Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edinboro Manor during CMS and state inspections, most recent first.
Housekeeping and equipment cleaning were not maintained in multiple resident rooms on C Hall and D Hall. Surveyors observed dirty IV poles, wheelchairs with food crumbs, dried liquid, and peeling vinyl, along with dust, debris, food wrappers, overflowing trash, and soiled toilet areas in resident rooms. The NHA confirmed the rooms and wheelchairs/cushions were not clean and in good repair.
A resident with a history of ankylosing spondylitis, COPD, respiratory failure, irregular heartbeat, and kidney disease had a physician order for DNR, but the POLST indicated CPR if no pulse and no breathing. The DON confirmed the physician order and POLST were not consistent with each other.
The facility failed to document a GDR attempt and a clinical rationale for continued use of Aripiprazole for a resident with dementia and delusional disorder. The resident had a physician order for daily Aripiprazole, but the record lacked evidence of a GDR or a note showing why continued use was clinically appropriate. The DON confirmed the missing documentation.
Failure to Communicate Clinical Information During Hospital Transfer: A resident with DM, CKD, and HTN was transferred to the hospital, but the clinical record lacked evidence that necessary clinical information was communicated to the receiving provider. The DON confirmed the record did not show that the required information was provided at the time of transfer.
Baseline care plan and admission summary not completed: the facility failed to provide a written summary of the baseline care plan and order summary to one resident and failed to develop a baseline care plan within 48 hours for another resident. The residents had diagnoses including DM, intellectual disabilities, CHF, COPD, and anxiety, and the DON confirmed the missing documentation in the clinical records.
Care plan not updated to match current bowel status. A resident with DM, intellectual disabilities, and CHF had MDS and task records showing bowel continence, but the bowel care plan still identified frequent bowel incontinence. The DON confirmed the care plan was not reviewed or revised to reflect the resident’s current care and services.
A resident with MS, COPD, and respiratory failure had an oxygen order to titrate O2 to keep sats at or above 90%. Surveyors observed the resident’s oxygen concentrator filters covered with a large amount of fluffy white substance on repeated checks, and the DON confirmed the filters should be clean.
Incomplete documentation was found for a resident with wounds and a resident receiving g-tube feedings. The DON confirmed that skin check notes for one resident were inaccurate because they documented Stage 3 pressure ulcers even though the wounds had resolved, and that MAR documentation for another resident was omitted and inconsistent for enteral feeding and free water totals, with required intake amounts not clearly documented.
Uncovered Feeding Tube Connection: A resident with MS, COPD, and respiratory failure had a gastric feeding tube and ordered enteral feeds via pump. Staff observed the tube feeding connection hanging over the pump and left uncovered, and the DON confirmed it should have been covered when not connected.
The facility's fire alarm system was found deficient due to unresolved issues where the DACT main and point did not receive signals from the fire system. Despite being identified in an inspection report, these deficiencies were not corrected by the time of the survey, as confirmed by the maintenance supervisor.
The facility was found non-compliant with smoking regulations due to an accumulation of cigarette butts outside the oxygen storage room and in the designated smoking area. This was confirmed by the maintenance supervisor, indicating a failure to prohibit smoking in areas where flammable materials are stored.
Edinboro Manor failed to document required emergency preparedness exercises, including an annual full-scale and tabletop exercise, as confirmed by a maintenance supervisor.
The facility failed to maintain the sprinkler system according to NFPA 101 standards, as observed in the beauty salon where a missing escutcheon plate created an opening in the ceiling. This issue, confirmed by the maintenance supervisor, could potentially affect sprinkler activation.
The facility failed to provide written summaries of baseline care plans and order summaries to two residents or their representatives upon admission. One resident had dementia and COPD, while the other had dementia, hypertension, and hyperlipidemia. The DON confirmed the absence of documentation in their clinical records.
A facility failed to develop a care plan for a resident requiring a left resting hand splint, despite physician orders specifying its use and care. The resident, with conditions including flaccid hemiplegia, diabetes, and hypertension, had no care plan addressing the splint, confirmed by the DON during an interview.
A facility failed to show evidence of conducting care plan meetings or inviting a resident with COPD, anxiety, and hypertension to these meetings. The resident and staff confirmed the absence of such meetings or invitations since the resident's admission.
