Health inspection·January 18, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's care plan was reviewed and revised to reflect the resident's current status for two of 22 residents reviewed (Residents 57 and 75). Findings include: Review of Resident 57's clinical record revealed diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and chronic kidney disease (CKD - gradual loss of kidney function). Review of Resident 57's current care plan on January 17, 2024, at 11:02 AM, revealed the following information: Resident 57 wore bilateral hearing aides, and staff were to ensure that the appliances were clean and in working order; Resident 57 was actively being treated for a UTI (Urinary Tract Infection); and Resident 57 was at risk of dehydration due to a 1600 cc per day fluid restriction. Observation of Resident 57 on January 17, 2024, at 1:00 PM, revealed he was not wearing any hearing aides. During an immediate interview with Employee 2, she confirmed that Resident 57 was not wearing hearing aides and that his wife had taken them home. Review of Resident 57's physician orders revealed no current orders for treatment of a UTI. Review of nursing progress notes revealed that the last notation made regarding treatment/tracking of a UTI was November 21, 2023, when it was noted that there were not signs or symptoms of a UTI or adverse reactions to previous antibiotic treatment. Review of Resident 57's current physician orders revealed an order for 1800 cc per day fluid restriction, effective December 19, 2023. During an interview with the Nursing Home Administrator (NHA) on January 18, 2024, at 11:50 AM, she revealed that Resident 57's care plan was updated to reflect that his hearing aides were not in use, and that Resident 57's care plan was under revision to ensure it reflected the correct fluid restriction amount. During a later interview with the NHA on January 18, 2024, at 2:40 PM, she acknowledged that Resident 57's care plan still included information about active treatment of a UTI, confirmed that Resident 57 was not currently receiving treatment for a UTI, and revealed that the care plan would be updated. Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 75's current care plan on January 16, 2024, at 2:00 PM, revealed the following information: Resident 75 was actively being treated for a UTI; and that he had an unstageable pressure ulcer. Review of Resident 75's Comprehensive MDS assessment (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an ARD (assessment reference date last day of the assessment period) of December 21, 2023, revealed Resident 75 was coded as having a stage III pressure ulcer. Email correspondence with the NHA on January 17, 2024, at 11:56 AM, the surveyor inquired about when Resident 75's pressure ulcer changed stages, and if he currently had an UTI. Review of select facility documentation provided on January 17, 2024, at 1:05 PM, revealed Resident 75's pressure ulcer changed from unstageable to stage III on December 21, 2023, and that Resident 75's UTI had resolved on January 8, 2023. Follow-up interview with the NHA on January 18, 2024, at 11:40 AM, revealed she would expect Resident 75's care plan to be updated to reflect the current stage of his wound and that he no longer has an UTI. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards that met the residents needs; and failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for two of 22 residents reviewed (Resident 70 and 75). Residents Affected - Few Findings include: Review of Resident 70's clinical record revealed diagnoses that included noninfective gastroenteritis and colitis, unspecified (inflammation of the stomach and intestines), and hypomagnesemia (electrolyte imbalance caused by a low level of magnesium in the blood). During an interview with Resident 70 on January 17, 2024, at 10:10 AM, she stated she has been suffering from diarrhea for several weeks. She reported the diarrhea to be severe causing her to be incontinent at times, and she stated, they can't seem to figure out what is causing it. Further review of Resident 70's clinical record on January 18, 2024, at approximately 10:30 AM, revealed a hospital discharge summary indicating she was admitted [DATE], to December 26, 2023, for electrolyte derangement (an imbalance of electrolytes in the blood) and diarrhea. Review of the hospital discharge summary revealed multiple stool tests were collected on December 18, 2023, and the results were pending at the time of discharge. The discharge summary also instructed to follow-up with outpatient gastroenterology (physicians that focus on the digestive system and disorders). Further review of Resident 70's clinical record failed to reveal results from any stool testing and a follow-up appointment for outpatient gastroenterology. