Inspection·August 21, 2024

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 review of facility policy, clinical records, facility documents, and staff interviews it was determined that the facility failed to ensure a resident was free from physical restraint (Resident R1). Residents Affected - Few Findings include: Review of facility policy Restraints dated 2024, revealed Physical restraints are defined as any manual or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of Resident R1's clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated June 18, 2024, indicated diagnoses of Hypo-Osmolality and Hyponatremia (chronic low sodium levels that effects energy levels and brings on a state of confusion), Major Depressive Disorder (persistent feeling of sadness), Schizophrenia (chronic mental disorder that affects how a person thinks, feels, and behaves), and Dementia (group of symptoms that affects memory, thinking, and interferes with daily life). Review of information dated August 15, 2024 submitted by the facility, indicated, Unit manager reports that [Resident R1] (BIMS of 2 out of 15-Brief Interview of Mental Status) was observed sitting in (his/her) wheelchair with a white sheet tied around (his/her) waist. The sheet was removed and [Resident 1] was assessed for injuries with none observed. CNA [Employee E1] was assigned to [Resident R1] over 11-7 shift and was suspended pending investigation. PB22 to follow. MD (Medical Doctor) and RP (Responsible Party) will be notified. Review of written witness statements obtained on August 15, 2024, including Certified Nursing Assistant (CNA) Employee E1 indicated, I [CNA Employee E1], place a sheet around [Resident R1] in the chair to prevent [resident] from falling on the floor. [Resident] was taking off (his/her) clothes as well as bending over to the floor. [Resident] didn't sleep all night. I had to sit besides [Resident R1] bed to keep (him/her) in bed. When I had to do my morning rounds that is when I put (him/her) in the chair and (he/she) was slumping over. Review of written witness statement obtained on August 15, 2024, from Certified Nursing Assistant (CNA) Employee E2 stated, I [CNA Employee E2] was trying to help a resident he was in a wheel chair (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 2 Event ID: 396083 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 396083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Health Care and Rehab Center 318 South Orange Street Media, PA 19063 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)