A resident with flaccid hemiplegia and other conditions did not receive the physician-ordered left resting hand splint to prevent further decrease in range of motion. Observations showed the splint was not worn during waking hours as required, and the Director of Nursing confirmed the non-compliance with the treatment plan.
The facility failed to store controlled Schedule II-V medications in a permanently affixed compartment and did not label an opened vial of Tubersol PPD with an open date, making discard date determination impossible. Additionally, an expired Humalog insulin pen was found in the A-Wing medication cart. These issues were confirmed by LPNs during interviews.
The facility did not meet the required minimum NA staffing ratios during an overnight shift, with only 6.50 NAs on duty for 113 residents, falling short of the required 7.53 NAs. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to meet the required LPN staffing ratios on multiple occasions, with shortages occurring during day, evening, and overnight shifts. The Nursing Home Administrator confirmed the deficiency, which was identified through a review of staffing documents and staff interviews.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day. A review of staffing documents revealed that on one day, the facility provided only 3.17 hours of care per resident. This was confirmed by the Nursing Home Administrator.
Housekeeping and Equipment Not Maintained Clean
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain a clean environment and clean equipment on two resident halls, affecting resident rooms on C Hall and D Hall. Facility policies reviewed required IV and enteral poles to be cleaned thoroughly, resident care equipment to be kept clean, daily room cleaning and disinfecting to include cleaning and disinfecting toilets and IV/tube feed poles, and wheelchairs to be cleaned per schedule and initialed when completed. Observations of rooms on C Hall revealed IV poles with thick yellow dried liquid on the bases and legs, wheelchairs with food crumbs and dried liquid on the cushions and legs, peeling vinyl on wheelchair armrests, chunks of food on the floor, paper and used tissue on the floor, a hole in the wall with plaster dust on the floor, a dark brown ring in the toilet bowl, and large amounts of gray fluffy substance under beds. Observations of rooms on D Hall revealed dust and debris under and around beds, food crumbs and wrappers on the floor, overflowing garbage, used washcloths and cups on the floor, brown substance smeared on raised toilet seats, and brown rings between toilet seats. The Nursing Home Administrator confirmed the condition of the C Hall and D Hall rooms and that the wheelchairs and cushions were not clean and in good repair, and also confirmed that resident rooms and wheelchairs should be clean and in good repair.
Inconsistent Code Status Orders and POLST
Penalty
Summary
The facility failed to assure that a physician's order and the resident's POLST were consistent for one resident. The resident had an admission diagnosis history that included ankylosing spondylitis of the mid-lower back, COPD, respiratory failure, irregular heartbeat, and kidney disease. The clinical record contained a physician's order for DNR status, but the resident's POLST indicated a wish to have CPR performed if there was no pulse and no breathing. During an interview, the DON confirmed that the physician's order and POLST were not consistent with each other.
Lack of GDR and Clinical Rationale for Psychotropic Medication
Penalty
Summary
The facility failed to provide evidence that a gradual dose reduction (GDR) was attempted and failed to document a clinical rationale for the continued use of a psychotropic medication for one resident reviewed for psychoactive medications. The resident had an admission date of 10/8/22 and diagnoses that included dementia and delusional disorder. The clinical record showed a physician’s order dated 7/12/24 for Aripiprazole 2 mg by mouth daily, but the record lacked evidence of a GDR attempt and lacked a rationale for continued use. Facility policy entitled Psychotropic Drugs stated that residents who use psychotropic drugs receive a GDR and that a physician note should indicate the drug is clinically appropriate and explain why. During interview, the DON confirmed that the resident’s Aripiprazole order lacked evidence of a GDR attempt or a clinical rationale for continued use.
Failure to Communicate Clinical Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when Resident R6 was transferred to the hospital. Resident R6 had an admission date of 1/13/16 and diagnoses that included diabetes, chronic kidney disease, and hypertension. A progress note dated 9/27/25 documented that Resident R6 was transferred to the hospital, but the clinical record did not contain evidence that the resident’s necessary clinical information was sent to the receiving provider. During an interview on 1/14/26 at 1:32 p.m., the DON confirmed that the record lacked evidence of the required clinical information being provided at the time of transfer and stated that clinical information should have been provided to the receiving health care provider.
