Thornton Care Center
THORNTON CARE CENTER in THORNTON, CO — inspection on September 2, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
in the facility's hallways were always high.
She said she was unsure when the water cooler was turned off and said only maintenance personnel were authorized to adjust the cooling fans. LPN #1 said on hot days, residents were provided with extra ice.
Certified nurse aide (CNA) #1 was interviewed on 8/19/25 at 1:05 p.m. CNA #1 said the facility hallways were hot and he said the cooler fan was off because a resident complained it was cold in the hallway.
The NHA was interviewed on 8/19/25 at 1:15 P.M.
The NHA said he was unaware of acceptable room temperatures and said he had no current complaints from residents about room temperatures.The NHA was interviewed again on 8/19/25 at 2:40 p.m.
The NHA said the maintenance director (MTD) was aware the cooling fan was not working in the morning (on 8/19/25) on the [NAME] unit and replaced a fan motor.
The NHA said the cooling fan was now operational and the MTD had verified that all the facility's water coolers were operational.
The NHA said on hot days, the facility provided extra ice and popsicles to the residents, closed dark shades, checked on residents frequently and offered outdoor activities.
The NHA was interviewed a third time on 8/20/25 at 9:40 a.m.
The NHA said the facility had rented two large water coolers for the [NAME] and East units because the residents' room temperatures remained high on 8/19/25.
The MTD was interviewed on 8/20/25 at 2:25 p.m.
The MTD said the facility was an old building and the water coolers were old and inefficient.
The MTD said the two rented water coolers were effective to cool the facility hallways and residents' room temperatures to safe temperatures.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/02/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Thornton Care Center
501 Thornton Pkwy Thornton, CO 80229
SUMMARY STATEMENT OF DEFICIENCIES
locate who made the appointment and who arranged and approved for the spouse to provide transportation.
The DON said the IDT did not review the fall because Resident #4 fell at a store, was treated by paramedics, and was transferred to the hospital.
The DON said neurological assessments were completed after unwitnessed falls or when a resident had a head injury.
The DON was unable to locate neurological assessments for the 8/4/25 fall.
The NHA said he recalled discussing Resident #1 and Resident #4 after their falls but was unsure of corresponding recommendations made by the IDT.
The NHA said the documentation of the reviews that were completed by the IDT were not documented in either residents' EMRs, but he had a daily log that indicated the reviews had occurred.
The NHA said he was unable to find IDT documentation pertinent to falls for Resident #1 and Resident #4.
The NHA said the IDT needed to improve documentation of clinical discussions.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/02/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Thornton Care Center
501 Thornton Pkwy Thornton, CO 80229
SUMMARY STATEMENT OF DEFICIENCIES
According to the August 2025 computerized physician orders (CPO), diagnoses included epilepsy (a seizure disorder), neurocognitive condition without behavioral disturbance, unspecified intracranial injury with loss of consciousness, insomnia, osteoarthritis, sacrum (pelvic) fracture and history of falling.The 4/24/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.
The resident was independent from staff assistance for bed mobility, sitting and standing, transferring and walking with a walker.B.
Record reviewReview of Resident #1's August 2025 CPO revealed the following physician's orders:Levetiracetam 1000 milligrams (mg) twice a day for seizures, administer at 6:00 a.m. and 4:00 p.m., ordered on 6/5/25.A review of Resident #1's July 2025 (from 7/1/25 to 7/31/25) medication administration record (MAR) revealed that a code of 9 was documented for the administration of levetiracetam on 7/8/25 and 7/9/25.
According to the MAR, the code of 9 indicated other/see progress notes.-A review of Resident #1's progress notes on 7/8/25 and 7/9/25 failed to reveal documentation to indicate whether or not the levetiracetam medication was administered to the resident as ordered on those dates.III.
Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/2/25 at 4:27 p.m. LPN #1 said he was the nurse assigned to administer medications to Resident #1 on 7/8/25 and 7/9/25. He said he documented a code of 9 for the resident's levetiracetam on both of those dates because he had been unable to locate the medication in order to administer it. He said on 7/8/25 and 7/9/25, another nurse had been able to find the medication in the facility's supply of emergency medications. LPN #1 said he had administered the medication to Resident #1 after receiving the doses from the nurse. LPN #1 said he should have documented a corresponding progress note in the EMR after the medication was administered.
The director of nursing (DON) was interviewed on 8/25/25 at 4:27 p.m.
The DON said LPN #1 should have documented a corresponding progress note in the EMR after Resident #1's levetiracetam was administered on 7/8/25 and 7/9/25.
The DON said LPN #1 was a new employee at the facility and he had been unsure how to document that the medication was administered after he had already entered a code of 9 on the MAR.
Facility ID: