A list of the most recent deficiencies for Edinboro Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-03 | 2023-04-05 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-03-03 | 2023-04-05 | N |
| 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. | Health | 2023-03-03 | 2023-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-03 | 2023-04-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-03 | 2023-04-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-03 | 2023-04-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-03-03 | 2023-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-03 | 2023-04-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-03 | 2023-04-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-03-03 | 2023-04-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-03 | 2023-04-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-03 | 2023-04-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-03 | 2023-04-05 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-03 | 2023-04-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-03 | 2023-04-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-28 | 2022-06-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-28 | 2022-06-22 | N |
| 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. | Health | 2022-04-28 | 2022-06-22 | N |
| 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. | Health | 2022-04-28 | 2022-06-22 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-08 | 2021-11-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-28 | 2021-07-21 | N |
| 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. | Health | 2021-05-28 | 2021-07-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-28 | 2021-07-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-28 | 2021-07-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-28 | 2021-07-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-28 | 2021-07-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-28 | 2021-07-21 | N |
| 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. | Health | 2021-05-28 | 2021-07-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-28 | 2021-07-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-28 | 2021-07-21 | N |
| 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. | Health | 2021-05-28 | 2021-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-07-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-05-28 | 2021-07-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-06-01 | 2021-07-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-01 | 2021-07-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-01 | 2021-07-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-01 | 2021-07-14 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2021-06-01 | 2021-07-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-01 | 2021-07-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-05 | Not Fixed | Y |