Baseline Care Plan and Admission Summary Not Completed
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to Resident R10 and/or the resident’s representative upon admission. Resident R10 was admitted on 6/10/25 with diagnoses that included diabetes, intellectual disabilities, and chronic heart failure. The clinical record lacked evidence that the required written summary of the baseline care plan and order summary was provided. The facility also failed to ensure that a baseline care plan was developed within 48 hours of admission for Resident R110 that included the minimum healthcare information necessary to provide proper care. Resident R110 was admitted on 7/8/25 with diagnoses that included heart failure, chronic obstructive pulmonary disease, and anxiety. During interview on 1/14/26 at 1:38 p.m., the DON confirmed that Resident R10’s record lacked evidence of the written summary and that Resident R110’s record lacked evidence of a baseline care plan developed within 48 hours with the required minimum healthcare information.
Care Plan Not Updated to Match Current Bowel Status
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect the current care and services for Resident R10. Facility policy required care plans to be periodically reviewed and revised by a team of qualified persons after each assessment, and to be updated at least quarterly in conjunction with the required quarterly MDS assessment. Review of the resident’s record showed an admission date of 6/10/25 and diagnoses including diabetes, intellectual disabilities, and chronic heart failure. Resident R10’s admission MDS indicated bowel continence was coded as 2, frequently incontinent, while later quarterly MDS assessments coded bowel continence as 0, always continent. The resident’s 30-day task record also showed the resident was always continent of bowel. However, the bowel care plan created on 6/23/25 with a target date of 3/10/26 still identified the resident as frequently incontinent of bowel. During interview, the DON confirmed the bowel care plan was not reviewed or revised to reflect the resident’s current care and that care plans should be reviewed and revised as necessary.
Oxygen concentrator filters were left visibly soiled
Penalty
Summary
The facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one resident receiving oxygen therapy. Facility policy for oxygen concentrators stated that external cabinet filters, if present, are to be cleaned weekly. The resident had diagnoses including multiple sclerosis, COPD, and respiratory failure, and had a physician order to titrate oxygen to maintain saturations at or greater than 90 percent every shift. On observation, the resident’s oxygen concentrator had a large amount of fluffy white substance covering the filters, and the same condition remained on the filters during a later observation the next day. The DON confirmed that the oxygen concentrator filters had a large amount of fluffy white substance and stated that the filters should be clean.
Incomplete wound and enteral feeding documentation
Penalty
Summary
Complete and accurate medical record documentation was not maintained for a resident with wounds and a resident receiving enteral nutrition. For Resident R9, who had diagnoses including pancreatic duct cancer, chronic pain syndrome, diabetes, Parkinson's disease, and high blood pressure, the clinical record showed a skin/wound note on 12/18/25 stating that open areas on the left glute and right calf had resolved. However, skin check notes dated 12/21/25, 12/29/25, and 1/08/26 each documented Stage 3 pressure ulcers to the left glute and right calf. During interview, the DON confirmed that the documentation on those skin checks was inaccurate and that the wounds were resolved on those dates. For Resident R94, who had diagnoses including stroke, malnutrition, difficulty swallowing, a g-tube, and prostate cancer, physician orders required documentation of total enteral feeding and water flushes each shift, along with specific feeding and hydration amounts. The record also included an order to disconnect the feeding for up to two hours for personal care. Review of the MAR showed omitted and inconsistent documentation of the amount of nutritional feeding and water administered through the g-tube each shift, and the record did not ensure that the resident received the recommended 1210 mL of enteral feeding and 919 mL of free water in a 24-hour period. The DON confirmed that documentation of nutritional feeding totals and free water was not complete and accurate.
Uncovered Feeding Tube Connection
Penalty
Summary
The facility failed to implement measures to prevent potential cross contamination for a gastric feeding tube used by one resident with a feeding tube. Facility policy for tube feedings stated that the end of the feeding tube should be covered with its plug or cap to prevent leakage and contamination, and the housekeeping policy stated that sanitary conditions include preventing the spread of disease-causing organisms by keeping residents' care equipment clean and properly stored. The resident had an admission date of 11/3/23 and diagnoses that included multiple sclerosis, COPD, and respiratory failure. The resident had a physician order for enteral feed Nurten 1.5 at 65 cc per hour via pump from 8:00 a.m. to 12:00 p.m. daily. During observations, the resident's tube feeding connection was seen hanging over the feeding pump and was not covered at 9:38 a.m. and again at 10:15 a.m. The DON confirmed during interview that the feeding tube connection was hanging over the feeding pump uncovered and that it should be covered when not connected to the resident's gastric feeding tube.
