Pennsylvania Department of Health
EDGEHILL NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EDGEHILL NURSING AND REHABILITATION CENTER - 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 July 13, 2026, at Edgehill Nursing and Rehabilitation 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 01 - Component: 01 - Tag: 0000
Facility ID #052702Component 01 Based on a Medicare/Medicaid Recertification Survey completed on July 13, 2026, it was determined that Edgehill Nursing and Rehabilitation Center was not in compliance with 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 two-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting one of two levels. Findings include: 1. Observation on July 13, 2026, at 10:00 a.m., revealed the battery back-up light in the generator enclosure failed to illuminate when tested. Exit interview with the Administrator and Maintenance Director on July 13, 2026, at 12:00 p.m., confirmed the battery back-up light deficiency.

Plan of Correction - To be completed: 08/30/2026

The Emergency light has been repaired. The Maintenance Director was in-serviced on Emergency lighting of at least 1-1/2 hours must be maintained in operable condition. Maintenance Director/Designee will perform weekly inspection and testing of all emergency lighting until compliance is met for three consecutive months and report findings at monthly QAPI meetings.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of two levels. Findings include: 1. Document review on July 13, 2026, at 9:30 a.m., revealed the January 2024 damper inspection report listed 3- dampers. Additional dampers were discovered during the survey. Exit interview with the Administrator and Maintenance Director on July 13, 2026, at 12:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 08/30/2026

The building was inspected for additional missing fire or smoke dampers with none found. The fire systems vendor performed inspection of the missed dampers. The Maintenance Director was in-serviced on fire and smoke damper inspection requirements. The results of the missed damper inspections will be reported at the next QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 BUILDING 01 - Component: 01 - Tag: 0918 Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: 1. Document review on July 13, 2026, at 9:00 a.m., revealed the facility lacked documentation indicating performance of monthly testing and recording of battery conductance of the generator's maintenance free batteries. (Refer to NFPA 110.8.3.7.1) Exit interview with the Administrator and Maintenance Director on July 13, 2026, at 12:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 08/30/2026

Maintenance Director was in-serviced on the requirements to document the monthly testing and recording of battery conductance of the generator's maintenance free batteries. Maintenance Director/ Designee will perform conductance testing monthly and record the test results. Testing and recording of the generator batteries will be audited for the next three months and report findings at monthly QAPI meetings.

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