Pennsylvania Department of Health
 WILLOWBROOKE COURT AT SPRING HOUSE ESTATES
Building Inspection Results

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WILLOWBROOKE COURT AT SPRING HOUSE ESTATES
Inspection Results For:

There are  46 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 SPRING HOUSE 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 April 30, 2025, at Willowbrooke Court at Spring House Estates, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN & NEW BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 971502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2025, it was determined that Willowbrooke Court at Spring House 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 one-story, Type III (211), protected ordinary building, with a partial basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN & NEW BUILDING 01 - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of two levels.

Findings include:

Observation on April 30, 2025, from 11:05 a.m. to 11:30 a.m., revealed penetrations in the fire barrier wall at the following locations:

a.11:05 a.m., above ceiling tile, an open penetration around electrical wires, ground level double fire doors, entrance to Willowbrooke Court near kitchen courtyard side.
b.11:32 a.m. above ceiling tile, an open penetration around cables and electrical wires, Willowbrooke Court double fire doors that lead to Cherry wing.

Exit interview with the Administrator and Maintenance Director on April 30, 2025, at 12:30 p.m., confirmed the fire wall penetrations.




 Plan of Correction - To be completed: 05/30/2025

-New fire caulk will be replaced in cited locations a and b. Cite (a) we will use a 3m fire barrier pass through device that is UL classified for 1,2 and 3 hour fire rating temperatures. Cite (b) a spec seal ready fire stop grommete will be used that meets UL 1479 rating.
-Weekly checks will be made on all fire-penetrations.

-Results of inspected fire-penetrations will be reviewed at QA meetings.

-Director of Property Management/Designee will be responsible.

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 & NEW BUILDING 01 - Component: 01 - Tag: 0211

Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of two levels.

Findings include:

Observation on April 30, 2025, at 11:10 a.m., revealed double doors leading to an enclosed courtyard could be mistaken for an exit and lacked signage indicating " Not an Exit", ground level corridor near Willowbrooke Court Kitchen.

Exit interview with the Administrator and Maintenance Director on April 30, 2025, at 12:30 p.m., confirmed the missing signage.




 Plan of Correction - To be completed: 05/21/2025

 A "Not Exit" sign leading to enclosed courtyard has been installed.

All areas that require A "Not Exit" sign are in compliance.

Director of Property Management/Designee will be responsible.
NFPA 101 STANDARD Fire Alarm System - Initiation: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 Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
Observations:
Name: MAIN & NEW BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of two levels.

Findings include:

Observation on April 30, 2025, at 12:04 p.m., revealed a smoke detector was not securely mounted to the ceiling, Pine Springs Supply Closet.

Exit interview with the Administrator and Maintenance Director on April 30, 2025, at 12:30 p.m., confirmed the smoke detector deficiency.




 Plan of Correction - To be completed: 05/21/2025

Smoke detector in the Pine Springs Supply Closet has been securely mounted to the ceiling.

All smoke detectors have been inspected for secure mounting

Smoke detectors will be inspected monthly by maintenance staff

Director of Property Management/designee will be responsible.
NFPA 101 STANDARD Electrical Systems - Other: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 - 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 & NEW BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain access to electrical panels, affecting one of two levels.

Observation on April, 2025, at 11:00 a.m., revealed, an electrical panel was obstructed by a kitchen prep table and supplies, Willowbrooke Court Kitchen.

Exit interview with the Administrator and Maintenance Director on April 30, 2025, at 12:30 p.m., confirmed the blocked electrical panel.




 Plan of Correction - To be completed: 05/30/2025

Prep table in the kitchen will be moved to an area where there is no electrical pane.

All areas that have an electrical panel have been inspected to insure no blockage.

During maintenance rounds all electrical panels will be inspected for compliance.

Director of Plant property management/designee will be responsible
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN & NEW BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices affecting one of two levels.

Findings include:

Observation on April 30, 2025, at 12:05 p.m., revealed an orange extension cord plugged into an outlet and being run into the ceiling above, Pine Springs Mud Room.

Exit interview with the Administrator and Maintenance Director on April 30, 2025, at 12:30 p.m., confirmed the unauthorized use of an extension cord.





 Plan of Correction - To be completed: 05/30/2025

Orange extension cord will be removed with a permanent outlet installed.

All areas have been inspected for any usage of extension cords.

Maintenance staff will insure that no extension cords are used.

Director of Property Management/designee will be responsible.

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