Health inspection·January 30, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on facility policy review, clinical record reviews, facility documentation review, and staff interviews, it was determined that the facility failed to report an allegation of abuse in a timely manner for one of four residents reviewed (Resident 1). Findings include: Review of facility policy, titled Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property, dated February 9, 2023, revealed, in part, Any incident of abuse must be reported to the Executive Director/Designee; All reports of alleged abuse/neglect shall be immediately and thoroughly investigated. The immediate response shall consist of: Social Services/Designee to interview the resident and if possible, obtain a signed statement from the resident. Interview with the person(s) reporting the alleged abuse/neglect and obtain a signed statement, if possible. Interview and obtain signed statements, if possible, from any witness or individual who has knowledge of the alleged incident. If any allegation of physical abuse is made, the nurse shall examine the resident. Findings of the examination must be recorded in the resident's medical record. Investigation of alleged sexual abuse requires a physical exam by a physician, unless the resident or resident representative expressly refuses. Review of Resident 1's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), chronic combined systolic diastolic heart failure (heart failure in which the heart cannot pump [systolic] or fill [diastolic] properly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 1's clinical record revealed a physician progress note written by Employee 2 dated January 9, 2025, at 10:28 AM, that indicated they had visited with Resident 1 this date and that she reported being assaulted in her genitalia. Specifically, she reported someone was cutting her in that area. She genuinely believes that these events occurred. The note further indicated, I did later talk to her nurse, who reviewed prior nursing notes with me. The note indicated that Resident 1 was alert and oriented to person and time, and that Employee 2 believed Resident 1's thought content was delusional. The documentation of their physical assessment failed to include any documentation that an assessment of Resident 1's genitalia was completed because of their reported assault. Review of Resident 1's clinical record revealed a physician progress note written by Employee 2 dated January 14, 2025, at 9:52 AM, that indicated they had visited with Resident 1 this date to follow-up on their delusions. The note indicated that Employee 2 had spoken to Resident 1's nurse who described her mental state as improving and that, as Employee 2 continued the conversation with Resident 1, she started to tell me again about being struck over the head, being assaulted in her genitalia, and being conspired against by staff. The note also indicated that Resident 1 was oriented to herself, and her thought content was delusional. The documentation of their physical assessment failed to include any documentation that an assessment of Resident 1 was completed because of their reported assault. Review of a facility provided witness statement written by Employee 6 (a Licensed Practical Nurse) dated January 30, 2025, revealed that on January 9, 2025, at approximately 8:20 AM, Employee 2 had approached them and was questioning them about Resident 1's delusions and accusations. The statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 2 of 6 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 01/30/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few further indicated that Employee 6 did not recall any specific comments regarding any 'assault towards genitalia'. Employee 6 said that they discussed side effects of medications, signs and symptoms of acute gastrointestinal illness, and possible side effects of dehydration that could be causing Resident 1 to experience delusions and confusion. During an interview with Employee 1 (Assistant Director of Nursing) on January 30, 2025, at approximately 10:55 AM, Employee 1 indicated that on January 22, 2025, at 10:30 AM, while reviewing the Physician Assistant's (PA-Employee 2) progress notes that morning in clinical meeting it was discovered that Employee 2 had documented that Resident 1 had been assaulted in her genitalia in a January 9, 2025, and January 14, 2025, progress notes. Employee 1 indicated that an investigation was initiated immediately when this was discovered. During a staff interview with the Nursing Home Administrator (NHA) and Employee 1 on January 30, 2025, at 3:32 PM, the NHA confirmed that she nor any other administrative staff were made aware of Resident 1's initial report of an allegation of sexual assault on January 9, 2025. She also confirmed that she nor any other administrative staff were made aware of Resident 1's continued allegation of sexual assault on January 14, 2025. The NHA confirmed that she would expect all staff to report all allegations of abuse immediately to her. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.20(a)(5) Staff development 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 3 of 6 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 01/30/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record reviews, review of facility reported incidents, review of facility documentation, and staff interviews, it was determined that the facility failed to complete thorough investigations of abuse allegations and, therefore, failed to protect the safety of a resident during abuse investigations for one of four residents reviewed (Resident 1). Residents Affected - Few Findings include: Review of facility policy, titled Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property, dated February 9, 2023, revealed, in part, All reports of alleged abuse/neglect shall be immediately and thoroughly investigated. The immediate response shall consist of: Social Services/Designee to interview the resident and if possible, obtain a signed statement from the resident. Interview with the person(s) reporting the alleged abuse/neglect and obtain a signed statement, if possible. Interview and obtain signed statements, if possible, from any witness or individual who has knowledge of the alleged incident. Upon notification that an employee is alleged to have committed abuse, the facility will: Ensure that the resident is safe. The individual may be suspended pending investigation. If the individual is not employed by the facility, the individual will be denied unsupervised access to the resident and visits may only be made in designated areas approved by the Executive Director/Designee. Review of Resident 1's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), chronic combined systolic diastolic heart failure (heart failure in which the heart cannot pump [systolic] or