Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOWBROOKE COURT SKILLED CARE CENTER FAIRHAVEN
SYKESVILLE, MD · 79 certified beds · Last Life Safety survey July 18, 2025
CMS Certification Number 215130 · first certified January 1981
Ownership
Operated by ACTS RETIREMENT-LIFE COMMUNITIES · Non profit - Corporation
- Ownership changed March 31, 2020 (change of ownership)to WILLOWBROOKE COURT SKILLED CARE CENTER AT FAIRHAVEN from FAIRHAVEN, INC.
Position within MD
14 citations — more than 14% of the 221 certified nursing homes in MD. Compared within MD 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 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 3 months from now. This facility’s last Life Safety survey was July 2025. Facilities in MD are typically surveyed 17–59 months after the last one (median 30), measured over 283 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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3 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.
Emergency preparedness
1 of the 14 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 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 14 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in MD | 22 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 15, 2018 | 5 |
| June 2, 2022 | 4 |
| July 18, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-07-18 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2025-07-18 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2022-06-02 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-07-18 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2022-06-02 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-07-18 |
| K-0331 | Construct fire resistant interior walls. | 1 | 2022-06-02 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2025-07-18 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 1
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 18, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 1, 2025) |
June 2, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (July 8, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 8, 2022) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (July 8, 2022) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (July 8, 2022) |
November 15, 2018 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 25, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 31, 2018) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 31, 2018) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (January 25, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 31, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.