Thornton Care Center

F-F600 was cited at a D level scope and severity, potential for more than minimal harm, isolated. Residents Affected - Some

F-F686 was cited at a G level scope and severity, isolated, actual harm.

F-F867 was cited at an E level scope and severity, a potential for more than minimal harm, pattern.

IV. Interviews

The nursing home administrator (NHA) was interviewed on 6/20/24 at 2:10 p.m. The NHA said residents with pressure injuries were reviewed at QAPI. However, he said the lack of assessment and timely treatment of wounds identified during the survey was an eye opener. The NHA said the facility had missed things in their

review of the wounds. The NHA said he did not have a clinical background and therefore did not check any of the clinical information himself.

The NHA said the staff needed more training on abuse and how to appropriately prevent, report and intervene in abuse situations. He said the facility additionally needed to keep a better record of training that was completed with staff on abuse.

The medical director (MD) was interviewed on 6/24/24 at 9:57 a.m. The MD said she had become the medical director of the facility two weeks ago (beginning of June 2024). She said the facility had been using

a lot of agency staff and they were working on recruiting staff for hire by the facility. She said she felt this contributed to the facility's failures. The MD said she knew the facility had changed wound care providers recently, but she was not aware wounds were not being assessed by the facility or treated timely.

The MD said she did not recall the staff to resident abuse when a staff person laid on a resident intentionally, causing multiple rib fractures and a pneumothorax. However, she said she had not been with the facility long.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 065193