Pennsylvania Department of Health
EDENBROOK OF YEADON
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 51 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 OF YEADON - 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 April 27, 2026, at Edenbrook of Yeadon, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0000
Facility ID# 122002

Component 01

Original/Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 27, 2026, it was determined that Edenbrook Of Yeadon (Original/Main Building) was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 III (200), unprotected ordinary building, with a lower level, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0211 Based on observation, document review and interview, it was determined the facility failed to ensure the means of egress was maintained free of obstructions, affecting 1 of three smoke compartments. Findings include: 1. Observation and document review on April 27, 2026, between 8:00 a.m. and 11:00 a.m., revealed the exit door by housekeeping storage, ceiling height was less than 6' feet 8", lower-level Main Bldg. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the headroom does not meet minimum requirements.

Plan of Correction - To be completed: 06/19/2026

The facility is acquiring a 3rd party vendor/contractor who is familiar with the rating worksheets completed.

Time limited waiver was submitted on 6/1/26

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 BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous enclosures, affecting one of two stories. Findings include: 1. Observation on April 27, 2026, at 9:40 a.m., revealed a broken door closer, Main Building Mattress Room near Clinical Reimbursement. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the broken closer.

Plan of Correction - To be completed: 06/19/2026

K0321 – Hazardous Area Door Closer Broken

1.The broken door closer on the mattress room door was repaired/replaced immediately.

2.Maintenance inspected all hazardous area doors throughout the facility to ensure door closers were functioning properly.

3.Preventive maintenance rounds were updated to include inspection of hazardous area doors and self-closing devices.

4. Doors latching fully will be added to the environmental rounds audit tool that is completed monthly in different areas of the building. The findings of these audits will be reported to the Safety Committee Monthly.

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

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 BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting one of two levels within the facility. Findings include: 1. Document review on April 27, 2026, at 8:00 a.m., revealed the kitchen hood suppression system inspection dated April 24, 2026, noted a nozzle did not provide compliant coverage. No documentation of remediation for this deficiency was available. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/19/2026

K0324 – Kitchen Hood Suppression Documentation

1.The vendor was contacted immediately to correct the nozzle coverage deficiency and provide documentation of remediation.

2.All kitchen suppression inspection documentation was reviewed to ensure compliance and completeness.

3.A tracking log was implemented for all vendor inspections, repairs, and follow-up documentation.

4.The Maintenance Director will be added to the dietary rounds audit tool that is completed monthly to ensure deficiencies are corrected in a timely manner.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility. Findings include: 1. Document review on April 27, 2026, at 8:00 am, revealed the fire alarm system inspection noted the following deficiencies: a. Fire panel in trouble; b. Two expired heat detectors; c. Bad horn/strobe by resident room 113. No documentation of the remediation of these deficiencies was available. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/19/2026

K0345 – Fire Alarm Deficiencies

1. The fire alarm vendor was contacted immediately to repair the fire panel trouble, replace expired heat detectors, and repair the horn/strobe near room 113.

2. An audit of the fire alarm system and documentation was completed to identify any additional unresolved deficiencies.

3.The facility implemented a process requiring all fire alarm deficiencies to be tracked through completion with supporting documentation maintained onsite.

4. Fire alarm documentation will be added to the environmental rounds audit tool that is completed monthly in different areas of the building. The findings of these audits will be reported to the Safety Committee Monthly.

NFPA 101 STANDARD Fire Alarm System - Out of Service:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:
Name: MAIN BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0346 Based on document review and interview, it was determined the facility failed to maintain required policies for the fire alarm system, affecting the entire facility. Findings include: 1. Document review on April 27, 2026, at 8:00 a.m., revealed the facility did not have a fire watch policy to implement in the event the required fire alarm system was out of service for more than four hours in a 24-hour period. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the missing policy.

Plan of Correction - To be completed: 06/19/2026

K0346 – Missing Fire Watch Policy

1. A fire watch policy was immediately developed and implemented.

2. Facility leadership reviewed emergency preparedness policies to identify any additional missing required policies.

3. Staff responsible for fire safety were educated on fire watch procedures and documentation requirements.

4. Emergency preparedness policies review will be added to the Fire Safety audit tool that is completed monthly in different areas of the building. The findings of these audits will be reported to the Safety Committee Monthly.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Findings include: 1. Observation on April 27, 2026, at 9:35 a.m., revealed two concealed sprinklers that were missing their protective caps, Main Building Mechanical Room next to Ivy Lounge. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the missing caps. 2. Document review on April 27, 2026, at 8:00 a.m., revealed the facility could not provide documentation showing an annual main drain test was conducted. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 06/19/2026

