Health inspection·October 5, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans and ensure each care plan contained goals and interventions for seven of nine residents reviewed (Residents R4, R5, R11, R12, R13, R14, and R16). Findings include: Review of facility policy dated 12/15/22, entitled Comprehensive Care Plans indicated Periodically reviewed and revised care plan by a team of qualified persons after each assessment. Review of Resident R4's clinical record revealed an admission date of 4/20/18, with diagnoses that included end stage renal disease (medical condition in which a person's kidney stop functioning leading to the need for dialysis), diabetes (too much sugar in the blood), and high blood pressure. Review of Resident R4's comprehensive care plan revealed that of the 25 care plans present, 25 had an outstanding target date (a date that the resident's care plan must be updated by) of 5/31/23. Review of Resident R5's clinical record revealed an admission date of 10/4/22, with diagnoses that included end stage renal disease, depression, and anemia. Review of Resident R5's comprehensive care plan revealed that of the 25 care plans present, 24 had an outstanding target date of 7/7/23, and one had no goal. Review of Resident R11's clinical record revealed an admission date of 12/11/20, with diagnoses that included diabetes, high blood pressure, and dementia (loss of memory, language, problem-solving, and other thinking abilities). Review of Resident R11's comprehensive care plan revealed that of the 25 care plans present, 24 had an outstanding target date of 4/12/23, and one had no goal or interventions. Review of Resident R12's clinical record revealed an admission date of 11/9/20, with diagnoses that included diabetes, high blood pressure, and dementia. Review of Resident R12's comprehensive care plan revealed that of the 29 care plans present, 29 had an outstanding target date of 9/22/23. Review of Resident R13's clinical record revealed an admission date of 10/8/22, with diagnoses that Page 1 of 2 395645 395645 10/05/2023 Edinboro Manor 419 Waterford Street Edinboro, PA 16412

F 0657 included diabetes, high blood pressure, and dementia. Level of Harm - Minimal harm or potential for actual harm Review of Resident R13's comprehensive care plan revealed that of the 23 care plans present, 23 had an outstanding target date of 8/31/23. Residents Affected - Some Review of Resident R14's clinical record revealed an admission date of 10/6/21, with diagnoses that included dementia, history of falls, and glaucoma (eye disease where the optic nerve is damaged and could lead to vision loss). Review of Resident R14's comprehensive care plan revealed that of the 19 care plans present, one had an outstanding target date of 6/1/23, and 18 had an outstanding target date of 7/26/23. Review of Resident R16's clinical record revealed an admission date of 1/26/22, with diagnoses that included diabetes, dementia, and high blood pressure. Review of Resident R16's comprehensive care plan revealed that of the 25 care plans present, 24 had an outstanding target date of 5/2/23, and one had an outstanding target date of 7/31/23. During an interview on 10/4/23, at 1:52 p.m. the Director of Nursing confirmed that Residents R4, R5, R11, R12, R13, R14, and R16's care plans were not reviewed and/or revised as required and they did not all contain a goal with interventions. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395645 Page 2 of 2