Pennsylvania Department of Health
EDINBORO MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 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:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on February 22, 2024, at Edinboro Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #053002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 22, 2024, it was determined that Edinboro Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for three of four quarters.

Findings include:

Document review on February 22, 2024, at 10:29 a.m., revealed the following quarters and shifts lacked fire drills:
A. (10:29 a.m.) Second quarter, second shift;
B. (10:29 a.m.) Third quarter, third shift;
C. (10:29 a.m.) Fourth quarter, first shift.

Interview with the maintenance supervisor on February 22, 2024, at 10:29 a.m., confirmed the deficiencies.

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.

Fire Drills shall be conducted quarterly on each shift to familiarize the facilities personnel (nurses, interns, maintenance, and administrative staff) with the signals and emergency action required under varied conditions. Edinboro Manor has policies and procedures in place to comply with NFPA requirements.

Maintenance will be in-serviced on the fire drill requirements and the proper documentation requirements for the Fire drills by March 22.

An audit will be done to ensure fire drills are conducted appropriately. We will monitor for two months each shift has a fire drill.

The administrator will monitor the fire alarm drills and any deficiencies will be reported to QAPI.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) 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 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.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system requirements, affecting the entire facility.

Findings include:

Document review on February 22, 2024, at 10:15 a.m., revealed the monthly conductance test was not completed. However, the facility had check marks for electrolyte levels for a maintenance-free battery.

Interview with the maintenance supervisor on February 22, 2024, at 10:15 a.m., confirmed the testing had not been completed at the time of the survey.

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

As part of the facilities emergency generator testing and inspection a monthly conductance test will be completed in the future testing.

Maintenance will be in-serviced on proper procedures for testing of the conductance testing by March 22.

An audit will be done for two months to ensure that Edinboro Manor is in proper compliance with Conductance testing.

Maintenance will monitor for proper operation and any deficiencies will be reported to QAPI.

Initial comments:Name: THERAPY SUITE - Component: 02 - Tag: 0000

Facility ID #053002
Component 02
Therapy Unit

Based on a Medicare/Medicaid Recertification Survey completed on February 22, 2024, it was determined that Edinboro Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: THERAPY SUITE - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system requirements, affecting the entire facility.

Findings include:

Document review on February 22, 2024, at 10:15 a.m., revealed the monthly conductance test was not completed. However, the facility had check marks for electrolyte levels for a maintenance-free battery.

Interview with the maintenance supervisor on February 22, 2024, at 10:15 a.m., confirmed the testing had not been completed at the time of the survey.

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