Deficiency Records for Thornton Manor Nursing and Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Thornton Manor Nursing and Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-15 | 2023-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-21 | 2023-03-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-21 | 2023-03-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-21 | 2023-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-21 | 2023-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-21 | 2023-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-21 | 2023-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-21 | 2023-02-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-11-01 | 2021-11-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-01 | 2021-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-01 | 2021-11-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-01 | 2021-11-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-11-01 | 2021-11-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-11-01 | 2021-11-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-01 | 2021-11-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-01 | 2021-11-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-01 | 2021-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-28 | 2019-09-25 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-22 | 2019-09-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-22 | 2019-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-28 | 2019-09-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-28 | 2019-08-29 | N |
