Pennsylvania Department of Health
EDENBROOK SOUTH
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EDENBROOK SOUTH - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Emergency Preparedness Survey completed on February 18, 2026, at Edenbrook South, 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# 641502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 18, 2026, it was determined that Edenbrook South 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

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 BUILDING 01 - Component: 01 - Tag: 0211

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

Findings include:

1. Observation on February 18, 2026, at 10:48 a.m., revealed an accumulation of storage items, located within the basement-level exit access corridor system, closest to exit discharge.

Exit interview on February 18, 2026, between 11:15 a.m., and 11:25 a.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the means of egress deficiency.

Plan of Correction - To be completed: 04/07/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1. The accumulation of storage items, located within the basement-level exit access corridor system, closest to exit discharge will be removed to maintain a means of egress. A review will be completed of facility exit locations to validate that a proper means of egress is present. The Maintenance Department will be educated related to the need to maintain a means of egress continuously free of all obstructions for all exit locations.

2. Audits will be conducted by the Maintenance Director/designee to validate that exit locations maintain a means of egress. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review. Date of compliance: April 7, 2026.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0225

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

Findings include:

1. Observation on February 18, 2026, at 10:28 a.m., revealed a trash can located within the basement-level portion of the exit stair tower.

Exit interview on February 18, 2026, between 11:15 a.m., and 11:25 a.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the stair tower enclosure deficiency.

Plan of Correction - To be completed: 04/07/2026

1. The trash can located within the basement-level portion of the exit stair tower has been removed. A review will be completed of exit stair tower to validate proper maintenance of the enclosure. The Maintenance Department will be educated related to the maintenance of exit stair tower enclosures.

2. Audits will be conducted by the Maintenance Director/designee to validate that exit stair tower enclosures are maintained. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review. Date of compliance: April 7, 2026.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 hazardous area enclosures in two locations, affecting one of two floors.

Findings include:

1. Observation on February 18, 2026, between 10:40 a.m., and 10:42 a.m., revealed penetrations of the following hazardous area enclosure doors:

a. 10:40 a.m., Housekeeping Storage.
b. 10:42 a.m., Medical Records Storage.

Exit interview on February 18, 2026, between 11:15 a.m., and 11:25 a.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the above deficiencies.

Plan of Correction - To be completed: 04/07/2026

1. The penetrations in the Housekeeping and Medical Records Storage doors will be repaired. A review will be completed of hazardous area enclosure doors to validate that no penetrations are present. The Maintenance Department will be educated related to the need to maintain hazardous area enclosures by repairing any penetrations.

2. Audits will be conducted by the Maintenance Director/designee to validate that hazardous area enclosures are maintained. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review. Date of compliance: April 7, 2026.

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 01 - Component: 01 - Tag: 0353

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

Findings include:

1. Observation on February 18, 2026, between 10:12 a.m., and 10:45 a.m., revealed storage items were located within eighteen inches of automatic sprinkler head assemblies in the following locations:

a. 10:12 a.m., Kitchen Storeroom.
b. 10:45 a.m., Medical Records Storage Room closet.

Exit interview on February 18, 2026, between 11:15 a.m., and 11:25 a.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/07/2026

1. The storage items in the Kitchen Storeroom and Medical Records Storage closet were moved. A review will be completed to validate that no additional storage items are located within eighteen inches of automatic sprinkler head assemblies. The Maintenance Department, Kitchen Manager and Assistant Administrator will be educated related to maintenance of storage items at least eighteen inches from automatic sprinkler head assemblies.

2. Audits will be conducted by the Maintenance Director/designee to validate that storage items are located at least eighteen inches from automatic sprinkler head assemblies. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review. Date of compliance: April 7, 2026.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

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

Findings include:

1. Observation on February 18, 2026, at 10:30 a.m., revealed a cleaning cart blocked the South-west smoke barrier separation door from closing upon activation of the building fire alarm system.

Exit interview on February 18, 2026, between 11:15 a.m., and 11:25 a.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the smoke barrier separation door deficiency.

Plan of Correction - To be completed: 04/07/2026

1. The cleaning cart was removed from the area of the South-West smoke barrier separation door. A review will be completed to validate items are not present that would prevent smoke barrier doors from closing upon activation of the building fire alarm system. The Maintenance Department and Housekeeping staff will receive education related to maintaining items an adequate distance from smoke barrier separation doors to permit closing of the doors with activation of the building fire alarm system.

2. Audits will be conducted by the Maintenance Director/designee to validate that items are not preventing closure of smoke barrier doors with activation of the building fire alarm system. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review. Date of compliance: April 7, 2026.

NFPA 101 STANDARD Fire Drills:

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.

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, affecting two of two floors.

Findings include:

1. Observation on February 18, 2026, at 10:55 a.m., revealed eight of twelve required fire drills had been conducted during the last week of each affected month.

Exit interview on February 18, 2026, between 11:15 a.m., and 11:25 a.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 04/07/2026

1. The Maintenance Department will receive education related to the expectation to vary the timing of fire drills to ensure the drills are less expected by staff.

2. Audits will be conducted by the Nursing Home Administrator/designee to validate that fire drills are completed at least quarterly on each shift and are held at expected and unexpected times. Audits will be conducted monthly for three months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review. Date of compliance: April 7, 2026.

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