Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Terrace Health Campus during CMS and state inspections, most recent first.
Kitchen sanitation and food dating deficiencies were identified during multiple observations. Surveyors observed food debris, grease buildup, burnt areas, dirty drip pans, and dried food residue on kitchen equipment and utensils, while an open bag of shredded lettuce past its expiration date and several brown salad greens past their expiration date were used or present during salad prep. The Dietary Mgr stated staff should monitor expiration dates, and the cleaning schedule did not include several areas where buildup was observed.
A resident with multiple chronic conditions, including COPD, CHF, DM2, depression, and dysphagia, had multiple meds and an open inhaler left at the bedside while asleep, but the record did not show a current self-administration order or recent self-medication assessment. An LPN stated she usually placed the meds on the bedside table and believed an old self-administration order still applied, even though the resident’s orders indicated staff administration and the resident also had an order for meds to be taken one at a time in a pureed carrier.
Inaccurate skin assessments and MDS coding were identified for three residents. One resident with diabetes, osteomyelitis, and a right foot ulcer had extensive wound treatment documented in the chart, but weekly skin assessments repeatedly failed to document the wound or any skin issues. Another resident with immobility, incontinence, MASD, and a history of skin breakdown had documented buttock and coccyx wounds, yet multiple weekly skin assessments still showed no skin impairment. A third resident’s MDS incorrectly coded an anticoagulant under high-risk drug classes even though the resident was not receiving an anticoagulant; the MDS Coordinator said it was a coding mistake.
A facility failed to revise and implement care plans for two residents with changing wound and skin conditions. One resident had diabetes, osteomyelitis, and an amputation, with multiple foot wounds and inconsistent wound documentation, but no updated wound-specific care plan was found. Another resident was severely cognitively impaired, incontinent, and dependent on a mechanical lift, yet had ongoing buttock and coccyx skin breakdown, MASD, and later pressure ulcers without updated care plan interventions despite continued wound changes.
Inaccurate and Inconsistent Wound Documentation: The facility failed to keep wound records accurate for 2 residents with complex skin and foot wounds. One resident’s buttocks wound was documented inconsistently as MASD, dermatitis, an unspecified ulcer, and Stage 2 pressure ulcers, with missing measurements and treatment details at times. Another resident with DM, osteomyelitis, and prior amputation had a right foot wound that was variously charted as a DTI, diabetic wound, surgical incision, and open area, with changing descriptions of drainage, tissue type, and staging. The DON/clinical leadership stated the documentation was confusing and not accurate or consistent.
A resident with anxiety and depression did not receive Ativan as ordered due to a failure in transmitting the prescription to the pharmacy. Despite aggressive behaviors and a physician's order, the medication was not provided, highlighting a lapse in the facility's medication order process.
The facility failed to monitor and dispose of expired influenza vaccines, with 41 vials found expired in the medication storage room. The oversight was acknowledged by the RN, ED, and DON, who attributed it to a lapse in monitoring by the DON, ADON, and evening shift supervisor.
Kitchen sanitation and expired food handling deficiencies
Penalty
Summary
The facility failed to ensure kitchen equipment was clean and sanitary during three kitchen observations. On 9/03/25 at 9:25 a.m., surveyors observed food debris and a bug trap on the floor between the fryer and stove, a yellowish-brown greasy substance running down the right side of the stove, three brown burnt areas on the back panel behind the stove burners, a drip pan under the stove top with a foil liner covered in tan substance and food debris, black build-up on the grill top griddle irons, a drip pan under the grill with a torn foil liner and brown liquid with heavy food debris, and dried food debris on a large slotted spoon hanging over the steam table. On 9/4/25 at 9:26 a.m., the Dietary Manager stated the char burner grill had been used the day before and cleaned, and that the stove top burners were cleaned every other day, but the drip pan under the stove top, grease down the side of the stove, food debris and grease on the floor, and burnt areas on the back panel were still present. The facility also failed to remove expired food items during salad preparation. On 9/3/25 at 11:07 a.m., an open bag of shredded lettuce with an expiration date of 9/1/25 was being used to assemble salads, and four bags of salad greens beside it were brown and had an expiration date of 8/28/25. The Dietary Manager stated that all staff should be monitoring expiration dates of foods and that she would take photos of the salad mix dates and send them back to the food company for a refund. The kitchen cleaning schedule listed daily cleaning tasks for tables, equipment, fryer, and grease trap, but did not include cleaning the drip pans under the stove or grill, or the sides and back panel of the stove. The Food Labeling and Dating Policy required food items to have a received-on label or a production date and use-by date.
