D69

EDINBORO MANOR

Grade D 69/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
3/5
Health Insp.
3/5
Quality
3/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

121

Ownership

For profit - Corporation

Total Fines

$18,738

Last Survey

N/A

419 WATERFORD STREET, EDINBORO, PA 16412
8147345021

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.42h
LPN
0.95h
CNA
2.19h
Total
3.56h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

HCF OPERATIONS, INC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2009

100%

CHAD M. UNVERFERTH 12-14-11 IRRV GRANTOR TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

DAVID V. UNVERFERTH 12-14-11 IRRV GRANTOR TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

HCF, INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2009

JEFFREY L. UNVERFERTH 12-14-11 IRRV GRANTOR TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOANN C. UNVERFERTH 12-29-04 REVOCABLE TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KENDRA M. U

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KERRI A. RO

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KEVAN R. UN

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KRISTEN S.

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KYLE J. UNV

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

JOSEPH L. UNVERFERTH 12-15-11 IRRV GRANTOR TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

LAWRENCE G. UNVERFERTH 12-13-11 IRRV GRANTOR TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

R. STEVEN UNVERFERTH 12-14-11 IRRV GRANTOR TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

HCF MANAGEMENT, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2009

BRADLEY, JENNIFER

IndividualCORPORATE DIRECTORSince Apr 2023

ROMES, KERRI

IndividualCORPORATE DIRECTORSince Mar 2019

UNVERFERTH, CHAD

IndividualCORPORATE DIRECTORSince Jan 2004

KLAY, CELESTE

IndividualCORPORATE OFFICERSince Jan 2016

ROMES, KERRI

IndividualCORPORATE OFFICERSince Nov 2019

SHAW, ANTHONY

IndividualCORPORATE OFFICERSince Jun 2015

UNVERFERTH, CHAD

IndividualCORPORATE OFFICERSince Jan 2004

BRADLEY, JENNIFER

IndividualW-2 MANAGING EMPLOYEESince Apr 2023

KLAY, CELESTE

IndividualW-2 MANAGING EMPLOYEESince Aug 2011

ROMES, KERRI

IndividualW-2 MANAGING EMPLOYEESince Apr 2013

SHAW, ANTHONY

IndividualW-2 MANAGING EMPLOYEESince Aug 1994

UNVERFERTH, CHAD

IndividualW-2 MANAGING EMPLOYEESince Mar 2003

Penalties & Fines (2)

$18,738total fines
DateTypeDescriptionAmount
May 8, 2023Fine$3,145
Mar 3, 2023Fine$15,593

Health Inspection Deficiencies (31)

January 31, 2025Health5 deficiencies
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Mar 28, 2025
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 28, 2025
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 28, 2025
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Mar 28, 2025
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Mar 28, 2025
February 15, 2024Health10 deficiencies
0575CNo harm, Widespread

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Resident Rights Deficiencies

Corrected Apr 15, 2024
0577EMinimal harm, Pattern

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies

Corrected Apr 15, 2024
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Apr 15, 2024
0585EMinimal harm, Pattern

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Apr 15, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 15, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 15, 2024
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Apr 15, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 15, 2024
0661DMinimal harm, Isolated

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 15, 2024
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 15, 2024
October 5, 2023Health1 deficiency
0657EMinimal harm, Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 20, 2023
March 3, 2023Health15 deficiencies1 severe
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Apr 5, 2023
0606DMinimal harm, Isolated

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 5, 2023
0625BNo harm, Pattern

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.

Resident Rights Deficiencies

Corrected Apr 5, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 5, 2023
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Apr 5, 2023
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Apr 5, 2023
0802FMinimal harm, Widespread

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies

Corrected Apr 5, 2023
0812LImmediate jeopardy, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 5, 2023
0835EMinimal harm, Pattern

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Apr 5, 2023
0865EMinimal harm, Pattern

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies

Corrected Apr 5, 2023
0867EMinimal harm, Pattern

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Apr 5, 2023
0868EMinimal harm, Pattern

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Administration Deficiencies

Corrected Apr 5, 2023
0881FMinimal harm, Widespread

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Apr 5, 2023
0882FMinimal harm, Widespread

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies

Corrected Apr 5, 2023
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Apr 5, 2023

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Frequently Asked Questions

What is the CareGrader rating for EDINBORO MANOR?

EDINBORO MANOR in EDINBORO, Pennsylvania has a CareGrader grade of D (Below Average), with a composite score of 68.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for EDINBORO MANOR?

EDINBORO MANOR has an overall CMS star rating of 3 out of 5, a health inspection rating of 3/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does EDINBORO MANOR have?

EDINBORO MANOR has 31 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has EDINBORO MANOR been fined?

Yes. EDINBORO MANOR has $18,738 in total fines from CMS enforcement actions across 2 penalties.

How many beds does EDINBORO MANOR have?

EDINBORO MANOR has 121 certified beds with approximately 112 current residents (93% occupancy). The facility is located at 419 WATERFORD STREET, EDINBORO, Pennsylvania 16412. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.