Pennsylvania Department of Health
EDINBORO MANOR
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EDINBORO MANOR
Inspection Results For:

There are  85 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
EDINBORO MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on February 15, 2024, it was determined that Edinboro Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:


Based on review of admission packet and facility documents, observations, and resident and staff interviews, it was determined that the facility failed to post the results of the most recent survey results in a place readily accessible to residents on four of four units (Units A, B, C, D).

Findings include:

The "Admission Notice Packet" presented on admission by the facility and posted on entrance and in the survey result book are the "Resident Rights. Sec.1919(c)(1) Examination of Survey Results" in the admission packet stated "the survey results must be made available for your examination by the facility in a place readily accessible to you."

Observation on 2/12/24, at 11:00 a.m. an unknown female (later identified by staff as being from "Medicaid") was working on a laptop in the resident library, and remained until approximately 4:00 p.m.

Observation on 2/13/24, at 8:15 a.m. an unknown female (later identified by staff as the Certified Registered Nurse Practitioner- CRNP) was working on a laptop in the resident library, and remained until approximately 3:00 p.m.

Interview on 2/13/24, at 3:00 p.m. with the Nursing Home Administrator (NHA) confirmed who the above visitors were there working in the library.

Observation on 2/13/24, revealed a sign located in a glass enclosed case in the facility entrance indicated that the survey results were located in the resident library.

Interviews on 2/13/24, at 10:00 a.m. with Resident Council Members confirmed that they did not know where the survey results were located, and stated they assumed they were in the "front office." Upon being informed that the survey results were located in the resident library, Resident Council Members confirmed that they do not have access to the resident library on "most days," and that there is often someone in there working.

Observation on 2/14/24, at approximately 8:45 a.m. five corporate consultants were working in the resident library until surveyors left the building at 3:45 p.m.

Interview on 2/14/24, at 1:08 p.m. with the NHA confirmed the presence of individuals working in the resident library.

Interview on 2/14/24, at 1:36 p.m. with the NHA identified that the survey results binder was not located in the resident library and was not able to state where it was.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(a) Management







 Plan of Correction - To be completed: 04/15/2024

Edinboro Manor has posted Department of Health survey results of the most recent surveys (3 years) in a prominent/accessible location for residents, resident representatives and other visitors to observe and access.

By March 22 the administrator/designee will educate all staff on the Department of Health Surveys being posted in a prominent location for all to access.

Administrator/designee will educate residents via resident council by March 22 on the posting of the Department of Health Survey results and where they are able to access them.

Administrator/designee will audit 3X a week for 3 weeks then 1X per week for 3 weeks then 1X per month for two months to ensure department of health hotline is posted in a prominent place for residents/families to access.

Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure Department of health Survey results are posted in a prominent place and all education has been completed.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of four residents reviewed for respiratory care and failed to follow physician's orders related to oxygen equipment for one of four residents reviewed for respiratory care (Residents R45 and R57).

Findings include:

Review of a facility policy entitled, "Disposable Supply Changes" dated 12/14/23, indicated that "Guidelines of when disposable supplies for medical equipment need changed for infection control purposes. Disposable supplies need to be dated when changed .... And Oxygen Cannulas (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen), Oxygen Supply Lines (tubing that connects from the oxygen source to the nasal cannula), and Oxygen Humidifier Bottles) plastic bottles filled with distilled water used to humidify oxygen) should be changed weekly or prn (as needed)."

Resident R45's clinical record revealed an admission date of 10/25/23, with diagnoses that included heart disease, irregular heartbeat, difficulty speaking and swallowing and hypertension. There was no evidence in the clinical record of a physician's order for supplemental oxygen.

Observations on 2/12/24, at 3:57 p.m. and 2/13/24, at 8:39 a.m. revealed Resident R45 sitting in a wheelchair in his/her room with supplemental oxygen via nasal canula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) set a 2 LPM (liters per minute).

During an interview on 2/12/24, at 4:39 p.m. Registered Nurse (RN) Employee E2 confirmed that Resident R45 had oxygen in place at 2 LPM.

Observation on 2/14/24, at 10:10 a.m. revealed Resident R45 sitting in wheelchair in D Hall with supplemental oxygen via nasal canula attached to a portable tank set at 2 LPM .

