Pennsylvania Department of Health
EDINBORO MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EDINBORO MANOR
Inspection Results For:

There are 107 surveys for this facility. Please select a date to view the survey results.

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EDINBORO MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Follow-up Survey completed on February 4, 2026, it was determined that Edinboro Manor failed to correct all the deficiencies cited during the revisit survey of Novenber 12, 2025, and continued to be out of compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of the facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents for the day shift for five of 17 days (1/17/26, 1/19/26, 1/26/26, 1/31/26, and 2/01/26); failed to ensure a minimum of one NA per 11 residents for the evening shift for four of 17 days (1/16/26, 1/19/26, 1/25/26, and 1/30/26); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for 16 of 17 days (1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/24/26, 1/25/26, 1/26/26, 1/27/26, 1/28/26, 1/29/26, 1/31/26 and 2/01/26).

Findings include:
Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26 revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
1/17/26 census of 116 residents 10.11 NA worked and 11.60 were required.
1/19/26 census of 114 residents 10.47 NA worked and 11.40 were required.
1/26/26 census of 117 residents 10.51 NA worked and 11.70 were required.
1/31/26 census of 116 residents 11.27 NA worked and 11.60 were required.
1/31/26 census of 115 residents 9.74 NA worked and 11.50 were required.

Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

1/16/26 census of 117 residents 9.85 NA worked and 10.64 were required.
1/19/26 census of 114 residents 10.14 NA worked and 10.36 were required.
1/25/26 census of 117 residents 9.24 NA worked and 10.64 were required.
1/30/26 census of 114 residents 9.77 NA worked and 10.36 were required.

Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

1/16/26 census of 117 residents 5.85 NA worked and 7.80 were required.
1/17/26 census of 116 residents 5.83 NA worked and 7.73 were required.
1/18/26 census of 116 residents 5.08 NA worked and 7.73 were required.
1/19/26 census of 114 residents 5.80 NA worked and 7.60 were required.
1/20/26 census of 113 residents 6.77 NA worked and 7.53 were required.
1/21/26 census of 116 residents 6.74 NA worked and 7.73 were required.
1/22/26 census of 117 residents 6.02 NA worked and 7.80 were required.
1/23/26 census of 115 residents 5.38 NA worked and 7.67 were required.
1/24/26 census of 116 residents 5.71 NA worked and 7.73 were required.
1/25/26 census of 117 residents 4.15 NA worked and 7.80 were required.
1/26/26 census of 117 residents 5.93 NA worked and 7.80 were required.
1/27/26 census of 118 residents 4.96 NA worked and 7.87 were required.
1/28/26 census of 118 residents 6.50 NA worked and 7.87 were required.
1/29/26 census of 114 residents 6.15 NA worked and 7.60 were required.
1/31/26 census of 116 residents 7.07 NA worked and 7.73 were required.
2/01/26 census of 115 residents 4.32 NA worked and 7.67 were required.

During an interview on 2/04/26, at 12:45 p.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above days and shifts.

Plan of Correction - To be completed: 04/16/2026

The facility was unable to correct the nurse aide staffing ratio's on the dates during the identified review period. The Administrator and/or designee will provide education to the Staffing Coordinator, Director of Nursing, Assistant Director of Nursing, Case Manager, RNAC, Restorative Nurse, Staff Development Coordinator, and charge nurses on the state required minimum staffing ratios regarding nursing assistants.
Administrator/ designee to utilize Edinboro Manors recruitment platform as well as Indeed (which is a public hiring/employment website) for job applicants, attend job fairs as able, corporate talent acquisition specialist, and continue 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. If the facility is consistently unable to meet the regulatory requirements, we will consider holding admissions.

The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, 3x weekly for 4 weeks to ensure that the state required minimum staffing ratios for nursing assistants are met per regulation. During these audits, call offs will be reviewed to determine if obtaining coverage was effectively attempted. The Staffing Coordinator is responsible for creating the nurse aide schedules, they will then be checked by the Administrator and/or Admin Nurses during the Monday-Friday Morning Meeting and Stand-Down Meeting to ensure they meet the required nurse aide ratios per census before call offs occur. Projected weekend staffing will be reviewed during the Friday meeting. All audits will be reviewed through the Quality assurance/performance improvement process.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure the Licensed Practical Nurse (LPN) ratios of one LPN per 25 residents were met on the day shift for 10 of 17 days (1/16/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/25/26, 1/26/26, 1/31/26, and 2/01/26); failed to ensure the ratios were met of one LPN per 30 residents on the evening shift for three of 17 days (1/16/26, 1/17/26, and 1/20/26); and failed to ensure the ratios were met of one LPN per 40 residents on the overnight shift for nine of 17 days (1/17/26, 1/18/26, 1/19/26, 1/22/26, 1/25/26, 1/29/26, 1/30/26, 1/31/26, and 2/01/26).

