Thorne Crest Retirement Center
THORNE CREST RETIREMENT CENTER in ALBERT LEA, MN — inspection on December 26, 2025.
Found 1 citation. 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
During an interview on 12/23/25 at 3:30 p.m., DON stated
small abrasion in the middle that looked like a scrape from the radiator cover and an area on his left
stated she read the progress note that stated blisters were present, but she never saw the blisters, and they must have resolved an hour after she walked in the room (which conflicted with comprehensive assessment on 12/18/25 completed by the hospice nurse that identified the blisters were still present).
Prior to the incident the beds were not being audited to verify length from radiators on wall. DON stated she audited the beds daily beginning 12/18/25, will begin weekly audits, monthly, and quarterly to make sure the facility is in compliance. A new policy was created on 12/19/25.
Maintenance reviewed the temperatures of all the room heaters. DON went to all rooms on 12/18/25, and verified the beds were 12 inches from the wall and placed orange duct tape on the floor indicating 12 inches.
Education to staff was completed on 12/18/25, and 12/19/25, regarding heaters, bed placement, basic first aid, and how to treat burns.ˆˆDuring a second interview on 12/24/25 at 12:13 p.m., DON stated R1 had his left hip towards the heater, and it was touching the heater. R1's right hip was against the bed. R1 was on his knees with right arm on the bed. R1 was facing the wall where the head of the bed was.
There was no way R1 would have been able to move away from the heater. R1's bed was 12 inches from the wall at the time of the incident, and that was the regulation (which was not consistent with observation and staff interviews that responded to incident when it occurred). DON went to all resident rooms and made sure the beds were all a minimum of 12 inches away from the heater and/or there was enough room where there would not be an entrapment issue if a resident were to fall or get up on that side of the bed.
During a phone interview on 12/24/25 at 9:05 a.m., medical doctor (MD)-A stated the DON sent an email on 12/18/25, about the burns R1 received but did not identify blisters were present.
Blisters would be considered second degree burns.
The facility should watch for infection, and pain for R1.
Silvadene was prescribed and that works amazing, helps immediately, and calms the burn down.
The facility Baseboard Radiators/Furniture policy dated 12/19/25, identified the facility will ensure that all heating unit covers/protective shields are intact and in good repair, work with staff, patients, and family to ensure furniture will not be placed against heater units with unsecure covers, transfer sides of the bed will be 12 inches from baseboard heating units.
This will be marked on floors to ensure compliance.
The DON or designee will audit furniture placement in rooms regarding heating unit quarterly and as needed.
Maintenance will monitor heat unit covers for temperature compliance annually and as needed.
All touchable heat surfaces should not exceed 159 degrees Fahrenheit.
The deficient practice was issued at past non-compliance after the following corrective actions were implemented on 12/19/25, and verified the facility took the following actions, prior to the start of the survey: -assessed R1 for injury and treated on 12/18/25 -rearranged R1's room and placed a fall mat on both sides of the bed to ensure adequate space between wall and bed to avoid getting stuck -applied orange duct tape to the floor in rooms signifying how far the bed could be in reference to the heaters on 12/18/25 -maintenance audited heaters in all rooms and verified temperatures of heaters were under 159 degrees on 12/19/25 -began audits of all rooms including rearranging to keep beds at least 12 inches away from the heaters -education provided at nursing assistant meeting on 12/18/25 -education provided to nurses included first aid and burn treatment along with bed placement at meeting on 12/19/25, all other staff received education on beds and heaters on 12/19/25 -created policy for radiators on 12/19/25
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.