Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOWBROOKE COURT-SOUTHAMPTON
SOUTHAMPTON, PA · 29 certified beds · Last Life Safety survey December 5, 2025
CMS Certification Number 395490 · first certified December 1980
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 PA
11 citations — more than 52% 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 2 citations; the earlier surveys on file 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 is open now: October 2026 to December 2026. This facility’s last Life Safety survey was December 2025. Facilities in PA are typically surveyed 11–12 months after the last one (median 11), measured over 1,101 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 about three years in Virginia. How the window is measured
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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 | 11 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 8, 2024 | 6 |
| January 8, 2025 | 3 |
| December 5, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 2 | 2025-12-05 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 2 | 2025-01-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-02-08 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-02-08 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2025-01-08 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-02-08 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2025-12-05 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-02-08 |
What the citations cover
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Construction Deficiencies 2
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Construction Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 5, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (January 9, 2026) |
| 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 (January 9, 2026) |
January 8, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (February 14, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 14, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 14, 2025) |
February 8, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (March 18, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 18, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 18, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 18, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (March 18, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (March 18, 2024) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.