Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WILLOWBROOKE COURT-SPRING HOUS

LOWER GWYNEDD, PA · 16 certified beds · Last Life Safety survey April 2, 2026

CMS Certification Number 395495 · first certified January 1981

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.

11
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
3
Inspection & testing records
Of the citations on file

Position within PA

11 citations — more than 51% 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens February 2027 — about 4 months from now. This facility’s last Life Safety survey was April 2026. 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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Which alerts

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

This facility11PA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility11
Median facility in PA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
62024-0552025-0402026-04
Citations at each Life Safety survey
Survey dateCitations
May 28, 20246
April 17, 20255
April 2, 20260

Most-cited tags

Most-cited tags at this facility
K-09112K-05211K-01311K-03211K-07611K-09201K-03421K-01331
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0911Meet requirements for the installation and maintenance of electrical systems.22025-04-17
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.12024-05-28
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.12024-05-28
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12024-05-28
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12024-05-28
K-0920Ensure proper usage of power strips and extension cords.12025-04-17
K-0342Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.12025-04-17
K-0133Install a two-hour-resistant firewall separation.12025-04-17

What the citations cover

Citations by CMS category
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Smoke Deficiencies 2
  • Construction Deficiencies 2
  • Egress Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Gas, Vacuum, and Electrical Systems Deficiencies4
Smoke Deficiencies2
Construction Deficiencies2
Egress Deficiencies1
Services Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 17, 2025 — 5 citations

Citations issued on April 17, 2025
TagWhat the surveyor checksStatus
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (May 30, 2025)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (May 30, 2025)
K-0342Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.Deficient, Provider has date of correction (May 30, 2025)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (May 30, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 30, 2025)

May 28, 2024 — 6 citations

Citations issued on May 28, 2024
TagWhat the surveyor checksStatus
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.Deficient, Provider has date of correction (August 1, 2024)
K-0321Ensure 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 (August 1, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (August 1, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (August 1, 2024)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (August 1, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (August 1, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.