Health inspection·April 26, 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 clinical record review, facility policy review, and observation, it was determined that the facility failed to ensure that physician's orders were implemented in regards to the use of a physical restraint for one of one sampled resident who was physically restrained. (Resident 38) Residents Affected - Few Findings include: Review of the facility policy entitled, Use of Restraints, last reviewed March 10, 2023, revealed that the opportunity for motion and exercise was to be provided every two hours when restraints were employed. Clinical record review revealed that Resident 38 had diagnoses that included Alzheimer's disease and dementia. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had memory impairment, required extensive assistance from staff for most activities of daily living, and used a restraint daily. On January 20, 2023, the physician ordered for staff to apply a Lap Buddy (a cushion device that prevents a resident from rising from a wheelchair) to Resident 38's wheelchair. Staff was to removed the restraint every two hours. Review of facility documentation revealed that there was no documented evidence that Resident 38's Lap Buddy was consistently removed every two hours as ordered on April 4, 5, 6, 8, 9, 12, 14, 16, 17, 18, 19, and 22, 2023. On April 23, 2023, from 10:30 a.m. through 1:15 p.m., and on April 24, 2023, from 11:00 a.m through 1:15 p.m. Resident 38 was observed with the Lap Buddy in place in the dining area on the nursing unit. At no time during these observations was Resident 38's restraint removed. On April 25, 2023, RN 1 asked the resident to remove the Lap Buddy from her wheelchair. Resident 38 could not remove the Lap Buddy from her wheelchair independently. The facility failed to consistently remove the resident's restraint as ordered by the physician and per facility policy. 28 Pa. Code 211.8(f) Use of Restraints. Page 1 of 3 396063 396063 04/26/2023 Seton Manor Nursing and Rehabilitation Center 1000 Seton Drive Orwigsburg, PA 17961

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview it was determined that the facility failed to follow physician's orders to monitor weights for one of 25 sampled residents. (Resident 104) Residents Affected - Few Findings include: Clinical record review revealed that Resident 104 had diagnoses that included congestive heart failure. On March 23, 2023, the physician ordered that staff weight the resident daily. Review of the weight record revealed that staff did not document the resident's weight on numerous days between March 24 and April 24, 2023. In an interview on 04/25/23 12:47 PM the Administrator confirmed that the resident was not weighed daily as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 396063 Page 2 of 3 396063 04/26/2023 Seton Manor Nursing and Rehabilitation Center 1000 Seton Drive Orwigsburg, PA 17961

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 interventions and adequate supervision to prevent accidents for one of five sampled residents at risk for falls and/or injury. (Resident 38) Findings include: Clinical record review revealed that Resident 38 had diagnoses that included dementia and Alzheimer's disease. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required staff assistance with activities of daily living including bed mobility, transferring, and toileting. The care plan identified that the resident had alterations to her skin and an intervention was to use caution during transferring and bed mobility. On January 10, 2023, nursing documentation indicated that Resident 38 obtained a skin tear on her second digit on her right hand during a transfer from a reclining chair to her merry walker. Review of the incident report revealed that her finger was pinched when staff was connecting the merry walker together. On February 12, 2023, nursing documentation indicated that Resident 38 obtained a skin tear to her right elbow. Review of the incident report revealed that the skin tear was obtained when staff removed her wheelchair cushion. On February 28, 2023, nursing documentation indicated that Resident 38 obtained a skin tear to her knee when staff was transferring her to her wheelchair. Review of the incident reported revealed that the resident's knee was bumped on the wheelchair. On March 10, 2023, a nurse documented that Resident 38 obtained a skin tear during a transfer from a comfort chair to her wheelchair by staff. On April 24, 2023, a nurse documented that the resident received a skin tear when staff was transferring her from her wheelchair to the toilet. Review of the incident report revealed that Resident 38's leg was bumped on the wheelchair. There was no documentation to support that the facility reviewed and provided adequate interventions to prevent skin tears during transfers for Resident 38 until April 24, 2023, when all staff on the unit were educated. In an interview on April 26, 2023, at 10:50 a.m. the Nursing Home Administrator confirmed there was no documented evidence that all staff were educated regarding safe transfers prior to April 24, 2023. Further review of Resident 38's care plan revealed that she had a history of multiple falls and an intervention was for staff to apply a chair alarm. On April 8, 2023, a nurse documented that the resident fell from her chair in the dining room. Review of the incident report revealed that the resident was often restless and that staff had failed to apply the chair alarm to Resident 38's chair prior to the fall. CFR. 483.25(d)(2) Accidents. Previously cited 4/8/22 28 Pa. Code 211.12(d)(1)(5) Nursing services. 396063 Page 3 of 3