Pennsylvania Department of Health
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


WILLOW BROOK REHABILITATION AND HEALTHCARE 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 March 26, 2024, at Willow Brook Rehabilitation and Healthcare 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 #111702
Component 01
Main Building, Unit 1

Based on a Medicare/Medicaid Recertification Survey completed on March 26, 2024, it was determined that Willow Brook Rehabilitation and Healthcare Center 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 two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):

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.

Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to monitor the placement of alcohol based hand rub dispensers, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on March 26, 2024, between 11:24 AM and 11:40 AM, revealed alcohol based hand rub dispensers located directly above an ignition source, at the following locations:

a) 11:24 AM, above a light switch, within the 2nd floor Lounge, by Resident Room 144;
b) 11:40 AM, above a light switch, at the 2nd floor Nurses' Station, by the generator annunciator panel.

Interview with the Maintenance Assistant on March 26, 2024, at 11:40 AM, confirmed the alcohol based hand sanitizer rub dispensers were located directly above an ignition source.

Plan of Correction - To be completed: 04/16/2024

1.Dispensers relocated immediately from the following locations 2nd floor lounge by resident room 144,2nd floor nurses station by the generator annunciator.
Placement of dispensers installed away
from light switch.
2. Audit of dispensers placement was
completed.
3.Director of maintenance or designee will
in-service maintenance staff on proper
dispenser placement.
4.Maintenance Director/Designee will audit monthlyX1 for three months. Any findings
will be reported to QAPI.

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 the facility failed to maintain hardware components of the automatic sprinkler protection system, and to maintain the system free from extraneous weight, affecting two of four smoke compartments within the component.

Findings include:

1. Observation on March 26, 2024, at 11:41 AM, revealed the sprinkler head protecting the 2nd floor Nurses' Station Storage Room was missing an escutcheon.

Interview with the Maintenance Assistant on March 26, 2024, at 11:41 AM, confirmed the sprinkler head was missing an escutcheon.

2. Observation on March 26, 2024, at 12:06 PM, revealed a brown wire zip-tied to sprinkler piping within the 1st floor Laundry Dryer Room.

Interview with the Maintenance Assistant on March 26, 2024, at 12:06 PM, confirmed the wire was supported by the sprinkler system.

Plan of Correction - To be completed: 04/16/2024

1.Sprinkler escutcheon was installed at the 2nd floor nurses station storage room.
Wire and zip-tie was removed from the sprinkler pipe located in the 1st floor laundry room.
2.Audit of wire on sprinklers was completed.
3. Director of maintenance or designee will in-service maintenance staff on not
installing any zip-ties and wires on the sprinkler pipes.
4.Maintenance Director/Designee will audit 1 X monthly for six months than
1X every 2months for 6months.All findings will be reported to monthly
Q.A.P.I.

5.Audits of sprinkler heads for full assembly throughout the facility, and also audits of the sprinkler piping for
extraneous weight when work is being performed above the ceiling. Audits will be done 1 X monthly for 6 months than 1Xmonthly every 2months for 6months.All
findings to be reported at monthly
Q.A.P.I meeting.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of soiled linen chutes, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on March 26, 2024, at 11:52 AM, revealed the access door to the 2nd floor Soiled Linen Chute failed to automatically close and positively latch within the frame.

Interview with the Maintenance Assistant on March 26, 2024, at 11:52 AM, confirmed the door did not automatically close and latch within the frame.

Plan of Correction - To be completed: 04/16/2024

1. Adjustments were made to laundry chute door. Door is now functioning properly
at this time.
2. Nursing staff in-serviced to inform
Administration or maintenance any time
door malfunctions.
3.Maintenance assistant to do frequent
checks at least weekly, to make sure door is functioning correctly.
4. All findings of audits will be reported monthly at Q.A.P.I.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on March 26, 2024, at 11:45 AM, revealed a surge suppressor supplying electrical power to another surge suppressor within the 2nd floor Unit 1 Nurses' Office.

Interview with the Maintenance Assistant on March 26, 2024, at 11:45 AM, confirmed the daisy-chained surge suppressors.

Plan of Correction - To be completed: 04/16/2024

1. Surge suppressor located on 2nd floor unit managers office was immediately
removed.
2.Inspection audit was completed for improper use of Surge suppressor.
3.Director of maintenance or designee will in-service all staff on improper use of
surge suppressor.
4. Maintenance Director/designee will audit monthly X1 for every six months, and then every 2 months for six months. Audit will then be conducted at least semi-annually. All findings of audits will be presented at Q.A.P.I.

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

Facility ID #111702
Component 02
Building 02, Unit 2

Based on a Medicare/Medicaid Recertification Survey completed on March 26, 2024, it was determined that Willow Brook Rehabilitation and Healthcare Center 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 V (III), protected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting one of five smoke compartments within the component.

Findings include:

1. Observation on March 26, 2024, at 12:31 PM, revealed an unprotected penetration of the corridor wall, behind a wall mounted kiosk, between Resident Room 211 and Resident Room 215.

Interview with the Maintenance Assistant on March 26, 2024, at 12:31 PM, confirmed the unprotected penetration of the corridor wall.

Plan of Correction - To be completed: 04/16/2024

1.Penetrations of the corridor wall, behind wall mounted kiosks have been
sealed, between Resident Room 211 and
Resident Room 215.
2.Audits of wall mounted kiosks will be
conducted monthly X 1 for three months
by Maintenance assistant and findings
will be reported to QAPI.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement