Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thorne Crest Retirement Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was injured after rolling out of bed and coming into contact with a wall heater that was positioned only 11 inches away, resulting in second-degree burns. Staff had not been consistently educated or auditing bed placement, and maintenance had not documented or continued regular checks to ensure beds were kept at a safe distance from heaters.
A resident with cerebral palsy and an elevated white blood count developed right eye pain, redness, and swelling, which progressed to suspected cellulitis and conjunctivitis. Nursing staff escalated care and new medications were ordered, but the resident's representative was not notified of the change in condition or treatment, as confirmed by staff interviews and record review.
A resident with cerebral palsy and a history of elevated WBC developed an eye infection, but staff failed to consistently monitor and document signs and symptoms of infection after antibiotics were started. Additionally, the resident was transported in a manual wheelchair without a safety assessment and left unattended at an outside appointment, despite being unable to self-mobilize. Communication lapses and lack of clear procedures contributed to the deficiencies.
A resident with a diagnosed eye infection did not receive prescribed oral and ophthalmic antibiotics on the day they were ordered, despite provider instructions for immediate administration. Medication records and staff interviews confirmed the delay, and the error was not communicated to the resident or their representative. Facility policy required timely administration and documentation of medication errors, but the process was not followed, and leadership was unaware of the incident until identified by surveyors.
Staff did not follow standard and contact precautions for a resident with active shingles, including failing to perform hand hygiene and use PPE when entering the room. The required PPE cart was not placed outside the room as expected, and staff interviews revealed a lack of understanding regarding infection control protocols, resulting in improper implementation of precautions.
A resident with severe cognitive impairment and identified as an elopement risk left the facility unsupervised through an unlocked door. The resident was found outside with hypothermia and minor injuries. Staff were unaware of the resident's elopement risk, and the facility's policy on elopement was not effectively communicated or implemented.
A resident with severe cognitive impairment was found to have inadequate hydration due to the water pitcher being placed out of reach, despite being able to drink independently. Observations and staff interviews revealed that the water pitcher was not consistently placed on a bedside table, and there was confusion among staff about the policy for refilling water pitchers. The facility's policy required water pitchers to be within easy reach and refilled each shift, but this was not consistently followed.
A facility failed to protect residents from sexual abuse by a resident with a known history of inappropriate behavior. Despite documented incidents and a care plan that included supervision and checks, these measures were inadequately implemented. Staff were not informed or trained to monitor the resident effectively, and documentation was insufficient, leading to a failure to protect residents from potential harm.
The facility failed to report incidents of inappropriate touching and sexual abuse allegations involving a resident to the State Agency within the required timeframe. Despite staff intervention, the incidents were not documented or reported promptly, as some staff perceived them as harmless. The facility's policy required immediate reporting, but a breakdown in communication and adherence to protocols led to the deficiency.
The facility failed to ensure proper hand hygiene during personal and wound care for two residents. A nursing assistant and a licensed practical nurse did not follow hand hygiene protocols, including changing gloves and washing hands at critical points during care activities, as confirmed by interviews and observations.