Fire Alarm System Deficiency Due to Unresolved Signal Issues
Penalty
Summary
The facility failed to meet the fire alarm system requirements as evidenced by a document review and interview conducted on February 4, 2025. The fire alarm inspection report, completed on October 14, 2024, identified two deficiencies that were not addressed by the time of the survey. Specifically, the Digital Alarm Communicator Transmitter (DACT) main and DACT point did not receive signals from the fire system, indicating a failure in the communication link between the fire alarm system and the monitoring station. An interview with the maintenance supervisor confirmed that these deficiencies were not corrected at the time of the survey. This lack of corrective action suggests a lapse in the facility's maintenance and testing program for the fire alarm system, which is required to comply with NFPA 70 and NFPA 72 standards. The failure to address these deficiencies could potentially compromise the safety and emergency response capabilities of the facility.
Plan Of Correction
The facility was provided with incorrect documentation by the inspection company. The company has provided the correct documentation depicting that there were/are no deficiencies present. The above-mentioned documentation will be provided upon submission of this Plan of Correction. The Maintenance Director will be educated on the importance of ensuring that the facility receives correct/accurate reports regarding any inspections that occur. All inspections/reports will be audited by the administrator and reviewed with the inspection companies prior to them exiting the facility. Once the written reports are obtained, the administrator and/or Maintenance Director will again review to ensure accuracy of findings. The results of inspections will be reviewed at the facilities monthly Quality Assurance and Performance Improvement Meeting. The facility was provided with incorrect documentation by the inspection company. The company has provided the correct documentation depicting that there were/are no deficiencies present. The above-mentioned documentation will be provided upon submission of this Plan of Correction. The Maintenance Director will be educated on the importance of ensuring that the facility receives correct/accurate reports regarding any inspections that occur. All inspections/reports will be audited by the administrator and reviewed with the inspection companies prior to them exiting the facility. Once the written reports are obtained, the administrator and/or Maintenance Director will again review to ensure accuracy of findings. The results of inspections will be reviewed at the facilities monthly Quality Assurance and Performance Improvement Meeting.
Non-compliance with Smoking Regulations
Penalty
Summary
The facility failed to adhere to smoking regulations as evidenced by an accumulation of cigarette butts observed outside the oxygen storage room and in various spots around the designated smoking area. This observation was made on February 4, 2025, at 1:15 p.m. The maintenance supervisor confirmed the presence of cigarette butts in these areas, indicating a lack of compliance with the requirement to prohibit smoking in areas where flammable materials, such as oxygen, are stored. This deficiency highlights the facility's failure to maintain a safe environment by not ensuring that smoking regulations are strictly followed, particularly in hazardous locations.
Plan Of Correction
The cigarette butts have been removed from the ground by the exit. The facility will ensure that ashtrays are being utilized properly. The Administrator and/or designee will educate the Maintenance Director on the importance of smoking regulations. The Maintenance Director will educate the staff on the importance of adhering to smoking regulations. Audits will be conducted 3 times a week for 4 weeks to ensure that smoking regulations are being met.
Failure to Document Emergency Preparedness Exercises
Penalty
Summary
Edinboro Manor was found to be non-compliant with the emergency preparedness requirements as outlined in 42 CFR 483.73. The facility failed to conduct and document the necessary exercises to test its emergency preparedness plan. Specifically, the facility did not have documentation to verify that an annual tabletop exercise had been conducted. This deficiency was identified during a document review on February 4, 2025. The survey revealed that the facility also lacked documentation for an annual full-scale exercise. These exercises are crucial for testing and evaluating the facility's emergency preparedness plan, ensuring that staff and systems are ready to respond effectively in the event of an emergency. The absence of such documentation indicates that the facility did not meet the regulatory requirements for emergency preparedness testing. An interview with the maintenance supervisor confirmed the lack of documentation for both the full-scale and tabletop exercises. This confirmation further substantiates the finding that Edinboro Manor did not fulfill its obligations to conduct and document these critical emergency preparedness activities, as required by federal regulations.
