Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOWBROOKE CT SKILLED CARE CTR AT MAGNOLIA TRACE
HUNTSVILLE, AL · 59 certified beds · Last Life Safety survey May 17, 2022
CMS Certification Number 015450 · first certified March 2003
Ownership
Operated by ACTS RETIREMENT-LIFE COMMUNITIES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AL
9 citations — more than 46% of the 224 certified nursing homes in AL. Compared within AL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2023 to October 2023), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was May 2022. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. AL has too few recent surveys to measure on its own, so the national interval is used.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 9 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in AL, and nationally. Surveyors differ markedly between states, so the AL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 9 |
| Median facility in AL | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 11, 2018 | 3 |
| October 17, 2019 | 4 |
| May 17, 2022 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-05-17 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2018-10-11 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2019-10-17 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2018-10-11 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2022-05-17 |
| K-0222 | 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. | 1 | 2019-10-17 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2019-10-17 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 1 | 2019-10-17 |
What the citations cover
- Smoke Deficiencies 4
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 17, 2022 — 2 citations
October 17, 2019 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (November 25, 2019) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (November 25, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 25, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 25, 2019) |
October 11, 2018 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 7, 2018) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 7, 2018) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 7, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.