Health inspection·January 13, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to maintain a clean, homelike environment for one of 20 residents rooms reviewed (Resident R5). Findings include: Review of a facility policy entitled, General/Routine Environmental Cleaning and Disinfection Policy dated 9/2/25, revealed, Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water; Process for Environmental cleaning and disinfection includes: Cleaning and disinfection of environmental surfaces immediately if surface(s) are visibly soiled. Daily cleaning and disinfection for high touch surfaces in resident rooms; Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc.) Review of Resident R5's clinical record revealed an admission date of 1/29/25, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), persistent vegetative state ( a severe brain injury condition where a person is awake, but shows no signs of awareness), and diabetes (a health condition caused by the body's inability to produce enough insulin). Observations of Resident R5's room on 1/11/26, at approximately 8:50 a.m. revealed a dried washcloth on the floor at the foot of the bed, alcohol wipe wrappers, and a clear plastic syringe lid under the bed by the foot controls. Further observations revealed a white, dry substance on the floor next to Resident R5's bed and in front of the oxygen concentrator. Observations of Resident R5's room on 1/11/26, at approximately 2:00 p.m. revealed the same dried washcloth remained on the floor at the foot of the bed; alcohol wipe wrappers, and a clear plastic syringe lid remained under the bed by the foot controls. Further observations revealed a white, dry substance remained on the floor next to Resident R5's bed and in front of the oxygen concentrator; and a white, dry substance on the front and back of the oxygen concentrator. Observations of Resident R5's room on 1/12/26, at approximately 11:00 a.m. revealed the same dried washcloth remained on the floor at the foot of the bed, alcohol wipe wrappers, and a clear plastic syringe lid remained under the bed by the foot controls. Further observations revealed a white, dry substance remained on the floor next to Resident R5's bed and in front of the oxygen concentrator; and a white, dry substance remained on the front and back of the oxygen concentrator. During an interview on 1/12/26, at 11:20 a.m. the Regional Director of Clinical Services confirmed the dried washcloth on the floor at the foot of the bed; alcohol wipe wrappers, and a clear plastic syringe lid under the bed by the foot controls. He/she also confirmed that there was a dried white liquid substance on the floor next to Resident R5's bed and on the front and back of Resident R5's oxygen concentrator. He/she confirmed that residents' rooms should be kept clean. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (e) (2.1) Management Page 1 of 6 395536 395536 01/13/2026 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 20 residents reviewed (Resident R8).Findings include: Review of facility policy entitled Comprehensive Care Planning Policy dated 9/2/25, indicated that An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. And The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes or change in condition. At a minimum this will occur with each comprehensive and quarterly assessment in accordance with Resident Assessment Instrument (RAI) requirements. Resident R8's clinical record revealed an admission date of 2/15/21, with diagnoses that included stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts causing brain cells to die often times, but not always leading to permanent disabilities), bipolar disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and dementia (loss of cognitive functioning affecting a person's memory and behaviors). Resident R8's physician's orders dated 7/2/25, revealed an order to discontinue Seroquel (Antipsychotic Medication (type of medications used to treat psychosis related conditions such as Dementia, Bipolar, Schizophrenia), 25 milligram (mg) daily. Further review revealed no additional orders for any antipsychotic medications. Resident R8's clinical record revealed a care plan started on 5/30/24, and reviewed on 10/24/25, with a problem Resident receives antipsychotic medication. During an interview on 1/12/26, at 2:43 p.m. the Regional Director of Clinical Services confirmed that Resident R8 was no longer receiving any antipsychotic medications, and his/her care plan was not updated to reflect their current status. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395536 Page 2 of 6 395536 01/13/2026 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one main kitchens and failed to monitor resident's personal refrigerators for temperatures for one of two residents reviewed with personal refrigerators (Resident R78). Findings include: Review of a facility policy entitled Storage of Refrigerated Foods Policy dated 9/2/25, indicated that Perishable foods will be stored in order to maximize food safety and quality. and Refrigerated, TCS (time / temperature control for safety) foods, prepared and held for more than 24 hours will be marked to indicate the date the food will be consumed or discarded. Review of a facility policy entitled Food Brought in From Outside the Facility with a policy review date of 9/2/25, indicated that, Resident room refrigerators: The refrigerator where the food will be stored will have an internal thermometer. Units will maintain safe internal temperature in accordance with state and federal standards for safe food storage temperatures. Temperatures should be monitored and recorded daily. Designated employees will check and record date, refrigerator temperature(s), and initials daily on tracking sheets for all refrigerators and freezers. Facility did not have policy to indicate how they will handle perishable foods with Best if used by/Before, Sell-By, Use-By, and Freeze-By dates. Tour of main kitchen on 1/10/26, between 10:20 a.m. and 10:50 a.m. revealed the following: Walk-in refrigerator had a container of French Onion Soup with a prepared date of 12/30/25, and use by date of 1/4/26; 17 half pint cartons of chocolate milk with a sell by date of 1/3/26; Reach-in refrigerator had a half full five pound container of sour cream with a best by date of 12/30/25, a half full five pound container of coleslaw with a use by date of 12/26/25, and a half full five pound container of egg salad with a use by date of 1/6/26. During an interview on 1/10/26, at 10:39 a.m. Dietary Manager confirmed that the French Onion Soup was six days past the use by date and the 17 cartons of chocolate milk were seven days past the sell by date. During an interview on 1/10/26, at 10:43 a.m. Dietary Manager confirmed that the sour cream was 11 days past the best by date, coleslaw was 15 days past the use by date, and the egg salad was four days past the use by date. During an interview on 1/12/26, at approximately 10:30 a.m. the Regional Director of Clinical Services confirmed the facility policy did not indicate how the facility would handle perishable foods regarding the best by date, sell by date, and use by date. During an interview and observation with Resident R78 on 1/10/26, at approximately 1:30 p.m. it was observed that Resident R78 had a personal refrigerator to store food items. Resident R78 gave permission for the surveyor to open the refrigerator and observe it for safe storage of food items. Upon observation, it was noted that there were food items in the refrigerator. Upon observation there was no thermometer present to determine the temperature of the refrigerator for safe storage of food items, and no recorded temperatures noted. During an interview with the Nursing Home Administrator (NHA) and the Regional Director of Clinical Services on 1/10/26, at 3:30 p.m. it was confirmed that there should be thermometers in each personal refrigerator and temperatures should be recorded in the resident chart by the designated employee. During an interview with the NHA on 1/11/26, at approximately 3:30 p.m., it was confirmed that there was no thermometer in Resident R78's personal refrigerator and no temperatures recorded in Resident R78s charting monitoring the personal refrigerator for safe storage of items. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management 395536 Page 3 of 6 395536 01/13/2026 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for two of 20 residents reviewed (Residents R5 and Closed Record CR91).Findings include: Review of a facility policy entitled Enteral Feeding Tube Policy dated 9/2/25, indicated Flush tube according to physician direction. Review of a facility policy entitled Dietary Enteral Nutrition Care Policy dated 9/2/25, indicated The use of an enteral nutrition tube has a major impact on a resident and his or her quality of life. Enteral nutrition tubes will be utilized only after assessment determines that the clinical condition of the resident makes the use of the feeding tube medically necessary. Review of a facility policy entitled Resident Change in Condition dated 9/2/25, indicated The Physician/Provider and Resident/Family/Responsible Party will be notified when there has been a significant change in the resident's physical/emotional/mental condition. Review of a facility policy entitled Post Mortem Care Policy dated 9/2/25, indicated Document postmortem care, time body was released and to whom and complete the inventory of personal effects nothing final disposition of everything listed: transported with resident, sent home with family/representative, left on resident's body, or retained by the facility. No policy provided by the facility regarding documentation. Review of Resident R5's clinical record revealed an admission date of 1/29/25, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), persistent vegetative state ( a severe brain injury condition where a person is awake, but shows no signs of awareness), and diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R5's clinical record revealed a physician's order dated 11/28/25, for enteral feeding, Free Water: Administer 200 cubic centimeter (cc) of water four times per