Pennsylvania Department of Health
 EDENBROOK AT HAMPTON
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EDENBROOK AT HAMPTON
Inspection Results For:

There are  40 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.
EDENBROOK AT HAMPTON - 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 June 30, 2025, at Edenbrook at Hampton, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID# 080302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2025, it was determined that Edenbrook at Hampton 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 two story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain one vertical opening, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:20 a.m., revealed a horizontal penetration of the elevator shaft enclosure, located within the Elevator Machine Room.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the vertical opening deficiency.



 Plan of Correction - To be completed: 07/25/2025

K 0311 – Vertical Openings- Enclosure

1. Penetration of elevator shaft enclosure located whin elevator machine room was sealed with 3M Fire Barrier Sealant, CP 25WB+ 4-hour rating.

2. The Maintenance Director to conduct weekly audits x4 then monthly audits x2 to ensure elevator shaft enclosure within elevator machine room remains sealed with no evidence of penetration.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:47 a.m., revealed the Laundry Dryer Room door required adjustment to fully latch.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the hazardous area enclosure deficiency.





 Plan of Correction - To be completed: 07/25/2025

K 0321- Hazardous Areas- Enclosure

1. The door to the laundry dryer room has been adjusted to fully latch.

2. Facility audit completed of all doors to ensure closure with positive latch.

3. Maintenance Director to be educated in accordance with regulation 0321.

4. NHA/Designee to conduct weekly audits x4 then monthly x2 of all doors close with positive latch. Results of audits to be presented to QAPI committee for review and recommendations.

NFPA 101 STANDARD Cooking Facilities: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.
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 documentation review, observation, and interview, it was determined the facility failed to maintain cooking facilities in two locations, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, between 11:34 a.m., and 12:25 p.m., revealed the following:

a. 11:34 a.m., the dietary range hood assembly lacked a drip tray.
b. 12:25 p.m., the facility lacked one of two required kitchen suppression testing and maintenance reports.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the cooking facilities deficiencies.




 Plan of Correction - To be completed: 07/25/2025

K 0324- Cooking Facilities

1a. Drip pan has been installed to Dietary range hood assembly.

2a. Cannot correct records documentation of 2024 Semi-annual kitchen suppression
testing.

b. First of semi-annual kitchen suppression testing completed 03/11/2025. Second
of semi-annual kitchen suppression testing scheduled for 09/2025.

c. NHA/Designee to review TELS system to ensure compliance of semi-annual testing
of kitchen suppression system completed and documented.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the building fire alarm system in one location, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:07 a.m., revealed the fire alarm pull station, located at the exit discharge location within Maintenance, was blocked from use by storage items.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the fire alarm system deficiency.



 Plan of Correction - To be completed: 07/25/2025

K 0345- Fire Alarm System- Testing and Maintenance

1. All storage items removed from the maintenance exit fire alarm pull system area.

2. Posting noted in the maintenance exit fire alarm pull system area ensuring area remain free of storage items.

3. NHA/Designee to randomly audit maintenance exit fire alarm pull system area to ensure area remains free of storage items.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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, interview, and documentation review, it was determined the facility failed to maintain the automatic sprinkler system in two locations, and two instances, affecting two of two floors.

Findings include:

1. Observation on June 30, 2025, between 11:32 a.m., and 12:10 p.m., revealed the following:

a. 11:32 a.m., penetrations of ceiling tiles, located within the first floor Electrical Room and Central Supply.
b. 12:10: p.m., the facility lacked required quarterly sprinkler maintenance and testing reports for the third and fourth quarter of calendar year 2024.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the automatic sprinkler system deficiencies.



 Plan of Correction - To be completed: 07/25/2025

K 0353- Sprinkler System- Maintenance and Testing

1a. First floor electrical room central supply ceiling tiles replaced.

b. All areas of the facility were checked for penetrations in ceiling tiles

c. Maintenance Director to be educated in accordance with regulation 0353

d. NHA/Designee to randomly audit of facility ceiling tiles to ensure no evidence of penetrations.

