Cycle 1
Health 2025-06-18 · Fire 2025-06-18
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lima, PA
Willowbrooke Court Skd Care Center At Lima Estates
5-star overall rating with 5-star inspections
411 N. Middletown Road, Lima, PA
(610) 565-8717
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
5
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1981-01-13
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.20
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.02
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
1.49
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.36
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.26% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 5.71% |
| Discharge to community | 69.09% |
50.57%
18.5 pts better
|
Better than the National Rate · Eligible stays 30 · Observed rate 80% · Lower 95% interval 52.69% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 73.08% |
53.69%
19.4 pts better
|
Numerator 19 · Denominator 26 |
| Discharge mobility score | 69.23% |
50.94%
18.3 pts better
|
Numerator 18 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 1 · Denominator 31 · Adjusted rate 4.82% |
| Healthcare-associated infections requiring hospitalization | 7.02% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 12.22% |
8.2%
4 pts better
|
Numerator 11 · Denominator 90 |
| Staff flu vaccination coverage | 85.71% |
42%
43.7 pts better
|
Numerator 84 · Denominator 98 |
| Discharge function score | 80.77% |
56.45%
24.3 pts better
|
Numerator 21 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.9% |
68.9%
8 pts better
|
81.7%
4.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 78.3% · Q3 69.2% · Q4 70.0% · 4Q avg 76.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.8%
1 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 6.9% · Expected 8.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
68.7%
31.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
23.1%
1.1 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 17.2% · Expected 17.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Ahern, Susan
Corporate Officer · Individual
Ahern, Susan
W-2 Managing Employee · Individual
Allmond, Susan
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Christiansen, Karen
W-2 Managing Employee · Individual
Clemens, Thomas
Corporate Director · Individual
Detweiler, Harold
Corporate Director · Individual
Dunn, Thomas
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Esterhai, John
Corporate Officer · Individual
Evans, Robert
Corporate Director · Individual
Fox, Glenn
Corporate Officer · Individual
Fox, Glenn
W-2 Managing Employee · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Grant, Gerald
W-2 Managing Employee · Individual
Kelly, Michael
Corporate Director · Individual
Kelly, Michael
Corporate Officer · Individual
Kulathum, Dilip
Corporate Director · Individual
Kulathum, Dilip
Corporate Officer · Individual
Lammers, John
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Marr, Larry
Corporate Director · Individual
Mashner, Marvin
Corporate Director · Individual
Worth, James
Corporate Director · Individual
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#3
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