Thornapple Manor
Thornapple Manor in Hastings, MI — inspection on September 4, 2025.
Found 2 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
Resident #103 reported she had two small bags with quarters in her nightstand in her room. Resident #103 reported one was a blue stuffed bird with approximately ten dollars of quarters inside, and the other was a small, dark-colored purse with an additional ten dollars of quarters. Resident #103 reported she recalled adding some money to one of the small bags (the blue stuffed one) and stated On Saturday morning (8/9/25) it was so full .I remember thinking I'm going to have to remove some quarters . Resident #103 reported on Monday, 8/11/25, she realized the small, dark-colored purse was missing and the blue stuffed bird bag was empty. Resident #103 reported she notified staff, and they searched her room with no bag or quarters found. Resident #103 reported the facility completed an investigation into her missing bag/money and showed her a photo of Agency CNA T holding a small bag near the vending machines. Resident #103 identified the small purse in the photo as her missing coin purse, and stated, They showed me her hand, and she was holding the bag . Resident #103 stated, I felt really bad. I was hurt because this is my home .I want to feel safe here. I didn't want to accuse anyone . Resident #103 recalled her interactions with Agency CNA T and described her as standoffish. Resident #103 reported she did not recall Agency CNA T ever assisting her (Resident #103) with care and stated she (Resident #103) makes her own bed and there was no reason for Agency CNA T to be in her (Resident #103's) room on 8/9/25.In an interview on 9/4/25 at 1:19 PM, Director of Social Services C reported on 8/11/25 there was a staff meeting and a life enrichment staff member reported Resident #103 had some missing money.
Director of Social Services C reported Administrator A and DON B were notified and an investigation was initiated.
Director of Social Services C reported Resident #103 reported a small change purse was missing which had contained approximately ten dollars of quarters, and a second fuzzy bag which contained another ten dollars of quarters was empty.
Director of Social Services C reported they reviewed the camera footage and observed Agency CNA T enter Resident #103's room on 8/9/25 at approximately 3:18 PM.
Director of Social Services C reported Agency CNA T was in the room for approximately 2-3 minutes.
Director of Social Services C reported when Agency CNA T exited the room, one of her pockets looked puffier and different than in previous camera views.
Director of Social Services C reported they pulled pictures from the camera footage and showed them to Resident #103, who was able to identify the bag in Agency CNA T's hand as her missing change purse.
Review of the policy/procedure Abuse, Neglect and Exploitation, dated 11/2024, revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .
Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Thornapple Manor
2700 Nashville Rd Hastings, MI 49058
SUMMARY STATEMENT OF DEFICIENCIES
lowered to the floor by (CNA U) on 8/17/25. (CNA U) was using a gait-belt and commode as is per the resident's plan of care.
She did however transfer (Resident #102) by herself .(Resident #102's) plan of care was changed on 8/11/25, prior to the incident to .2 assist with gait belt to stand at grab bar in bathroom while commode is placed behind her .Review of an Incident/Accident Report for Resident #102, dated 8/17/25 at 9:34 PM, revealed .I (LPN K) was called into resident's room to see resident lying on her right side in the bathroom.
Resident was on the commode before this. (CNA U) was with her and stated that resident did not fall and that she lowered her down to the floor. CNA was sitting on the floor with resident.
The resident had a pillow under her head .Resident was assessed and no pain was noted. I asked resident if she hit her head and she stated no. I asked resident if she got hurt and she said no she didn't get hurt.
CNA and I helped her back into her wheelchair with her gait belt and another staff member put her wheelchair underneath her. I had help with a CNA and assisted resident into bed using her pivot disc .
Note this Incident/Accident report was not created/completed until after Resident #102's fracture was identified.
Review of the policy/procedure Maintaining and Establishing Care Guides, dated 9/2025, revealed .A care guide/kardex is a quick reference tool based off the resident's individualized plan of care that was developed by the resident and members of the interdisciplinary team.
This information should be easily located and used by staff to assist the resident with their direct care needs .
Review of the policy/procedure Incident Reports, dated 8/2025, revealed It is the policy of (Facility Name) to complete an investigation i.e. incident report (IR) when a resident falls or sustains an injury.
The purpose of the IR is to complete a thorough assessment of the incident, identify the root cause, and a corrective action in hopes of preventing the incident from re-occurring. An Accident/Incident Report must be completed on the shift in which the accident/incident occurred .An incident report will be completed by the nurse whom the incident is reported to or identified by .The incident report will include the (resident's) recollection (when available) and .A description of what happened, including staff/witness statements .In the event of a fall, a Fall Huddle will be completed .The (nurse's) assessment and description of the medical treatment administered .A description of the corrective actions and/or preventive measures implemented to prevent such accident/incident from recurring .A comprehensive investigation will be completed by the Risk Management nurse as soon as possible .During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education to all staff on checking the care guide before providing care or assistance, re-education to the nursing staff on the policy/procedure Maintaining and Establishing Care Guides as well as the importance of checking the care guide before providing any care, and a process change to how changes in the care guides are communicated to nursing staff via the huddle board.
The policy/procedure Incident Reports was updated to better define a fall, and nurses were educated on this policy/procedure and when an incident report must be completed.
The facility was able to demonstrate monitoring of the corrective action and maintained compliance.
Compliance date of 9-3-25.
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