Provider Name: WILLOWBROOKE COURT-SPRING HOUS
Address: 728 NORRISTOWN ROAD, LOWER GWYNEDD, PA 19002
Phone: (215) 628-3545
County: Montgomery (560)
Ownership Type: Non profit - Corporation
Certified Beds: 16
Average Residents Per Day: 11.4 ()
Provider Type: Medicare, Resides in Hospital: No
Legal Business Name: ACTS RETIREMENT-LIFE COMMUNITIES INC
First Approved Date: January 31, 1981
Affiliated Entity: ACTS RETIREMENT-LIFE COMMUNITIES (9)
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 5 ()
Long Stay QM Rating: (2)
Short Stay QM Rating: 5 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.48954, LPN Staff Hours Per Day: 0.6844, RN Staff Hours Per Day: 1.4321, Licensed Staff Hours Per Day: 2.1165
Total Nurse Staff Hours Per Day, per resident: 4.60610
Weekend Nurse Staff Hours: 4.48617, Weekend RN Staff Hours: 1.2426
PT Staff Hours Per Day, per resident: 0.7422
Nurse Staff Turnover: 0.0, Nurse Turnover Note:
RN Turnover: 0.0, RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 2.1683, Case Mix LPN Hours Per Day: 0.7260, Case Mix RN Hours Per Day: 0.3708
Adjusted Nurse Aide Hours Per Day, per resident: 2.33900, Adjusted LPN Hours Per Day: 0.6956, Adjusted RN Hours Per Day: 1.4551
Total Adjusted Nurse Hours Per Day, per resident: 4.44632
Adjusted Weekend Nurse Hours Per Day, per resident: 4.33056
Health Survey Dates and Scores: Cycle 1: 2023-08-11 (Score: 0), Cycle 2: 2022-11-03 (Score: 0), Cycle 3: 2021-11-24 (Score: 0)
Total Weighted Health Score: 0.000
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 650.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 728 NORRISTOWN ROAD,LOWER GWYNEDD,PA,19002 (40.1785, -75.201)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0131, Version: New
Description: Meet requirements for sections of health care facilities separated by fire resistive construction.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-25
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-25
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-25
Type: Fire Safety, Tag: 0281, Version: New
Description: Install proper backup exit lighting.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-11
Type: Fire Safety, Tag: 0325, Version: New
Description: Have properly installed hallway dispensers for alcohol-based hand rub.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-11
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-11
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-11
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-11
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-11
Type: Fire Safety, Tag: 0111, Version: New
Description: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-22
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-14
Type: Fire Safety, Tag: 0271, Version: New
Description: Have exits that are accessible at all times.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-16
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-14
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-14
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-14
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-14
Type: Fire Safety, Tag: 0912, Version: New
Description: Have power receptacles that are properly grounded.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-14