Bedside Medications Left Without Current Self-Administration Order
Penalty
Summary
The facility failed to ensure a resident had an order to self-administer medications when multiple medications were found left at the bedside for a resident who did not have a current self-administration order in the record. During observation, the resident had a medicine cup containing multiple medications on the bedside table, along with an open inhaler, while no staff were present in or near the room. The resident was asleep and did not observe the medications sitting next to breakfast bowls. The resident involved had multiple diagnoses including COPD, hypertensive heart disease with heart failure, chronic diastolic CHF, type 2 diabetes mellitus with hyperglycemia, morbid obesity, obstructive sleep apnea, depression, dysphagia, anemia, cognitive communication deficit, and a history of falling. The care plan directed staff to encourage independence as safely possible and to administer medications per physician order. The record contained physician orders for numerous medications, including amlodipine, omeprazole, bumetanide, tramadol, allopurinol, sertraline, Breo Ellipta, lysine, metoprolol, potassium, senna, tart cherry supplement, ferrous sulfate, vitamin D3, fenofibrate, ropinirole, and Wellbutrin, all ordered for staff administration. The record also showed the resident had swallowing issues and an order to take medications one at a time in a pureed carrier. A physician order allowing staff to leave medications at bedside for the resident to self-administer was dated after the bedside medications were observed and after notification related to the medications being left at bedside. The clinical record lacked a physician order or current self-administration assessment before the survey, and there was no documentation of a self-medication evaluation since the resident transferred for assisted living. An LPN stated she usually set the resident's medications on the bedside table and believed the resident still had a self-administration order from the assisted living hall.
Inaccurate Skin Assessments and MDS Coding
Penalty
Summary
The facility failed to ensure accurate skin assessments for two residents and failed to ensure accurate MDS coding for one resident. For one resident with diagnoses including osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation, the record showed ongoing right foot wound care, including heel and toe wounds, blistering, drainage, redness, debridement, antibiotics, and physician follow-up. However, the weekly skin assessments repeatedly lacked documentation of the resident’s right foot wound or other skin issues, and several assessments were marked as having no skin impairment despite the documented wound history. For another resident with diagnoses including dyskinesia, chronic ischemic heart disease, paraplegic immobility syndrome, weakness, difficulty walking, repeated falls, and a history of skin breakdown, the record showed a history of buttock and coccyx skin breakdown, MASD, and later pressure ulcers and wound treatment. During observation, the resident had a reddened circular area on the left hip, multiple areas of scarring on the coccyx, a quarter-sized wound with white granulation tissue, additional quarter-sized wounds around it, and red areas on the left buttock. Despite this history and the documented skin issues, the weekly skin assessments on multiple dates lacked documentation of skin impairment or skin issues. For a third resident with Parkinson’s disease, dementia, Takotsubo syndrome, hypertensive heart disease with heart failure, chronic combined systolic and diastolic heart failure, and hypertension, the quarterly MDS dated 7/16/25 coded the resident as receiving a high-risk drug class anticoagulant in the last 7 days or since admission. Review of the physician’s orders showed the resident was not prescribed or taking an anticoagulant during the assessment period. The MDS Coordinator stated the anticoagulant box should not have been checked and that it was a coding mistake, noting it should have been marked for antibiotic instead.
Care plans not revised for residents with evolving wound and skin conditions
Penalty
Summary
The facility failed to ensure care plans were revised and implemented with interventions for two residents with changing skin and wound conditions. For one resident, the record showed diagnoses including osteomyelitis, type II diabetes mellitus with a foot ulcer, and orthopedic care following a surgical amputation. The care plan identified risk for skin breakdown and included general preventive interventions such as heel floating, pressure-reducing surfaces, moisture barrier use, turning and repositioning, and weekly skin assessments. However, the clinical record lacked documentation that the wound care nurse saw the resident before 12/2/24, revised the care plan with new interventions, or initiated a new wound care plan when wounds were identified. The resident’s record showed multiple wound-related findings over time, including a right heel wound and right pinky toe wound, later documentation of a purplish-brown area to the heel, a callused area beneath the pinky toe, and subsequent wound measurements and treatment notes. The record also reflected that the resident had a history of diabetic ulcerations, a prior left foot ulcer with osteomyelitis, a below-the-knee amputation, and noncompliance with wearing prescribed pressure-reducing devices. During interviews, the Director of Clinical Operation stated the wound documentation was not accurate and consistent, the DON stated there should have been a care plan specifically for the resident’s right lateral wound, and the MDS Coordinator stated new skin issues or wound-related changes should be added to the care plan within 24 hours unless identified over a weekend. For the second resident, the record showed severe cognitive impairment, incontinence of bowel and bladder, paraplegic immobility syndrome, and a need for a mechanical full body lift. The resident had existing care plans for skin breakdown risk and MASD, but the record lacked updated care plan interventions related to wounds after 5/2/24 through 9/2/25 despite ongoing skin impairment. The chart documented open buttock and coccyx areas, later stage 2 pressure ulcers to the buttocks, and a new foul-smelling open area on the bottom that required wound assessment and antibiotic treatment. During observation, the resident was incontinent during wound care, the dressing was soiled, multiple reddened and open areas were present on the buttocks and coccyx, and the wound care nurse noted the wound looked worse than the prior week. The report stated the comprehensive care plan should be reviewed no less than quarterly and revised to reflect changes in the resident’s condition as they occur.
