Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER
WILMINGTON, MA · 142 certified beds · Last Life Safety survey September 12, 2025
CMS Certification Number 225568 · first certified April 1993
Ownership
Operated by MARQUIS HEALTH SERVICES · For profit - Corporation
- New ownershipOwnership changed October 31, 2024 (change of ownership)from WILMINGTON REHAB CENTER LLC
Position within MA
13 citations — more than 59% of the 341 certified nursing homes in MA. Compared within MA 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 9 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to November 2026. This facility’s last Life Safety survey was September 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 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.
Physical environment (health survey)
5 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 13 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 8, 2023 | 0 |
| September 19, 2024 | 4 |
| September 12, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-09-12 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-09-12 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-09-12 |
| 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 | 2025-09-12 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2025-09-12 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-09-12 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2025-09-12 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-09-19 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 3
- Miscellaneous Deficiencies 2
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 12, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 31, 2025) |
| 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 (October 31, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 31, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (October 31, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 31, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 31, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 31, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 31, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 31, 2025) |
September 19, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 20, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.