Pennsylvania Department of Health
CEDARBROOK SENIOR CARE AND REHABILITATION
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CEDARBROOK SENIOR CARE AND REHABILITATION - 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 May 19-20, 2025, at Cedarbrook Senior Care and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 550102
Component 02
Main Campus
B, C, and D Wings

Based on a Medicare/Medicaid Recertification Survey completed May 19-20, 2025, it was determined that Cedarbrook Senior Care and Rehabilitation 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 seven story, Type II (222), fire resistive building, with a basement, and basement-level crawl space, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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: BUILDING 02 - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in three locations, affecting two of eight floors.

Findings include:

1. Observation on May 19, 2025, between 10:48 a.m., and 12:12 p.m., revealed the following:

a. 10:48 a.m., the first floor, B Wing Nurse's Station area lacked a rated ceiling access panel.
b. 11:07 a.m., bonnet protection required "touch-up" within the first floor portion of the center stair tower enclosure.
c. 12:12 p.m., a penetration of the monolithic portion of the rated ceiling assembly, located within second floor, C222 (where new valve is installed).

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the building construction deficiencies.

Plan of Correction - To be completed: 06/19/2025

1.
a) The first floor B wing Nurse's Station area ceiling access panel was incapsulated with a layer of 5/8" drywall to ensure smoke integrity. Facilities staff will monitor the access panels to ensure they maintain rated integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

b) The bonnet protection around the ceiling light within the first-floor portion on the center stair tower was adjusted. Facilities staff will monitor the bonnet protection assemblies to ensure they maintain rated integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

c) The penetration of the monolithic portion of the rated ceiling assembly located within second floor C222 was sealed with a layer of 5/8" drywall to ensure smoke integrity. Facilities staff will monitor the monolithic rated ceiling assembly to ensure they maintain rated integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

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 - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one stair tower enclosure, affecting three of three floors.

Findings include:

1. Observation on May 19, 2025, between 10:30 a.m., and 1:55 p.m., revealed the first floor, center stair tower doors required adjustment to fully latch (north side).

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the stair tower enclosure deficiency.

Plan of Correction - To be completed: 06/19/2025

1.
Adjustments were made to the first floor, center stair tower doors door to ensure it fully closes and latches within its frame. All repairs and adjustments were made immediately. Facilities staff will monitor the doors to ensure they operate as designed to fully close and latch within its frame on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

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: BUILDING 02 - Component: 02 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings, affecting eight of eight floors within this component.

Findings include:

1. Observation on May 19, 2025, at 11:30 a.m., revealed vertical shaft enclosures did not achieve the required, two-hour, fire resistive fire rating.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the vertical openings deficiency.

Plan of Correction - To be completed: 06/19/2025

1.
The facility is requesting the Department of Health Life Safety conducts a FSES as previously approved in prior years under NFPA 101-2012 requirements.

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: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in seven locations, affecting three of eight floors.

Findings include:

1. Observation on May 19, 2025, between 10:40 a.m., and 1:02 p.m., revealed the following:

a. 10:40 a.m., ceiling tiles were missing within the first floor, B Wing, Custodian's Closet.
b. 10:55 a.m., a ceiling tile was missing within the B Wing, Room 208.
c. 11:50 a.m., a damaged ceiling tile, located at the entrance to the second floor, East Lounge.
d. 12:20 p.m., a damaged ceiling tile, located within the C-1, Admissions Office.
e. 1:02 p.m., a missing escutcheon plate, as well as a missing ceiling tile, located within the basement-level, Wheelchair Storage Room.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 06/19/2025

1.
a) The missing ceiling tile within the first floor Custodian's closet in the B Wing was replaced. All repairs and adjustments were made immediately. Facilities staff will monitor ceiling tiles on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

b) The missing ceiling tile within the B Wing room 208 was replaced. All repairs and adjustments were made immediately. Facilities staff will monitor ceiling tiles on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

c) The missing ceiling tile at the entrance of the second floor East Lounge was replaced. All repairs and adjustments were made immediately. Facilities staff will monitor ceiling tiles on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

d) The damaged ceiling tile within C-1 Admissions Office was replaced. All repairs and adjustments were made immediately. Facilities staff will monitor ceiling tiles on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

e) The missing escutcheon plate and ceiling tile within the Wheelchair Storage Room in the basement-level was replaced. All repairs and adjustments were made immediately. Facilities staff will monitor ceiling tiles on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

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 02 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in four locations, affecting three of eight floors.

