Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Willowbrooke Court Skilled Care Center at Mease Li
DUNEDIN, FL · 100 certified beds · Last Life Safety survey July 25, 2024
CMS Certification Number 105732 · first certified June 1991
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 FL
8 citations — more than 57% of the 694 certified nursing homes in FL. Compared within FL 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 5 citations; the earlier surveys in the window averaged 1.5. 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 (November 2025 to June 2026), and past the point by which nine in ten FL facilities have been surveyed. This facility’s last Life Safety survey was July 2024. Facilities in FL are typically surveyed 15–23 months after the last one (median 17), measured over 729 consecutive surveys in the last two years of CMS records.
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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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
How that compares
Compared with the median facility in FL, and nationally. Surveyors differ markedly between states, so the FL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 8 |
| Median facility in FL | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 2, 2021 | 3 |
| August 18, 2022 | 0 |
| July 25, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-07-25 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-07-25 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2021-04-02 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2024-07-25 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2024-07-25 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-07-25 |
What the citations cover
- Smoke Deficiencies 3
- Miscellaneous Deficiencies 2
- Services Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 25, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 23, 2024) |
April 2, 2021 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 24, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 1, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 12, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.