Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thornton Manor Nursing And Care Center during CMS and state inspections, most recent first.
The facility served a seven-layer salad as a substitution for a Mandarin spinach salad without Dietician approval or documentation of nutritional equivalence. The substitution was not recorded on the menu, lacked a nutrient analysis, and did not meet the facility's policy for menu changes. The CDM maintained a handwritten log of substitutions without Dietician sign-off, and there was no system in place to ensure substitutions were nutritionally appropriate.
Surveyors found that cold food items, including a seven-layer salad, were served at unsafe temperatures above 41°F, and that a CDM handled serving utensils by the serving end with bare hands before serving food to multiple residents. The facility lacked a system for monitoring and documenting cold food temperatures, and staff were not fully trained on proper food safety practices.
A resident with severe cognitive impairment and total dependence on staff for eating had a care plan that did not specify whether a Paid Nutritional Assistant (PNA) could provide meal assistance. Staff, including the DON and case manager, were unaware that care plans needed to address the use of PNAs, and the facility lacked a policy for updating care plans to reflect this. The deficiency was identified through record review and staff interviews.
A resident receiving daily Doxycycline and Erythromycin eye ointment for chronic eye conditions was not tracked on the facility's Infection Control Logs, as prophylactic antibiotics were excluded from monitoring. The Pharmacy Review Logs also lacked documentation of review for these antibiotics, and the facility's Antibiotic Stewardship Policy did not address monitoring of prophylactic antibiotic use.
A resident with severe cognitive impairment and a pureed diet was assisted with meals by a PNA without documented assessment or care plan inclusion, and staff were unaware of requirements for evaluating or documenting PNA use. Facility staff demonstrated confusion about supervision and assignment of PNAs, and the process outlined in facility policy was not followed.
The facility failed to prevent contamination by allowing dietary aides to touch the drinking rim surfaces of glasses with bare hands during meal service. Observations revealed that dietary aides served glasses to residents while touching the drinking rim surfaces with their bare fingers. The facility lacked a policy on hand placement during dining service, and the Dietary Supervisor acknowledged this absence, explaining that staff are educated to handle cups from the side and keep silverware ends wrapped.
Unapproved Menu Substitutions Without Nutritional Equivalence
Penalty
Summary
The facility failed to ensure that approved menu substitutions of similar nutritional content were served to residents, as required by policy. On a scheduled meal, the Certified Dietary Manager (CDM) substituted a seven-layer salad for the planned Mandarin spinach salad without documenting the substitution or the reason for the change on the menu. The substitution was not approved by the Consulting Dietician, who later confirmed that the seven-layer salad did not have similar nutritional content to the original menu item. The seven-layer salad was served to 19 residents at the noon meal, and its recipe lacked a nutrient analysis. In contrast, the original Mandarin spinach salad had a documented nutritional breakdown. Further review revealed that the CDM maintained a handwritten log of menu substitutions, none of which were signed off by the Dietician. The CDM stated that the previous Dietician did not require notification or approval of substitutions, and there was no established system in place for documenting or approving menu changes. The facility's substitution policy required collaboration with the Dietician and proper documentation, including the reason for substitutions, but this was not followed. The deficiency was identified through observation, interviews, and review of facility policies and documentation.
Improper Cold Food Holding and Utensil Handling During Meal Service
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety practices during meal preparation and service. Specifically, a large bowl of seven-layer salad was left sitting on a cart without any cold holding measures, such as ice or a cold container, to keep it at a safe temperature. The Certified Dietary Manager (CDM) pureed and prepared servings of the salad for several residents, placing some portions in cold containers only after initial preparation. Temperature checks revealed that the salad was served at temperatures ranging from 45.3 to 47.9 degrees Fahrenheit, which is above the recommended maximum of 41 degrees for cold foods. The CDM did not refrigerate or cool the salad before serving, and the facility did not have a system in place to monitor or document the temperatures of cold food items, except for milk. Additionally, the CDM was observed handling serving utensils by the serving end with bare hands after touching other surfaces, such as the menu, and then using those utensils to serve food to residents. Ten residents were served apricot chicken using tongs that had been handled improperly. Staff interviews confirmed that there was a lack of awareness and training regarding proper cold food temperature monitoring and utensil handling. The facility's food handling policy did not provide clear direction on holding and monitoring cold food temperatures, contributing to the observed deficiencies.
