Pennsylvania Department of Health
EDINBORO MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on January 8, 2026, it was determined that Edinboro Manor was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to develop an emergency preparedness plan that included annual emergency preparedness plan staff training for one of one plan.

Findings include:

Document review on January 8, 2026, at 11:30 a.m., revealed the facility lacked documentation that all staff had annual emergency preparedness training within the previous twelve months.

Interview with the administrator and maintenance supervisor on January 8, 2026, at 11:30 a.m., confirmed the facility lacked documentation that all staff had annual emergency preparedness training within the previous twelve months.

Plan of Correction - To be completed: 02/17/2026

ESS will be educated by the NHA on the importance of annual education on the Emergency Preparedness Plan.

The facility has scheduled training to review the Emergency Preparedness Plan with all staff. All staff will be educated by 02/01/2026.

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, the facility failed to full-scale exercise, test, evaluate, and table-top exercise one of one emergency preparedness plan.

Findings include:

Document review on January 8, 2026, at 11:32 a.m., revealed the facility lacked documentation for an annual table top exercise.

Interview with the administrator and maintenance supervisor on January 8, 2026, at 11:32 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 02/17/2026

ESS has been educated on the importance of conducting annual Emergency Preparedness drills. The facility held full scale emergency preparedness drill as well as a post incident tabletop on 01/06/2026 at 8:43am.

A bomb threat tabletop is scheduled to occur 01-23-25 at 9:00am.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #053002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2026, it was determined that Edinboro Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress Requirements - Other:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
18.2, 19.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200

Based on observation and interview, the facility failed to maintain evacuation diagrams for three of over eight diagrams.

Findings include:

Observation on January 8, 2026, at 10:37 a.m., revealed the evacuation diagrams failed to show two exit routes from the viewer's location.

Ref: NFPA 170 - 11.2.4 and 11.3.2

Interview with the maintenance technician on January 8, 2026, at 10:37 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 02/17/2026

The facility will update egress maps to show two exit routes from the viewers' location.

NFPA 101 STANDARD Doors with Self-Closing Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of over five doors.

Findings include:

Observation on January 8, 2026, at 10:51 a.m., revealed the exterior oxygen cylinder storage room door failed to properly close and self-latch in the frame.

Interview with the maintenance technician on January 8, 2026, at 10:51 a.m., confirmed the door did not close and self-latch.

Plan of Correction - To be completed: 02/17/2026

The exterior oxygen cylinder storage room door will be repaired so that it closes properly and latches shut as designed.

The ESS will be educated on the importance of the O2 door properly shutting and latching.

Audits will be conducted 3 times a week for 4 weeks.

Results of the audits will be reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Emergency Lighting:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to provide documentation for functional tests of battery-powered emergency lighting for one of two building components.

Findings include:

Document review on January 8, 2026, at 9:54 a.m., revealed the facility lacked documentation for the annual battery back-up lighting.

Interview with the maintenance supervisor on January 8, 2026, at 9:54 a.m., confirmed the facility could not provide annual testing documentation.

Plan of Correction - To be completed: 02/17/2026

The NHA will educate the ESS on the importance of conducting an annual 1.5-hour emergency lighting test.

On 01/16/2026, regarding annual battery back-up lighting, the facility completed an annual emergency lighting test for a period of 1.5 hours during the power outage drill.

The date of the most recent annual test (01/16/2026) will be entered into the TELS workorder system with a reminder date to alert prior to the next annual test date. This will ensure quality assurance and completion of the task.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain the fire barrier in two of over four hazardous areas.

Findings include:

Observation on January 8, 2026, at 9:07 a.m., revealed the basement boiler room and storage room failed to maintain one-hour fire barrier requirements, with unsealed drywall repairs, penetrations, holes in the ceiling, and loose and missing joint tape/sealing throughout the adjoining rooms.

Interview with the maintenance technician on January 8, 2026, at 9:07 a.m., confirmed the fire barrier deficiencies.

