Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES
Building Inspection Results

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WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES
Inspection Results For:

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WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES - 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 April 24, 2019, at Willowbrooke Court Skilled Care Center at Brittany Pointe Estates, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0000


Facility ID# 740902
Component 02
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on April 24, 2019, it was determined that Willowbrooke Court Skilled Care Center at Brittany Pointe Estates was not in compliance with the following requirements of the Life Safety Code for an existing Skilled 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 non-combustible construction, with a partial basement, which 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: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0161
Based on observation and interview, it was determined the facility failed to maintain the integrity of the rated assembly, affecting two of three levels.

Findings Include:

1. Observation on April 24, 2019, at 10:40 am, revealed, above the suspended ceiling at the 2nd floor West elevator lobby, there was an unsealed penetration between the ceiling and the attic, due to a gap in the block wall.

Interview at the exit conference with the Administrator, Assistant Administrator, and the Maintenance Director on April 24, 2019, at 1:50 pm, confirmed the unsealed penetration.




 Plan of Correction - To be completed: 06/23/2019

Preparation and /or execution of this plan of correction does not constitute admission for agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.
The facility shall seal the penetration/gap at the gypsum board ceiling and exterior block wall of the elevator shaft above the suspended ceiling at the second floor West elevator lobby. The penetration/linear gap shall be sealed with a UL/manufacturer approved fire stop system WW-D-0074. The Director of Physical Plant Services (DPPS) shall inform all contractors prior to beginning of services that all applied materials shall be installed according to the UL system as identified on the Life Safety Plan Drawing. To ensure continued quality the DPPS will inspect the completed work to ensure penetrations have been sealed with an approved UL system.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls affecting two of three levels.

Findings include:

1. Observation on April 24, 2019, between 10:45 am, and 1:05 pm, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 10:45 am, 2nd floor West, above the smoke doors around data lines.
b. 12:30 am, 1st floor West, above smoke doors by the elevator, 2 " hole cut in wall.
c. 1:00 pm, 1st floor East by resident room 101, above smoke doors around wires.
d. 1:10 pm, 1st floor East by resident room 115, above smoke doors around wires.

Interview at the exit conference with the Administrator, Assistant Administrator, and the Maintenance Director on April 24, 2019, at 1:50 pm, confirmed the unsealed penetrations.




 Plan of Correction - To be completed: 06/23/2019

a. 10:45 am, 2nd floor West, above the smoke doors around data lines.
POC: The facility shall seal the penetration at the data lines on the 2nd floor west above the ceiling at the smoke doors. (by elevator). The penetration shall be sealed with a UL/manufacturer approved fire stop system. (W-L-3110) The Maintenance Foreman shall inform all contractors prior to beginning services that all penetrations will be sealed with an approved firestop system. To ensure continued quality the Facility maintenance department will inspect the completed work to ensure penetrations have been sealed with an approved UL fire stop system.

b. 12:30 am, 1st floor West, above smoke doors by the elevator, 2 " hole cut in wall.
POC: The facility shall seal the 2" hole penetration at the 1st floor west smoke doors by the elevator above the ceiling. The 2" hole shall be sealed/patched with a UL/manufacturer approved system U465. The Maintenance Foreman shall inform all contractors prior to beginning services that all penetrations will be sealed with an approved firestop system. To ensure continued quality the Facility maintenance department will inspect the completed work to ensure penetrations have been sealed according to the UL application.

c. 1:00 pm, 1st floor East by resident room 101, above smoke doors around wires.
POC: The facility shall seal the penetration around wires above the ceiling at the 1st floor east smoke doors by resident room 101. The penetration shall be sealed with a UL/manufacturer approved fire stop system for data lines W-L-3110 and armored cables W-L-3015. The Maintenance Foreman shall inform all contractors prior to beginning services that all penetrations will be sealed with an approved firestop system. To ensure continued quality the Facility maintenance department will inspect the completed work to ensure penetrations have been sealed with an approved UL fire stop system.

d. 1:10 pm, 1st floor East by resident room 115, above smoke doors around wires.
POC: The facility shall seal the penetration around wires above the ceiling at the 1st floor east smoke doors by resident room 115. The penetration shall be sealed with a UL/manufacturer approved fire stop system for data lines W-L-3110 and armored cables W-L-3015. The Maintenance Foreman shall inform all contractors prior to beginning services that all penetrations will be sealed with an approved firestop system. To ensure continued quality the Facility maintenance department will inspect the work completed to ensure penetrations have been sealed with an approved UL fire stop system.




































NFPA 101 STANDARD Electrical Systems - Other: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.
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 (NEW BUILDING) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting one of three levels.

Findings include:

1. Observation on April 24, 2019, at 12:45 pm, revealed, in 1st floor West, above the suspended ceiling outside clean utility room, a junction box with exposed inner electrical wiring, due to a missing cover plate.

Interview at the exit conference with the Administrator, Assistant Administrator, and the Maintenance Director on April 24, 2019, at 1:50 pm, confirmed the missing cover plate.

~Refer to the 2011 edition of NFPA 70-314.28.





 Plan of Correction - To be completed: 06/23/2019

The Facility Shall install a cover plate on the open junction box located at the 1st floor West Front Hall Clean Utility room above the suspended ceiling.
The maintenance foreman shall inform all service contractors that that all junction boxes and power supply covers are to be installed in compliance with NFPA 70 314.28. The maintenance Foreman shall educate the maintenance staff regarding cover plates for power supply junction boxes. To ensure continued quality the Facility maintenance department will inspect electrical tasks involving junction box cover plate work upon completion to ensure junction boxes are covered


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