fill [diastolic] properly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 1 clinical record revealed a progress note written by Employee 4 (Director of Social Services) dated January 8, 2025, at 2:38 PM, that indicated Resident 1's behavior care plan was updated related to delusions that may include staff that are people of color. Further review of Resident 1's clinical record progress notes revealed a progress note written by Employee 3 (a Registered Nurse) dated January 8, 2025, at 2:39 PM, that indicated Resident 1 had told the Social Worker I was out in the snow looked for the person who hit me in the head and pulled me. It was two black girls I'd know one if I saw her. The note also indicated that Resident 1 said to Employee 3 I was hit on the head and dragged into the Cat Scan. They scanned my (pointed to private area). I was so full of urine. I had to relieve myself. I peed in the trash can. Now I am being punished. Review of facility provided investigation documentation revealed a statement written by Employee 4 (Director of Social Services) dated January 8, 2025, at 10:45 AM, indicated that she had stopped by to see Resident 1 and that she was tearful and said They've maligned me in every way because I peed in the trash can. What would you do? I was out in the snow looking for the person who hit me in the head and pulled me. No other investigation or witness statements were provided as part of the investigation. Review of a facility reported incident with an original submission date of January 8, 2025, at 2:26 PM, indicated that Resident 1 had stated to Employee 4 that staff have maligned me in every way because I peed in the trashcan. What would you do? I was out in the snow looking for the person who hit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 4 of 6 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 01/30/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm me in the head and pulled me. The report further indicated that the facility was unable to identify any individual involved. Further review of this report revealed that an update was submitted on January 13, 2025, indicating that the allegation was found to be unsubstantiated as the facility was unable to identify a perpetrator. Residents Affected - Few An update was submitted on January 16, 2025, that indicated, At time of accusation, resident was experiencing increased confusion and delusions. The facility reported incident failed to indicate that Resident 1 had shared a description of the alleged perpetrator(s) and said that she would be able to identify her if she saw her or that the facility had taken any measures to identify the alleged perpetrator. During a staff interview with Employee 1 (Assistant Director of Nursing) on January 30, 2025, at 10:55 AM, Employee 1 confirmed that the facility does have female staff fitting the resident's description and that one had cared for Resident 1 on one shift. Employee 1 confirmed that she had not obtained investigation or witness statements from any nursing staff regarding Resident 1's allegation and that Resident 1 had not been asked to identify the alleged perpetrator. Although, Resident 1 had provided a description and said that she would be able to identify her if she saw her. Employee 1 indicated that she usually reviews clinical notes daily. Employee 1 indicated that Resident 1 had been discussed in the daily clinical meetings because of her changes in health status. She indicated that they utilize the 24-hour report from the facility's electronic health record to discuss residents. She further indicated that this was an electronic report and that do not print them. Review of a facility reported incident with an original submission date of January 22, 2025, at 12:22 PM, indicated that on January 22, 2025, at 10:30 AM, it was discovered that Employee 2 had documented that Resident 1 had been assaulted in her genitalia in a January 9, 2025, and January 14, 2025, progress note. Further review of this report revealed that an update was submitted on January 27, 2025, indicating that Employee 2 did not communicate the Resident's concern to any facility staff member; and on January 28, 2025, indicating that Employee 1 had provided Employee 2 with education on the abuse policy, and he was given a copy of the policy. Review of provided investigation documentation revealed a statement written by Employee 5 (a Social Worker) which indicated that they had interviewed Resident 1 on January 22, 2025, and Resident 1 stated that she was hit on the head and a nurse was sticking something sharp inside of me. The resident also described the appearance of the two alleged employees. During a staff interview with the Nursing Home Administrator (NHA) on January 30, 2025, at 12:07 PM, the NHA indicated that, during daily clinical meeting, the interdisciplinary team reviews incidents and accidents, as well as verbal nursing reports. She said that the facility's electronic health record pulls a 24-hour report that reveals notes that have occurred in the prior 24 hours so that appropriate follow-up can be completed or initiated. When asked if open investigations are reviewed during this meeting, the NHA indicated that it depends on where they are in the investigation process and sometimes; they are not done in this meeting because of the nature of the investigation. The NHA attempted to pull 24-hour history reports from prior dates, but the system would not enable the report to be pulled. At time of conclusion of field office investigation on January 30, 2025, at 3:25 PM, the facility was unable to provide any documentation that indicated they had obtained investigation or witness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 5 of 6 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 01/30/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few statements from any nursing staff regarding Resident 1's abuse allegations or that Resident 1 had been asked to identify the alleged perpetrator(s). Although, Resident 1 had again provided a description and that she would be able to identify her if she saw her. During a staff interview with the NHA and Employee 1 on January 30, 2025, at 3:32 PM, the NHA confirmed that the facility had not thoroughly investigated Resident 1's allegations of abuse. She confirmed that Resident 1 was never asked to identify the alleged perpetrator(s); although, Resident 1 had provided a physical description and said that she would be able to identify her if she saw her again on two separate occasions over a 14-day timespan. The NHA confirmed that no staff members were suspended while the facility was completing the investigations for Resident 1. The NHA indicated that she would expect all abuse investigations to be completed thoroughly to enforce resident safety. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395802 If continuation sheet Page 6 of 6