Thornwald Home

In the surveyor’s words

From the most serious findings on record at Thornwald Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 21, 2025

  Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a 10 cm (centimeter) x 8 cm x 1 cm laceration (a deep cut or tear in the skin) to the right leg, requiring 15 sutures (stitches), for one of seven residents reviewed (Resident 1). […]

• No harm, potential for more than minimal, patternF725Jul 7, 2026

  Based on observations, clinical record review, review of call bell audit reports, and resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing was provided to meet resident needs, as evidenced by extended call bell wait times, for four of 13 residents reviewed (Residents 4, 10, 11, and 12).Findings include: During an interview with Resident 13 on July 7, 2026, at 10:31 AM, she stated that she had concerns with call bell wait times, especially for her roommate, Resident 10. She stated that the prior day her roommate had to wait 45 minutes to be assisted to the bathroom. Review of call bell audit reports confirmed that Resident 10's call light was illuminated for 45 minutes and 12 seconds on July 6, 2026. […]

• No harm, potential for more than minimal, patternF641Dec 11, 2025

  Based on clinical record review, policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 18 residents reviewed (Residents 4, 12, and 14). Findings include: Review of policy titled Bed Entrapment Prevention Program, revised November 11, 2022, read, in part, monitoring of resident's health status that may affect the risk of bed entrapment will be done periodically (at least quarterly) to assess resident continued need for the device and document in the electronic medical record. Review of facility policy, titled Trauma Informed Care, revised October 2024, read, in part, trauma informed care shall be an integral part of a person-centered environment. […]

• No harm, potential for more than minimal, patternF690Dec 12, 2024

  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. […]

• No harm, potential for more than minimal, patternF812Jan 18, 2024

  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 [DATE], at 2:20 PM. No further policies were provided. […]