Pennsylvania Department of Health
WILLOW GROVE POST ACUTE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WILLOW GROVE POST ACUTE - 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 May 21, 2026, at Willow Grove Post Acute, 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# 069002Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, it was determined that Willow Grove Post Acute 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 noncombustible building, with a basement and partial attic space, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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 upon observation and interview, it was determined the facility failed to maintain the building construction's fire resistive rating, affecting one of three levels. Findings include: 1. Observation on May 21, 2026, revealed missing rated ceiling tiles in the following locations: a. 12:00 p.m., on the first floor electric/IT room by elevator. b. 12:10 p.m., on the first floor Nurse Station. Exit Interview with the Administrator and Maintenance Director on May 21, 2026, at 12:45 p.m., confirmed the missing rated ceiling tiles

Plan of Correction - To be completed: 06/24/2026

1) a. The missing rated ceiling tiles were installed on the first floor by the electrical/IT room by the elevator.
b. The missing rated ceiling tiles were installed on the first-floor nursing station
2) The Plant Operations Director will be educated by NHA, ensuring the Maintenance Staff understands that rated ceiling tiles must be in place and undamaged at all times.
3) The Plant Operations Director/ Designee to complete audits weekly x 4 weeks and quarterly thereafter to ensure all ceiling tiles are in place.
4) The results of these audits will be submitted to the QAPI committee monthly for further review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain sprinkler components, affecting two of three levels. Findings include: 1. Observation on May 21, 2026, revealed household items were stored directly under and within 18 inches of sprinklers in the following locations: a. 10:20 a.m., on the first floor Administration suite closet. b. 10:30 a.m., on the second floor PT closet. Exit Interview with the Administrator and Maintenance Director on May 21, 2026, at 12:45 p.m., confirmed the obstructed sprinklers.

Plan of Correction - To be completed: 06/24/2026

1) a. The identified household items were removed from the first-floor Administration Suite closet, which was stored within 18 inches of the sprinkler head.
b. The items that were within 18 inches of the sprinkler head in the second-floor PT closet were removed.
2) The Center staff were educated by the NHA about proper storage in closets and storage rooms to keep items stored in these areas at least 18 inches from the sprinkler head devices.
3) The Plant Operations Director / Designee to complete audits weekly x 4 weeks and monthly thereafter to identify and correct any storage issues with the 18-inch rule concerning Sprinkler head clearance.
4) The results of these audits will be submitted to QAPI committee monthly for review and recommendations as needed.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 ensure portable fire extinguishers had monthly quick checks conducted and documented, affecting one of three levels. Findings include: 1. Observation on May 21, 2026, at 11:55 a.m., revealed the wall mounted portable fire extinguisher in dining kitchenette, on the second floor, was missing its monthly quick checks since February. Exit Interview with the Administrator and Maintenance Director on May 21, 2026, at 12:45 p.m., confirmed the missing quick checks.

Plan of Correction - To be completed: 06/24/2026

1) A fire extinguisher located in the kitchenette on the second floor was properly checked and signed off on the quick check tag. All other fire extinguishers were also checked throughout the building to ensure proper sign-off was completed.
2) The Plant Operations Director is to be educated by NHA on ensuring proper steps are taken to ensure all fire extinguisher quick check tags are signed off on monthly as required.
3)Plant Operations Director / Designee to complete audits weekly x4 and monthly thereafter to ensure proper compliance with fire extinguisher check tags.
4) The results of these audits will be submitted to QAPI committee monthly for review and recommendations as needed.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 01 - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of three levels. Findings include: 1. Observation on May 21, 2026, revealed unsealed penetrations of smoke barrier walls in the following locations: a. 11:15 a.m., above smoke doors by room 216, around data wire bundle. b. 11:30 a.m., above smoke doors by room 122, around data wire. Exit Interview with the Administrator and Maintenance Director on May 21, 2026, at 12:45 p.m., confirmed the unsealed penetrations.

Plan of Correction - To be completed: 06/24/2026

1a) The unsealed wall penetrations above the smoke doors by room 216 on the second floor were filled by using the UL fire stop system W-L-8095, 3M fire barrier sealant FD 150 + Red color, and CP 25 WB+ to ensure the walls are smoke-tight.
1b). The unsealed wall penetrations above the smoke doors by room 122 on the second floor were filled by using the UL fire stop system W-L-8095, 3M fire barrier sealant FD 150 + Red color, and CP 25 WB+ to ensure the walls are smoke-tight.
2)Plant Operations Director to be educated by NHA on policy and procedure for maintaining smoke barrier walls.
3) The Plant Operations Director / Designee to complete audits weekly x4 and monthly thereafter to ensure proper compliance with smoke barrier walls.
4) The results of these audits will be submitted to QAPI committee monthly for review and recommendations as needed.

NFPA 101 STANDARD Fire Drills:

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 document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly for one of twelve required drills. Findings include: 1. Document review on May 21, 2026, at 9:30 a.m., revealed the facility could not provide documentation that a fire drill had been conducted for the 2nd quarter, 3rd shift. Exit Interview with the Administrator and Maintenance Director on May 21, 2026, at 12:45 p.m., confirmed the missing fire drill.

Plan of Correction - To be completed: 06/24/2026

1) A fire drill for each shift will be conducted within the next 30 days to ensure the staff is aware and educated on best practices of a fire drills.
2)Plant Operations Director to be educated by NHA on ensuring proper and timely fire drills per regulation
3) Plant Operations Director / Designee to complete each monthly required fire drill and provide a copy to the NHA as well as a copy being placed into the Life Safety binder.
4) The results of each monthly fire drill will be submitted to QAPI committee monthly for review and recommendations as needed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 01 - Component: 01 - Tag: 0918 Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, per NFPA 110.8.3.7.1, affecting the entire facility. Findings include: 1. Document review on May 21, 2026, at 9:20 a.m., revealed the facility lacked documentation indicating performance of monthly testing and recording of battery conductance testing since May 2025. Exit Interview with the Administrator and Maintenance Director on May 21, 2026, at 12:45 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/24/2026

1) Battery Conductance test will be completed and recorded monthly as part of the required monthly load test.
2)Plant Operations Director to be educated by NHA on ensuring proper battery conductance testing per regulation
3)Plant Operations Director / Designee to complete monthly audits x12 to ensure the battery's conductance test is being performed and recorded.
4) The results of this audit will be submitted to QAPI committee monthly for review and recommendations as needed.

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