Plan of Correction - To be completed: 02/17/2026

Areas will be repaired regarding basement boiler room and storage room so that they effectively maintain one-hour fire barrier requirements. Drywall will be repaired, so that there are no penetrations, or holes in the ceiling, or loose and missing joint tape/sealing throughout the adjoining rooms.

The ESS will be educated by the NHA on the importance of intact fire barriers.

During environmental rounds, the ESS will monitor for any penetrations, holes, or loos and missing joint tape 3 times a week for 4 weeks.

The results of the findings will be discussed at the monthly QAPI meeting.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, the facility failed to maintain cooking equipment in one of one kitchen.

Observation and interview on January 8, 2026, at 9:32 a.m., revealed the kitchen staff members interviewed were uncertain of the procedure to operate the hood fire suppression system's manual activation.

Interview with the maintenance technician on January 8, 2026, at 9:32 a.m., confirmed the cooking equipment deficiency.

Plan of Correction - To be completed: 02/17/2026

The NHA will educate the Nutrition Services Supervisor on the importance of ensuring that all staff are aware of how to operate the hood fire suppression system.

All kitchen staff have been reeducated on the procedure to operate the hood fire suppression system's manual activation.

All new hires will be trained on operation of the suppression system going forward.

New hires will be audited monthly for the next two months to ensure that the necessary training has occurred.

Results of the audits will be reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, the facility failed to remain in compliance with sprinkler system regulations for one of one system.
Findings include:
Observations and interviews on January 8, 2026, between 9:16 a.m. and 10:35 a.m., revealed the following deficiencies:
A. (9:16 a.m.) Basement sprinkler system room failed to have a sprinkler wrench present at the time of the survey;
B. (10:10 a.m.) Ground floor laundry room had three sprinkler heads covered in dust and dirt, potentially causing a delay in sprinkler activation;
C. (10:11 a.m.) Ground floor soiled utility room had a sprinkler head covered in dust and dirt, potentially causing a delay in sprinkler activation;
D. (10:35 a.m.) Ground floor D wing closet, near the smoke doors, had a gap around the escutcheon on the sprinkler head, potentially causing a delay in sprinkler activation.
Interview with the maintenance technician on January 8, 2026, at 10:35 a.m., confirmed the deficiencies at the time of the survey.

Plan of Correction - To be completed: 02/17/2026

ESS will be educated by the NHA on the importance of keeping a sprinkler wrench in the Sprinkler Room. The ESS will be educated on the importance of properly fitting escutcheon plates.

A sprinkler wrench has been placed in the basement sprinkler system room. Sprinkler heads in the Ground floor laundry room and ground floor soiled utility room have been cleaned and are free of dust and dirt to ensure proper activation.

The escutcheon on the sprinkler head in the ground floor D wing closet will be repaired so that there is no gap present.

The sprinkler room will be audited weekly for 4 weeks to ensure that the sprinkler head is present. During environmental rounds, the ESS will monitor that all escutcheon plates have no gaps present 3 times a week for 4 weeks.

Results of the audits will be reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, the facility failed to maintain, inspect, and test smoke barrier doors, in accordance with regulations, for two of over four doors.

Findings include:

Observation on January 8, 2026, between 9:45 a.m. and 10:05 a.m., revealed the following smoke barrier door deficiencies:

A. (9:45 a.m.) Ground floor dining room corridor smoke door had a gap exceeding the 1/8" maximum allowance;
B. (10:05 a.m.) Ground floor A wing smoke door had a gap exceeding the 1/8" maximum allowance.

Interview with the maintenance technician on January 8, 2026, at 10:05 a.m., confirmed the smoke barrier door deficiencies.

Plan of Correction - To be completed: 02/17/2026

The dining room corridor smoke door and ground floor A wing smoke door will be repaired and no longer have 1/8-inch gaps.

The ESS will be educated by the NHA regarding the importance of smoke doors fitting properly.

Smoke doors will be inspected weekly for 4 weeks to ensure that there are no gaps present.

Results of the audits will be reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, the facility failed to perform one of 12 required fire drills.

Findings include:

Document review on January 8, 2026, at 10:10 a.m., revealed the facility lacked documentation for a second quarter, third shift fire drill.

