Pennsylvania Department of Health
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WILLOWBROOKE COURT AT SOUTHAMPTON 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 February 28, 2024, at Willowbrooke Court at Southampton Estates, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0000

Facility ID #151302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 28, 2024, it was determined that Willowbrooke Court at Southampton 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 III (200), unprotected, ordinary building, with a lower level and partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the healthcare occupancy from other occupancies in one instance, affecting the entire facility.

Findings include:

Observation above the ceiling at the occupancy separation door between skilled nursing and assisted living on February 28, 2024, at 8:37 a.m., revealed there were multiple unsealed data wires in the occupancy separation wall (on the assisted living side of the wall).

Interview with the Facility Administrator and the Maintenance Director on February 28, 2024, at 1:00 p.m., confirmed the listed occupancy separation wall deficiency.

Plan of Correction - To be completed: 02/29/2024

Penetrations sealed on observed wall on 2/29/2024 according to UL system WL-3423. DPPS checked occupancy separation walls in SNF by 2/29/2024 to ensure two-hour fire resistance rating maintained without penetration.
Monthly audit to be completed x3 months by Director of Physical Plant or designee for penetrations and reported monthly to Safety Committee and quarterly to Quality Assurance committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to perform annual automatic fire alarm system inspection and testing within the last twelve months.

Findings Include:

Review of documentation on February 28, 2024, at 11:15 a.m., revealed the facility lacked documentation to confirm the required annual automatic fire alarm system inspection/testing had been performed.

Interview with the Facility Administrator and the Maintenance Director on February 28, 2024, at 1:00 p.m., confirmed the listed automatic fire alarm system inspection/testing deficiency.

Plan of Correction - To be completed: 02/29/2024

Annual automatic fire alarm system inspection test for 2023 was completed on 7/11/2023. Annual inspections will be scheduled by Director of Physical Plant (DPPS) or designee and maintained in the safety binders to ensure they are readily available. DPPS or designee will report annual completion to safety committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of seven smoke compartments.

Findings include:

Observation on February 28, 2024, revealed the following automatic sprinkler system
deficiencies:

a) 9:24 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were multiple unsealed pipe penetrations in the ceiling of the lower-level maintenance storage room:
b) 9:31 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were multiple unsealed data wires in the ceiling above the server in the SG IT closet.

Interview with the Facility Administrator and the Maintenance Director on February 28, 2024, at 1:00 p.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 03/15/2024

Penetrations identified will be sealed by DPPS or designee using the appropriate fire rating system by 3/15/2024. Director of Physical Plant Services (DPPS) completed walkthrough of SNF by 3/15/2024 to ensure no additional gaps in the automatic sprinkler system. UL Systems used for pipe penetrations are C-AJ-1027 and WL-3232 and UL system for data wires is C-AJ-3030. DPPS to provide education to vendors on necessity of sealing penetrations following work completion by 3/15/2024. DPPS or designee will complete rounds monthly x3 months for penetrations and report to QAPI Committee.

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 BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0363

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

Findings include:

Observation on February 28, 2024, at 8:44 a.m., revealed the door to resident room 34 was warped at the top and not touching the frame when closed and latched leaving the door unable to resist the passage of smoke when tested.

Interview with the Facility Administrator and the Maintenance Director on February 28, 2024, at 1:00 p.m., confirmed the listed corridor door deficiency.

Plan of Correction - To be completed: 03/18/2024

Resident room doors in SNF including room 34 checked for gaps for possible smoke passage and adjusted to ensure no gaps using seal as needed by 3/18/2024. Director of Physical Plant (DPPS) or designee to complete audit of SNF doors every 2 months x2 for gaps and report to QAPI Committee.

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 BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of seven smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101.

Findings include:

Observation on February 28, 2024, at 9:20 a.m., revealed an open electrical junction box above water heater number one in the boiler room.

Interview with the Facility Administrator and the Maintenance Director on February 28, 2024, at 1:00 p.m., confirmed the listed electrical wiring deficiency.

Plan of Correction - To be completed: 02/29/2024

Upon observation on 2/28/2024, cover was placed on junction box identified. Audit of junction boxes was done in SNF by 2/29/2024 to ensure all junction boxes and electrical wiring were properly covered and secured. Director of Physical Plant (DPPS) or designee will complete audit monthly x3 months for appropriate coverings of electrical wires and report to Safety Committee.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in four instances, affecting three of seven smoke compartments.

Findings include:

Observation on February 28, 2024, revealed the following electrical receptacles within six feet of a sink that were not GFCI protected:

a) 8:47 a.m., in the supply closet by resident room 27:
b) 8:52 a.m., in the med room by the main lobby:
c) 8:58 a.m., there were two in the supply closet by resident room 2:
d) 9:08 a.m., there were two in the resident laundry room.

Interview with the Facility Administrator and the Maintenance Director on February 28, 2024, at 1:00 p.m., confirmed the listed electrical receptacle deficiencies.

Plan of Correction - To be completed: 03/06/2024

Identified electrical receptacles were replaced on 3/6/2024 with GFCI protected outlets. All outlets within 6 feet of a sink were audited by Director of Physical Plant(DPPS) to ensure GFCI protection for all appropriate outlets and completed by 3/6/2024. DPPS or designee will audit outlets quarterly for 3 months and report to Safety Committee.

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