Thornton Care Center

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Thornton Care Center

501 Thornton Pkwy Thornton, CO 80229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Thornton Care Center

501 Thornton Pkwy Thornton, CO 80229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#1) of two residents reviewed for medication documentation out of 14 sample residents.Specifically, the facility failed to ensure Resident #1's electronic medical record (EMR) contained complete and accurate documentation related to the administration of the resident's scheduled levetiracetam (a medication used to treat epilepsy, a seizure disorder) medication.Findings include:I. Facility policy and procedureThe Administering Medications policy, dated 8/4/25, was provided by

the nursing home administrator (NHA) on 9/2/25 at 11:05 a.m. The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications. Record the results of medications administered per facility policy and procedure. Each time a medication is administered it must be documented.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE REDACTED], discharged to the hospital on 7/9/25, and was readmitted on [DATE REDACTED]. 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.

Event ID:

Facility ID:

If continuation sheet