Interview with the maintenance supervisor on January 8, 2026, at 10:10 a.m., confirmed the facility lacked the fire drill documentation.

Plan of Correction - To be completed: 02/17/2026

The ESS will be reeducated by the NHA regarding the required frequency of fire drills per regulation.

The facility will ensure that fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift.

The completeness of fire drills per regulation will be monitored weekly for 4 weeks.

The results will be reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles for four of over ten receptacles.

Findings include:

Observation on January 8, 2026, between 9:56 a.m. and 10:53 a.m., revealed the following electrical receptacle deficiencies:

A. (9:56 a.m.) Ground floor activity room water cooler was plugged into a receptacle that was not ground fault circuit interrupter (GFCI)-protected;
B. (10:18 a.m.) Ground floor A wing biohazard room had a receptacle located within six feet of the sink and not GFCI-protected;
C. (10:30 a.m.) Ground floor C wing biohazard room had a receptacle located within six feet of the sink and not GFCI-protected;
D. (10:53 a.m.) Ground floor kitchen entrance had an ice machine plugged into a receptacle that was not GFCI-protected.

Interview with the maintenance technician on January 8, 2026, at 10:53 a.m., confirmed the electrical outlet deficiencies.

Plan of Correction - To be completed: 02/17/2026

The water cooler has been removed from the activity room. The following areas will have GFCI's installed: A-wing biohazard room, C-wing biohazard room, and the ice machine by the kitchen entrance.

The ESS will be educated by the NHA regarding the importance of utilizing GFCI outlets per code.

The ESS will complete a whole house audit to ensure that GFCI where required by code. If any non-GFCI outlets are located where they are not supposed to be, they will be immediately replaced with GFCI outlets.

The results of the Audit will be reviewed at the next held QAPI meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power and extension cords in one of one beauty salon.

Observation on January 8, 2026, at 9:55 a.m., revealed the ground floor beauty salon had a power strip used as an extension cord for three hot curling irons and a hair dryer.

Interview with the maintenance technician on January 8, 2026, at 9:55 a.m., confirmed the electrical power strip deficiency.

Plan of Correction - To be completed: 02/17/2026

The power strip that was being used as an extension cord for three hot curling irons and a hair dryer has been removed.
The beautician will be educated to not utilize power strips/extension cords going forward.

The ESS will audit the beauty salon for usage of power strips 3 times a week for 4 weeks.

Initial comments:Name: THERAPY SUITE - Component: 02 - Tag: 0000

Facility ID #053002
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2026, it was determined that Edinboro Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: THERAPY SUITE - Component: 02 - Tag: 0355

Based on observation and interview, the facility failed to comply with regulations for one of over thirty fire extinguishers.

Findings include:

Observation on January 18, 2026, at 10:40 a.m., revealed the physical therapy room corridor had blocked access to a portable fire extinguisher.

Interview with the maintenance technician on January 18, 2026, at 10:40 a.m., confirmed access to the fire extinguisher was blocked.

Plan of Correction - To be completed: 02/17/2026

Wheelchair was removed from physical therapy room corridor which was blocking access to a portable fire extinguisher.

The Therapy Director will be educated on the importance of keeping fire extinguishers clear.

The ESS will monitor the physical therapy room fire extinguisher to ensure that it is not blocked. Audits will be completed 3 times a week for 4 weeks.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Observations:
Name: THERAPY SUITE - Component: 02 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles, per NFPA 70, for one of over three receptacles.

Findings include:

Observation on January 8, 2026, at 10:42 a.m., revealed the main level physical therapy room had a clothes washing machine connected to a receptacle not protected by a ground fault circuit interrupter (GFCI).

Interview with the maintenance supervisor on January 8, 2026, at 10:42 a.m., confirmed the receptacle deficiency.

Plan of Correction - To be completed: 02/17/2026

The ESS will be educated by the NHA on the importance of GFCI receptacles.

The outlet located in the therapy room which supplies power to the washing machine will be replaced with a GFCI receptacle.

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