Inaccurate and Inconsistent Wound Documentation
Penalty
Summary
The facility failed to ensure wound documentation was accurate for size, staging, and treatment for 2 residents with non-pressure wounds. For one resident, the record showed a long history of buttocks skin breakdown that was variously documented as MASD, dermatitis, an unspecified ulcer, and Stage 2 pressure ulcers. Notes described open areas, purple discoloration, pinpoint openings, foul odor, drainage, and changing treatments, but the wound documentation was inconsistent and at times lacked measurements or treatment details. The resident also had an infection tracker entry for cellulitis/soft tissue/wound of the buttocks with redness, tenderness, and purulent drainage, and later hospice involvement with antibiotic treatment for the wound area. The same resident’s wound record included multiple conflicting descriptions over time, including MASD, dermatitis, unspecified ulcer, and Stage 2 pressure ulcers, with wound management assessments and physician orders that did not consistently match the wound descriptions. The record also showed that the wound was not always included in Wound Management, and the documentation did not clearly show what the wound was at times. The Regional Director of Clinical Operations stated the wound documentation was confusing and that the wound should have been staged, and also stated that not every wound would be included in Wound Management even though all types of skin areas were to be documented there. For the second resident, the record showed a right foot wound that progressed from a deep tissue injury and blistered tissue to a diabetic wound, surgical incision, and later open areas with drainage, redness, warmth, edema, purulent drainage, and necrotic tissue. The resident had diagnoses including osteomyelitis, diabetes with foot ulcer, and prior amputation, and later required hospitalization, debridement, antibiotics, and a skin graft attempt. The wound documentation changed repeatedly over time, including descriptions of the wound as a diabetic wound, surgical incision, open area, and other inconsistent terms, and the clinical record lacked documentation showing the wounds were stage appropriate and that recommended treatments were implemented as documented. The Director of Clinical Operations stated the wound documentation was not accurate and consistent and that the wound type should have been determined consistently with the diagnoses.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, which resulted in a deficiency in pharmaceutical services. Resident 34, who had diagnoses including anxiety disorder and depression, exhibited aggressive behaviors such as punching and choking staff members. Despite a physician's order for Ativan 1 mg every 8 hours PRN to manage the resident's agitation, the prescription was never sent to the pharmacy. This oversight occurred even after the physician was informed of the resident's increased combativeness and issued the medication order. The facility's policy required that telephone or verbal orders be recorded in the system when received by the nurse. However, the process failed as the prescription for Ativan was not transmitted to the pharmacy, leaving the resident without the necessary medication to manage his symptoms. An LPN indicated that staff should follow up with the pharmacy or physician if an order is not filled within a couple of hours, but this protocol was not adhered to in this instance.
Expired Influenza Vaccines Not Disposed
Penalty
Summary
The facility failed to ensure that influenza vaccinations were monitored for expiration dates and properly disposed of once expired. During an observation of the medication storage room, it was found that four boxes and an open box containing a total of 41 vials of Fluzone influenza vaccine had expired in June 2024. The RN present acknowledged the expiration and indicated that the vaccines had not been administered since the end of the influenza season. Interviews with the Executive Director, LPNs, and the DON revealed that the expired vaccines were overlooked due to an oversight in monitoring. The facility's policy, revised in January 2018, mandates that all expired medications be removed from the active supply and destroyed, which was not adhered to in this instance. The oversight was attributed to a lapse in the monitoring process by the DON, ADON, and the evening shift supervisor.
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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 Hanover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Hanover | 0.5 mi | ★★★★★ | 26 | 0 |
| Waters Of Clifty Falls, The | 4.8 mi | ★★★★★ | 9 | 0 |
| River Terrace Health Campus | 5.2 mi | ★★★★★ | 8 | 0 |
| Hickory Creek At Madison | 5.2 mi | ★★★★★ | 3 | 0 |
| Bedford Springs Health And Rehabilitation | 12.5 mi | ★★★★★ | 0 | 0 |
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