Thornton Terrace Health Campus

In the surveyor’s words

From the most serious findings on record at Thornton Terrace Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 21, 2022

  Based on observation, record review, and interview, the facility failed to ensure interventions and assessments were implemented to prevent the development or worsening of new pressure ulcers for 2 of 5 residents reviewed for pressure ulcers, which resulted in the development of two stage III pressure ulcers. (Residents 18 and 20) Findings include: 1. The clinical record for Resident 18 was reviewed on 6/16/22 at 10:15 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 4/22/22, indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF812Sep 10, 2025

  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. […]

• No harm, potential for more than minimal, patternF761Jul 3, 2023

  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. […]

• No harm, potential for more than minimal, isolatedF554Sep 10, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF641Sep 10, 2025

  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. […]