Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Thornapple Manor during CMS and state inspections, most recent first.
Failure to obtain informed consent for psychotropic medications affected two residents. One resident with advanced cognitive impairment and another resident with moderately impaired cognition were prescribed multiple psychotropic drugs, including antianxiety, antipsychotic, antidepressant, and hypnotic agents, but their charts contained no consent forms or documentation showing that the residents or their representatives were informed of the risks, benefits, and alternatives. The DON and DSS acknowledged missing consents and stated the facility had previously limited forms to antipsychotics or could not locate the documentation.
Failure to implement EBP for a resident with a hip pressure wound. A resident with dementia and a history of infectious disease had a stage 3 pressure wound on the hip, but staff did not consistently place the resident in EBP or post EBP signage in the room. The RN/IP, RN, CNA, and DON gave conflicting explanations about whether the wound qualified as chronic, and the facility policy and CDC guidance cited in the report identified pressure injuries and wounds as indications for gown and glove use during high-contact care.
Staff failed to follow abuse reporting policies when a CNA, frustrated during an interaction with a cognitively intact resident with dementia, anxiety, depression, and a trauma history, threw a tablet cover that struck the resident’s coffee cup and spilled coffee into the resident’s lap. The incident was witnessed by another CNA, who believed the behavior was inappropriate but did not immediately notify a nurse, instead seeking advice from life enrichment staff and submitting a written statement later. An LPN was informed hours after the event and relayed the concern to an RN, who further delayed action before contacting the house supervisor. Video review confirmed the CNA looked at the resident and threw the cover, yet the DON and NHA were not promptly informed of the full circumstances, resulting in a delay of many hours before the potential abuse allegation reached facility leadership, contrary to the facility’s abuse policy requiring immediate reporting to the Administrator, DON, or designee.
A resident with multiple medical conditions, including dementia and osteoporosis, was assisted by a CNA in the bathroom without the required two-person assist as specified in the care plan. The resident was lowered to the floor after losing balance, but no incident report was completed at the time. Over the following days, the resident experienced increasing right leg pain, which was later diagnosed as a fibula fracture. The incident was not properly documented or investigated until after the injury was identified, contrary to facility policy.
A resident with anxiety and intact cognition reported missing two coin purses containing quarters from her nightstand. Facility investigation, including review of surveillance footage, revealed an agency CNA entered the resident's room while she was absent, removed a purse matching the resident's description, and used it to purchase items from a vending machine. The resident identified the purse in the footage as her own, confirming misappropriation of property.
A resident at high risk for falls, with conditions including dementia and heart failure, had non-skid strips incorrectly placed under his recliner instead of in front, as required by his care plan. This misplacement was observed multiple times, despite the care plan's directive to aid in safe transfers, leading to potential fall risks.
The facility failed to provide adequate oxygen management and tubing care for three residents, leading to potential infection risks. A resident with cardiorespiratory conditions had unlabeled and outdated oxygen tubing, and an empty portable tank. Another resident with COPD was found with an empty oxygen tank and outdated tubing, expressing difficulty breathing. A third resident's oxygen tubing was improperly stored and not dated, despite not needing oxygen recently. The facility did not adhere to its policy for weekly tubing changes and proper storage.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers, as CNAs did not wear gowns or change gloves during care. Additionally, soiled linen was improperly handled by a CNA, contrary to facility policy, increasing the risk of cross-contamination and infection.