day (QID) for total of 800cc/day. Flush tube with 60cc free water before and 30cc free water between meds. (Record amounts every shift); a physician's order dated 12/17/25, for Diabetisource AC at 100 ml per hour continuous via gastric tube x 20 hours (Up at 12:00 a.m., down at 8:00 p.m. or when total amount infused. Total volume 2000ml per day. Day =1200ml, Night=800ml). Review of documentation of water flushes for Resident R5 from 12/1/25, through 1/10/26, under the medication administration record revealed Resident R5 received less than the ordered 200 cc of water flush QID (not counting medication flushes) fifteen times. Documentation also revealed that facility lacked any evidence of water flushes four times. Review of documentation of formula intake for Resident R5 from 12/17/25, through 1/10/26, under the medication administration record revealed Resident R5 received less than the ordered 2000 ml of formula per day eighteen times, and more than the ordered 2000 ml of formula per day one time. During an interview on 1/11/25, at 2:45 p.m. the Regional Director of Clinical Services confirmed 395536 Page 4 of 6 395536 01/13/2026 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident R5's clinical record contained incomplete and inaccurate documentation related to his / her tube feeding formula and water flushed. Resident CR91's clinical record revealed an admission date of 10/3/25, with diagnoses that included sepsis (a reaction to an infection that causes extensive inflammation throughout the body, potentially leading to tissue damage, organ failure, and even death), cerebral palsy (a brain disorder that appears in infancy or early childhood, permanently affecting body movement and muscle coordination. It is caused by changes in the developing brain that disrupts its ability to control movement and maintain posture and balance), and Non-ST Elevation Myocardial Infarction (NSTEMI – a type of heart attack characterized by a partial blockage of an artery that leads to a lack of blood flow to the heart muscle). Resident CR91's clinical record progress note dated 10/20/25, at 9:10 a.m. revealed Call to PCMA regarding elevated Temp, face flushed, decreased oral intake and lethargy. A progress note dated 10/20/25, at 11:00 a.m. revealed New Orders received PRN (as needed) Tylenol every 6 hours, STAT chest x-ray, and lab in the morning. A progress note dated 10/20/25, at 9:34 p.m. revealed Resident ceased to breath at 2118 (9:18 p.m.), the RN called the sister and notified her about the brother's demise. The body is to be discharged to funeral home. A progress note dated 10/20/25, at 9:45 p.m. revealed Placed a phone call to Funeral Home, provided required information, a crew will be here shortly, the body is ready to be picked up. Resident CR91's clinical record lacked evidence of assessment of Resident CR91's condition between 10/20/25, at 9:10 a.m. and 10/20/25, at 9:34 p.m. when Resident CR91's sister was notified of his/her passing. Resident CR91's clinical record also lacked evidence of physician notification of his/her death, physician order to release body to the funeral home, and information regarding when he/she was released from the facility to the funeral home and if any belongs were sent with him/her at the time he/she was released to the funeral home. During an interview on 1/13/26, at 1:43 p.m. the Director of Nursing confirmed that Resident CR91's clinical record lacked any evidence of assessment of Resident CR91 on 10/20/25, between 9:10 a.m. and 9:34 p.m. when Resident CR91's sister was notified of his/her passing, physician notification of his/her death, physician order to release the body and when Resident CR91 was actually released to the funeral home and if any of his/her belongings were sent with him/her. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395536 Page 5 of 6 395536 01/13/2026 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of one residents reviewed (Resident R49). Findings include: Review of the facility policy entitled, Call Light Resident Communication System Policy with a policy review date of 9/2/2025 , revealed that it is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. Observation in Resident R49's room revealed the call bell system in the corridors did not illuminate when resident call bell button was pressed. There was also no signal to the front desk area that the call light was activated. Resident R49 revealed that there are constantly long wait times when he/she calls for help of over 60 minutes and last night nobody came to assist him/her at all.During an observation and interview on 1/10/26, at approximately 1:00 p.m. the Maintenance Director confirmed that call bell button for Resident R49 was not functioning and needed replaced.During an interview on 1/10/26, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that the call light button for Resident R49 was not functioning and needed replaced preventing Resident R49 from alerting staff for assistance. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management Residents Affected - Few 395536 Page 6 of 6