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 18, 2024, at 11:50 AM, results of the stool testing and information on a follow-up gastroenterology appointment were requested. In a follow-up interview with the NHA and DON on January 18, 2024, at 2:47 PM, the NHA stated a call had been placed to the hospital requesting results of the stool testing. She also stated a call had been placed to the facility physician and Resident 70's family to check if further gastroenterology follow-up and treatment is wanted. During an additional interview with the DON on January 18, 2024, at 3:54 PM, results from the stool testing were provided. Review of the results provided revealed Resident 70's calprotectin stool test (a test used to check for inflammation in the intestines) results were 525 mcg/g (micrograms/gram). The reference range indicated a normal calprotectin level is less than 50 mcg/g and levels greater than 120 mcg/g are elevated. The DON stated that after the facility physician reviewed the results of the testing, he had ordered a follow-up with gastroenterology and the facility has placed a call to schedule an appointment. The DON confirmed the result of testing should have been obtained and reviewed, and the follow-up appointment should have been scheduled when Resident 70 returned from the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 75's clinical record revealed diagnoses that included pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin), basal cell carcinoma of skin (skin cancer), and obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating). Review of Resident 75's care plan revealed a focus area for skin conditions [Resident 75] is at risk for skin impairment/pressure ulcers related to impaired mobility and incontinence; unstageable pressure on coccyx, with an intervention for treatment as ordered, with a start date of December 14, 2023. Further review of Resident 75's care plan focus area for skin conditions revealed, [Resident 75] has a lower back wound that may be a malignancy, with an intervention for, Be seen by MD and receive debridement until healed, with a start date of December 28, 2023. Review of Resident 75's physician orders revealed an order for Sacral wound care- Once daily night shift. Cleanse with NSS and pat dry. Fluff and apply Calcium Alginate with Ag and cover with bordered gauze daily at night. May replace if soiled or lifted. Code: 1 = no sign of infection, 2 = sign of infection, note required, 3 = small amount of drainage, 4 = moderate amount of drainage, 6 = no pain, 7 = signs/symptoms of pain. For sacral wound once daily. Review of Resident 75's TAR (Treatment Administration Record - documentation for treatment administered or monitored) failed to reveal documentation to indicate the treatment order was completed on January 9, 2024. Review of Resident 75's physician orders revealed an order for Dressing change LL (left lower) back .once daily wash area of LL back and pat dry. Fluff and apply Ca Alg (Calcium Alginate- wound treatment) to wound bed and cover with bordered gauze. May replace if soiled or lifting. For back wound once daily, with a start date of December 21, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate the treatment order was completed on January 2 and 9, 2024. Interview with the NHA on January 18, 2024, at 11:40 AM, revealed she did not have any information to provide related to the missing documentation, and she would expect physician orders to be followed and documented as completed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of two residents reviewed for catheters (Resident 75). Findings include: Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 75's physician orders revealed an order for Catheter Protocol Foley Check: Code 1=Patent, output good, No sediment; 2=Low output; 3=sediment- Every shift, with a start date of December 14, 2023, and an end date of December 28, 2023. Review of Resident 75's TAR (Treatment Administration Record - documentation for treatment administered or monitored) failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on December 21, 2023, day shift; and December 23 and 26, 2023, night shift. Review of Resident 75's physician orders revealed an order for Catheter Foley tubing Stabilization Adhesive Anchor Type - Catheter Care - Every shift. Anchor site check, change anchor as needed. Code 0 = Skin intact, 1 = Red, 2 = Pink, 3 = Open area, once daily, with a start date of December 14, 2023, and an end date of December 18, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed for the duration of the order. Review of Resident 75's physician orders revealed an order for Catheter Graduated Container Change Type - Catheter Care - Once daily (weekly on Saturday). Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on January 16, 2023. Review of Resident 75's physician orders revealed an order for Catheter Protocol Foley Check: Code 1=Patent, output good, No sediment; 2=Low output; 3=sediment- Every shift, with a start date of December 28, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on January 12, 2024, day shift; January 8, 12, and 14, 2024, evening shift; and December 30, 2023, and January 9, 2024, night shift. Review of Resident 75's physician orders revealed an order for Catheter Foley tubing Stabilization Adhesive Anchor Type - Catheter Care - Every shift. Anchor site check, change anchor as needed. Code 0 = Skin intact, 1 = Red, 2 = Pink, 3 = Open area, every shift, with a start date of December 18, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on December 21, 2023, and January 12, 2024, day shift; December 18, 2023, and January 8, 12, 14, 2024, evening shift; and December 18, 23, 26, and 30, 2023, and January 9, 2024, night shift. Interview with the Nursing Home Administrator on January 18, 2024, at 11:40 AM, revealed she would expect physician orders to be followed and documented as completed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and two of two dining areas. Findings include: Review of facility policy, titled Food Storage, revealed, Food storage areas shall be maintained in a clean, safe, and sanitary manner. The surveyor requested a food storage labeling policy that pertains to labeling and dating of food items on January 17, 2024, at 2:20 PM. No further policies were provided. Observation of the walk-in freezer unit on January 16, 2024, at 11:51 AM, revealed three packs of onion rings not dated. Interview with Employee 1 (Food Service Director) on January 16, 2024, at 11:52 AM, revealed food items should be labeled with the date they are received if they are removed from the original package. Observation of the walk-in refrigerator on January 16, 2024, at 11:53 AM, revealed a container of shredded mozzarella cheese labeled 12-18 and some of the cheese had turned blue; one bin of celery dated 12-24 that was brown and wilted; one bin of cabbage labeled 12-23 and the outer leaves of the cabbage were black; and one box of tomatoes without a date, and half of the tomatoes were rotten. Interview with Employee 1 on January 16, 2024, at 11:55 AM, revealed produce is labeled with the date it was received, and should be used before it goes bad or tossed when it goes bad. Observation in the main kitchen on January 16, 2024, at 11:56 AM, revealed two containers of crisped rice cereal, one was dated 9-21 and one was dated 7-24. Interview with Employee 1 on January 16, 2024, at 11:57 AM, revealed the bins have been filled since those dates and should be relabeled. Observation during initial tour of the [NAME] dining area refrigerator on January 16, 2024, at 12:05 PM, revealed one container of apple juice labeled 11-3 that was open; one container of apple juice labeled 12-29 that was open; one container of cranberry juice labeled 11-7 that was open; and two containers of thickened orange juice labeled 12-15 that were open. Observation of the [NAME] dining area freezer on January 16, 2024, at 12:07 PM, revealed one box of ice cream sandwiches without a date, and they appeared freezer burned; two lime sherbet without a date; and one orange sherbet without a date. Observation during initial tour of the Courtyard dining area on January 16, 2024, at 12:17 PM, revealed 29 boxes of cereal varieties all not labeled with use by dates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the Courtyard dining area refrigerator on January 16, 2024, at 12:17 PM, revealed two containers of tomato juice labeled 12-26 and they were open; one container of grape juice labeled 1-2 and it was open; one container of cranberry juice labeled 9-29 and it was open; one container of ketchup without a date; and one container of mustard without a date. Observation of the pantry in the Courtyard dining area on January 16, 2024, at 12:19 PM, revealed one bag of wheat bread with a best by date of January 14, 2024; one bag of white bread with a best by date of January 14, 2024; and one bag of bagels not dated. Observation of the Courtyard dining area refrigerator on January 16, 2024, at 12:21 PM, revealed one bin of ice cream sandwiches without a date; and 10 lime sherbet without a date. Interview with Employee 1 on January 16, 2024, at 12:24 PM, revealed the facility's process is to label juices with their received date once removed from the original package; juices should be labeled with an open date once open and discarded after seven days; freezer items not dated should be labeled with a use by date; cereals, condiments, and breads should be dated; and food items should be discarded once past their best by date. Interview with the Nursing Home Administrator on January 17, 2024, at 12:20 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility process, and that food and beverage items are stored and utilized in accordance with professional standards, and discarded once expired. 28 Pa. Code 211.6(f) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 9 of 9