Pennsylvania Department of Health
LECOM AT VILLAGE SQUARE, LLC
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LECOM AT VILLAGE SQUARE, LLC
Inspection Results For:

There are  61 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.
LECOM AT VILLAGE SQUARE, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on a Revisit to an Emergency Preparedness Survey completed on December 12, 2023, at Lecom at Village Square, LLC, 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 #382602
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 12, 2023, it was determined that Lecom at Village Square, LLC was not in compliance with the following requirements of the Life Safety Code for an existing 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 three-story, Type II (111), protected, non-combustible building, with a basement, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Building Rehabilitation:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0111

Based on document review, observation, and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.

Findings include:

Document review on December 12, 2023, at 9:41 a.m., revealed the facility updated the fire alarm panel and installed 28 photo smoke detectors, 10 manual pull stations, and seven heat detectors without state approved plans or a granted occupancy from the Division of Life Safety. The facility had multiple "lift cover pull fire alarm" box covers disconnected but not decommissioned, possibly creating confusion in the event of an emergency situation.

Interview with the maintenance director on December 12, 2023 at 9:41 a.m., confirmed the facility had not submitted plans for the equipment.

****************************************
Based on document review and interview during an Onsite Revisit Survey conducted on January 31, 2024, at 11:35 a.m., the facility failed to provide corrective documentation for the above deficiencies.

Interview with the administrator and maintenance supervisor on January 31, 2024, at 11:35 a.m., confirmed the facility did not provide documentation at the time of the Revisit Survey.
















 Plan of Correction - To be completed: 02/18/2024

After further investigation, Wilkins fire alarm systems confirmed that Swartz repaired the main control panel leaving all existing field devices untouched all in functional, working order.
The confusion of adding smoke detectors, pull stations and heat detectors was in a proposed estimate by Swartz Fire Alarms, that never was completed.

Based off of Wilkins information, the proposed estimate provided was not necessary.

Field devices were gradually upgraded to newer addressable type devices over a period of several years. There was no evidence of changing the overall quantity of detection devices or notification appliances or their locations.

Documents are available to review during revisit.

The "lift cover pull fire alarm" box covers disconnected were decommissioned after survey.
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 Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916

Based on observation and interview, the facility failed to meet electrical system requirements for one of one generator.

Findings include:

Observation on December 12, 2023, at 1:30 p.m., revealed the facility lacked a remote annunciator that operates outside of the generating room and is readily available to operating personnel.

Interview with the maintenance supervisor and administrator on December 12, 2023, at 1:30 p.m., confirmed the facility lacked a remote annunciator.

********************
Based on document review and interview during an Onsite Revisit Survey conducted on January 31, 2024, at 11:40 a.m., the facility failed to correct the above annunciator deficiency. However, the facility provided a copy of three options to address the deficiency, including a generator replacement, at the time of the survey.
Interview with the administrator and maintenance supervisor on January 31, 2024, at 11:40 a.m., confirmed the facility lacked a remote annunciator.










 Plan of Correction - To be completed: 03/31/2024

The facility generator stopped functioning after the survey.

A temporary replacement generator was placed in front of building from Spaeder Electrical company until a permanent generator is approved to be a replacement.

The new generator with remote annunciator will be installed after the state and local code reviewers approve the plans/drawings.

Facility representative will submit narrative & plans/drawings to Plan Office for review.


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 document review and interview, the facility failed to maintain essential electrical system requirements for one of one generator.

Findings include:

Document review on December 12, 2023, between 11:14 and 11:25 a.m., revealed the facility was unable to provide the following generator maintenance documentation:
A. (11:14 a.m.) Monthly conductance testing;
B. (11:25 a.m.) Annual fuel quality sample.

Interview with the maintenance supervisor on December 12, 2023, at 11:25 a.m., confirmed the facility could not find the documentation at the time of the survey.
*********************************
Based on document review and interview during an Onsite Revisit Survey conducted on January 31, 2024, at 11:35 a.m., the facility failed to provide conductance test documentation (Item A) for the emergency generator at the time of the Revisit Survey.
Interview with the administrator and maintenance supervisor on January 31, 2024, at 11:35 a.m., confirmed Item A was not completed.








 Plan of Correction - To be completed: 03/31/2024

Facility generator stopped functioning after revisit survey.

Maintenance Director is monitoring that monthly conductance test is being completed on temporary generator provided by Spaeder Electric.

When permanent generator is approved and installed, Maintenance Director will be performing monthly conductance testing.

This will be monitored and signed off by Administrator for 6 months.
Initial comments:Name: WEST WING - Component: 02 - Tag: 0000


Facility ID #382602
Component 02
West Wing

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on December 12, 2023, it was determined that Lecom at Village Square, LLC was not in compliance with the following requirements of the Life Safety Code for an existing 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 three-story, Type III (200), unprotected, ordinary building, with a basement, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Building Rehabilitation:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
Observations:
Name: WEST WING - Component: 02 - Tag: 0111

Based on document review, observation, and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.

Findings include:

Document review on December 12, 2023, at 9:41 a.m., revealed the facility updated the fire alarm panel and installed 28 photo smoke detectors, 10 manual pull stations, and seven heat detectors without state approved plans or a granted occupancy from the Division of Life Safety. The facility had multiple "lift cover pull fire alarm" box covers disconnected but not decommissioned, possibly creating confusion in the event of an emergency situation.

Interview with the maintenance director on December 12, 2023 at 9:41 a.m., confirmed the facility had not submitted plans for the equipment.

****************************************
Based on document review and interview during an Onsite Revisit Survey conducted on January 31, 2024, at 11:35 a.m., the facility failed to provide corrective documentation for the above deficiencies.

Interview with the administrator and maintenance supervisor on January 31, 2024, at 11:35 a.m., confirmed the facility could not provide the documentation at the time of the Revisit Survey.











 Plan of Correction - To be completed: 02/18/2024

After further investigation, Wilkins fire alarm systems confirmed that Swartz repaired the main control panel leaving all existing field devices untouched all in functional, working order.
The confusion of adding smoke detectors, pull stations and heat detectors was in a proposed estimate by Swartz Fire Alarms, that never was completed.

Based off of Wilkins information, the proposed estimate provided was not necessary.

Field devices were gradually upgraded to newer addressable type devices over a period of several years. There was no evidence of changing the overall quantity of detection devices or notification appliances or their locations.

Documents are available to review during revisit.

The "lift cover pull fire alarm" box covers disconnected were decommissioned after survey.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: WEST WING - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electrical system requirements for one of one generator.

Findings include:

Document review on December 12, 2023, between 11:14 and 11:25 a.m., revealed the facility was unable to provide the following generator maintenance documentation:
A. (11:14 a.m.) Monthly conductance testing;
B. (11:25 a.m.) Annual fuel quality sample.

Interview with the maintenance supervisor on December 12, 2023, at 11:25 a.m., confirmed the facility could not find the documentation at the time of the survey.
*********************************
Based on document review and interview during an Onsite Revisit Survey conducted on January 31, 2024, at 11:35 a.m., the facility failed to provide conductance test documentation (Item A) for the emergency generator.

Interview with the administrator and maintenance supervisor on January 31, 2024, at 11:35 a.m., confirmed Item A was not completed at the time of the Revisit Survey.






 Plan of Correction - To be completed: 03/31/2024

Facility generator stopped functioning after revisit survey.

Maintenance Director is monitoring that monthly conductance test is being completed on temporary generator provided by Spaeder Electric.

When permanent generator is approved and installed, Maintenance Director will be performing monthly conductance testing.

This will be monitored and signed off by Administrator for 6 months.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port