Failure to Maintain Safe Bed Distance from Heater Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was placed a safe distance away from a wall heater, resulting in the resident becoming entrapped and sustaining second-degree burns. The resident involved had severe cognitive impairment, a diagnosis of neurocognitive disorder with Lewy Bodies dementia, anxiety, and a history of falls and self-transfers. The care plan indicated the resident required assistance with transfers and bed mobility, but was independent with rolling in bed. Despite these needs, the bed was positioned too close to the heater, with staff measuring the distance at only 11 inches at the time of the incident. On the morning of the incident, the resident was found between the bed and the heater, having rolled out of bed and come into contact with the heater. The resident sustained burns to the left hip and back, with multiple blistered areas and bruising on both knees. Staff interviews revealed that the bed had been near the heater for an extended period, and that the resident frequently attempted to get out of bed independently. Staff also reported that the heaters felt hot to the touch and that there was no prior education or consistent auditing to ensure beds were kept at a safe distance from the heaters. Documentation and interviews indicated that maintenance had previously performed a visual audit of bed placement but did not document the results or continue regular checks. Nursing staff were not routinely verifying bed distance from heaters, and there was no established policy or education regarding the required minimum distance prior to the incident. The lack of consistent monitoring and clear procedures contributed to the resident's ability to access the hazardous area and sustain injury.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition for one resident with a history of cerebral palsy and an elevated white blood count. The resident began experiencing right eye pain, redness, and swelling, which progressed over two days. Nursing staff documented the symptoms, administered acetaminophen, and escalated the concern to the DON, who suspected cellulitis and contacted the nurse practitioner for further evaluation. A telemedicine visit confirmed preseptal cellulitis and conjunctivitis, and new medications were ordered, including oral antibiotics and antibiotic eye drops. Despite these developments, there was no documentation that the resident's representative was notified of the change in condition or the new medical interventions. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the resident's representative was not informed of the change in condition, and all acknowledged that notification should have occurred and been documented. The resident's representative expressed frustration at not being informed and stated she only learned of the situation during a visit. The resident also indicated a preference for having his representative notified of health changes. Review of the electronic health record and staff interviews confirmed the lack of notification and documentation, and the facility was unable to provide a policy regarding notification of changes in condition.
Failure to Monitor Infection and Ensure Safe Transport for Resident with Mobility Impairments
Penalty
Summary
The facility failed to monitor for signs and symptoms of infection for a resident who was at risk due to refusal of vaccinations and had a history of cerebral palsy and elevated white blood count. The resident developed redness, swelling, and pain in the right eye, which was identified as possible cellulitis. Orders were given for oral and eye drop antibiotics, and staff were instructed to mark the area of redness and monitor for spread. However, there was no consistent daily or shift-based documentation or comprehensive assessment of the infection from the time antibiotics were started through the following week, as confirmed by multiple staff interviews and review of the electronic health record. The lack of monitoring was acknowledged by the LPN, ADON, DON, and the nurse practitioner, all of whom stated that regular assessments should have been performed and documented to detect changes in the resident's condition. Additionally, the facility failed to ensure safe transportation for the same resident to an outside appointment. The resident, who normally used a specialized electric wheelchair due to immobility from cerebral palsy and scoliosis, was transferred to a manual wheelchair for transport because the facility van could not accommodate the electric wheelchair. The resident was left unattended in the manual wheelchair at the clinic for approximately 20 to 25 minutes, during which time he was unable to move himself or seek assistance due to lack of core strength. The family member and staff interviews confirmed that the resident was not assessed for safety in a manual wheelchair prior to transport, and the director of therapy expressed concern about the lack of such an assessment given the resident's physical limitations. Communication failures also contributed to the incident, as the transport driver was not provided with proper paperwork or clear instructions regarding the resident's destination, resulting in the resident being left at the wrong location. The family member was not immediately informed of the resident's whereabouts, and facility staff were unaware that the resident had been left unattended. Facility policies for infection monitoring and safe transport were requested but not provided for review.
Failure to Timely Administer Ordered Antibiotics for Eye Infection
Penalty
Summary
A resident with intact cognition and diagnoses of cerebral palsy and elevated white blood count developed symptoms of an acute right eye infection, including redness, swelling, pain, and discharge. During a telemedicine visit, the provider ordered both oral and ophthalmic antibiotics to be started immediately due to concerns for preseptal cellulitis and conjunctivitis. The provider's orders specified that the medications should be started the same day, and nursing staff were instructed to check the emergency kit for the required eye drops and to monitor the resident for worsening symptoms. Despite these orders, the resident did not receive the prescribed oral or ophthalmic antibiotics on the day they were ordered. Medication administration records showed that both medications were not started until the following day, with missed doses documented for the initial day. Interviews with family members, the resident, and multiple staff confirmed that the medications were not administered as ordered, and the delay was not communicated to the resident or their representative. Nursing staff and leadership acknowledged that this constituted a medication error, as provider orders were not followed and the required medications were not made available or administered as directed. Facility policy required that medications be administered according to provider orders and that any medication errors be documented, assessed, and reported. However, the Director of Nursing was not aware of the error until it was identified by the surveyor, and there was inconsistency in the documentation and reporting process. The facility's medication error policy and forms did not clearly specify requirements for resident or representative notification or documentation of resident assessment following a medication error.