Plan Of Correction
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 either legally or factually correct. This plan of correction is not meant to establish any 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. The facility will ensure that there is at least one tabletop exercise, and one full-scale exercise completed annually. The facility recently had a change in Administrators effective 12/30/2024. During the Life Safety Survey, proof of an Emergency Preparedness Tabletop discussion could not be found during the inspection. After exit, the facility located documentation of an Emergency Preparedness Tabletop discussion that occurred on 03/21/2024 by past administration. Sign-in sheet and documentation will be provided with this Plan of Correction. The facility will conduct a "full-scale exercise" by 03/13/2025. The full-scale exercise will be reviewed at the monthly Quality Assurance and Performance improvement meeting.
Sprinkler System Deficiency in Beauty Salon
Penalty
Summary
The facility failed to maintain the sprinkler system in compliance with NFPA 101 standards, as evidenced by an observation on February 4, 2025. During the inspection, it was noted that the first floor beauty salon had a missing escutcheon plate, which resulted in an opening in the ceiling. This deficiency could potentially affect the activation of the sprinkler system in that area. The maintenance supervisor confirmed the absence of the escutcheon plate during an interview conducted at the same time as the observation.
Plan Of Correction
The missing escutcheon plate was ordered during the week of the inspection. The plate will be installed when it is received. The Maintenance Director will be educated on the importance of properly installed escutcheon plates. The facility will ensure that all sprinkler heads have proper escutcheon plates installed. Audits of all escutcheon plates will be conducted 3 times a week for 4 weeks. The results of the audits will be reviewed at the facility's monthly quality assurance performance improvement meeting.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to two residents, R110 and R112, or their representatives. Resident R110 was admitted on 9/6/24 with diagnoses including dementia and chronic obstructive pulmonary disease. The clinical record for R110 did not contain evidence that a written summary of the baseline care plan and order summary was provided to the resident or their representative. Similarly, Resident R112, admitted on 9/17/24 with diagnoses of dementia, hypertension, and hyperlipidemia, also lacked documentation in their clinical record indicating that a written summary of the baseline care plan and order summary was provided. The Director of Nursing confirmed during an interview that the clinical records for both residents did not include evidence of the required documentation being provided upon admission.
Plan Of Correction
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 either legally or factually correct. This plan of correction is not meant to establish any 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. The facility will ensure that all new admissions are provided with baseline care plans and order summaries. R110's representatives were provided with a written summary of their current care plan and order summary. R112's representatives were provided with a written summary of their current care plan and order summary. The DON/Nursing designee will audit all admissions within the last 30 days to ensure residents receive a written summary of their baseline care plan and order summaries. The Administrator and/or designee will provide education to the Resident Services Coordinator regarding the importance of providing residents with a written summary of their baseline care plan and order summaries during care conferences. Audits of all new admissions will be conducted 3 times a week for 4 weeks. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Failure to Develop Care Plan for Splint Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R27, who required a left resting hand splint. The deficiency was identified during a review of the facility's policy and clinical records, as well as through staff interviews. Resident R27 was admitted with diagnoses including flaccid hemiplegia affecting the left non-dominant side, diabetes, and hypertension. A physician's order dated December 26, 2024, specified the use of a left resting hand splint during waking hours, with instructions for frequent skin checks for irritation or breakdown and removal for hygiene purposes. Despite these orders, there was no evidence of a care plan addressing the use of the left resting hand splint in Resident R27's records. During an interview, the Director of Nursing confirmed the absence of a care plan for the splint and acknowledged that one should have been developed. This oversight indicates a failure to comply with the requirement to create a comprehensive, person-centered care plan that includes all necessary services to meet the resident's needs.
