Health inspection·May 11, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 observation, it was determined the facility failed to ensure that use of a physical restraint was medically justified and failed to conduct an on-going assessment of a restraint for one of 21 sampled residents. (Resident 62) Residents Affected - Few Findings include: Review of the facility policy entitled, Restraint Policy, dated July 25, 2022, revealed that the interdisciplinary team would review and re-evaluate the use of all restraints ordered by physicians. The review would focus on the success or failure of the implementation of the plan, documentation, and recommendations for change if a problem was not resolved. The residents would be followed every 30 days or sooner until the restraint was eliminated or the least restrictive device was found to resolve the area of concern. Further review of the policy revealed that a physician's order must be obtained for use of a restraint and the order would indicate the type of restraint, the specific medical reason for its use, and frequency. Clinical record review revealed that Resident 62 had diagnoses that included moderate intellectual disability and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance with dressing and toileting. On May 24, 2022, the physician ordered for staff to apply a jumpsuit to Resident 62 in the evening and remove promptly in the morning. The physician's order did not indicate the specific medical reason for the use of the jumpsuit. Review of the care plan revealed Resident 62 was at risk for behavioral symptoms. Interventions included for staff to apply a jumpsuit in the evening and remove it in the morning when the resident awoke. On May 10, 2023, from 8:00 a.m. through 10:15 a.m., Resident 62 was observed out of bed wearing a one piece jumpsuit that zipped down the back on the nursing unit. The jumpsuit limited his access to his own body and staff assistance was required to put on and take off the jumpsuit. Review of monthly restraint evaluation forms from December 2022 through April 2023, revealed that there was no documented evidence that the interdisciplinary team reviewed or re-evaluated the use of Resident 62's restraint to determine if it was the least restrictive device. 28 Pa. Code 211.8(e)(f) Use of restraints. 28 Pa. Code 201.12(d)(1)(5) Nursing services. Page 1 of 4 395880 395880 05/11/2023 Phoebe Berks 1 Heidelberg Drive Wernersville, PA 19565

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 21 sampled residents. (Residents 52, 62) Residents Affected - Few Findings include: Clinical record review revealed that Resident 52 had diagnoses that included fracture left hip and anxiety. Section B of the MDS assessment dated [DATE], indicated that the resident was not in a vegetative state and that the resident's hearing, speech, and vision should be assessed. The MDS indicated Resident 52's hearing, speech, and vision were coded as not assessed. In an interview on May 11, 2023, at 11:19 a.m., the Administrator stated that Resident 52's hearing, speech, and vision should have been assessed. Clinical record review revealed that Resident 62 had diagnoses that included moderate intellectual disability and depression. On May 24, 2022, a physician ordered for staff to apply a jumpsuit to Resident 62 in the evening and to remove promptly in the morning. On May 10, 2023, from 8:00 a.m. through 10:15 a.m., Resident 62 was observed wearing a jumpsuit that zipped down the back that restricted the resident's movement. Section P of the MDS assessment dated [DATE], indicated that the resident did not use a restraint device. In an interview on May 11, 2023, at 11:25 a.m., the Administrator confirmed that Section P of the MDS indicated that Resident 62 did not use a restraint device. 395880 Page 2 of 4 395880 05/11/2023 Phoebe Berks 1 Heidelberg Drive Wernersville, PA 19565

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 21 sampled residents. (Resident 75, 88) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had cognitive impairment. The Care Area Assessment (CAA) summary, identified that cognitive loss/dementia was a problem area for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address Resident 75's cognitive loss/dementia. Clinical record review revealed that Resident 88 had diagnoses that included depression and anxiety. Review of the MDS assessment dated [DATE], identified that the resident received psychotropic medications. According to the CAA summary, the facility identified that the resident's psychotropic medication use was a problem and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop a care plan with interventions to address the need for psychotropic medications. In an interview conducted on May 11, 2023, at 11:59 a.m., the Administrator confirmed that there was no care plan developed with interventions to address the above problem areas for Residents 75 and 88. 28 Pa. Code 211.11(d) Resident care plan. 395880 Page 3 of 4 395880 05/11/2023 Phoebe Berks 1 Heidelberg Drive Wernersville, PA 19565

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 clinical record review and staff interview, it was determined that the facility failed to provide services to increase range of motion and/or prevent further decrease in range of motion for one of 21 sampled residents. (Resident 75) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and difficulty in walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive assistance from staff for activities of daily living, such as transferring, moving in bed, and dressing. A physical therapy Discharge summary dated [DATE], noted that staff were to implement a restorative nursing program for ambulation of 25 to 100 feet. There was a lack of documentation to support that the physical therapist's recommendation for a restorative walking program was implemented for Resident 75. During an interview on May 11, 2023, the Therapist confirmed that there was no documentation that the restorative walking program for Resident 75 was implemented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395880 Page 4 of 4