Pennsylvania Department of Health
BROOKLINE NURSING AND REHAB
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BROOKLINE NURSING AND REHAB - 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 February 18, 2026, at Brookline Nursing and Rehab, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #022902

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 18, 2026, it was determined that Brookline Nursing and Rehab, 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 structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293 Based on observation and interview, it was determined the facility failed to maintain exit signage, affecting one of three smoke compartments within the component. Findings include: 1. Observation on February 18, 2026, at 10:58 AM, revealed the exit sign, located above the door to Resident Room 218, directed egress into the TV Room, instead of toward to the exterior exit door. Interview with the Administrator on February 18, 2026, at 10:58 AM, confirmed the exit sign directed egress through an intervening room, not directly towards an exit from the corridor.

Plan of Correction - To be completed: 03/31/2026

1. Exit sign outside of room 218 had the directional arrow changed to direct egress to the exit at the end of the corridor.

2. Staff educated on exit signage and pointing to direct egress to the nearest exit.

3. Audits will be completed quarterly to ensure all exit signage is directing egress to the nearest exit and reported in QAPI monthly times three months.

NFPA 101 STANDARD Sprinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0351 Based on observation and interview, it was determined the facility failed to install sprinkler heads with a spacing of at least six feet, affecting one of three smoke compartments within the component. Findings include: 1. Observation on February 18, 2026, at 11:06 AM, revealed two sprinkler heads, located within the Wing 2 Nurses' Station, were spaced less than six feet apart from each other. Interview with the Administrator on February 18, 2026, at 11:06 AM, confirmed the sprinkler heads were not at least six feet apart from each other.

Plan of Correction - To be completed: 03/31/2026

1. One of the two sprinkler heads that are within 6 feet of each other will be removed and capped.

2. Staff educated on the required distance between sprinkler heads.

3. A onetime audit of the facility will be completed to ensure all sprinkler heads are not closer than 6 feet apart and reported in QAPI.

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