Failure to Revise Care Plan to Specify Use of Paid Nutritional Assistants for Meal Assistance
Penalty
Summary
The facility failed to revise the care plan for a resident who required assistance with eating to specify the use of Paid Nutritional Assistants (PNAs). The resident in question had severely impaired decision-making, memory problems, and was dependent on staff for eating, with diagnoses including stroke, anxiety, and Alzheimer's Disease. The care plan indicated the need for one-person assistance during meals but did not clarify whether this assistance could be provided by a PNA. Staff interviews revealed that neither the Director of Nursing (DON) nor the case manager were aware that care plans needed to specify if a PNA could safely assist a resident with meals. Additionally, a list of staff certified to feed residents did not reference specific residents or care plans. The deficiency was identified through observation, clinical record review, and staff interviews, which confirmed that the care plan lacked documentation regarding the use of PNAs for meal assistance. The facility did not have a policy in place for revising care plans to include this information, and there was no evidence that any resident care plans addressed the use of PNAs for meal assistance at the time of the survey.
Failure to Track Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to track the use of prophylactic antibiotics for a resident with a history of hemiplegia, depression, and anxiety, who was prescribed daily Doxycycline and Erythromycin eye ointment for keratitis and keratoconjunctivitis. Observations and record reviews revealed that the resident's ongoing use of these antibiotics, as ordered by an ophthalmologist, was not documented in the facility's Infection Control Logs for several months. The Infection Preventionist confirmed that prophylactic antibiotics were not being tracked on these logs, as she did not consider them necessary to include. Additionally, the facility's Pharmacy Review Logs lacked documentation that the resident's antibiotic regimen was reviewed during routine monthly pharmacist reviews. The facility's Antibiotic Stewardship Policy did not provide instructions for monitoring prophylactic antibiotics, only directing the Pharmacy Consultant to review antibiotic use during medication regimen reviews. The Director of Nursing stated that all prophylactic antibiotics should be tracked on the monthly Infection Control log and was unaware they were not being tracked until informed during the survey.
Failure to Assess and Care Plan for Feeding Assistant Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed for appropriateness before being assigned to the Paid Nutritional Assistant (PNA) program, and did not document or reflect the use of PNAs in the residents' care plans. For one resident with severely impaired decision-making, memory problems, and a history of stroke and Alzheimer's Disease, there was no documented assessment to determine if a PNA could safely assist with feeding. The care plan did not specify whether a PNA could provide meal assistance, and staff interviews revealed a lack of awareness regarding the need for such assessments or care plan documentation. Observations confirmed that a PNA assisted the resident with meals, but staff, including the DON and RNs, were unaware of the requirement for assessment or care plan inclusion for PNA use. Further, staff interviews indicated confusion about supervision and assignment of PNAs, with some staff unsure who was responsible for supervising PNAs or how residents were selected for PNA assistance. The facility's policy required that a nurse assign PNAs only to residents without complicated feeding problems, based on assessment and care plan, but this process was not followed. Documentation and staff knowledge gaps led to the use of PNAs without proper assessment, care planning, or clear supervision, as required by facility policy and regulatory standards.
Failure to Prevent Contamination During Meal Service
Penalty
Summary
The facility failed to prevent possible contamination by allowing dietary aides to touch the drinking rim surfaces of glasses with bare hands during meal service. Observations during the noon meals on two consecutive days revealed that Staff A and Staff B, both dietary aides, served glasses to residents while touching the drinking rim surfaces with their bare fingers. Specifically, on the first day, Staff A served 12 glasses to 9 residents, and on the second day, Staff B served 25 glasses to 14 residents in this manner. The facility did not have a policy regarding hand placement during dining service, which contributed to this deficiency. In an interview, the Dietary Supervisor, Staff C, acknowledged the absence of such a policy and explained that staff are educated through an online program to handle cups from the side and keep silverware ends wrapped. Staff are expected to complete this education before starting work, and the supervisor expected staff to touch only the napkin and not the silverware itself, and to grab glasses from the side or the handle of a coffee cup, avoiding the drinking surface.
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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 Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northgate Care Center | 13.6 mi | ★★★★★ | 18 | 1 |
| Good Samaritan - Waukon | 13.6 mi | ★★★★★ | 9 | 1 |
| Prairie Maison | 22.4 mi | ★★★★★ | 0 | 0 |
| Vernon Manor | 22.7 mi | ★★★★★ | 11 | 0 |
| Soldiers Grove Health Services | 23.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.