Health inspection·December 12, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed (Resident 27). Findings include: Review of Resident 27's clinical record revealed diagnoses that included Parkinson's Disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and muscle weakness. Review of Resident 27's care plan revealed that the Resident had an impaired functional status and approaches/interventions included transfers: 1-person assist, stand pivot with a walker and to have right AFO (Ankle Foot Orthotic - braces support the ankle, keeping the toes aligned with the rest of the foot) on for transfers and when OOB [out of bed], OOB to pedal Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) with cushion and bilateral leg rests for proper positioning, dated January 27, 2024; and Walking: non-ambulatory, dated January 27, 2024. Observation of Resident 27 on December 9, 2024, at 10:26 AM, revealed that the Resident was in their room, seated in their Broda chair with no leg rests, leaning slightly to the left, and that the Resident had slippers on both feet. The leg rests for the Broda chair, their AFO, and their shoes were noted on the floor nearby in front of a nightstand. Observation of Resident 27 on December 10, 2024, at 10:18 AM, revealed that the Resident was in their room, seated in their Broda chair with leg rests present, and that the Resident had gripper socks on both feet. Their AFO and shoes were noted on the floor nearby in front of a nightstand. Observation of Resident 27 on December 10, 2024, at 12:52 PM, revealed that the Resident was in the dining room, seated in their Broda chair with leg rests in place, and the Resident had on sneakers. The AFO was not present. Immediate observation of Resident 27's room revealed that their AFO was present in their room on the floor in front of the nightstand. Observation of Resident 27 on December 11, 2024, at 10:09 AM, revealed that the Resident was in their room, seated in their Broda chair with leg rests present, and that the Resident had their AFO in place and was wearing sneakers. Page 1 of 6 395802 395802 12/12/2024 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 27's Physical Therapy Discharge summary dated [DATE], revealed that Discharge Recommendations included a Restorative Nursing Program (RNP) for sit to stand transfers and bilateral lower extremities therapeutic exercises in order to maintain current level of function. In addition, it was noted that Resident 27's long-term therapy goal for Pt. will ambulate 25 feet safely with front wheeled walker and min assist (25% assist) on even surfaces was discontinued on November 22, 2024, and stated rationale indicated ambulation discontinued due to decreased safety. This discharge summary failed to include any mention of Resident 27's AFO. Review of Resident 27's nurse aide task documentation revealed that the Resident was on a Restorative Nursing Program for range of motion and walking. Review failed to reveal any documentation regarding Resident 27's use of their AFO. Further review of this documentation from November 22, 2024, through December 11, 2024, revealed that on November 25 and 27, 2024; December 4 and 9, 2024, there was no documentation indicating that Resident 27 was provided their range of motion or ambulation programs. In addition, it was noted that on November 30, 2024, and December 1, 2, 3, and 6, 2024, there was no documentation that Resident 27 was provided their ambulation program. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2024, at 1:50 PM, concerns were shared regarding the observations of Resident 27, missing RNP documentation, missing AFO documentation, and conflicting information regarding Resident 27 being non-ambulatory, but on a walking RNP. During a staff interview with the NHA on December 12, 2024, at 9:49 AM, the NHA indicated that Resident 27's walking program was placed on hold sometime back in July. The NHA said she was not sure why it would have been still populating for staff to perform/document. She confirmed that the Resident 27's care plan indicated that she was non-ambulatory and that the therapy discharge summary indicated on November 22, 2024, that ambulation was not safe. During a final staff interview with the NHA and DON on December 12, 2024, at 11:12 AM, the NHA indicated that she had no additional information to provide regarding Resident 27's AFO use or why staff would be ambulating Resident 27 if they were not ambulatory. The NHA confirmed that she would expect range of motion exercises to have been provided and documented accordingly, and that she would expect Resident 27's care plan to have been followed for the use of their AFO. 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services 395802 Page 2 of 6 395802 12/12/2024 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for two of three residents reviewed (Residents 65 and 72). Findings include: Review of facility policy, titled Procedure: Guidelines For Prevention of Catheter Associated Urinary Tract Infections, with a last review date of January 25, 2024, revealed that Special meatus [opening leading to the interior of the body] care with an indwelling urinary catheter is not required. Daily soap and water cleansing of the perineal area is an important part of the hygiene for all patients. Review of Resident 65's clinical record revealed diagnoses that included urinary retention (a condition where your bladder doesn't empty all the way or at all when you urinate) and use of an indwelling foley catheter (a tube placed and held in the bladder to drain urine). Review of Resident 65's nurse aide task documentation from October 1, 2024, through December 12, 2024, revealed that there was no documentation of catheter care being provided as follows: October: 6th evening shift; 11th evening shift; 18th evening shift; 19th night shift; 21st day and evening shift; 22nd day and evening shift; 23rd evening shift; 27th day shift; 30th evening shift; November: 4th day shift; 8th day and evening shift; 13th evening shift; 14th day shift; 18th day and evening shift; 22 day and night shift; 24th day shift; 