A resident with dementia developed multiple unexplained bruises and scratches, which were observed by facility staff but not reported to the State Agency. Despite internal reporting and concern from a hospice nurse, the facility's DON and NHA did not report the injuries, believing they were not related to abuse. The facility's policy lacked clear guidance on handling injuries of unknown origin, contributing to the failure to report.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for two residents reviewed, with no documentation of communication or education to the residents or their representatives for initiation and/or dose changes of those medications. The deficiency involved Resident #80, who was admitted with diagnoses including Alzheimer's disease, dementia with anxiety, dementia with psychotic disturbance, and depression, and whose BIMS could not be completed due to cognitive impairment. Her physician orders included Xanax 0.25 mg as needed for anxiousness, Olanzapine 10 mg at bedtime for dementia with other behavioral disturbance, and Escitalopram 10 mg at bedtime for depression, but the chart contained no consents for these psychotropic medications and no progress notes or other documentation showing the process was completed. The deficiency also involved Resident #88, who was admitted with diagnoses including Alzheimer's disease, anxiety, dementia without psychotic disturbance, and depression. Her BIMS score was 11 out of 15, indicating moderately impaired cognition. Her physician orders included Buspirone 5 mg in the morning for depression and generalized anxiety, Trazodone 100 mg at bedtime for depression, and Cymbalta 20 mg in the morning for depression, but the chart contained no consents for these psychotropic medications and no progress notes or other documentation showing this was completed. During interviews, the DON stated the facility had "dropped the ball" on the regulation updates from April 2025 and did not have consents for the two residents' psychotropic medications. The DON also stated the facility had developed a new psychotropic consent form in February and would use it moving forward. The DSS stated the facility used psychotropic medication forms for new admits on psychotropics, for increases, or when a new psychotropic medication was added, but also stated that Resident #80's consent could not be found and that Resident #88 did not have consents because the facility had previously completed consents only for antipsychotic medications and not for antidepressant or antianxiety medications.
Failure to Implement EBP for Resident With Hip Pressure Wound
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure wound on the hip. Resident #5 was admitted with diagnoses including a personal history of infectious and parasitic diseases, dementia, and dermatitis. The resident had a stage 3 pressure wound on the left hip documented in wound care notes and the pressure injury log, and orders were in place for wound treatment to the hips. Despite this, the infection preventionist and nursing staff did not consistently identify the resident as needing EBP, and no EBP signage was observed in the resident’s room during multiple observations. Interviews showed conflicting understanding among staff about when EBP should be used. The RN/IP stated EBP was used for chronic wounds and said the resident was not in EBP because the wound had not been open for 4 weeks, while the RN and DON also described chronic wounds as wounds lasting longer than 4 weeks. The RN/IP later stated that if the resident had a wound, she should have been in EBP and said she would place the resident in EBP immediately. The CNA confirmed the resident had a hip wound but reported the resident was not in EBP. The facility policy stated EBP would be initiated for chronic wounds, including pressure injuries/pressure ulcers, and CDC guidance cited in the report stated gown and gloves are indicated for nursing home residents with wounds during high-contact care activities.
Delayed Reporting of Alleged Staff-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to effectively implement its abuse, neglect, and exploitation policy by not ensuring that staff immediately reported an alleged incident of staff-to-resident abuse to the NHA or designee. The facility’s policy required employees, consultants, physicians, family members, and visitors to promptly report suspected incidents of neglect or abuse to facility management, specifically to the Administrator, DON, or designee, and to other officials and the state survey agency as required. Despite this policy, an incident involving a CNA throwing a tablet cover that struck a resident’s coffee cup and spilled coffee into the resident’s lap was not promptly reported through the appropriate chain of command, resulting in a delay of approximately 17 hours before the DON was notified of the potential abuse allegation. The resident involved, identified as Resident #101, had diagnoses including dementia, early onset Alzheimer’s disease, anxiety, and depression, and had a BIMS score of 13 indicating cognitive intactness. The resident’s care plan documented a history of significant trauma, including past verbal and physical abuse by her father, a mother with mental health issues, and abusive or controlling spouses, as well as a trauma and stressor-related disorder. The resident reported that when people are mean to her, she tends to shut down, and described that on one occasion in the facility, a CNA had a temper tantrum and threw something that knocked her coffee onto her lap. The resident stated she had forgiven the CNA and did not want to dwell on the incident. Multiple staff interviews detailed the sequence of events and the delayed reporting. CNA K stated that while cleaning a tablet cover, she became frustrated when the resident and another CNA teased her, and she tossed the cover toward the other CNA, knocking over the resident’s coffee onto her lap. CNA M confirmed that she observed the incident, felt the CNA’s behavior was inappropriate in front of the resident, but did not immediately report it; instead, she sought advice later in the day from life enrichment staff, who in turn consulted another staff member and suggested placing a written statement in an RN’s mailbox rather than immediately notifying a nurse. The concern was eventually reported to an LPN around the early evening, who passed it to the next nurse on duty. That RN delayed further action until after midnight, at which point the house supervisor was contacted and video footage was reviewed, showing the CNA looking at the resident and throwing the tablet cover, which hit the resident’s cup and spilled coffee into her lap. The DON and NHA both reported that they were not promptly informed of the full nature of the incident, and the record notes that approximately 17 hours elapsed between the incident and the DON being notified of the potential abuse allegation.
