Pennsylvania Department of Health
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES
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 53 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 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 January 28, 2025, at Willowbrooke Court At Southampton Estate, 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
Building 01
Willowbrooke Court, Special Care Unit, Oakbridge

Based on a Medicare/Medicaid Recertification Survey completed on January 28, 2025, 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 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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL 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 levels.

Findings include:

Observation on January 28, 2025, at 10:30 a.m., revealed, above the common wall doors separating Willowbrooke Court and Independent Living Unit, an unsealed penetration around data wires.

Exit Interview with the Administrator and Maintenance Director on January 28, 2025, at 11:45 a.m., confirmed the penetration.

Plan of Correction - To be completed: 02/14/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of State and Federal Law. The plan of corrections represents the community's credible allegation of compliance.

Maintenance technician sealed the identified penetrations around the data wires above the common wall doors separating Willowbrooke Court and Independent Living Unit using UL system WL-3423 on 1/29/2025. The Maintenance Department will be in-serviced by 2/14/2025 the Director of Property Management/ Designee on maintaining the fire resistance rating of common walls. All fire door separations in Willowbrooke Court were audited by 2/12/2025 by maintenance technician for penetrations and maintenance of fire rating. The Director of Property Management or designee will conduct random weekly audits x4 weeks to check fire resistance rating of common walls, affecting one of two levels. All findings will be reported to QAPI Committee.

NFPA 101 STANDARD Means of Egress - General:

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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of two levels.

Findings include:

Observation on January 28, 2025, at 11:20 a.m., revealed Willowbrooke Dining Room emergency exit egress path was obstructed by ice/snow along the path to the public way.

Exit Interview with the Administrator and Maintenance Director on January 28, 2025, at 11:45 a.m., confirmed the obstructed egress path.

Plan of Correction - To be completed: 02/14/2025

On 1/28/2025 upon identification, the maintenance technician cleared the identified ice/snow from the Willowbrooke Dining Room emergency exit egress path. All other emergency exit paths in Willowbrooke Court were checked by maintenance technician on 1/28/2025 for clear egress. The Maintenance Department will be in-serviced by the Director of Property Management/ Designee by 2/14/2025 on maintaining emergency exit egress paths. The Property Management/ Designee will conduct random weekly audits x4 weeks to ensure the community keeps all emergency exit paths unobstructed by ice/snow. All findings will be reported to QAPI Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 BLDG 01(WILLOWBROOKE COURT, SPECIAL 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 one of two levels.

Findings include:

Observation on January 28, 2025, at 11:20 a.m., revealed an unsealed penetration around a sprinkler pipe, above the smoke doors to phase 2 construction space.

Exit Interview with the Administrator and Maintenance Director on January 28, 2025, at 11:45 a.m., confirmed the penetration.

Plan of Correction - To be completed: 02/14/2025

Maintenance technician sealed the penetrations around the Sprinkler pipe above the smoke doors to phase 2 construction space using UL System C-AJ-1027 stop penetration system on 1/29/2025. All fire door separations in Willowbrooke Court were audited by 2/12/2025 by maintenance technician for penetrations and maintenance of fire rating. The Maintenance Department will be in-serviced by 2/14/2025 the Director of Property Management/ Designee on maintaining the fire resistance rating of common walls. The Director of Property Management or designee will conduct random weekly audits x4 weeks to check fire resistance rating of common walls, affecting one of two levels. All findings will be reported to QAPI Committee.

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