Plan Of Correction
R27 no longer needed the left-hand splint; therefore, the order has been discontinued. R27's care plan has been reviewed, and it has been determined to be personalized and appropriate. The Administrator will educate the Director of Nursing and Assistant Director of Nursing on the importance of the development and periodic review/revision of comprehensive person-centered care plans for each resident. The DON and/or the Assistant Director of Nursing will audit care plans of all residents with splints to ensure there's a comprehensive, personalized care plan that includes splint care. The DON and/or Assistant Director of Nursing will audit care plans for 5 random residents 3 times a week for 4 weeks to ensure that each one has a comprehensive, personalized care plan in place which appropriately reflects their specific needs. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Lack of Evidence for Resident Care Plan Meetings
Penalty
Summary
The facility failed to provide evidence of conducting resident care plan conference meetings or inviting residents to these meetings, as required by regulations. Specifically, for one resident, identified as Resident R106, there was no documentation indicating that the resident or their representative had been invited to or attended a care plan conference meeting. This deficiency was identified through a review of clinical records, facility policies, and staff interviews. Resident R106, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, anxiety, and hypertension, reported not having attended or been invited to a care plan conference meeting. This was confirmed by interviews with the Social Services Coordinator and the Director of Nursing, who acknowledged the lack of evidence for such meetings or invitations in the resident's records since their admission.
Plan Of Correction
A care plan conference has been scheduled for R106. The facility will ensure that residents and/or resident representatives are invited to attend care plan conference meetings to discuss their goals and plan of care. Documentation of attendance/refusal will be noted in the clinical record. The Administrator will educate the Resident Services Coordinator regarding the importance of inviting and documenting attendance/refusal of residents and/or resident representatives to care plan conference meetings. The RSC will review documentation of resident care conferences held within the past 30 days to ensure appropriate individuals were invited to care conferences. The Assistant Director of Nursing will conduct a weekly audit of care conferences for 4 weeks to ensure that appropriate individuals were invited to care conferences with supportive documentation. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Failure to Provide Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the physician-ordered treatment and services necessary to prevent further decrease in range of motion. Resident R27, who was admitted with conditions including flaccid hemiplegia affecting the left non-dominant side, diabetes, and hypertension, had a physician's order for a left resting hand splint to be worn during waking hours. The order also required frequent skin checks for signs of irritation or breakdown and allowed removal of the splint for hygiene purposes. Observations over several days revealed that Resident R27 was not wearing the left resting hand splint as ordered. On multiple occasions, the splint was observed lying on the resident's bedside table while the resident was either in bed or sitting in a wheelchair in the lounge. During an interview, the Director of Nursing confirmed that the resident did not have the splint on as per the physician's orders, acknowledging the failure to comply with the prescribed treatment plan.
Plan Of Correction
R27 no longer needed the left-hand splint; therefore, the order has been discontinued. The facility has ensured that all current residents with physician-ordered treatments and services to prevent further decrease in range of motion are utilized as ordered. An initial audit was conducted by the Director of Nursing after the concern was brought to the facility's attention. The Director of Nursing and/or designee will educate the nursing staff on the importance of providing residents with a limited range of motion, the appropriate treatment and services to increase range of motion, and/or to prevent further decrease in range of motion. A nursing designee will conduct audits on 5 random residents 3 times a week for four weeks to ensure residents with physician-ordered treatments and services to prevent further decrease in range of motion are utilized as ordered. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Deficiencies in Drug Storage and Labeling
Penalty
Summary
The facility failed to comply with regulations regarding the storage and labeling of drugs and biologicals. Specifically, controlled Schedule II-V medications were not stored in a separately locked, permanently affixed compartment as required. Instead, these medications were found in two separately locked containers attached to a removable shelf in the main medication room refrigerator. Additionally, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the appropriate discard date. Further deficiencies were observed in the A-Wing medication cart, where an open injector pen of Humalog insulin was found with an open date indicating it was expired. The pen had been opened on 12/25/24, and according to the manufacturer's guidelines, it should have been discarded after 28 days. These findings were confirmed by LPNs during interviews, highlighting lapses in the facility's adherence to proper medication storage and labeling protocols.