During an interview at that time RN Employee E1 confirmed that Resident R45 was wearing supplemental oxygen, there was no physician's order and that it was applied in response to an episode of respiratory distress on 12/14/23, and staff failed to obtain a physician's order.


Resident R57's clinical record revealed an admission date of 1/6/23, with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), pneumonia, and Heart Failure (a progressive heart disease that affects pumping action of the heart muscles, causing fatigue and shortness of breath).

Resident R57's clinical record revealed a physician's order dated 1/6/23, indicating to "Change O2 [oxygen] tubing and supply bag weekly ... Change water jug (bottle) weekly."

Review of Resident R57's treatment records for February 2024, revealed that Resident R57's oxygen tubing and water bottle was last changed on February 9, 2024.

Observations on 2/12/24, at 2:30 p.m. and on 2/14/24, at 8:35 a.m. revealed Resident R57 lying in bed in his/her room with supplemental oxygen on. Resident R56's oxygen tubing had a piece of tape on it indicating it was last changed on 2/4/24, and the water bottle had 2/6/24 written on the top.

During an interview on 2/14/24, at 8:42 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that the oxygen tubing was dated 2/4/24, and was not changed per physician's orders and the water bottle was dated 2/6/24, and was not changed per physician's orders.

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing Services





 Plan of Correction - To be completed: 04/15/2024

An order was obtained for resident R45's oxygen and resident R57 was provided new oxygen tubing and humidification on 2-14-24."
A whole house sweep was done on 2/14/24 to ensure all residents with oxygen had orders and that tubing and humidification changes had been completed as required.
By March 22 the administrator/designee will educate nursing on all residents that are wearing oxygen should have an order. Residents who are wearing oxygen should have their tubing and water changed per orders.
The administrator/designee will audit 3X a week for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to ensure compliance with oxygen related orders.
Resident R45's clinical record was updated to discharge the oxygen.
DON/designee will audit 1 hall per week x3 weeks, then 1 hall every other week, then 1 hall monthly for 2 months to ensure that all residents wearing oxygen have orders.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure to ensure compliance with and presence of oxygen orders.

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on review of facility policy and facility documentation, observations, resident and staff interviews, it was determined that the facility failed to make certain residents were aware of the procedure for filing a concern/grievance (written or verbal, the procedure to file a grievance anonymously), and make certain concern forms are easily located and accessible to all residents and/or representatives on four of four nursing units (A, B, C, D).

Findings include:

Review of the facility policy entitled, "Grievance Policy" last reviewed 12/14/23, indicated that: all persons will be provided with an opportunity to present their complaints through a formal grievance procedure; the grievance procedure will be reviewed with all residents at the time of admission, and posted in the Manor; if filing a written grievance, the forms are located in the Administrator's office, must be submitted in writing and signed by the resident or person filing the grievance on behalf of the resident, and lacked guidance related to filing an anonymous grievances.

Observation on 2/12/24, at 11:00 a.m. revealed a green sample grievance form in flip chart at the entrance with a round wooden table blocking access to the chart, and no blank forms for resident use, or a box to anonymously place completed grievance forms.

During an interview on 2/13/24, at 10:15 a.m. Resident Council Members confirmed that they tell someone if they have a complaint, and do not know if there is an official form or where to get it.

During an interview on 2/14/24, at 1:11 p.m. the Nursing Home Administrator confirmed there was no postings of grievance procedures and no way for residents/family to anonymously submit a grievance.

28 Pa. Code 201.29(a)(b)(c) Resident rights

28 Pa. Code 201.18(e)(4) Management







 Plan of Correction - To be completed: 04/15/2024

Edinboro Manor has placed a grievance submission box and forms in the soda shoppe for residents/representatives who wish to file an anonymous grievance. Forms are also located in designated areas of each hall.

By March 22 the administrator/designee will educate all staff and resident council on the anonymous grievance process and location of submission box and forms. There will be follow up at each resident council meeting to ensure all residents understand the steps to submit an anonymous grievance.

The administrator/designee will audit 3X a week for 3 weeks then 1X per week for 3 weeks then 1X per month for 2 months to ensure availability of grievance forms in designated areas.

Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure Grievance forms are posted in prominent places and that all education has been completed.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment on one of four units (B Unit).

Findings include:

Review of facility policy entitled "Housekeeping and Maintenance Services" dated 12/14/23, indicated "The Manor will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior."

Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in Room 48 a white/brown substance on the floor to the right side of the resident's bed, a white substance on the floor to the left side of the resident's bed, pieces of paper under the bed and under the nightstand, and a large amount of gray fluffy substance over the floor of the resident room, under the resident's bed and covering the flat surfaces of the bed frame.

Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in Room 51 a round quarter-size brown object under bed two, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both bed frames. In the resident bathroom observation of a brown dry substance on the floor to both sides of the toilet.

Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in Room 55 a crumpled up facial tissue under bed one, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both resident's bed frames.

Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in Room 61 empty candy wrappers under bed one, paper from dressing supplies under bed one, a used band aide stuck to the floor between bed one and bed two, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both bed frames.

During observations with the Nursing Home Administrator on 2/14/24, at 9:00 a.m. he/she confirmed that Resident Rooms 48, 51, 55, and 61 were not appropriately cleaned. He/she also confirmed that resident rooms should be clean.

During observations with Housekeeping Employee E4 on 2/14/24, at 9:15 a.m. he/she confirmed that the above resident rooms on B Unit were not appropriately cleaned. He/she also confirmed that resident rooms should be clean.

28 Pa. Code 201.14 (a) Responsibility of Licensee





 Plan of Correction - To be completed: 04/15/2024

All resident rooms 48, 51,55, and 61 were all cleaned by February 14, 2024. All other facility rooms were checked for housekeeping needs on February 14, 2024. Any resident rooms that had housekeeping needs were cleaned on this date.

By March 22 the administrator/designee will educate Housekeeping Staff on providing housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior.

The administrator/designee will audit 5X a week for four rooms from each hall for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to assure that Edinboro Manor is maintaining a sanitary, orderly and comfortable interior.

Audit results will be reviewed by the
Quality Assurance and Planned Improvement Committee to ensure Edinboro Manor maintains a sanitary, orderly and comfortable interior for our residents and all education has been completed.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to include the recapitulation of stay (summary of resident's stay and course of treatment in the facility) for one of four closed records reviewed (Resident CR111).

Findings include:

Review of Resident CR111's clinical record revealed an admission date of 6/30/23, with diagnosis that include Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), and Diabetes.

Review of clinical record revealed that Resident CR111 was discharged on 12/14/23.

Review of Resident CR111's clinical record lacked evidence of a recapitulation of Resident CR111's stay.

During an interview on 2/15/24, at 12:00 p.m. with Employee E3 he/she confirmed that Resident CR111's closed record lacked a recapitulation of his/her stay.

28 Pa. Code 211.5(d)(f)(iv)(xi) Medical records



 Plan of Correction - To be completed: 04/15/2024

Resident CR111 has been discharged.
A review of all residents discharged within the last 30 days has been completed to ensure that a discharge summary has been completed."
By March 22 the administrator/designee will educate licensed nurses on requirement to complete a discharge summary at the time a resident is discharged.
The administrator/designee will audit 3X a week for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to to ensure discharge summaries are completed for discharged residents.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure completion of discharge summaries."

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to update a care plan for one of 24 residents reviewed (Resident R81).

Findings include:

Review of a facility policy entitled "Comprehensive Care Plan" dated 12/14/2023, indicated that, care plans are periodically reviewed and revised by a team of qualified persons after each assessment.

Review of Resident R81's clinical record revealed an admission date of 10/06/2021, with diagnoses that included dementia, history of falling and abnormalities of gait and mobility.

Review of Resident R81's clinical record revealed a progress note dated 9/20/2023, that indicated Resident R81 was lying on his/her back on the floor with feet towards the door and a large amount of bloody drainage noted on the floor and Resident R81's clothes. Resident R81 was assessed with a head laceration to posterior scalp. An order was received from the physician to transfer Resident R81 to the hospital.

Review of clinical record documentation and fall investigation tool for Resident R81, revealed that he/she fell on 9/20/23, resulting in a head laceration requiring staples. There was no evidence that the care plan was updated to reflect the fall and interventions.

