Pennsylvania Department of Health
WILLOWBROOKE COURT SKILLED CARE CENTER AT LIMA ESTATES
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 LIMA 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 3, 2025, at Willowbrooke Court Skilled Care Center at Lima 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 01 - Component: 01 - Tag: 0000

Facility ID# 151902
Component 01
Health Care

Based on a Medicare/Medicaid Recertification Survey completed on April 3, 2025, it was determined that Willowbrooke Court Skilled Care Center at Lima 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 one-story, Type III (200), unprotected ordinary building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345
Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting one of three smoke compartments.

Findings include:

1. Observation on April 3, 2025, at 9:30 am, revealed the January 17, 2025, fire alarm inspection report listed the following deficiency, which remained uncorrected at time of survey:

a. Damper wires are exposed in ceiling and not sure if damper still operational. Need to investigate further and cap wires.

Exit Interview with the Director of Nursing and Maintenance Director on April 3, 2025, at 11:00 am, confirmed the fire alarm deficiency.

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

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

Our HVAC vendor to assess and provide any needed repairs to the damper. Our Fire alarm vendor to then test for functionality.
A preventative maintenance schedule is in place semi-annually and will be checked by our Fire Alarm vendor as per protocol.
Director of Property Management or designee will observe damper during monthly fire drills x 3 months to ensure proper operation and compliance with Life Safety Code and NFPA 101 standard with findings to be reported to the Safety Committee and QAPI Committee.

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 smoke compartments.

Findings include:

Observation on April 3, 2025, at 10:30 am, revealed an unsealed penetration around data wires, above smoke doors by room 19.

Exit Interview with the Director of Nursing and Maintenance Director on April 3, 2025, at 11:00 am, confirmed the penetrations.

Plan of Correction - To be completed: 04/30/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

Penetration of the firewall will be sealed with an approved UL fire stop gap system.
Future construction/vendor activity will be checked by our Maintenance Department to ensure that fire penetrations are sealed according to the NFPA 101 standard.
Director of Property Management or designee will conduct monthly audits above the ceiling to check fire penetration x 3 months with findings to be reported to the Safety Committee and QAPI Committee.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient bed locations, affecting two of three smoke compartments.

Findings include:

1. Document review on April 3, 2025, at 9:30 am, revealed electrical receptacles at patient bed locations, were not tested as required for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity.
b. correct polarity of the hot and neutral connections.
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

*The facility only included c) retention force portion of receptacle testing.

Exit Interview with the Director of Nursing and Maintenance Director on April 3, 2025, at 11:00 am, confirmed testing of electrical receptacles was incomplete.

Plan of Correction - To be completed: 04/30/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

Director of Property Management to make corrections to the electronic work order system, for electrical receptacles testing to include polarity of the hot and neutral, correct grounding, and retention force.
All electrical receptacles at resident bed locations will be retested and documented utilizing the new electronic work order management system.
A preventative maintenance schedule is in place annually and will be carried out utilizing the updated electronic work order. Also, our Maintenance Department will perform monthly checks on the status of electrical receptacle testing at resident bed locations utilizing our electronic work order management system x 3 months with findings to be reported to the Safety Committee and QAPI Committee.

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