Failure to Follow Care Plan and Incident Reporting Leads to Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions and thoroughly document or investigate a fall for a resident with multiple diagnoses, including cerebral palsy, Alzheimer's disease, dementia, osteoporosis, and arthritis. The resident's care guide had been updated to require two-person assistance with a gait belt for toileting, but this was not followed. On the evening of the incident, a CNA assisted the resident alone in the bathroom, did not check the care guide beforehand, and subsequently lowered the resident to the floor when she began to lose her balance. The CNA was unaware of the updated care plan requirement for two-person assistance. Following the incident, the resident did not initially complain of pain, and the LPN who responded did not complete an incident report at the time. Over the next several days, the resident began to complain of increasing pain in her right leg, which was noted by multiple staff members during care. The pain and decreased mobility led to the use of a mechanical lift for transfers, which was unusual for the resident. Despite these complaints, there was no immediate documentation or investigation linking the pain to the earlier incident in the bathroom. It was only after the resident's pain persisted and an X-ray was ordered that a right fibula fracture was identified. A review of facility records and camera footage later confirmed that the resident had been lowered to the floor by a single CNA, contrary to the care plan. The incident report was not completed until after the fracture was discovered, and the initial investigation did not identify the fall as the cause of the injury. The facility's policies required staff to check care guides before providing care and to complete incident reports promptly when a resident falls or sustains an injury, but these procedures were not followed in this case.
Misappropriation of Resident Property by Agency CNA
Penalty
Summary
A cognitively intact female resident with a diagnosis of anxiety reported missing personal property, specifically a small zippered purse and a second change pouch, each containing approximately ten dollars in quarters. The resident stated she last saw both items after putting away her bingo winnings on a Friday and noticed them missing the following Monday morning. She recalled that the items were kept in her nightstand drawer and described the missing purse in detail. Upon realizing the loss, she notified staff, who searched her room but did not find the missing items. The facility initiated an investigation, which included a review of surveillance camera footage from the weekend. The footage showed an agency CNA entering the resident's room when the resident was not present and exiting a few minutes later with what appeared to be a heavy object in her scrub pocket. The CNA was then observed in the hallway removing a dark-colored pouch from her pocket, unzipping it, and using it to purchase items from a vending machine. Still images from the footage were shown to the resident, who identified the pouch as her missing change purse. Interviews with facility leadership and staff confirmed the sequence of events observed on the camera footage. The resident expressed feeling hurt and unsafe as a result of the incident, emphasizing that the facility was her home and she wanted to feel secure. The facility's policy on abuse, neglect, and exploitation was reviewed, which defines misappropriation of resident property as the deliberate or wrongful use of a resident's belongings or money without consent. The evidence indicated that the agency CNA took the resident's property without permission, constituting misappropriation.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for a resident identified as high risk for falls. The resident, a male with diagnoses including dementia, heart failure, diabetes, and high blood pressure, was observed multiple times in his recliner with non-skid strips incorrectly positioned under the recliner rather than in front of it, as specified in his care plan. This misplacement of the non-skid strips was noted on several occasions over a period of days, despite the care plan's directive to place them in front of the recliner to provide additional traction during transfers. A registered nurse confirmed that the non-skid strips were intended to be positioned in front of the recliner following a fall incident to aid in safe transfers. However, observations consistently showed the strips were not placed as required, indicating a failure to adhere to the care plan. This oversight resulted in the potential for falls and injury, as the resident was independent with transfers and ambulation but had a history of falls.