Failure to Follow Contact Precautions and Proper PPE Use
Penalty
Summary
Staff failed to follow standard and transmission-based precautions for a resident who was on contact precautions due to an active shingles infection affecting the right eye. The resident had a history of cerebral palsy and an elevated white blood count, and laboratory results confirmed a positive test for varicella zoster virus. Upon return from the hospital, the resident was placed on contact precautions, with a sign posted on the door indicating the need for hand hygiene and the use of gowns and gloves before entering the room. Despite these precautions, observations revealed that a hospitality aide entered the resident's room to deliver a meal tray without performing hand hygiene or donning the required personal protective equipment (PPE) as indicated by the signage. The aide was unaware of the reason for the contact precautions and could not articulate the need for PPE. Additionally, the PPE cart, which should have been placed outside the resident's room for easy access and to prevent contamination, was instead located inside the room, contrary to best practices and the facility's own infection control expectations. Interviews with staff, including a licensed practical nurse, a nursing assistant, the assistant director of nursing (who also served as the infection control nurse), and the director of nursing, confirmed inconsistent understanding and implementation of infection control protocols. Staff acknowledged the resident was on contact precautions and that hand hygiene and PPE use were required, but the PPE cart was not properly positioned, and staff did not consistently follow hand hygiene or PPE protocols. Facility policies outlined the need for standard and transmission-based precautions, but did not specify PPE cart placement, contributing to the observed deficiencies.
Resident Elopement Due to Inadequate Supervision and Unlocked Door
Penalty
Summary
The facility failed to maintain adequate supervision and safety measures for a resident identified as an elopement risk, leading to the resident leaving the facility unsupervised. The resident, who had severe cognitive impairment and was recently admitted, expressed a desire to go home and was not accepting of the facility placement. Despite being identified as at risk for elopement, no interventions were implemented to prevent the resident from leaving the facility unattended. On the night of the incident, the resident exited the building through an unlocked door to a courtyard without staff awareness. The resident was found outside in the early morning hours, suffering from hypothermia and minor injuries. The staff, including the LPN and nursing assistant on duty, were not aware of the resident's elopement risk and did not provide the necessary supervision or assistance. The facility's policy on elopement and wandering residents was not effectively communicated or implemented, contributing to the incident. Interviews with staff revealed a lack of communication and awareness regarding the resident's risks and needs. The interdisciplinary team did not effectively communicate or develop appropriate interventions to address the resident's elopement risk. The courtyard door was not equipped with a wanderguard system and was left unlocked, allowing the resident to leave the facility unsupervised.
Removal Plan
- The facility locked the courtyard doors.
- Placed all residents on checks until all residents were re-assessed for elopement risk.
- Residents at risk for elopement were placed on checks until individualized interventions were developed and implemented.
- Reviewed all resident care plans.
- Revised the elopement policy.
- Re-educated all staff on the elopement policy and on risk factors to watch for.
- Upon R1's hospital return, the facility re-assessed R1 for elopement and fall risks and implemented interventions to mitigate the risks.
