Pennsylvania Department of Health
 WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES
Building Inspection Results

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WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

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WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES - 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 July 22, 2024, at Willowbrooke Court Skilled Care Center At Brittany Pointe 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 (NEW BUILDING) - Component: 02 - Tag: 0000


Facility ID# 740902
Component 02
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on July 22, 2024, it was determined that Willowbrooke Court Skilled Care Center At Brittany Pointe 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 483.70(a).

This is a two story, Type II (111), protected non-combustible construction, with a partial basement, which is fully sprinklered.










 Plan of Correction:


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: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure there were no impediments to egress, affecting 1 of three levels.

Findings Include:

1. Observation made on July 22, 2024, between 2:33 p.m. and 3:02 p.m., revealed the following exiting deficiencies:

a. one leaf of the exit discharge doors by the fire wall separation to the non-health care building was difficult to open, it was dragging on the ground, 1st floor;

b. the doors leading to the enclosed courtyard lacked a No Exit sign, 1 east.

Exit Interview with the Facility Administrator, Director of Nursing, Director of the Northeast Region, and Building Services Director on July 22, 2024, at 3:30 p.m., confirmed the obstructions to egress.








 Plan of Correction - To be completed: 09/20/2024

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.

0211- Means of Egress
a.) The Property manager will contact the vendor to repair the affected door. All doors were checked for function and no issues identified at this time.
The door will be repaired and the door will continue to be inspected and/or serviced as required by regulations to ensure continued compliance with egress areas.
b.) All non- exit areas were checked for proper signage and no other issues identified.
NHA will contact the sign vendor and have a " no exit sign" made to be hung on the 1 east doorway to the courtyard. The sign will be affixed to the door by maintenance.

The property manager or designee will monitor and audit for continued compliance with door function and signage in these areas at least monthly for three months and then the study results will be presented to the QAPI committee and the committee will determine the frequency and continuation of the audit based on the results of the audits completed.


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 (NEW BUILDING) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with positive latching and smoke tight resistance, in sprinklered locations, affecting 1 of seven smoke compartments.

Findings Include:

Observation made on July 22, 2024, at 3:11 p.m., revealed the corridor door to the Supervisor's office was propped open with a wooden chock. The door was equipped with a self-closing device, 2nd floor.

Exit Interview with the Facility Administrator, Director of Nursing, Director of the Northeast Region, and Building Services Director on July 22, 2024, at 3:30 p.m., confirmed the corridor door was obstructed from closing.







 Plan of Correction - To be completed: 09/20/2024

0363- Corridor
The door prop on the 2nd floor supervisor office was immediately removed and discarded.
All doors were checked to ensure no other doors were propped opened incorrectly.
Team members were immediately reeducated regarding door fire safety. The DON or designee will audit monthly for 3 months to ensure continued compliance with the proper door closure. It will be presented to the QAPI Committee and the committee will determine the frequency and continuation of the audit based on the results of the audits completed.

NFPA 101 STANDARD Fire Drills: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.
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 (NEW BUILDING) - Component: 02 - Tag: 0712

Based on document review and interview, it was determined the facility failed to maintain the requirements for fire drills, affecting 3 of twelve drills.

Findings Include:

1. Documentation reviewed on July 22, 2024, revealed the following fire drill deficiencies:

a. Three of the last four fire drills for the third shift were conducted within the 11 o'clock hour:
June 19, 2024 at 11:11 p.m.;
July 24, 2024 at 11:03 p.m.;
December 21, 2023 at 11:15 p.m.

b. Third shift fire drills for the 3rd and 4th quarter were conducted almost 5 months apart between July 24, 2024 and December 21, 2023.

Exit Interview with the Facility Administrator, Director of Nursing, Director of the Northeast Region, and Building Services Director on July 22, 2024, at 3:30 p.m., confirmed fire drills were not conducted at varying times.








 Plan of Correction - To be completed: 09/20/2024

0712- Fire Drills
a.) and b.)
The property manager will revise the current fire drill schedule with months and times to assure the required rotated monthly fire drill and the varied times throughout the shifts are scheduled and performed correctly.
The property manager will perform an audit utilizing the fire drill schedule monthly to ensure compliance with the fire drill requirements. The audit will be presented to the QAPI Committee and the committee will determine the frequency and continuation of the audit based on the results of the audits completed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - Essential Electric System Receptacles
Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
Observations:
Name: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0917

Based on document review and interview, it was determined the facility failed to maintain electrical receptacle components in operable condition, affecting 3 of seven smoke compartments.

Findings Include:

Documentation reviewed on July 22, 2024, revealed electrical receptacle testing conducted on March 28, 2024 listed device failures or no testing information, for the following locations:

1E Room 106B - failure;
2E Room 209 - no testing information;
2E Hallway FH - BH, failure;
2W Hall receptacle - failure.

Exit Interview with the Facility Administrator, Director of Nursing, Director of the Northeast Region, and Building Services Director on July 22, 2024, at 3:30 p.m., confirmed the receptacle deficiencies listed above.










 Plan of Correction - To be completed: 09/20/2024

0917-Electrical systems- receptacles

The receptacles identified were rechecked to ensure proper function. The documentation of these receptacle checks were added to the receptacle checks log book.
Team members were re-educated regarding proper documentation on the receptacle checks.
The property manager will audit the receptacle testing log, as indicated, for accurate and complete documentation for 3 months and ongoing to assure continued compliance with receptacle check documentation. As indicated, the checks will be reviewed by the QAPI committee and the committee will determine the frequency and continuation of the audit based on the results of the audits completed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0918

Based on observation and interview, it was determined the facility failed to install required emergency generator components, affecting the entire facility.

Findings Include:

Observation made on July 22, 2024, at 2:12 p.m., revealed the generator set location (transformer room) lacked battery back-up emergency lighting, basement.

Exit Interview with the Facility Administrator, Director of Nursing, Director of the Northeast Region, and Building Services Director on July 22, 2024, at 3:30 p.m., confirmed the back-up lighting was not provided.









 Plan of Correction - To be completed: 09/20/2024

0918- Electrical systems- Emergency Generator back up lighting

Battery back- up emergency lighting will be installed in the transformer room. This lighting will be added to the battery back -up testing checklist to ensure continued compliance. Team members will be educated regarding the need for a battery back- up emergency light in this area and being added to the checklist.
The property manager with audit the checklist to ensure the lighting is being checked per the schedule and present to the QAPI Committee and the committee will determine the frequency and continuation of the audit based on the results of the audits completed.


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