2a. Cannot correct the required documentation for 3rd and 4th quarter of calendar year 2024.

b. Sprinkler testing for 1st and 2nd quarter of calendar year 2025 completed and documented.

c. NHA/Designee to review TELS system to ensure sprinkler testing completed
and documented in accordance with regulations.


NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in one location, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:41 a.m., revealed the second floor, Resident Lounge door lacked positive latching capabilities due to removal of door hardware.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 07/25/2025

K 0363 Corridor- Doors

1. New hardware was installed on second floor resident lounge door.

2. Facility Audit completed for all smoke doors to ensure positive latching.

3. NHA/Designee to conduct weekly audits x4 then monthly x2 of all smoke doors to ensure positive latching. Results of audits to be presented to QAPI for review and recommendations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:44 a.m., revealed a penetration of the C Wing smoke barrier separation wall, located above the smoke barrier doors.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the smoke barrier separation wall deficiency.



 Plan of Correction - To be completed: 07/25/2025

K 0372 Subdivision of Building Spaces- Smoke Barriers

1. Penetration of the C Wing smoke barrier separation wall, located above the smoke barrier doors, was sealed with 3M Fire Barrier Sealant, CP 25WB+ 4-hour rating.

2. Maintenance Director will conduct weekly audits x4 then monthly x2 of smoke barrier walls to ensure no evidence of penetration. Results of audits will be presented to QAPI committee for review and recommendations.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain heating, ventilation and air conditioning in one location, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:13 a.m., revealed portable air conditioning unit duct work vented into the interstitial spaces beyond the suspended ceiling assembly, located within the Maintenance Shop.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the HVAC deficiency.



 Plan of Correction - To be completed: 07/25/2025

K 0521 HVAC

1. Portable air conditioning unit located within maintenance shop was removed.

2. Maintenance Director to be educated in accordance with regulation 0521.

NFPA 101 STANDARD Fire Drills: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.
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 documentation review and interview, it was determined the facility failed to maintain fire drills in four of twelve instances, affecting two of two floors.

Findings include:

1. Observation on June 30, 2025, at 12:15 p.m., revealed the facility lacked first, second, and third shift fire drills for the fourth quarter of calendar year 2024, as well as a third shift fire drill for the third quarter of calendar year 2024.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the fire drill deficiencies.



 Plan of Correction - To be completed: 07/25/2025

K 0712 Fire Drills

1. Cannot correct documentation of prior fire drills for 4th quarter, 1st, 2nd and 3rd shifts.

2. Fire Drills for 1st, 2nd and 3rd shifts are completed and documented for quarter 1 and quarter 2 for current calendar year 2025.

3. NHA/Designee will audit TELS system to ensure fire drills are completed and documented for quarter 3 and quarter 4 for 1st, 2nd and 3rd shifts of current calendar year 2025 in accordance with regulation 0712.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire doors in one instance, affecting two of two floors.

Findings include:

1. Observation on June 30, 2025, at 12:22 p.m., revealed the facility did not have the stair tower enclosure doors listed on annual fire door inspection forms.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the fire door deficiencies.



 Plan of Correction - To be completed: 07/25/2025

K 0761 Maintenance, Inspection and testing- Doors

1. Stair tower enclosure doors were added to annual fire door inspection forms.

2. Stair tower enclosure doors will be inspected in accordance with regulation 0761.

3. NHA/Designee will audit TELS system to ensure stair tower enclosure doors are, listed, testing completed and documented in accordance with regulation 0761.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of two floors.

Findings include:

1. Observation on June 30, 2025, at 11:17 a.m., revealed a junction box was unsecured within the ceiling assembly, located closest to the first floor elevator enclosure.

Exit interview with the Facilities Manager and the Human Resources Manager on June 30, 2025, between 12:40 p.m., and 12:50 p.m., confirmed the electrical deficiency.



 Plan of Correction - To be completed: 07/25/2025

K 0914 Electrical Systems- Maintenance and Testing

1. Junction box was secured within the ceiling assembly located closet to the first-floor elevator.

2. Maintenance director to conduct weekly audits x4 then monthly x2 to ensure junction box remains secure within ceiling assembly located closet to first floor elevator enclosure. Results of audits will be presented to QAPI committee for review and recommendations.


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