Pennsylvania Department of Health
WILLOWBROOKE COURT SKILLED CARE CENTER AT BRITTANY POINTE ES
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 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 9, 2025, 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 9, 2025, it was determined 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 483.90(a).

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

Plan of Correction:

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: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls, affecting two of three levels.

Findings include:

Observations on July 9, 2025, from 9:55 a.m. to 10:35 a.m., revealed unsealed penetrations of smoke barrier walls in the following locations:

a. At 9:55 a.m., around multiple wires, in the basement, above the double doors between Old Med and WBC, door CF1-4.

b. At 11:45 a.m., open penetrations, on the first floor, the double doors at entrance to 1-East, door 1E-M-E-X.

Exit interview with the Administrator and the Director of Property Management, on July 9, 2025, at 11:30 a.m., confirmed the smoke wall penetrations.

Plan of Correction - To be completed: 07/31/2025

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.

K 0372 - The unsealed through wall penetration in the basement above the double doors between Old Med and WBC, door CF1-4 was sealed with system No. C-AJ-3030 and the open through wall penetrations on the first floor at the double doors at entrance to 1-East, door 1E-M-E-X were sealed with system No. W-L-3110.

The Director of Property Management or designee will reeducate maintenance staff on monthly smoke barrier door preventative maintenance check process.

The Director of Property Management or designee will monitor and conduct random monthly audits at least monthly for three months and then the study results will be presented to 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 Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING (NEW BUILDING) - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke doors affecting one of three levels.

Findings include:

Observation on July 9, 2025, at 10:20 a.m., revealed the double corridor smoke doors would not close smoke tight when tested, on the first floor near room 130, door DC1-5.

Exit interview with the Administrator and the Director of Property Management, on July 9, 2025, at 11:30 a.m., confirmed the smoke wall penetrations.

Plan of Correction - To be completed: 07/31/2025

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.

K 0374 - The double corridor smoke doors on the first floor near room 130, door DC1-5 were serviced, and the doors are now closing properly and are smoke tight.

The Director of Property Management or designee will reeducate maintenance staff on monthly smoke barrier door preventative maintenance check process.

The Director of Property Management or designee will monitor and conduct random monthly audits at least monthly for three months and then the study results will be presented to 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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