Health inspection·January 21, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Actual harm Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that a resident was free from abuse regarding the use of a physical restraint not required to treat a resident's medical symptoms for one of one resident reviewed for restraints resulting in actual harm (Resident 1). Residents Affected - Few Findings include: Review of the policy entitled Abuse Prohibition, last reviewed on September 27, 2024, indicates that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Anyone who witnesses an incident of suspected abuse is to report the incident to his or her supervisor immediately. Review of the policy entitled Use of Restraints, last reviewed on September 27, 2024, indicates the patients have the right to be free from any physician or chemical restraints imposed for purpose of discipline or convenience, and not required to treat the patient's medical symptoms. Convenience is defined as the result of any action that has the effect of altering a patient's behavior such that the patient requires a lesser amount of effort or care and is not in the patient's best interest. A physical restraint is defined as any manual method, physical or mechanical device, equipment or material that is attached or adjacent to the body, cannot be easily removed by the patient, and restricts the patient's freedom of movement or normal access to their body. When the use of a restraint is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint. Consent must be obtained prior to the application of the restraint. Emergency restraint use may be used for as a last resort to protect the safety of the patient and others if the patient's unanticipated violent or aggressive behavior places self or others in imminent danger. The order for the restraint must be obtained from the physician either during the application or immediately after the restraint has been applied. Supporting documentation must reflect what the patient was doing and what happened that presented the imminent danger. Review of a facility submitted information to the Department of Health dated January 11, 2025, indicated that employees used a sheet across Resident 1's chest and tied her to her chair on January 8, 2025, and again on January 11, 2025. Review of the facility's investigation into Resident 1's use of a sheet as a restraint revealed a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395359 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 395359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jersey Shore Skilled Nursing and Rehabilitation Ce 1008 Thompson Street Jersey Shore, PA 17740 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)