Health inspection·February 15, 2024

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on review of admission packet and facility documents, observations, and resident and staff interviews, it was determined that the facility failed to post the results of the most recent survey results in a place readily accessible to residents on four of four units (Units A, B, C, D). Residents Affected - Some Findings include: The admission Notice Packet presented on admission by the facility and posted on entrance and in the survey result book are the Resident Rights. Sec.1919(c)(1) Examination of Survey Results in the admission packet stated the survey results must be made available for your examination by the facility in a place readily accessible to you. Observation on 2/12/24, at 11:00 a.m. an unknown female (later identified by staff as being from Medicaid) was working on a laptop in the resident library, and remained until approximately 4:00 p.m. Observation on 2/13/24, at 8:15 a.m. an unknown female (later identified by staff as the Certified Registered Nurse Practitioner- CRNP) was working on a laptop in the resident library, and remained until approximately 3:00 p.m. Interview on 2/13/24, at 3:00 p.m. with the Nursing Home Administrator (NHA) confirmed who the above visitors were there working in the library. Observation on 2/13/24, revealed a sign located in a glass enclosed case in the facility entrance indicated that the survey results were located in the resident library. Interviews on 2/13/24, at 10:00 a.m. with Resident Council Members confirmed that they did not know where the survey results were located, and stated they assumed they were in the front office. Upon being informed that the survey results were located in the resident library, Resident Council Members confirmed that they do not have access to the resident library on most days, and that there is often someone in there working. Observation on 2/14/24, at approximately 8:45 a.m. five corporate consultants were working in the resident library until surveyors left the building at 3:45 p.m. Interview on 2/14/24, at 1:08 p.m. with the NHA confirmed the presence of individuals working in the resident library. Interview on 2/14/24, at 1:36 p.m. with the NHA identified that the survey results binder was not located in the resident library and was not able to state where it was. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment on one of four units (B Unit). Findings include: Review of facility policy entitled Housekeeping and Maintenance Services dated 12/14/23, indicated The Manor will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] a white/brown substance on the floor to the right side of the resident's bed, a white substance on the floor to the left side of the resident's bed, pieces of paper under the bed and under the nightstand, and a large amount of gray fluffy substance over the floor of the resident room, under the resident's bed and covering the flat surfaces of the bed frame. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] a round quarter-size brown object under bed two, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both bed frames. In the resident bathroom observation of a brown dry substance on the floor to both sides of the toilet. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] a crumpled up facial tissue under bed one, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both resident's bed frames. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] empty candy wrappers under bed one, paper from dressing supplies under bed one, a used band aide stuck to the floor between bed one and bed two, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both bed frames. During observations with the Nursing Home Administrator on 2/14/24, at 9:00 a.m. he/she confirmed that Resident Rooms 48, 51, 55, and 61 were not appropriately cleaned. He/she also confirmed that resident rooms should be clean. During observations with Housekeeping Employee E4 on 2/14/24, at 9:15 a.m. he/she confirmed that the above resident rooms on B Unit were not appropriately cleaned. He/she also confirmed that resident rooms should be clean. 28 Pa. Code 201.14 (a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policy and facility documentation, observations, resident and staff interviews, it was determined that the facility failed to make certain residents were aware of the procedure for filing a concern/grievance (written or verbal, the procedure to file a grievance anonymously), and make certain concern forms are easily located and accessible to all residents and/or representatives on four of four nursing units (A, B, C, D). Findings include: Review of the facility policy entitled, Grievance Policy last reviewed 12/14/23, indicated that: all persons will be provided with an opportunity to present their complaints through a formal grievance procedure; the grievance procedure will be reviewed with all residents at the time of admission, and posted in the Manor; if filing a written grievance, the forms are located in the Administrator's office, must be submitted in writing and signed by the resident or person filing the grievance on behalf of the resident, and lacked guidance related to filing an anonymous grievances. Observation on 2/12/24, at 11:00 a.m. revealed a green sample grievance form in flip chart at the entrance with a round wooden table blocking access to the chart, and no blank forms for resident use, or a box to anonymously place completed grievance forms. During an interview on 2/13/24, at 10:15 a.m. Resident Council Members confirmed that they tell someone if they have a complaint, and do not know if there is an official form or where to get it. During an interview on 2/14/24, at 1:11 p.m. the Nursing Home Administrator confirmed there was no postings of grievance procedures and no way for residents/family to anonymously submit a grievance. 