Health inspection·November 8, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of facility policy, clinical record, and staff interview, it was determined that the facility failed to notify the resident's emergency contact/representative regarding a change in condition for one of three residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Notification of Changes Policy dated 12/6/2022, indicated that the facility must inform the resident's representative, or interested family member when there is an accident involving the resident, which may or may not result in injury and when there is a significant change in the resident's physical, mental or psychosocial status. Review of Resident R1's clinical record revealed an admission date of 9/29/23, with diagnoses that included alcoholic cirrhosis of liver with ascites (a degenerative disease of the liver caused by alcohol abuse which results in a build-up of fluid [ascites] in the abdomen), hepatic encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage), Type II Diabetes (condition of improper blood sugar control) and Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath). Review of Resident R1's clinical record revealed a progress note dated 9/30/2023, at 9:49 p.m. indicating the resident fell resulting in transport to the emergency room. The clinical record lacked evidence that the resident's emergency contact/representative was notified of Resident R1's fall or transfer to the emergency room. Further review of the clinical record progress note dated 10/7/23, at 2:17 a.m. revealed that Resident R1's health was declining. Resident was non-responsive to touch / voice and mottling (when skin appears red, bluish, purple or brown due to lack of blood flow to the skin) evident in bilateral lower extremities (legs). Progress note dated 10/7/23, at 8:54 a.m. revealed the resident was very lethargic, not responding normally, and congested with upper airway secretions. The clinical record lacked evidence that the resident's emergency contact/representative was notified of his/her declining health and change in condition. During an interview on 11/7/23, at 2:20 p.m. the Director of Nursing and Nursing Home Administrator In-Training confirmed that the clinical record lacked evidence of Resident R1's emergency contact/representative being notified of the above incidents and changes in conditions and that the facility staff should have notified the resident's emergency contact/representative and documented the notification in the clinical record. Page 1 of 2 395650 395650 11/08/2023 Warren Manor 682 Pleasant Drive Warren, PA 16365

F 0580 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395650 Page 2 of 2