Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER
KUTZTOWN, PA · 140 certified beds · Last Life Safety survey February 7, 2025
CMS Certification Number 395680 · first certified November 1984
Ownership
Operated by PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES · For profit - Limited Liability company
- Ownership changed December 29, 2021 (change of ownership)to WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER LLC from KUTZTOWN MANOR INC
Position within PA
19 citations — more than 80% of the 656 certified nursing homes in PA. Compared within PA 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 3 citations; the earlier surveys in the window averaged 5.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to February 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was February 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 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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1 inspection-and-testing tag has 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)
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 19 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 16, 2023 | 9 |
| January 23, 2024 | 2 |
| March 15, 2024 | 5 |
| February 7, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-02-07 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 2 | 2024-03-15 |
| K-0100 | Meet other general requirements. | 2 | 2025-02-07 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-02-07 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2024-03-15 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2024-03-15 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-03-16 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2023-03-16 |
What the citations cover
- Smoke Deficiencies 11
- Construction Deficiencies 3
- Services Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Construction Deficiencies | 3 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 7, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (April 8, 2025) |
| 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 (April 8, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 8, 2025) |
March 15, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (April 16, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 16, 2024) |
| 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 (April 16, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (April 16, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 16, 2024) |
January 23, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (February 29, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (February 29, 2024) |
March 16, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (May 11, 2023) |
| 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 (May 11, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 11, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.