Plan Of Correction
The facility immediately disposed of the medication which was not dated upon notification of the concern. The facility immediately disposed of the expired Humalog insulin upon notification of the concern. The DON and ADON have audited all medication carts and the facility medication room to ensure that there were no expired or un-dated medications present. The facilities Maintenance Director permanently attached/affixed the removable shelf on the date that it was brought to the facilities' attention. The Director of Nursing and/or designee will educate the facilities nurses on the importance of properly dating medication, disposing of expired medication, and ensuring proper storage of controlled schedule II-V medications. An audit of all medication rooms and medication carts has been conducted to ensure that there are no undated or expired medications present, as well as ensuring that controlled substances are secured and stored properly. The Assistant Director of Nursing and/or designee will conduct a weekly audit of the med room refrigerator to ensure that controlled substances are secured/stored properly and one (1) med cart a week for 4 weeks to ensure that there are no undated and/or expired medications present and that the controlled substances are secured/stored properly within the medication cart(s). The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios during the overnight shift on January 1, 2025. Specifically, the facility had a census of 113 residents but only 6.50 NAs were on duty, whereas 7.53 NAs were required to meet the regulatory standard of one NA per 15 residents. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on January 8, 2025.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, administrative nurses, and charge nurses on the state required minimum staffing ratios regarding nursing assistants. The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, 3 times weekly for 4 weeks to ensure that the state required minimum staffing ratios for nursing assistants are met per regulation. All audits will be reviewed through the Quality Assurance/Performance Improvement process. The Administrator/designee will utilize recruitment platforms and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program, and tuition reimbursement for recruitment efforts. Charge Nurses will be provided employee contact listings and will be responsible for calling staff when ratios are projected to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call-offs are to be addressed by these charge nurses to ensure staffing requirements are met.
LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on multiple occasions between December 31, 2024, and January 6, 2025. Specifically, the facility did not have the minimum number of LPNs per resident during the day, evening, and overnight shifts on several days. On January 2 and January 5, 2025, the day shift was understaffed with 4.06 and 4.25 LPNs working, respectively, when 4.52 and 4.64 were required based on the resident census. Similarly, the evening shift on January 3 and January 6, 2025, was short with 3.59 and 3.43 LPNs working, while 3.77 and 3.90 were needed. The overnight shift also experienced shortages on December 31, 2024, and January 2 and 3, 2025, with fewer LPNs than required. The Nursing Home Administrator confirmed during a telephone interview on January 8, 2025, that the facility did not meet the minimum LPN staffing ratios on the specified days and shifts. This deficiency was identified through a review of the facility's nursing staffing documents and staff interviews, highlighting a failure to comply with the regulation effective July 1, 2023, which mandates specific LPN-to-resident ratios for different shifts.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, charge nurses, and administrative nurses on the state required minimum staffing ratios for licensed practical nurse requirements. The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, and 3 times weekly for 4 weeks to ensure that the state required minimum staffing ratios for licensed practical nurses are met per regulation. All audits will be reviewed through the Quality assurance/performance improvement process. The Administrator and/or designee will utilize recruitment platforms and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program, and tuition reimbursement for recruitment efforts. Charge Nurses will be provided with employee contact listings and will be responsible for calling staff when ratios are projecting to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call offs are to be addressed by these charge nurses to ensure that the staffing requirements are met.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's nursing staffing documents for the period from December 31, 2024, to January 6, 2025. Specifically, on January 5, 2025, the facility provided only 3.17 hours of direct nursing care per resident, falling short of the mandated minimum. This shortfall was confirmed during a telephone interview with the Nursing Home Administrator on the same day.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, charge nurses, and administrative nurses on the state required minimum staffing of 3.2 hours of direct care per patient day requirements. A new staffing meeting will be conducted after the morning clinical meeting to review deployment sheets and the PA DOH staffing excel sheet. The current day and upcoming days will be reviewed at each meeting to ensure that the facility meets the required PPD at the projected census level. The Administrator will keep the admission team updated and informed. Attendees will be the Administrator, Scheduler, and Nursing Administration. The Administrator and/or designee will review staffing 4 times a week for 2 weeks, 3x weekly for 4 weeks to ensure that the state required minimum staffing minimum PPD requirement of 3.2. All audits will be reviewed through the Quality assurance/performance improvement process. The Administrator and/or designee will utilize recruitment platform and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program and tuition reimbursement for recruitment efforts. Charge Nurses will be provided with employee contact listings and will be responsible for calling staff when ratios are projected to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call offs are to be addressed by these charge nurses to ensure staffing requirements are met.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 231 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Edinboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crawford Care Center | 12.1 mi | ★★★★★ | 18 | 1 |
| Forestview | 12.5 mi | ★★★★★ | 3 | 0 |
| Pleasant Ridge Manor East/west | 12.9 mi | ★★★★★ | 0 | 0 |
| Walnut Creek Nursing And Rehab | 13.3 mi | ★★★★★ | 14 | 0 |
| Millcreek Manor | 13.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.