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. 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: 396063 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 396063 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seton Manor Nursing and Rehabilitation Center 1000 Seton Drive Orwigsburg, PA 17961 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)