatures from 45.3 to 47.9 degrees Fahrenheit prior to serving. The facility identified a census of 31 residents. Findings include: On 4/01/25 at 10:26 AM the following kitchen observations were made: a. At 10:26 AM the Surveyor entered the kitchen and observed a large stainless steel bowl of seven-layer salad sitting on top of a cart without a cold container or ice under the bowl to keep cold. b. […]

• No harm, potential for more than minimal, patternF812May 30, 2024

  Based on observation, policy review, and staff interview the facility failed to keep bare hands off the drinking surface of glasses to prevent possible contamination. The facility reported a census of 31 residents. Findings include: During an observation of the noon meal on 5/28/24 from 11:28 AM to 12:00 PM Staff A, Dietary Aide served 12 glasses to 9 residents with bare fingers touching the drinking rim surface of the glass. During an observation of the noon meal on 5/29/24 from 11:05 AM to 11:30 AM Staff B, Dietary Aide served 25 glasses to 14 residents with bare fingers touching the drinking rim surface of the glass. […]

• No harm, potential for more than minimal, patternF758Feb 15, 2023

  Based on record review, interview, and facility policy review, the facility failed to ensure the physician documented their rationale for extending as-needed (PRN) antianxiety medication beyond 14 days, ensured there was a specific duration for the PRN order, and failed to ensure the order was reviewed timely for 3 (Residents #5, #14, and #24) of 4 residents reviewed for unnecessary medications who had a PRN order for a psychotropic medication. Findings included: Review of a facility policy titled, PRN Psychotropic Medication Prescribing and Monitoring, undated, revealed, PRN orders for psychotropic drugs are limited to 14 days. […]