Findings include:

1. Observation on May 19, 2025, between 10:30 a.m., and 1:50 p.m., revealed the following:

a. 10:30 a.m., the first floor, B Wing, Lounge door required adjustment to fully latch.
b. 11:15 a.m., the second floor, Director of Therapeutic Recreation door was held open by unapproved means (door chock).
c. 11:57 a.m., a hole, located within the second floor, C-214 door.
d. 1:50 p.m., the sixth floor, Resident Room 616 door required adjustment to fully latch.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 06/19/2025

1.
a) Adjustments were made to the first floor B Wing Rear Lounge door to ensure it fully closes and latches within its frame. All repairs and adjustments were made immediately. Facilities staff will monitor the doors to ensure they operate as designed to fully close and latch within its frame on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

b) Facility staff has removed the unapproved door holder at the second floor Director of Therapeutic Recreation door. All repairs were made immediately. Facility staff was educated on not to use such items to ensure areas remain closed. Facilities staff will monitor to ensure that the entry door will remain closed on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

c) The penetration located within the second floor C214 door was sealed with fire rated material. All repairs and adjustments were made immediately. Facilities staff will monitor doors to ensure smoke barrier integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

d) Adjustments were made to the sixth-floor resident room 616 door to ensure it fully closes and latches within its frame. All repairs and adjustments were made immediately. Facilities staff will monitor the doors to ensure they operate as designed to fully close and latch within its frame on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

NFPA 101 STANDARD HVAC:

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: BUILDING 02 - Component: 02 - Tag: 0521

Based on observation and interview, it was determined the facility failed to install and maintain the heating, ventilation, and air conditioning systems in three locations, affecting three of seven floors within this component.

Findings include:

1. Observation on May 20, 2025, at 10:00 a.m., revealed the following exit access corridors were used as HVAC return air plenums for both corridor, and off-corridor locations.

a. First floor, B Wing and C Wing exit access corridors.
b. Second floor, B Wing and C Wing exit access corridors.
c. Third floor, B Wing and C Wing exit access corridors.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the HVAC deficiencies.

Plan of Correction - To be completed: 06/19/2025

1. The facility is requesting the Department of Health Life Safety conducts a FSES as previously approved in prior years under NFPA 101-2012 requirements.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of eight floors.

Findings include:

1. Observation on May 19, 2025, at 12:52 p.m., revealed cigarette butts were located within a trash receptacle, located closest to the C-1, lower D stair tower enclosure.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the smoking regulations deficiency.

Plan of Correction - To be completed: 06/19/2025

1.
Staff being educated of the potential hazard of not using cigarette rated dispensers. Facilities staff will monitor the outdoor smoking areas to ensure they are free from cigarette materials on a daily basis during facility rounds. Non-compliance will be reported at the Quality Assurance Committee.

Initial comments:Name: BUILDING 05 - Component: 05 - Tag: 0000

Facility ID# 550102
Component 05
Building 05
Fountain Hill Campus

Based on a Medicare/Medicaid Recertification Survey completed May 19-20, 2025, it was determined that Cedarbrook Senior Care and Rehabilitation 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 (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Vertical Openings - Enclosure:

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings, affecting four of four floors within this component.

Findings include:

1. Observation on May 20, 2025, at 10:30 a.m., revealed vertical enclosures did not achieve the required hourly rating, due to the unprotected restroom exhaust ducts throughout this component, and an open shaft enclosure, located beyond the suspended ceiling assembly, within the first floor Dining Room.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the vertical openings deficiencies.

.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors.

Findings include:

1. Observation on May 20, 2025, at 10:33 a.m., revealed a "loaded" sprinkler head assembly, located within the first floor, Financial Office.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 06/19/2025

1.
a) The sprinkler head assembly located within the first floor Financial Office was cleaned to ensure its proper operation. All repairs and adjustments were made immediately. Facilities staff will monitor sprinkler assemblies to ensure they operate as designed on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0363

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

Findings include:

1. Observation on May 20, 2025, between 9:23 a.m., and 10:31 a.m., revealed the following:

a. 9:33 a.m., the third floor Charting Room door was not smoke-tight.
b. 9:40 a.m., a penetration of the Ice Room door.
c. 10:31 a.m., the first floor, Chapel door was not smoke-tight.

Exit interview with the Facilities Manager on May 20, 2025, between 11:00 a.m., and 11:10 a.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 06/19/2025

1.
a) An astragal will be installed at the third floor Charting Room door to ensure smoke integrity. Facilities staff will monitor the doors to ensure they maintain smoke integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

b) The penetration located within the Ice Room door was sealed with fire rated material. All repairs and adjustments were made immediately. Facilities staff will monitor doors to ensure smoke barrier integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

c) An astragal will be installed at the first floor Chapel door to ensure smoke integrity. Facilities staff will monitor the doors to ensure they maintain smoke integrity on a monthly basis during facility rounds for the next three months. Non-compliance will be reported at the Quality Assurance Committee.

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