Pennsylvania Department of Health
EDISON MANOR NURSING & REHAB CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 36 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.


EDISON MANOR NURSING & REHAB CENTER - 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 28, 2024, it was determined that Edison Manor Nursing and Rehab Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, the facility failed to maintain the emergency prepardness plan for one of one plan.

Findings include:

Document review on February 28, 2024, at 8:55 a.m., revealed the facility failed to provide documentation of the annual review date of policies and procedures.

Interview with the maintenance supervisor on February 28, 2024, at 8:55 a.m., confirmed the annual review date had not been updated at the time of the survey.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from the facility failing to provide documentation for the annual review date of emergency preparedness policies and procedures. On 3/11/2024 the administrator and leadership team will meet to review the facility's emergency preparedness procedures and document the review as required. The administrator will provide education to maintenance director and leadership team on 3/11/2024 regarding the expectation to provide a documented annual review of the facility's emergency preparedness procedures. The administrator or designee will be responsible for ongoing quarterly audits to ensure a documented annual review of the facility's emergency preparedness procedures is completed and results of the audits will be reported to the Quality Assurance Performance Improvement committee quarterly.

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain one of one emergency preparedness plan.

Findings include:

Document review on February 28, 2024, at 8:40 a.m., revealed the facility failed to provide the following documentation:
A. (8:40 a.m.) Annual site-specific emergency preparedness training for all employees set forth by the facility's policies and procedures;
B. (8:40 a.m.) Tabletop drill.

Interview with the administrator on February 28, 2024 at 8:40 a.m., confirmed the facility failed to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from the facility failing to provide documentation for the annual site-specific emergency preparedness training for all employees set forth by the facility's policies and procedures. On 3/13/2024 the administrator will provide annual site-specific emergency preparedness training for all employees set forth by the facility's policies and procedures. Furthermore, the administrator and leadership team will complete a tabletop exercise on 3-12-2024. Administrator or designee will be responsible for ongoing compliance to ensure annual site-specific emergency preparedness training is completed by facility staff and results of the education will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

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

Facility ID #025902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 28, 2024, it was determined that Edison Manor Nursing and Rehab Center 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 three-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain the building construction type on all building levels.

Findings include:

Observation on February 28, 2024, at 9:44 a.m., revealed the facility exceeded the height requirement for a three-story, Type II (000), unprotected, non-combustible building.

Interview with the maintenance supervisor on February 28, 2024 at 9:44 a.m., confirmed the building exceeded the height requirement for this construction type.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from the facility exceeding the height requirement for this construction type. Life Safety Consultant Peters Rice Associates conducted an FSES on 3/20/2017, which is on file with the Department of Health.
Edison Manor has been working with various vendors on a construction proposal that will minimize disturbance to the residents of the facility. Once a viable proposal has been acquired the facility will submit architectural plans and determine the time frame to have the work completed to stay in compliance.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to meet doors with self-closing device requirements on one of three building levels.

Findings include:

Observation on February 28, 2024, at 11:50 a.m., revealed the first floor laundry soiled utility door had the following deficiencies:
A. (11:50 a.m.) The magnet that automatically releases the door was damaged;
B. (11:50 a.m.) The door was propped open by a five gallon bucket;
C. (11:50 a.m.) The door was damaged, keeping it from latching properly.

Interview with the maintenance supervisor on February 28, 2024, at 11:50 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from the first floor laundry door failing to meet doors with self-closing device requirements. On 3/1/2024 the maintenance director repaired the damage to the magnet that auto releases the door, removed the five gallon bucket holding open the door, and repaired the damage to the door which kept it from latching properly.
All residents have the potential to be affected by doors with self-closing devices not meeting requirements. The maintenance director will inspect all doors in the facility with self-closing devices to ensure they meet requirements by 3/13/2024.
To prevent this from reoccurring the administrator will provide education to the maintenance director and environmental services staff on 3/12/2024 regarding expectations that doors with self-closing devices are kept in a state of repair and not propped open.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit of 5 doors with self-closing devices 3 times weekly for 4 weeks then monthly for 2 months to ensure they meet requirements. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to meet emergency lighting requirements for one of one emergency light.

Findings include:

Document review on February 28, 2024, at 9:01 a.m., revealed the facility failed to provide the following emergency lighting documentation at the time of the survey:
A. (9:01 a.m.) Annual 90-minute testing;
B. (9:01 a.m.) Monthly 30-second testing.

Interview with the maintenance supervisor on February 28, 2024, at 9:01 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from not providing documentation for emergency lighting annual 90- minute testing or monthly 30 second testing for one emergency light. On 2/28/2024 the maintenance director completed and documented the annual 90 minute testing.
All residents have the potential to be affected emergency light testing is not completed as required. To prevent this from reoccurring the administrator provided education to the maintenance director on 2/28/2024 regarding ensuring emergency light testing is completed as required.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit monthly for 2 months to ensure requirements are met. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, the facility failed to meet door maintenance testing and inspection requirements for one of one component.

Findings include:

Document review on February 28, 2024, at 9:12 a.m., revealed the facility failed to provide documentation for the annual fire door inspection at the time of the survey.

Interview with the maintenance supervisor on February 28, 2024, at 9:12 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from the facility failing to meet annual fire door maintenance testing and inspection requirements. All residents have the potential to be affected if annual fire door maintenance testing and inspection requirements are not completed as required. By 3/13/2024 the maintenance director will complete door testing and inspection requirements for all fire doors. To prevent this from reoccurring the administrator provided education to the maintenance director on 2/28/2024 regarding annual fire door maintenance testing and inspection requirements. To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit monthly for 2 months to ensure annual fire maintenance testing and inspection requirements are met. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to meet gas equipment requirements for one of three oxygen storage rooms.

Findings include:

Observation on February 28, 2024, at 11:10 a.m., revealed the second floor oxygen room had the following deficiencies:
A. (11:10 a.m.) Full cylinders mixed with empty cylinders;
B. (11:10 a.m.) Two cylinders were unsecured.

Interview with the maintenance supervisor on February 28, 2024, at 11:10 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 03/18/2024

No adverse effects occurred from the facility failing to meet gas equipment requirements for one of the three oxygen storage rooms. On 2/28/2024 the maintenance director ensured no full cylinders were mixed with empty cylinders and that the two unsecured cylinders were secured. All residents have the potential to be affected if the facility fails to meet gas equipment requirements. To prevent this from reoccurring the administrator will provide education to the maintenance director and nursing personnel on 3/12/2024 regarding gas equipment requirements.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit of oxygen storage rooms 3 times weekly for 4 weeks then monthly for 2 months to ensure gas equipment requirements are met. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement