Pennsylvania Department of Health
EDENBROOK ON SECOND AVE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EDENBROOK ON SECOND AVE - 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 May 21, 2026, at Edenbrook on Second Avenue, 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# 900102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, it was determined that Edenbrook on Second Ave 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 one story, Type III (200), unprotected, ordinary building, that is fully sprinklered.

Plan of Correction:

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 one floor.

Findings include:

1. Observation on may 21, 2026, at 1:33 p.m., revealed the Med Bridge Staff Closet door required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on May 21, 2026, between 2:55 p.m., and 3:00 p.m., confirmed the hazardous area enclosure deficiency.

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

The Med Bridge Staff closet door was fixed and now fully latches.

Audit was completed on other staff closet doors to ensure their doors fully latch.

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

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

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 Portable Fire Extinguishers:

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.

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 BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in multiple locations, affecting one of one floor.

Findings include:

1. Observation on May 21, 2026, at 1:40 p.m., revealed fire extinguisher projecting placards had been removed above the flush-mounted fire extinguisher cabinets.

Exit interview with the Facility Administrator and the Facilities Manager on May 21, 2026, between 2:55 p.m., and 3:00 p.m., confirmed the fire extinguisher deficiencies.

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

The fire extinguisher place cards have been replaced above the flush-mounted extinguisher cabinets.

Audit was completed to ensure all place cards were in place above the flush-mounted fire extinguisher cabinets.

The maintenance team will be educated, when hired, on the fire safety audit which now includes place cards above the flush mounted fire extinguisher cabinets.

The place cards will be added to the Safety Committee audit, Fire Safety Checklist. This audit is typically performed every other month. 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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

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

Findings include:

1. Observation on May 21, 2026, at 1:55 p.m., revealed an unlocked electrical panel, located within the Med Bridge, South Hall, exit access corridor system.

Exit interview with the Facility Administrator and the Facilities Manager on May 21, 2026, between 2:55 p.m., and 3:00 p.m., confirmed the electrical systems deficiency.

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

The electrical panel was locked on the Med Bridge, South Hall, exit access corridor.

Audit was completed to ensure all electrical panels were appropriately locked.

The contractors and maintenance team will be educated, when hired, on the requirements for the electrical panels.

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.

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