29th night shift; and December: 1st evening shift; 2nd day shift; 3rd evening shift; 5th evening and night shift; 6th evening shift; 7th evening and night shift; and 8th evening shift. Further review of Resident 65's clinical record revealed that the Resident was diagnosed with a urinary tract infection (UTI) on October 25, 2024, and that their final urine culture dated October 28, 2024, indicated that their urine contained greater than 100,000 CFU/ml of E-coli (Escherichia coli-a bacteria that lives harmlessly in your gut which can cause an infection if it enters your urinary system from stool). During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2024, at 1:44 PM, they both confirmed that they would expect catheter care to be provided and documented every shift. Review of Resident 72's clinical record revealed diagnoses that included benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland) and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 72's physician orders revealed orders for catheter check every shift, with a start date of September 27, 2024. 395802 Page 3 of 6 395802 12/12/2024 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013

F 0690 Review of Resident 72's nurse aide task documentation from October 1, 2024, through December 10, 2024, revealed that there was no documentation of catheter care being provided as follows: Level of Harm - Minimal harm or potential for actual harm October: 10th night shift; 12th night shift; 16th evening shift; 30th evening shift; 31st evening and night shift; Residents Affected - Some November: 1st night shift; 2nd evening shift; 6th day shift; 12th evening shift; 13th day shift; 25th day shift; December: 3rd evening shift; and 10th evening shift. Further review of Resident 72's clinical record revealed he was started on an antibiotic for a UTI on October 27, 2024, twice daily for seven days; and on December 9, 2024, daily with a stop date of December 20, 2024. Interview with the DON on December 11, 2024, at 1:58 PM, revealed she would expect catheter care to be completed and documented per facility protocol, daily every shift. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa code 211.12(d)(1)(2)(5) Nursing services 395802 Page 4 of 6 395802 12/12/2024 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status and failed to notify the physician of a significant weight change for two of 21 residents reviewed (Residents 38 and 79). Residents Affected - Few Findings include: Review of facility policy, titled Procedure: Weighing and Documenting Resident Weights, last reviewed January 25, 2024, read, in part, Unit coordinators review weights and transfer all weights to include any re-weights to resident medical records via Care Tracker. Dietitian will notify nursing via [NAME] of any significant weight loss or weight gain, as well as physician after reviewing the weight detail report in Care Tracker. If nurse aide reports a variance, weight must be done again in presence of a licensed staff on that shift. A weight variance is defined as any resident weighing greater than 120 pounds with a gain or loss of five pounds or more, or a resident weighing less than 120 pounds with a weight gain or loss of three pounds or more. admission weekly weights will be obtained for four weeks post admission from day of admission. Review of Resident 38's clinical record revealed diagnoses that included moderate protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 38's physician orders revealed an order for Weekly weight Tuesday day shift- every week, with a start date of November 26, 2024. Review of Resident 38's clinical record revealed he had a significant weight loss of 20.8 pounds (11.9%) from November 3 to 26, 2024. Further review of Resident 38's clinical record revealed he was not weighed again until December 3, 2024. Review of Resident 38's clinical record revealed a dietitian note on November 26, 2024, in response to the weight loss that read, in part, Unsure if weight loss is true weight loss or water loss. Recommend fortified cereal to increase caloric intake. Further review of the dietitian note on November 26, 2024, failed to reveal documentation that the physician was notified. During an email correspondence with the Nursing Home Administrator (NHA) on December 10, 2024, at 12:27 PM, the surveyor inquired if there had been communication to the physician related to Resident 38's significant weight change. Interview with Employee 1 (Physician Assistant) on December 11, 2024, at 10:56 AM, revealed he was notified of Resident 38's weight loss the previous evening of December 10, 2024, by nursing. He further revealed he is typically only notified of significant weight changes that the nursing staff are 395802 Page 5 of 6 395802 12/12/2024 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013

F 0692 concerned about, and he rarely has communication with the dietitian. Level of Harm - Minimal harm or potential for actual harm Interview with the NHA on December 11, 2024, at 1:55 PM, the surveyor revealed the concern with the missed re-weigh measure for the weight variance and lack of physician notification of resident 38's significant weight loss. The NHA revealed she would expect weight monitoring and physician notification per facility policy. Residents Affected - Few Review of Resident 79's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and osteoporosis (a condition that weakens bones and increases the risk of fractures). Review of Resident 79's physician orders revealed an order for Weekly weight Tuesday 3-11 shift weightsevery week, with a start date of September 17, 2024. Review of Resident 79's clinical record failed to reveal a weekly weight measure was obtained during the week of September 15 through 21, 2024. Interview with the NHA and Director of Nursing on December 12, 2024, at 11:16 AM, revealed they are unable to locate a weekly weight measure between the aforementioned dates, and she would expect weekly weights to be obtained per physician order and facility policy. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services 395802 Page 6 of 6