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Edinboro Manor

For profit - Corporation  ·  419 Waterford Street, Edinboro, PA 16412  ·  See home’s Medicare page

Affiliated With Hcf Management
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
3.58
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.8
51.4%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 50.5%
121
Certified beds
Qualifying beds in the certified provider or supplier facility.
85
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Hcf Operations, Inc (100%)
Indirect owners
Chad M. Unverferth 12 14 11 Irrv Grantor Tr
David V. Unverferth 12 14 11 Irrv Grantor Tr
Hcf, Inc
Jeffrey L. Unverferth 12 14 11 Irrv Grantor Tr
Joann C. Unverferth 12 29 04 Revocable Trust
Joann C. Unverferth 12 31 12 Irrevocable Grantor Trust Fbo Kendra M. U
Joann C. Unverferth 12 31 12 Irrevocable Grantor Trust Fbo Kerri A. Ro
Joann C. Unverferth 12 31 12 Irrevocable Grantor Trust Fbo Kevan R. Un
Joann C. Unverferth 12 31 12 Irrevocable Grantor Trust Fbo Kristen S.
Joann C. Unverferth 12 31 12 Irrevocable Grantor Trust Fbo Kyle J. Unv
Joseph L. Unverferth 12 15 11 Irrv Grantor Tr
Lawrence G. Unverferth 12 13 11 Irrv Grantor Tr
R. Steven Unverferth 12 14 11 Irrv Grantor Tr
Managerial control
Hcf Management, Inc. since Mar, 2009
Managing employee(s)
Jennifer Bradley since Apr, 2023
Celeste Klay since Aug, 2011
Kerri Romes since Apr, 2013
Anthony Shaw since Aug, 1994
Chad Unverferth since Mar, 2003

Inspection Reports

34

total deficiencies

3

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Oct 5, 2023
Complaint report
1 deficiency
E

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Mar 3, 2023
Standard report
15 deficiencies
(2 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

$15,593 Fine
B

to L
L

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
Immediate jeopardy to resident health or safety
Scope
Many people affected
Seriousness
L

Nutrition and Dietary Deficiency — F0802
Failure to: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Infection Control Deficiency — F0881
Failure to: Implement a program that monitors antibiotic use.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Infection Control Deficiency — F0882
Failure to: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Resident Rights Deficiency — F0550
Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0725
Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0835
Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0865
Failure to: Have a plan that describes the process for conducting QAPI and QAA activities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0867
Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0868
Failure to: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0606
Failure to: Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0641
Failure to: Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0756
Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0561
Failure to: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0625
Failure to: Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave.
Severity
No actual harm, with potential for minimal harm
Scope
Some people affected
Seriousness
B

Apr 28, 2022
Standard report
4 deficiencies
D

Resident Rights Deficiency — F0558
Failure to: Reasonably accommodate the needs and preferences of each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0758
Failure to: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0584
Failure to: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 8, 2021
Complaint report
1 deficiency
E

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

May 28, 2021
Standard report
13 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

C

to F
F

Nutrition and Dietary Deficiency — F0806
Failure to: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0641
Failure to: Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0655
Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0842
Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0849
Failure to: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nursing and Physician Services Deficiency — F0947
Failure to: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0625
Failure to: Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
C

Penalties

$18.7K

total fines

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
May 8, 2023
No corresponding inspection report.
Mar 3, 2023