During an interview on 2/15/2024, at 11:50 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R81's care plan was not updated to reflect the fall with injury from 9/20/23 and interventions.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(1)(5) Nursing services




 Plan of Correction - To be completed: 04/15/2024

The care plan for R81 has been updated to reflect fall interventions.
A review of resident falls in the last 30 days has been completed to ensure that care plan reflects fall interventions.
The DON/designee will re-educate licensed nurses by March 22 on requirement to care plan fall interventions.
The administrator/designee will audit 3X a week for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to ensure fall interventions are care planned.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure fall interventions are care planned.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to provide a resident and/or his/her representative with a summary of the baseline care plan for one of 24 residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed an admission date of 11/3/23, with diagnosis that included Chronic Obstructive Pulmonary disease (a disease that obstructs air flow from the lungs), Hypertension (high blood pressure), and Quadriplegia (a condition where a person is paralyzed and unable to move their body from the neck down).

Review of Resident R1's clinical record lacked evidence that a summary of the care plan that included goals, treatments and services, and a summary of medications and dietary instructions was provided to Resident R1 and/or his/her representative.

During an interview on 2/14/24, at 3:26 p.m. with the Director of Nursing he/she confirmed that there was no evidence that Resident R1 and/or his/her representative was provided a summary of the care plan that included goals, treatments and services, and a summary of medications and dietary instructions.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 211.12 (d)(1)(e) Nursing Services






 Plan of Correction - To be completed: 04/15/2024

Resident R1 has been provided a copy of their current care plan.
.
A review of all residents admitted in the last 30 days has been completed to ensure that a copy of their baseline care plan was provided.
Education will be completed by the Director of Nursing/designee regarding baseline care plans to the Case Manager and Charge Nurses. This education will be completed by March 22.
The administrator/designee will audit 3X a week for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to verify completion of the baseline care plans and that they were given to the resident and his/her representative.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure Edinboro Manor maintains compliance with baseline care plans.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for one of 23 residents reviewed (Resident R59).

Findings include:

Review of facility policy entitled "Resident Assessment Policy" dated 12/14/23, indicated "Accuracy of assessment. The assessment will accurately reflect the resident's status."

Resident R59's clinical record revealed an admission date of 4/20/2018, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), dependence of renal dialysis (a mechanical treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), and diabetes (condition of improper blood sugar levels).

Review of Resident R59's clinical record revealed a physician's order dated 1/29/24, that identified that the resident was ordered to go to dialysis on Monday, Wednesday, and Friday at 7:30 a.m.

Review of Resident R59's Care Plans revealed a care plan with a focus that indicated "I am receiving dialysis services related to kidney failure and chronic kidney disease stage five," with a care plan creation date of 2/15/21.

Review of the MDS dated 1/8/24, Special Treatments, Procedures, and Programs Section O0100 revealed to "check all of the following treatments, procedures, and programs that were performed during the last 14 days." Documentation on the MDS for O0100 while a resident under J Dialysis revealed it was answered "no."

During an interview on 2/14/24, at 1:42 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident was currently receiving dialysis. The RNAC also confirmed that Section O0100 of the MDS dated 1/8/24, was incorrectly coded for Resident R59 regarding receiving dialysis.

28 Pa. Code 201.14 (a) Responsibility of Licensee







 Plan of Correction - To be completed: 04/15/2024

Resident R59's has been changed to reflect dialysis status and resubmitted.
All other residents who receive dialysis have been reviewed to ensure dialysis is coded on their MDS.
By March 22 the RNAC will be re-educated by a regional designee on required MDS coding as it relates to special treatments, procedures and programs"
The administrator/designee will audit 3X a week for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to ensure accurate data entry of dialysis on MDS's.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure accurate dialysis MDS coding.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury in a timely manner for one of 24 residents reviewed (Resident R81).

Findings include:

Review of a facility policy entitled, "Accidents and Incidents" dated 12/14/2023, indicated that, all accidents and/or incidents occuring on Manor premises involving residents must be investigated.

Review of Resident R81's clinical record revealed an admission date of 10/06/2021, with diagnoses that included dementia, history of falling and abnormalities of gait and mobility.

Review of Resident R81's clinical record revealed a progress note dated 9/20/2023, that identified Resident R81 was lying on his/her back on the floor with feet towards the door and a large amount of bloody drainage noted on the floor and Resident R81's clothes. Resident R81 was assessed with a head laceration to posterior scalp. An order was received from the physician to transfer Resident R81 to the hospital.

Review of Resident R81's clinical record and incident documentation revealed a lack of evidence that a full investigation was completed. Further review of the clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff.

During an interview on 2/15/2024, at 11:00 a.m. the Nursing Home Administrator confirmed that there was not a complete investigation completed on Resident R81's unwitnessed incident with injury, and also confirmed that all incidents should be investigated which included obtaining written statements.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(1)(5) Nursing services










 Plan of Correction - To be completed: 04/15/2024

A post fall investigation has been completed for resident R81.
Residents who have had a fall in the last 30 days have been reviewed to ensure that post fall investigations have been completed.
By March 22 the administrator/designee will educate nursing staff on post fall investigation requirements.
The administrator/designee will audit 3X a week for 3 weeks then 2X per week for 3 weeks then 1X per week for 2 months to ensure post fall investigations are completed as required.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure Edinboro Manor is completing investigations as required.

483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:


Based on observations and staff interview, it was determined that the facility failed to display the Department of Health (DOH) Hotline (toll-free telephone number) number in a prominent/accessible location for residents, resident representatives, and other visitors to observe and access in the facility.

Findings include:

Observations throughout the facility between 2/12/24, and 2/15/24, revealed that the DOH Hotline phone number was not posted for residents, resident representatives, and other visitors.

During an interview on 2/14/24, at 1:11 p.m. the Nursing Home Administrator confirmed the facility failed to display the DOH Hotline phone number number in a prominent/accessible location for residents, resident representatives, and other visitors to observe and access in the facility.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(e) (2.1) Management







 Plan of Correction - To be completed: 04/15/2024

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are legal or factually correct. This plan of correction is not meant to establish a standard of care, contract, obligation or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding, please accept this plan of correction as Edinboro Manor's credible allegation of compliance. All residents received appropriate care and services to meet their needs on all identified days and there was no direct correlation to an individual resident.
Edinboro Manor has been posted Department of Health toll free hotline number in a prominent/accessible location for residents, resident representatives and other visitors to observe and access.
By March 22 the administrator/designee will educate all staff on the Department of Health Hotline being posted in prominent places. Administrator/designee will educate residents via resident council on the posting of the Department of Health hotline and where they are able to access it.
The administrator/designee will audit 3X a week for 3 weeks then 1X per week for 3 weeks then 1X per month for 2 months to ensure the department of health hotline remains posted in a prominent place for all to access.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure Department of health hotline is posted in a prominent position and all education has been completed.

211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to include the discharge summary in the closed record for three of four closed records reviewed (Residents CR109, CR110, and CR111).

Findings include:

Review of Resident CR109's clinical record revealed an admission date of 12/6/23, with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and diabetes (condition of improper blood sugar levels).

Review of clinical record revealed that Resident CR109 ceased to breath (passed away) on 12/9/23.

Review of Resident CR109's clinical record revealed there was no discharge summary included in the record.


Review of Resident CR110's clinical record revealed an admission date of 11/30/23, with diagnoses that included diabetes, fusion of spine (a surgery that connects two or more bones together to prevent them from moving), and obesity (a condition of abnormal or excessive weight).

Review of Resident CR110's clinical record revealed that Resident CR110 was discharged to the hospital on 12/5/23 with no anticipated return to the facility.

Review of Resident CR110's clinical record revealed there was no discharge summary included in the record.


Review of Resident CR111's clinical record revealed an admission date of 6/30/23, with diagnoses that included hypertension, hyperlipidemia, and diabetes.

Review of Resident CR111's clinical record revealed that Resident CR111 was discharged on 12/14/23.

Review of Resident CR111's clinical record revealed there was no discharge summary included in the record.

During an interview on 2/15/24, at 12:00 p.m. with Medical Records Employee E3, he/she confirmed that the closed records for Residents CR109, CR110 and CR111's did not have discharge summaries included in their records as required.








 Plan of Correction - To be completed: 04/15/2024

Residents CR 109, CR110 and CR111 have been discharged.
A review of all residents discharged within the last 30 days has been completed to ensure that a discharge summary has been completed and is present in medical record.
By March 22 the administrator/designee will educate Medical Records licensed nurses on requirement to complete a discharge summary at the time a resident is discharged.
The administrator/designee will audit 3X a week for 3 weeks then 1X per week for 3 weeks then 1X per month for 2 months to to ensure discharge summaries are completed and present in medical record for discharged residents.
Audit results will be reviewed by the Quality Assurance and Planned Improvement Committee to ensure completion of discharge summaries and presence in medical record."


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