Inadequate Hydration and Accessibility of Water for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident with severe cognitive impairment, who was independent with eating and drinking but required extensive assistance for mobility, transfers, and toileting. The resident's care plan indicated that refreshments should be provided in the afternoon and that the resident could drink water without assistance if it was within reach. However, observations revealed that the resident's water pitcher was consistently placed out of reach, across the room from the bed, and not on a bedside table as required. Interviews with staff confirmed that the resident could not reach the water pitcher while in bed, and there was confusion among staff regarding the policy for refilling water pitchers. Despite the facility's policy stating that water pitchers should be placed within easy reach of residents and refilled each shift, the resident's water pitcher was often not accessible. Staff interviews indicated a lack of awareness or adherence to this policy, with some staff unsure of the procedures for refilling water pitchers. The director of nursing confirmed the existence of a policy requiring fresh water within reach, but observations showed that the resident's water pitcher was not consistently placed within reach, contributing to the resident's complaints of dry mouth and thirst.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to implement appropriate interventions to protect residents from sexual abuse by a resident with a known history of inappropriate sexual behavior. This resident, who had been admitted from another skilled facility, was observed inappropriately touching another resident in the day room. Despite the resident's history of sexual advances towards women, which was documented in physician notes and reported by family members, the facility did not have adequate measures in place to prevent such incidents. The resident's care plan, initiated after previous incidents, included measures such as constant supervision during recreation programs and 15-minute checks. However, these interventions were not effectively implemented or documented. Staff interviews revealed that the 15-minute checks were deemed inadequate, and there was a lack of communication regarding the resident's behaviors and necessary precautions. The facility's documentation was insufficient, failing to record specific incidents and the resident's whereabouts accurately. The facility's abuse policy did not adequately address the protection of residents from abuse, and staff were not informed or trained to monitor the resident effectively. The Director of Nursing was unaware of the resident's history and the severity of the incidents until after they occurred. This lack of awareness and inadequate documentation contributed to the facility's failure to protect residents from potential harm.
Removal Plan
- The facility reviewed and updated their abuse policy and procedure pertaining to resident-to-resident sexual abuse
- R1's care plan was updated with 1:1 to prevent him from having contact with vulnerable females related to his sexual inappropriate touching.
- R1 will have a video monitor on.
- R1 is not to be left by any female residents.
- The facility provided education to all facility staff on the policy and on implementation of individualized care plan and protection measures.
- The facility completed trauma informed care assessments and care plan updated on the residents affected by R1's behaviors.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report incidents of inappropriate and unwanted touching, as well as allegations of sexual abuse, to the facility administrator and the State Agency for six residents. The incidents involved a resident, R1, who was observed by a nursing assistant (NA-A) with his hand under another resident's shirt, performing inappropriate actions. Despite immediate intervention by staff, the incident was not reported to the State Agency within the required timeframe. The Assistant Director of Nursing (ADON) was informed but did not have the authority to report to the State Agency, and the Director of Nursing (DON) initially deemed the incident non-reportable. Further interviews revealed that R1 had a history of inappropriate sexual behaviors towards other residents, including R3, R4, and R6. These incidents were either not documented or not reported to supervisors, as some staff perceived them as harmless. R3 recounted uncomfortable encounters with R1, including attempts to hold her hand and inappropriate gestures. Staff interventions were noted, but the lack of documentation and timely reporting contributed to the deficiency. The facility's policy required immediate reporting of abuse allegations, defined as within two hours for serious incidents. However, the DON was unaware of R1's background and did not initiate a report or investigation promptly. The social worker eventually reported the incident to the State Agency and law enforcement after consulting with corporate, highlighting a breakdown in communication and adherence to reporting protocols within the facility.
Failure to Ensure Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during personal care and wound care for two residents. One resident, diagnosed with dementia, traumatic brain injury, and weakness, required substantial assistance with dressing and grooming. During an observation, a nursing assistant (NA) did not change gloves or perform hand hygiene after providing incontinent care and before assisting the resident with other activities, such as sitting up in bed and moving to a wheelchair. The NA only used hand sanitizer after pushing the resident to the dining room, which was confirmed during an interview with the NA. Another resident, diagnosed with malignant neoplasm of the pancreas and adult failure to thrive, had a stage two pressure injury on the coccyx. During wound care, a licensed practical nurse (LPN) and a trained medication aide (TMA) failed to perform hand hygiene at multiple critical points, including after removing soiled dressings, before applying new gloves, and after scratching the resident's back. The LPN and TMA did not follow the facility's hand hygiene policy, which was confirmed during an interview with the LPN. The facility's policy required hand hygiene immediately before and after resident contact, after contact with blood or body fluids, and after glove removal.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Albert Lea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Johns On Fountain Lake | 2 mi | — | 15 | 0 |
| Good Samaritan Society - Albert Lea | 3 mi | — | 5 | 0 |
| Lutheran Retirement Home | 15.8 mi | — | 8 | 0 |
| New Richland Care Center | 17.7 mi | — | 2 | 0 |
| Sacred Heart Care Center | 18.2 mi | — | 0 | 0 |
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