Pennsylvania Department of Health
WILLOWBROOKE COURT AT GRANITE FARMS ESTATES
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

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WILLOWBROOKE COURT AT GRANITE FARMS ESTATES - 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 23, 2024, at Willowbrooke Court at Granite Farms 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 01 - Component: 01 - Tag: 0000

Facility ID #073602
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on April 23, 2024, it was determined that Willow Brooke Court at Granite Farms Estates was not in compliance with the following 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 III (211), protected ordinary structure, with a partial basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Discharge from Exits:

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.

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain exit discharges at one of multiple exit locations from the first floor.

Findings include;

1. Observation on April 23, 2024, at 1:12 pm revealed the pathway to the public way from the exit near room 308 CBL, was obstructed with a survey stake and an uneven walking surface.

Interview at the time of the exit conference with the Director of Physical Plant Services on April 23, 2024, at 2:00 pm, confirmed the construction activities at this exit had rendered it unsafe to the public way.

Plan of Correction - To be completed: 05/24/2024

Preparation and/or execution of this plan of correction does not constitute admission or 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.

Kramer Marks Architecture has designed a new route of egress that now exits through room 308. This new route of egress contains proper exit signage, and anti-elopement device which meets regulatory requirements. The exit in question has been permanently eliminated. A temporary wooden structure with anti-slip treads has been constructed to obtain an even walking path from the building to the parking lot. Will review quarterly at QAPI meeting.

Egress plan was submitted to the Department of Health on May 3rd, 2024. Our submission is currently number 114 on the wait list.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 failed to maintain portable fire extinguishers in one of five smoke compartments.

Findings include;

1. Observation on April 23, 2024, at 1:00 pm, revealed the fire extinguisher in the CBL kitchen was not secured on a hanger or in a cabinet.

Interview at the time of the exit conference with the Director of Physical Plant Services on April 23, 2024, at 2:00 pm confirmed the extinguisher was sitting on the floor.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one of five smoke compartments.

Findings include;

1. Observation on April 23, 2024, at 12:50 pm, revealed the B-hall tub room door, near room 126, failed to latch in the frame (due to construction activites this door needs to latch).

Interview at the time of the exit conference with the Director of Physical Plant Services on April 23, 2024, at 2:00 pm, confirmed the door lacked positive latching.

Plan of Correction - To be completed: 05/24/2024

Preparation and/or execution of this plan of correction does not constitute admission or 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 B Hallway tub room door has been adjusted to make positive latch. In addition, a temporary fixture has been installed on the inside to prevent the door from opening into the construction area. The tub room is not in use as it is undergoing a full renovation. It is temporarily barricaded to prevent access.
Will review quarterly at QAPI meeting.

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 the electrical system in one of five smoke compartments.

Findings include:

1. Observation on April 23, 2024, at 12:42 pm, revealed the B bed in room 126 was against an unprotected electrical outlet.

Interview at the time of the exit conference with the Director of Physical Plant Services on April 23, 2024, at 2:00 pm, confirmed the bed was against the outlet.

Plan of Correction - To be completed: 05/24/2024

Preparation and/or execution of this plan of correction does not constitute admission or 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 outlet in room 126 has been eliminated by a certified electrician. The outlet was disconnected, the wires were safed off by installing wire nuts to each individual wire and a blank plate was put on the box.

Audits done bi-weekly during environmental rounds to maintain compliance. Will review quarterly at QAPI meeting.

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