Inadequate Oxygen Management and Tubing Care
Penalty
Summary
The facility failed to provide appropriate and adequate oxygen management and tubing care for three residents, resulting in potential risks for infection and harm. Resident R19, who had a diagnosis of debilitating cardiorespiratory conditions and was dependent on supplemental oxygen, was observed with oxygen tubing that was not labeled and dated beyond the recommended weekly change. The resident expressed discomfort, feeling dry and experiencing a runny nose. Additionally, the portable oxygen tank was found empty, and agency staff were not equipped with access to the oxygen storage area, leading to delays in replacing the tank. Resident R46, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was observed using a portable oxygen tank with unlabeled tubing and an empty tank. The resident expressed feeling unwell and was audibly gasping for breath. The facility staff failed to ensure the resident was connected to the oxygen concentrator while in the room, and the tubing was not changed weekly as per the facility's policy. The humidifier bottle was also dated beyond the recommended change date, indicating a lapse in infection control practices. Resident R117, who had heart disease, high blood pressure, and cancer, was observed with oxygen tubing laying on the floor, not stored in a plastic bag, and without a date indicating when it was last changed. Although the resident reported not needing supplemental oxygen for several weeks, the facility failed to maintain the equipment in a clean and safe manner. The facility's policy required weekly changes of oxygen tubing and proper storage, which was not adhered to, posing a risk of infection to the resident.
Failure to Implement Enhanced Barrier Precautions and Handle Soiled Linen Properly
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to standards of practice for a resident with non-traumatic brain dysfunction and unhealed stage 3 and stage 4 pressure ulcers. During an observation, two Certified Nursing Assistants (CNAs) did not don gowns as required by EBP signage before performing a brief change for the resident. The CNAs only wore gloves and did not change them after removing the soiled brief, despite the presence of a deep wound on the resident's coccyx. The facility's Kardex did not specifically indicate the resident was on EBP, and the Director of Nursing (DON) expressed a preference for not placing EBP signs on the outside of residents' doors to avoid making them feel isolated. Additionally, the facility failed to handle soiled linen adequately, as observed when a CNA carried soiled linen in a clear plastic bag against her clothes without wearing gloves. This action was contrary to the facility's policy on laundry transportation, which requires contaminated linen to be transported without being held close to the body. The facility's policies on Enhanced Barrier Precautions and Nursing Standards of Care were not followed, leading to potential cross-contamination and increased infection risk among residents.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin for a resident, resulting in a lack of reporting and potential delay in investigation. The resident, who had dementia, was admitted to the facility and later developed a significant bruise on her right bicep. Despite the resident's inability to describe the cause of the injury, she expressed pain, and the bruise was noted to spread to her chest. The facility staff, including nurses and CNAs, observed additional bruises and scratches on the resident's body over the following days, but the origin of these injuries remained unknown. Interviews with various staff members revealed that the bruises and scratches were reported internally to the Director of Nursing (DON) and Assistant Director of Nursing (ADON), but no external report was made to the State Agency. The staff, including LPNs and CNAs, documented the injuries and communicated them to the hospice nurse, who also expressed concern over the unexplained nature of the injuries. Despite these observations, the facility's DON and Nursing Home Administrator (NHA) did not report the injuries to the State Agency, as they did not believe the injuries were related to abuse. The facility's policy on abuse, neglect, and exploitation did not provide clear guidance on handling injuries of unknown origin, which contributed to the failure to report. The hospice nurse and family members were concerned about the extent of the injuries, leading to a request for a medical examiner's assessment. The lack of a defined protocol for reporting such injuries in the facility's policy may have contributed to the oversight in reporting the incident to the appropriate authorities.
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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 Hastings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clearstream Rehabilitation And Nursing Center | 4.1 mi | ★★★★★ | 20 | 0 |
| The Laurels Of Bedford | 18.4 mi | ★★★★★ | 14 | 0 |
| The Oaks At Battle Creek | 19.1 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Battle Creek | 19.2 mi | ★★★★★ | 12 | 0 |
| Eaton County Medical Care Facility | 20.3 mi | ★★★★★ | 6 | 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.