Nursing Investigation Results -

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

WILLOWBROOKE COURT SKILLED CARE CENTER AT LIMA ESTATES
Inspection Results For:
There are 38 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 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 June 29, 2022, 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 June 29, 2022, it was determined 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 structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of common walls to non-conforming buildings, affecting one of three smoke compartments within the facility.

Findings include:

1. Observation on June 29, 2022, at 11:26 a.m., revealed unprotected penetrations, shared common wall, between Resident Room 1 and the Storage Closet, around two insulated pipes, as viewed from the Storage Closet.

Exit Interview with the Director of Physical Plant Services on June 29, 2022, at 11:26 a.m., confirmed the unprotected penetrations of the fire wall.

Plan of Correction - To be completed: 08/12/2022

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.

A. Penetration of the firewall will be sealed with an approved UL stop gap generation system.

B. Future construction or modification will follow up by the Maintenance dept. to ensure fire penetration are sealed according to the NFPA 101 standard.

C. The Director of Physical Plant/designee shall conduct a monthly audit above the ceiling to check fire penetration for four months.

D. All findings will be report to the Safety Committee and QAPI committee.

NFPA 101 STANDARD Utilities - Gas and Electric:

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.

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical wiring, affecting one of three smoke compartments within the facility.

Findings include:

1. Observation on June 29, 2022, between 11:57 a.m. and 12:07 p.m, revealed exit signs, Main Hallway Corridor, were wired with non-metallic sheathed electrical cable, with a manufacture date of "12/6/07," within the center smoke compartment.

Exit Interview with the Director of Physical Plant Services on June 29, 2022, at 12:07 p.m., confirmed the installation of non-metallic sheathed electrical cable after the effective date of the adoption of the 2000 edition of the Life Safety Code.

Plan of Correction - To be completed: 08/12/2022

A. Our electrical vendor will rewire the identified device with department approved materials.

B. All future electrical repairs will be performed and comply with all local, state, and NFPA 70 code of regulations.

C. The Director of Physical Plants Services (DPPS) will perform a monthly inspection, for four months, of all electrical cable making sure comply with Life Safety code, and NFPA 70.

D. All findings will be reported to the Safety Committee and QAPI Committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of three smoke compartments within the facility.

Findings include:

1. Observation on June 29, 2022, at 11:44 a.m., revealed a surge suppressor supplying electrical power to another surge suppressor, against the wall, behind the Nurses' Station.

Exit Interview with the Director of Physical Plant Services on June 29, 2022, at 11:44 a.m., confirmed the daisy chained surge suppressors.

2. Observation on June 29, 2022, at 11:50 a.m., revealed a surge suppressor supplying electrical power to another surge suppressor, Exam/Treatment Room, behind the Nurses' Station.

Exit Interview with the Director of Physical Plant Services on June 29, 2022, at 11:50 a.m., confirmed the daisy chained surge suppressors.

Plan of Correction - To be completed: 08/12/2022

A. The surge suppressor was immediately removed.

B. The Director of Physical Plant or designee will in-service staff on electrical safety, usage of extension cords, and surge protector by 7/29/22.

C. Director of Physical Plant/designee will perform monthly inspection, for four months, to ensure compliance with this requirement.

D. Results of these inspections will be reported to the Safety Committee and QAPI to assure 100% compliance.

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