Pennsylvania Department of Health
WILLOWBROOKE COURTSKILLEDCARECENTER AT NORMANDYFARMS ESTATES
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOWBROOKE COURTSKILLEDCARECENTER AT NORMANDYFARMS ESTATES
Inspection Results For:

There are  43 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.
WILLOWBROOKE COURTSKILLEDCARECENTER AT NORMANDYFARMS 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 17, 2024, at Willowbrooke Court Skilled Care Center At Normandy Farms Estates, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.






 Plan of Correction:


Initial comments:Name: BUILDING 01 (MAIN HEALTH & SUB ACUTE CARE) - Component: 01 - Tag: 0000


Facility ID# 142502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 17, 2024, it was determined that Willowbrooke Court Skilled Care Center At Normandy 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 one-story, Type V (111), protected wood frame building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: BUILDING 01 (MAIN HEALTH & SUB ACUTE CARE) - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of two common wall separations.

Findings Include:

Observation made on April 17, 2024, at 10:40 a.m., revealed above the fire doors to the Independent Living service corridor there was an unsealed penetration around a large copper pipe.

Exit Interview with the Executive Director and Maintenance Director on April 17, 2024, at 12:30 p.m., confirmed the unsealed penetration.






 Plan of Correction - To be completed: 04/30/2024

The penetration was sealed by the maintenance staff using approved firestop materials.
A thorough inspection of the entire egress route was completed, and no other penetrations were found.
Weekly random inspections above ceilings throughout WBC will be conducted by the Maintenance Director/designee for the next 3 months.
Results of the inspections will be documented and reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee for further recommendation.







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.


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BUILDING 01 (MAIN HEALTH & SUB ACUTE CARE) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of six smoke compartments.

Findings include:

Observation on April 17, 2024, at 10:20 a.m., revealed the exit door in IL shared corridor leading to an enclosed courtyard lacked signage indicating " Not an Exit. "

Exit Interview with the Executive Director and Maintenance Director on April 17, 2024, at 12:30 p.m., confirmed the missing signage.








 Plan of Correction - To be completed: 04/30/2024

A temporary sign was put on the door and a permanent sign ordered and installed by the maintenance staff.
An inspection of all doors exiting the egress path was done and no others enter an enclosed area.
Weekly random inspections of doors will be conducted by the Maintenance Director/designee for the next 3 months to ensure compliance.
Results of the inspections will be documented and reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee for further recommendation.

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.

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: BUILDING 01 (MAIN HEALTH & SUB ACUTE CARE) - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of six smoke compartments.

Findings include:

Observation on April 17, 2024, at 11:55 a.m., revealed a smoke detector detached from its housing, Apple electrical room.

Exit Interview with the Executive Director and Maintenance Director on April 17, 2024, at 12:30 p.m., confirmed the detached smoke detector.







 Plan of Correction - To be completed: 04/30/2024

The smoke detector was reattached immediately (4/17/24) by the maintenance staff and tested for proper functioning.
A thorough inspection of all smoke detectors throughout WBC was completed and no others were found to be disconnected from their housing.
Weekly random inspections of smoke detectors will be conducted by the Maintenance Director for the next 3 months to ensure compliance.
Results of the inspections will be documented and reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee for further recommendation.

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.

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: BUILDING 01 (MAIN HEALTH & SUB ACUTE CARE) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting two of six smoke compartments.

Findings include:

Observation on April 17, 2024, at 11:20 a.m., revealed above the smoke doors by Administrator' s office, an unsealed penetration around a sprinkler pipe.

Exit Interview with the Executive Director and Maintenance Director on April 17, 2024, at 12:30 p.m., confirmed the penetration.





 Plan of Correction - To be completed: 04/30/2024

The penetration was sealed by the maintenance staff using approved firestop materials.
A ceiling inspection was conducted throughout WBC and no other penetrations were found.
Weekly random inspections above ceilings will be conducted by the Maintenance Director/designee for the next 3 months to ensure compliance.
Results of the inspections will be documented and reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee for further recommendation.

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.



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