EDINBORO MANOR
Open-data reference.
EDINBORO MANOR is a for profit - corporation facility in EDINBORO, PA with 121 certified beds and a 3-star overall CMS rating. The facility has 31 deficiency records on file. Total penalties: $3K.
419 WATERFORD STREET, EDINBORO, PA 16412
Phone: 8147345021
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 395645
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 121
- Residents
- 113
- In Hospital
- No
- County
- Erie
- Last Inspection
- Jan 22, 2026
Staffing Data
- RN Hours
- 0.40 (nat'l avg: 0.68)
- LPN Hours
- 0.92
- CNA Hours
- 2.13
- Total Nursing Hours
- 3.45 (nat'l avg: 3.89)
- PT Hours
- 0.03
- Nursing Turnover
- 48.8%
- RN Turnover
- 66.7%
What the CMS Record Reveals About EDINBORO MANOR
EDINBORO MANOR operates 121 certified beds in EDINBORO, PA with approximately 113 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (2★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 31 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $3K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.45 total nursing hours per resident day (national average 3.89), with RN coverage at 0.40 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, EDINBORO MANOR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 48.8%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (31 most recent)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Mar 28, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 28, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 28, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 28, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 28, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 15, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2024
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2024
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 20, 2023
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Apr 5, 2023
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category: Infection Control Deficiencies
Corrected: Apr 5, 2023
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Apr 5, 2023
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Apr 5, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Apr 5, 2023
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Apr 5, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Apr 5, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 5, 2023
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 5, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Apr 5, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 5, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 5, 2023
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Category: Resident Rights Deficiencies
Corrected: Apr 5, 2023
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 5, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 5, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 3.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.6% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.8% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 97.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.6% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 3.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 48.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 19.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 30.9% | Yes |
Penalty History 1 penalties totaling $3K
| Date | Type | Amount |
|---|---|---|
| May 8, 2023 | Fine | $3K |
| Mar 3, 2023 | Fine | $16K |
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for EDINBORO MANOR?
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How many beds does EDINBORO MANOR have?
Does EDINBORO MANOR have any deficiencies on record?
Has EDINBORO MANOR received any fines or penalties?
Who owns EDINBORO MANOR?
When was EDINBORO MANOR last inspected?
What quality measures are tracked for EDINBORO MANOR?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.