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 (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: 395645 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 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 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)