A list of the most recent deficiencies for Thorne Crest Retirement 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? |
|---|---|---|---|---|
| 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 | 2023-10-26 | 2023-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-26 | 2023-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-12-15 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-26 | 2023-12-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-26 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-12-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-26 | 2023-12-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-26 | 2023-12-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-26 | 2023-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-24 | 2023-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-08 | 2023-01-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-08 | 2023-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2023-01-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-08 | 2023-01-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-08 | 2023-01-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-08 | 2023-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-20 | 2021-10-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-20 | 2021-10-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-20 | 2021-10-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-20 | 2021-10-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-20 | 2021-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-20 | 2021-10-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-20 | 2021-10-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-20 | 2021-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-20 | 2021-10-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-08-20 | 2021-10-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-20 | 2021-10-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-20 | 2021-10-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-20 | 2021-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-17 | 2021-08-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-17 | 2021-08-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-17 | 2021-08-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-09 | 2021-04-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-03-09 | 2021-04-10 | Y |
