Pennsylvania Department of Health
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  36 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.
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID #111702
Component 01
Main Building, Unit 1

Based on an abbreviated survey, as part of a complaint investigation completed on January 23, 2024, it was determined that Willow Brook Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Notification:This is a less serious (but not lowest level) 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 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.
Fire Alarm - Notification
2012 EXISTING
Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire.
19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0343

Based on observation and interview, it was determined the facility failed to maintain a complete automatic fire alarm system, affecting four of four smoke zones within the component.

Findings include:

1. Observation on January 23, 2024 at 1:00 PM, revealed the facility failed to maintain a complete automatic fire alarm system. At the time of the observation, the facility lacked a main fire alarm panel, as it had been damaged by water and removed.

Interview with the Administrator on January 23, 2024, at 1:00 PM, confirmed the facility lacked a main fire alarm panel.



 Plan of Correction - To be completed: 02/16/2024

1.Fire alarm company (Johnson Controls) was called immediately to make the necessary repairs to the fire alarm system.
2.Fire Alarm system Audit was completed to ensure no other fire alarm devices were affected.
3.NHA will in-service the maintenance director and assistant on getting and
finding addresses in a timely manner.
4.Director or designee will report findings to the monthly QAPA meetings
X3 months.
5.Date of completion per Johnson controls for main fire panel as the earliest 2/22/2024


NFPA 101 STANDARD Sprinkler System - Out of Service: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.
Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0354

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system, in a continuously reliable operating condition, affecting one of four smoke zones within the component.

Findings include:

1. Observation on January 23, 2024, at 1:30 PM, revealed the facility failed to protect the automatic sprinkler protection system from damage, due to environmental factors. At the time of the observation, a sprinkler branch line had ruptured due to frozen water within the pipe, in the attic.

Interview with the Administrator on January 23, 2024, at 1:30 PM, confirmed the automatic sprinkler protection system had been damaged by environmental factors.




 Plan of Correction - To be completed: 02/29/2024

1.Fire sprinkler company (Viozzi)was called immediately to make necessary repairs to the fire sprinkler system.
JDS construction was called to insulate
the attic. This will keep the fire sprinkler pipes protected from environmental factors.
2. Fire sprinkler system Audit was completed to ensure no other fire sprinkler pipes or sprinkler heads were affected.
3.NHA/designee will in-service the
maintenance director and assistant maintenance worker on getting any finding
addresses in a timely manner.
4.Director of Maintenance or Designee will report findings to the monthly QAPI meetings X 3 months.

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