Health inspection·August 21, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 for three of 13 residents reviewed (Resident R8, R11, and R13). Findings include: Review of facility policy dated 12/19/23, entitled Comprehensive Care Plans indicated A Comprehensive Care Plan must be developed within seven days after completion of the comprehensive assessment and Periodically reviewed and revised by a team of qualified persons after each assessment. Resident R8's clinical record revealed an initial admission date of 7/19/24, and a readmission date of 7/24/24, with diagnoses that included diabetes, high blood pressure, and chronic kidney disease (kidneys do not function properly in removal of excessive fluids and waste that is then removed through your urine). Review of Resident R8's comprehensive care plan on 8/19/24, revealed that of the 16 care plans present, 16 had an outstanding target date of 8/13/24. The care plans included the problem categories of: self-care, discharge plan, skin integrity, falls, activities, nutrition, code status, anti-anxiety medications, cardiovascular, ostomy, diabetes, antibiotic use, pain, constipation, catheter, and hypothyroid. Resident R11's clinical record revealed an admission date of 7/23/24, with diagnoses that included left hip fracture, diabetes, and high blood pressure. Review of Resident R11's comprehensive care plan on 8/19/24, revealed that of the 14 care plans present, 14 had an outstanding target date of 8/12/24. The care plans included the problem categories of: self-care, falls, bleeding due to anticoagulant use, cardiovascular, skin integrity, discharge plan, constipation, GERD, nutrition, activities, pain, code status, bladder incontinence, and antibiotic use. Resident R14's clinical record revealed an admission date of 6/30/23, with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors) chronic obstructive pulmonary disease (COPD - a lung disease that affects airflow from the lungs resulting in difficulty breathing, cough, mucus production and wheezing), and gastroesophageal reflux disease (GERD - a chronic disease when the stomach acids frequently flow back into the esophagus causing irritation and discomfort). Page 1 of 2 395650 395650 08/21/2024 Warren Manor 682 Pleasant Drive Warren, PA 16365

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of Resident R14's comprehensive care plan on 8/19/24, revealed that of the 17 care plans present, 17 had an outstanding target date of 8/10/24. The care plans included the problem categories of: falls, skin integrity, code status, self-care, discharge plan, pain, nutrition, activities, psychotropic medication use, constipation, cognition, bladder incontinence, COPD, anti-anxiety medication, anti-depressant medication, behaviors, and GERD. Residents Affected - Few During a telephone interview on 8/21/24, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that Residents R8, R11, and R14's care plans were not reviewed and/or revised within the required timeframe. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395650 Page 2 of 2