Thorne Crest Retirement Center: Family Not Notified - MN
Nobody had called her.
The licensed practical nurse who assessed the resident on September 4th told inspectors she saw redness in his right eye and on his eyelid, extending above his eyebrow. She knew it was a change in condition. She acknowledged she should have contacted the family representative, a woman identified in inspection records as FM-B. She did not.
The eye worsened overnight. By September 5th, the swelling had increased and warmth had set in. A virtual physician was brought in to evaluate what had by then become a documented infection. FM-B still had not been called.
When inspectors reached FM-B by phone on the morning of September 18th, she was direct about what she expected and what she didn't get. "They should have called me when R1's eye first started getting red," she said. She told inspectors she wanted to be notified of any changes in his condition, and that she didn't learn about the infected eye until she came to the facility herself to visit him.
The resident, found lying in bed eating breakfast when inspectors observed him that morning, said the same thing in his own words: when his health changes, he wants the facility to notify FM-B.
The director of nursing reviewed the electronic medical record during the inspection and confirmed there was no documentation that FM-B had been notified at any point. The assistant director of nursing said the same thing and went further, stating it did not look like anyone had notified the family of the change in condition and that they should have. Both said notification should have happened immediately and should have been entered into the medical record.
It was not.
Inspectors requested the facility's written policy on notifying families during a change in condition. The facility did not provide it.
The deficiency was cited under F0580, which covers the requirement that facilities notify resident representatives of changes in condition. Inspectors rated the level of harm as minimal harm or potential for actual harm, with few residents affected. The inspection was conducted as a complaint survey and completed September 18, 2025.
What the records show is a resident whose eye infection went from redness to swelling to a telehealth visit over the course of two days, with no one at the facility contacting the person he had designated to speak for him. The nurse who first assessed him knew she hadn't made the call. The director of nursing confirmed the record was empty where a notification entry should have been. The assistant director of nursing said it plainly: the family should have been told immediately.
FM-B found out the way families aren't supposed to find out, by showing up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thorne Crest Retirement Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 22, 2026 · Our methodology
Thorne Crest Retirement Center in ALBERT LEA, MN was cited for violations during a health inspection on September 18, 2025.
She knew it was a change in condition.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.