K0353 – Sprinkler System Maintenance and Testing

The missing sprinkler caps in the Main Building Mechanical Room were immediately replaced. The vendor was contacted to complete and provide documentation of the annual main drain test.
All sprinkler heads and sprinkler system documentation throughout the facility were reviewed for compliance.
Preventive maintenance tracking was updated to include sprinkler inspections, main drain testing, and required documentation.
The Maintenance Director/designee will audit sprinkler systems and documentation monthly for 3 months and report findings to QAPI.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0355 Based on document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility. Findings include: 1. Document review and interview on April 27, 2026, at 8:00 a.m., revealed the facility could not produce the following documentation: a. Annual portable fire extinguisher inspection/certification; b. Certificate of the fire extinguisher technician. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/19/2026

K0355 – Portable Fire Extinguishers

1. The fire extinguisher vendor was contacted immediately to complete the annual inspection/certification and provide the technician certification documentation.

2. All portable fire extinguisher inspection records and certifications throughout the facility were reviewed for compliance.

3. A tracking system was implemented to ensure annual fire extinguisher inspections, certifications, and technician credentials are maintained onsite and readily available.

4.The Maintenance Director/designee will audit fire extinguisher inspection documentation monthly for 3 months and report findings during QAPI.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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 BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0761 Based on document review and interview, it was determined the facility failed to ensure rated fire door assemblies were inspected and tested annually, affecting the entire facility. Findings include: 1. Document review on April 27, 2026, at 8:00 a.m., revealed the facility could not provide documentation that rated fire door assemblies were inspected and tested within the previous twelve months. Exit Interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the facility could not provide documentation that fire door assemblies were inspected and tested within the previous twelve months.

Plan of Correction - To be completed: 06/19/2026

K0761 – Maintenance, Inspection & Testing – Doors

The facility scheduled the required annual fire door inspection/testing with a qualified vendor and obtained supporting documentation.

All rated fire door assemblies throughout the facility were reviewed to ensure compliance with annual inspection/testing requirements.

A preventive maintenance schedule was implemented to ensure annual fire door inspections/testing are completed timely and documentation is maintained onsite.

The Maintenance Director/designee will review fire door inspection documentation quarterly for ongoing compliance and report findings to QAPI.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BLDG 01 (ORIGINAL BLDG) - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility. Findings include: 1. Document review on April 27, 2026, at 8:00 a.m., revealed the facility could not produce documentation showing the following tests and inspections were performed: a. Weekly inspection of battery water level or battery voltage; b. Monthly testing of battery specific gravity or conductance. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/19/2026

K0918 – Electrical Systems – Essential Electrical System

The generator vendor was contacted immediately to review generator maintenance/testing records and ensure compliance with NFPA requirements.

All generator, transfer switch, and emergency power documentation were reviewed to identify any missing maintenance or testing records.

A tracking log was implemented for generator inspections, load testing, transfer switch testing, and required maintenance documentation.

The Maintenance Director/designee will complete monthly audits of generator and emergency power system documentation for 3 months and review findings during QAPI.

Initial comments:Name: BUILDING 02 (B & C WINGS) - Component: 02 - Tag: 0000
Facility ID# 122002

Component 02

B &; C Wings

Based on a Medicare/Medicaid Recertification Survey completed on April 27, 2026, it was determined that Edenbrook Of Yeadon (B &; C Wings) was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: BUILDING 02 (B & C WINGS) - Component: 02 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain the smokeproof enclosure of the stairwell, affecting one of two stories. Findings include: 1. Observation on April 27, 2026, at 9:55 a.m., revealed chairs and rock salt bags stored within the stair tower, on the first floor near Lobby double smoke doors. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the storage withing a stair tower.

Plan of Correction - To be completed: 06/19/2026

K0225 – Smokeproof Enclosure
1.The chairs and rock salt bags stored within the stair tower were immediately removed.
2.All stair towers and exit enclosures throughout the facility were inspected to ensure no additional items were being stored in these areas.
3. Maintenance was educated that stair towers and exit enclosures must remain free of storage and obstructions at all times.
4. The Maintenance Director/designee will add checking stair towers and exit enclosures to the monthly environmental checklist.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: BUILDING 02 (B & C WINGS) - Component: 02 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, in one of two stories. Findings include: 1. Observation on April 27, 2026, at 9:50 a.m., revealed a broken emergency duplex outlet in the corridor, on the first floor, C-Hall near Room 104. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the broken duplex. Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.