Findings include:

Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26, revealed the following LPN staffing shortages for the day shift where the LPN ratios were not met:

1/16/26 census of 117 residents 4.19 LPNs worked and 4.68 were required.
1/19/26 census of 114 residents 4.19 LPNs worked and 4.56 were required.
1/20/26 census of 113 residents 4.07 LPNs worked and 4.52 were required.
1/21/26 census of 116 residents 4.61 LPNs worked and 4.64 were required.
1/22/26 census of 117 residents 4.13 LPNs worked and 4.68 were required.
1/23/26 census of 115 residents 4.06 LPNs worked and 4.60 were required.
1/25/26 census of 117 residents 4.06 LPNs worked and 4.68 were required.
1/26/26 census of 117 residents 4.13 LPNs worked and 4.68 were required.
1/31/26 census of 116 residents 4.22 LPNs worked and 4.64 were required.
2/01/26 census of 115 residents 4.06 LPNs worked and 4.60 were required.

Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26, revealed the following LPN staffing shortages for the evening shift where the LPN ratios were not met:

1/16/26 census of 117 residents 3.67 LPNs worked and 3.90 were required.
1/17/26 census of 116 residents 3.42 LPNs worked and 3.87 were required.
1/20/26 census of 113 residents 2.88 LPNs worked and 3.77 were required.

Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

1/17/26 census of 116 residents 2.51 LPNs worked and 2.90 were required.
1/18/26 census of 116 residents 1.57 LPNs worked and 2.90 were required.
1/19/26 census of 114 residents 2.66 LPNs worked and 2.85 were required.
1/22/26 census of 117 residents 2.64 LPNs worked and 2.93 were required.
1/25/26 census of 117 residents 2.92 LPNs worked and 2.93 were required.
1/29/26 census of 114 residents 2.79 LPNs worked and 2.85 were required.
1/30/26 census of 114 residents 2.69 LPNs worked and 2.85 were required.
1/31/26 census of 116 residents 2.06 LPNs worked and 2.90 were required.
2/01/26 census of 115 residents 2.06 LPNs worked and 2.88 were required.

During an interview on 2/04/26, at 12:45 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratio for the above days and shifts.

Plan of Correction - To be completed: 04/16/2026

The facility was unable to correct the LPN staffing ratio's on the dates during the identified review period. The Administrator and/or designee will provide education to the staffing coordinator, Staffing Coordinator, Director of Nursing, Assistant Director of Nursing, Case Manager, RNAC, Restorative Nurse, Staff Development Coordinator, and charge nurses on the state required minimum staffing ratios regarding Licensed Practical Nurses.
Administrator/ designee to utilize Edinboro Manors recruitment platform as well as Indeed (which is a public hiring/employment website) for job applicants, attend job fairs as able, corporate talent acquisition specialist, continue to 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. If the facility is consistently unable to meet the regulatory requirements, we will consider holding admissions.

The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, 3x weekly for 4 weeks to ensure that the state required minimum staffing ratios for LPNs are met per regulation. During these audits, call offs will be reviewed to determine if obtaining coverage was effectively attempted. The Staffing Coordinator is responsible for creating the LPN schedules, they will then be checked by the Administrator and/or Admin Nurses during the Monday-Friday Morning Meeting and Stand-Down Meeting to ensure they meet the required LPN ratios per census before call offs occur. Projected weekend staffing will be reviewed during the Friday meeting. All audits will be reviewed through the Quality assurance/performance improvement process.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.20 hours of direct resident care hours per resident in a 24-hour period for 11 of 17 days reviewed (1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/25/26, 1/26/26, 1/27/26, 1/29/26, 1/31/26, and 2/01/26).

Findings include:

Review of facility nursing staffing documents for the time period from 1/16/26, through 2/01/26, revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) on the following dates:

1/16/26 3.07
1/17/26 2.88
1/18/26 2.90
1/19/26 2.75
1/20/26 3.09
1/25/26 2.62
1/26/26 3.08
1/27/26 3.07
1/29/26 3.11
1/31/26 2.95
2/01/26 2.75

During an interview on 2/04/26, at 12:45 p.m. the Nursing Home Administrator confirmed the facility did not meet the 3.2 minimum hours of direct resident care on the above dates.

Plan of Correction - To be completed: 04/16/2026

The facility was unable to correct the failure to provide the 3.2 hours of direct care for each resident, in the identified 24-hour periods included in the review period. The Administrator and/or designee will provide education to the staffing coordinator, Staffing Coordinator, Director of Nursing, Assistant Director of Nursing, Case Manager, Registered Nurse Assessment Coordinator, Restorative Nurse, Staff Development Coordinator, and charge nurses on the state required minimum staffing of 3.2 hours of Direct Care Per Patient Day of 3.2 hours in each 24-hour period for each resident. A staffing meeting will be conducted after the morning clinical meeting held on Monday through Friday to review deployment sheets and the Pennsylvania Department of Health 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 utilize Edinboro Manors recruitment platform as well as Indeed (which is a public hiring/employment website) 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 the required minimum PPD is 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. If the facility is consistently unable to meet the regulatory requirements, we will consider holding admissions.

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 staffing minimum of Direct Care Per Patient Day of 3.2 hours in each 24-hour period is met. During this staffing meeting, the previous day as well as the upcoming days will be audited to ensure the required staffing PPD requirements are met and projected to be met. Also, during these audits, call offs will be reviewed to determine if obtaining coverage was effectively attempted. The Staffing Coordinator is responsible for creating the schedules and they will be checked by the Administrator and/or Admin Nurses during the Monday-Friday Morning Meeting and Stand-Down Meeting to ensure they meet the required PPD per census before call offs occur. Projected weekend staffing will be reviewed during the Friday meeting. All audits will be reviewed through the Quality assurance/performance improvement process.

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