28 Pa. Code 201.29(a)(b)(c) Resident rights 28 Pa. Code 201.18(e)(4) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury in a timely manner for one of 24 residents reviewed (Resident R81). Residents Affected - Few Findings include: Review of a facility policy entitled, Accidents and Incidents dated 12/14/2023, indicated that, all accidents and/or incidents occuring on Manor premises involving residents must be investigated. Review of Resident R81's clinical record revealed an admission date of 10/06/2021, with diagnoses that included dementia, history of falling and abnormalities of gait and mobility. Review of Resident R81's clinical record revealed a progress note dated 9/20/2023, that identified Resident R81 was lying on his/her back on the floor with feet towards the door and a large amount of bloody drainage noted on the floor and Resident R81's clothes. Resident R81 was assessed with a head laceration to posterior scalp. An order was received from the physician to transfer Resident R81 to the hospital. Review of Resident R81's clinical record and incident documentation revealed a lack of evidence that a full investigation was completed. Further review of the clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff. During an interview on 2/15/2024, at 11:00 a.m. the Nursing Home Administrator confirmed that there was not a complete investigation completed on Resident R81's unwitnessed incident with injury, and also confirmed that all incidents should be investigated which included obtaining written statements. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for one of 23 residents reviewed (Resident R59). Residents Affected - Few Findings include: Review of facility policy entitled Resident Assessment Policy dated 12/14/23, indicated Accuracy of assessment. The assessment will accurately reflect the resident's status. Resident R59's clinical record revealed an admission date of 4/20/2018, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), dependence of renal dialysis (a mechanical treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), and diabetes (condition of improper blood sugar levels). Review of Resident R59's clinical record revealed a physician's order dated 1/29/24, that identified that the resident was ordered to go to dialysis on Monday, Wednesday, and Friday at 7:30 a.m. Review of Resident R59's Care Plans revealed a care plan with a focus that indicated I am receiving dialysis services related to kidney failure and chronic kidney disease stage five, with a care plan creation date of 2/15/21. Review of the MDS dated [DATE], Special Treatments, Procedures, and Programs Section O0100 revealed to check all of the following treatments, procedures, and programs that were performed during the last 14 days. Documentation on the MDS for O0100 while a resident under J Dialysis revealed it was answered no. During an interview on 2/14/24, at 1:42 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident was currently receiving dialysis. The RNAC also confirmed that Section O0100 of the MDS dated [DATE], was incorrectly coded for Resident R59 regarding receiving dialysis. 28 Pa. Code 201.14 (a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on clinical record review and staff interview, it was determined that the facility failed to provide a resident and/or his/her representative with a summary of the baseline care plan for one of 24 residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission date of 11/3/23, with diagnosis that included Chronic Obstructive Pulmonary disease (a disease that obstructs air flow from the lungs), Hypertension (high blood pressure), and Quadriplegia (a condition where a person is paralyzed and unable to move their body from the neck down). Review of Resident R1's clinical record lacked evidence that a summary of the care plan that included goals, treatments and services, and a summary of medications and dietary instructions was provided to Resident R1 and/or his/her representative. During an interview on 2/14/24, at 3:26 p.m. with the Director of Nursing he/she confirmed that there was no evidence that Resident R1 and/or his/her representative was provided a summary of the care plan that included goals, treatments and services, and a summary of medications and dietary instructions. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12 (d)(1)(e) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm 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 update a care plan for one of 24 residents reviewed (Resident R81). Residents Affected - Few Findings include: Review of a facility policy entitled Comprehensive Care Plan dated 12/14/2023, indicated that, care plans are periodically reviewed and revised by a team of qualified persons after each assessment. Review of Resident R81's clinical record revealed an admission date of 10/06/2021, with diagnoses that included dementia, history of falling and abnormalities of gait and mobility. Review of Resident R81's clinical record revealed a progress note dated 9/20/2023, that indicated Resident R81 was lying on his/her back on the floor with feet towards the door and a large amount of bloody drainage noted on the floor and Resident R81's clothes. Resident R81 was assessed with a head laceration to posterior scalp. An order was received from the physician to transfer Resident R81 to the hospital. Review of clinical record documentation and fall investigation tool for Resident R81, revealed that he/she fell on 9/20/23, resulting in a head laceration requiring staples. There was no evidence that the care plan was updated to reflect the fall and interventions. During an interview on 2/15/2024, at 11:50 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R81's care plan was not updated to reflect the fall with injury from 9/20/23 and interventions. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on clinical record review and staff interview, it was determined that the facility failed to include the recapitulation of stay (summary of resident's stay and course of treatment in the facility) for one of four closed records reviewed (Resident CR111). Findings include: Review of Resident CR111's clinical record revealed an admission date of 6/30/23, with diagnosis that include Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), and Diabetes. Review of clinical record revealed that Resident CR111 was discharged on 12/14/23. Review of Resident CR111's clinical record lacked evidence of a recapitulation of Resident CR111's stay. During an interview on 2/15/24, at 12:00 p.m. with Employee E3 he/she confirmed that Resident CR111's closed record lacked a recapitulation of his/her stay. 28 Pa. Code 211.5(d)(f)(iv)(xi) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of four residents reviewed for respiratory care and failed to follow physician's orders related to oxygen equipment for one of four residents reviewed for respiratory care (Residents R45 and R57). Residents Affected - Some Findings include: Review of a facility policy entitled, Disposable Supply Changes dated 12/14/23, indicated that Guidelines of when disposable supplies for medical equipment need changed for infection control purposes. Disposable supplies need to be dated when changed And Oxygen Cannulas (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen), Oxygen Supply Lines (tubing that connects from the oxygen source to the nasal cannula), and Oxygen Humidifier Bottles) plastic bottles filled with distilled water used to humidify oxygen) should be changed weekly or prn (as needed). Resident R45's clinical record revealed an admission date of 10/25/23, with diagnoses that included heart disease, irregular heartbeat, difficulty speaking and swallowing and hypertension. There was no evidence in the clinical record of a physician's order for supplemental oxygen. Observations on 2/12/24, at 3:57 p.m. and 2/13/24, at 8:39 a.m. revealed Resident R45 sitting in a wheelchair in his/her room with supplemental oxygen via nasal canula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) set a 2 LPM (liters per minute). During an interview on 2/12/24, at 4:39 p.m. Registered Nurse (RN) Employee E2 confirmed that Resident R45 had oxygen in place at 2 LPM. Observation on 2/14/24, at 10:10 a.m. revealed Resident R45 sitting in wheelchair in D Hall with supplemental oxygen via nasal canula attached to a portable tank set at 2 LPM . During an interview at that time RN Employee E1 confirmed that Resident R45 was wearing supplemental oxygen, there was no physician's order and that it was applied in response to an episode of respiratory distress on 12/14/23, and staff failed to obtain a physician's order. Resident R57's clinical record revealed an admission date of 1/6/23, with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), pneumonia, and Heart Failure (a progressive heart disease that affects pumping action of the heart muscles, causing fatigue and shortness of breath). Resident R57's clinical record revealed a physician's order dated 1/6/23, indicating to Change O2 [oxygen] tubing and supply bag weekly . Change water jug (bottle) weekly. Review of Resident R57's treatment records for February 2024, revealed that Resident R57's oxygen tubing and water bottle was last changed on February 9, 2024. Observations on 2/12/24, at 2:30 p.m. and on 2/14/24, at 8:35 a.m. revealed Resident R57 lying in bed in his/her room with supplemental oxygen on. Resident R56's oxygen tubing had a piece of tape on it indicating it was last changed on 2/4/24, and the water bottle had 2/6/24 written on the top. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinboro Manor 419 Waterford Street Edinboro, PA 16412 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/14/24, at 8:42 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that the oxygen tubing was dated 2/4/24, and was not changed per physician's orders and the water bottle was dated 2/6/24, and was not changed per physician's orders. 28 Pa. Code 211.10(d) Resident care policies Residents Affected - Some 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395645 If continuation sheet Page 11 of 11