Plan of Correction - To be completed: 06/19/2026

1.The broken emergency duplex outlet located on C-Hall near Room 104 was immediately replaced/repaired.
2. All emergency duplex outlets and electrical outlets throughout the facility were inspected for damage or safety concerns. Any identified issues were corrected immediately.
3.Maintenance staff were educated on identifying and correcting damaged electrical outlets.
4.Electrical outlet inspections were added to the maintenance checklist and will be monitored monthly.

Initial comments:Name: BUILDING 03 (ANNEX) - Component: 03 - Tag: 0000
Facility ID# 122002

Component 03

Annex Building

Based on a Medicare/Medicaid Recertification Survey completed on April 27, 2026, at Edenbrook Of Yeadon (Annex Building), it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing 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 II (000), unprotected non-combustible building, with a lower level, that is fully sprinklered.

Plan of Correction:

Initial comments:Name: BUILDING 04 (ARCADIA) - Component: 04 - Tag: 0000
Facility ID# 122002

Component 04

Transitional Care Unit Building/Arcadia

Based on a Medicare/Medicaid Recertification Survey completed on April 27, 2026, it was determined that Edenbrook Of Yeadon (Transitional Care Unit Building/Arcadia) was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: BUILDING 04 (ARCADIA) - Component: 04 - Tag: 0222 Based on observation and interview, it was determined the facility failed to ensure egress doors with delayed-egress locking systems had required signage displayed on the doors, affecting one of two levels. Findings include: 1. Observation on April 27, 2026, at 9:25 a.m., revealed a delayed-egress door lacked the required signage that states, "PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS", on the first floor, the Service Hall emergency exit that leads to parking lot. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the missing signage.

Plan of Correction - To be completed: 06/19/2026

Missing delayed-egress signage was immediately installed on the identified exit door.

All delayed-egress doors throughout the facility were checked for proper signage.

Maintenance staff were educated on required egress door signage requirements.

The Maintenance Director/designee will audit egress doors monthly for 3 months and report findings to QAPI.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: BUILDING 04 (ARCADIA) - Component: 04 - Tag: 0342 Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of two levels. Findings include: 1. Observation on April 27, 2026, at 9:15 a.m., revealed a dislodged smoke detector, Arcadia Boiler Room. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the dislodged smoke detector.

Plan of Correction - To be completed: 06/19/2026

The dislodged smoke detector in the Arcadia Boiler Room was immediately repaired/resecured.

All smoke detectors throughout the facility were inspected for proper placement and function.

Fire alarm initiating devices were added to routine preventive maintenance rounds.

The Maintenance Director/designee will complete monthly fire alarm audits for 3 months and report findings to QAPI.

NFPA 101 STANDARD Corridor - Doors:

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: BUILDING 04 (ARCADIA) - Component: 04 - Tag: 0363 Based on observation and interview it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting one of two levels. Findings include: 1. Observation on April 27, 2026, between 9:05 a.m., and 9:20 a.m., revealed the following doors failed to positively latch: a. 9:05 a.m., Elevator Room, on the first floor, Service Hall Arcadia. b. 9:10 a.m., Storage Room, on the first floor, Service Hall Arcadia. c. 9:15 a.m., Boiler Room, on the first floor, Service Hall Arcadia. d. 9:20 a.m., Housekeeping Storage, on the first floor, Service Hall Arcadia. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the doors failed to positively latch.

Plan of Correction - To be completed: 06/19/2026

The identified doors that failed to positively latch were immediately repaired/adjusted.

All corridor and smoke barrier doors throughout the facility were checked for proper latching.

Door inspections were added to routine maintenance rounds to ensure corridor doors positively latch.

The Maintenance Director/designee will conduct monthly corridor door audits for 3 months and report findings to QAPI.

NFPA 101 STANDARD Electrical Systems - Other:

Observations:
Name: BUILDING 04 (ARCADIA) - Component: 04 - Tag: 0911 Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels. Findings include: 1. Observation on April 27, 2026, at 9:15 a.m., revealed a junction box missing it's cover plate near back wall, Arcadia Boiler Room. Exit interview with the Assistant Administrator and the Maintenance Director on April 27, 2026, at 11:00 a.m., confirmed the missing cover plate.

Plan of Correction - To be completed: 06/19/2026

K0911 – Electrical Systems Other

The missing junction box cover plate in the Boiler Room was immediately replaced.

All electrical junction boxes throughout the facility were inspected for missing covers or exposed wiring.

Electrical safety checks were added to preventive maintenance rounds.

The electrical panels will be added to the Safety Committee Department Safety Inspection: Building Interior– General audit. This audit is typically performed four times a year. We will complete audit monthly for the next three months and then transition back to the normal audit schedule. The findings of these audits will be reported to the Safety Committee Monthly.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement