Pennsylvania Department of Health
 JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Building Inspection Results

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JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Inspection Results For:

There are  40 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.
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE - 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 15, 2025, at Juniper Village at Brookline-Rehabilitation and Skilled Care, 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# 281302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2025, it was determined that Juniper Village at Brookline-Rehabilitation and Skilled Care was not in compliance with the following requirements of the Life Safety Code for an existing 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 three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
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 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting three of three floors.

Findings include:

1. Observation on April 15, 2025, at 11:30 a.m., revealed this component exceeded the maximum allowable story height by one story for the type of building construction.

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the building construction deficiency.



 Plan of Correction - To be completed: 06/03/2025

- The facility requests Division of life safety conduct FSES waiver.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain two exit stair tower enclosures in eight locations, affecting three of three floors.

Findings include:

1. Observation on April 15, 2025, between 11:30 a.m., and 12:30 p.m., revealed the following:

a. 11:30 a.m., recessed heating units, located within the third floor portion of the east and west stair tower enclosures compromise the required one-hour, fire resistive integrity of the enclosures (two locations).
b. 12:00 p.m.,-12:30 p.m., hose reel cabinets, located at the first, second, and third floor level of the east and west stair tower enclosures compromise the required one-hour, fire resistive integrity of the enclosures (6 locations).

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the stair tower enclosure deficiencies.








 Plan of Correction - To be completed: 06/03/2025

- Maintenance Director to obtain quotes from contractors for correction of identified deficiencies in stairways and smokeproof enclosures, repairs to be scheduled with contractor.

- Maintenance Director educated on NFPA 101 Standard stairways and smokeproof enclosures.

- Maintenance Director will be responsible for this process

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 facility failed to maintain portable fire extinguishers in one location, affecting one of one floor.

Findings include:

1. Observation on April 15, 2025, at 11:12 a.m., revealed the fire extinguisher, located within Laundry, had not been inspected since February of 2025.

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the portable fire extinguisher deficiency.




 Plan of Correction - To be completed: 06/03/2025

- The fire extinguisher located within laundry has been inspected.
- Maintenance Director educated on NFPA 101 Standard Fire Extinguishers, ensuring that Fire extinguishers are maintained in accordance with NFPA 10, standard for Portable Fire Extinguishers.
- Maintenance Director will be responsible for maintaining compliance with this process.

NFPA 101 STANDARD Corridor - Doors: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.
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 two corridor openings, affecting two of three floors.

Findings include:

1. Observation on April 15, 2025, between 11:30 a.m., and 11:55 a.m., revealed the following:

a. 11:30 a.m., the distance between the Chapel doors exceeded one-eighth-inch.
b. 11:55 a.m., the third floor, resident Room 302 corridor door was not smoke-tight.

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 06/03/2025

- The Chapel Doors and the third floor Resident Room 302 door, have been adjusted and tested to ensure doors are smoke-tight.

- Nursing home administrator educated Maintenance staff on NFPA 101 Standard Corridor- Doors. Corridor Doors and doors to rooms shall be smoke-tight and not exceed one-eighth-inch.

- Regular rounds of Corridor and room doors will be conducted in order to identify and correct any doors needing repair.

- Maintenance Director will be responsible for this process. Tracking will be conducted through TELS program.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain one soiled linen chute, affecting three of three floors.

Findings include:

1. Observation on April 15, 2025, at 11:16 a.m., revealed the soiled linen chute termination room door was held open by unapproved means (door chock).

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the soiled linen chute deficiency.



 Plan of Correction - To be completed: 06/03/2025

- The door chock has been removed from soiled linen room.

- Maintenance Director educated laundry staff on NFPA 101 Standard rubbish shuts, incinerators, and Laundry Shutes and use of door chocks not permitted.

- Maintenance Director will be responsible for maintaining compliance with this process.

NFPA 101 STANDARD Fire Drills:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to maintain fire drills, affecting three of three floors.

Findings include:

1. Observation on April 15, 2025, at 12:45 p.m., revealed eight of twelve required fire drills were performed in the last week of each month.

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the fired drill deficiencies.




 Plan of Correction - To be completed: 06/03/2025

- Maintenance Director educated on NFPA 101 Fire drill requirements and documentation.

- Maintenance Director will be responsible for maintaining compliance with Fire Drills and documentation from each shift quarterly. Tracking will be conducted through TELS program.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire doors, affecting three of three floors.

Findings include:

1. Observation on April 15, 2025, at 12:50 p.m., revealed annual, fire door functional and visual testing had not been completed since 6/28/2022.

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the fire door deficiencies.



 Plan of Correction - To be completed: 06/03/2025

- Annual fire door functional and visual testing completed.

- Nursing home administrator educated Maintenance staff on NFPA 101 Standard Maintenance, Inspection & Testing-Doors- including yearly function and visual testing.

- Maintenance Director will be responsible for this process

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain electrical systems in multiple locations, affecting three of three floors.

Findings include:

1. Observation on April 15, 2025, at 12:58 p.m., revealed electrical receptacles lacked yearly testing past October of 2023.

Exit interview with the Facility Administrator and the Facilities Manager on April 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the electrical receptacle testing deficiency.



 Plan of Correction - To be completed: 06/03/2025

- Audit of Electrical Receptables to identify yearly testing.

- Nursing home administrator educated Maintenance staff on NFPA 101 Standard electrical Systems- Maintenance and testing of electrical receptacles including yearly testing.

- Regular rounds of the electrical receptacles will be conducted to identify and correct any receptables that need yearling testing.

- Maintenance Director will be responsible for this process


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