Pennsylvania Department of Health
EDENBROOK OF GREENWOOD HILL
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EDENBROOK OF GREENWOOD HILL - 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 17, 2026, at Edenbrook of Greenwood Hill Rehabilitation and Nursing Center, 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 #383802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 17, 2026, it was determined that Edenbrook of Greenwood Hill 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 three-story, Type II (000), unprotected noncombustible structure, with a ground floor, and an unused, inaccessible basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Review of documentation on June 17, 2026, between 10:30 PM and 1:00 PM, revealed the facility is a three-story, Type II (000), unprotected noncombustible structure, with a ground floor and an unused, inaccessible basement, which is fully sprinklered, and exceeded the maximum allowable story height for this type of construction.

Interview with the Administrator and Director of Maintenance on June 17, 2026, at 1:00 PM, confirmed the construction type is not permitted in health care.

Plan of Correction - To be completed: 08/12/2026

The facility is requesting DSI to conduct an FSCS Survey. TLW will be submitted to LS Field Office.

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was revealed the facility failed to maintain hazardous area doors to positively latch, in one of seven smoke zones within the component.

Findings include:

1. Observation on June 17, 2026, at 12:45 PM, revealed Zone 7 Soiled Linen door, in the basement, failed to positively latch.

Interview with Administrator and Director of Maintenance on June 17, 2026, at 1:00 PM, confirmed the hazardous area door failed to positively latch.

Plan of Correction - To be completed: 08/12/2026

1. Zone 7 Soiled Linen Door has been fixed by Maintenance Director and now positively latches.

2. Maintenance Director/designee will complete audit on Soiled Utility Doors to ensure all doors positively latch closed.

3. Staff will be educated on entering a ticket into our electronic work system when they identify a door that is not latching fully.

4. Doors latching fully will be added to the environmental rounds audit tool that is completed monthly in different areas of the building. These rounds include a walk through with the Director of Maintenance, Housekeeping Director and Administrator. 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 BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined that the facility failed to maintain the sprinkler piping system to be free of extraneous weight, in three of seven smoke zones within the component.

Findings include:

1. Observation on June 17, 2026, between 10:45 AM and 11:15 AM, revealed wiring was resting on the sprinkler pipes, at the following locations:

a. 10:45 AM, 3rd floor, Zone 1, in the corridor outside of Room 362;
b. 11:00 AM, 3rd floor, Zone 2, right above the Nurses' Station;
c. 11:15 AM, 1st floor, Zone 5, right above the Nurses' Station.

Interview with the Administrator and the Director of Maintenance on June 17, 2026, at 1:00 PM, confirmed the sprinkler piping system was subject to extraneous weight.

Plan of Correction - To be completed: 08/12/2026

1. The wiring resting on the sprinkler piping system identified during the Life Safety Survey has been removed and properly secured at the following locations:
- 3rd Floor, Zone 1, corridor outside Room 362
- 3rd Floor, Zone 2, above the Nurses' Station
- 1st Floor, Zone 5, above the Nurses' Station

2. Maintenance Director/Designee will complete audit on all sprinkler piping throughout facility to ensure no other wiring/materials resting on system.

3. The Maintenance Director and maintenance staff were educated regarding NFPA requirements prohibiting sprinkler piping from supporting wiring or any other extraneous weight.

4. Sprinkler piping from supporting wiring or any other extraneous weight will be added to the facility's Fire Safety audit tool to verify that sprinkler piping remains free of extraneous weight. This audit is typically performed every other month. Maintenance Director/Designee 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.

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