Southampton, PA

Willowbrooke Court-Southampton

5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle

238 Street Road, Southampton, PA

(215) 364-2550

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

29

Certified beds

Average residents

21

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Acts Retirement-Life Communities

Operator or chain grouping

Approved since

1980-12-19

CMS approved date

Coverage

Medicare

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.32

Registered nurse staffing

LPN hours / resident day

0.46

Licensed practical nurse staffing

Aide hours / resident day

2.20

Nurse aide staffing

Weekend hours

3.70

Weekend nurse staffing

RN turnover

9%

Annual RN turnover

Total nurse turnover

18%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.9% 13.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents experiencing one or more falls with major injury	4.3%	3.2% 1.1 pts worse	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.0%	6.5% 6.5 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	7.7%	6.5% 1.2 pts worse	5.4% 2.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.0%	19.9% 0.1 pts worse	19.6% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	6.1%	18.7% 12.6 pts better	16.7% 10.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	3.1%	19.6% 16.5 pts better	16.3% 13.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	7.5%	18.3% 10.8 pts better	14.9% 7.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.8%	0.9% 1.9 pts worse	1.0% 1.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.4%	1.7% 2.7 pts worse	1.7% 2.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.4%	26.4% 1 pts better	19.8% 5.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	6.5%	5.3% 1.2 pts worse	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	68.9% 31.1 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	6.8%	9.8% 3 pts better	12.0% 5.2 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	68.7% 31.3 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.3%	23.1% 0.8 pts better	23.9% 1.6 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-05 · Fire 2025-12-05

0 health deficiencies

No concentrated health issue counts in this cycle.

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2025-01-08 · Fire 2025-01-08

0 health deficiencies

No concentrated health issue counts in this cycle.

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2024-02-08 · Fire 2024-02-08

0 health deficiencies

No concentrated health issue counts in this cycle.

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-12-05

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2026-01-09

E · Potential for more than minimal harm 2025-12-05

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2026-01-09

E · Potential for more than minimal harm 2025-01-08

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2025-02-14

E · Potential for more than minimal harm 2025-01-08

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-02-14

E · Potential for more than minimal harm 2025-01-08

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-02-14

F · Potential for more than minimal harm 2024-02-08

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-03-18

F · Potential for more than minimal harm 2024-02-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-08

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-08

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-03-18

Inspection history

Recent health citations

Penalties and ownership

What sits behind the stars

Ownership

Acts Retirement-Life Communities Inc

5% Or Greater Direct Ownership Interest · Organization

100% 19 facilities 1997-05-01

Acts Management Services, Inc.

Operational/Managerial Control · Organization

0% 27 facilities 2012-01-01

Acts Retirement-Life Communities Inc

Operational/Managerial Control · Organization

0% 19 facilities 2012-01-01

Acts Retirement-Life Communities Inc

5% Or Greater Mortgage Interest · Organization

0% 19 facilities 1997-05-01

Acts Retirement-Life Communities Management, LLC

Operational/Managerial Control · Organization

0% 25 facilities 2022-12-31

Ahern, Susan

Operational/Managerial Control · Individual

0% 27 facilities 2020-01-01

Ahern, Susan

Corporate Officer · Individual

0% 27 facilities 2020-01-01

Allmond, Susan

Corporate Director · Individual

0% 23 facilities 2015-01-01

Allmond, Susan

Corporate Officer · Individual

0% 23 facilities 2025-01-01

Brod, Kathryn

Corporate Director · Individual

0% 22 facilities 2024-02-15

Callaway, Warren

Corporate Director · Individual

0% 19 facilities 2022-03-30

Chamberlain, Linda

Corporate Director · Individual

0% 20 facilities 2025-01-01

Christiansen, Karen

Operational/Managerial Control · Individual

0% 27 facilities 2009-01-26

Christiansen, Karen

Corporate Director · Individual

0% 27 facilities 2020-01-01

Christiansen, Karen

Corporate Officer · Individual

0% 27 facilities 2014-08-01

Detweiler, Harold

Corporate Director · Individual

0% 25 facilities 2009-01-26

Esterhai, John

Corporate Director · Individual

0% 21 facilities 2009-01-26

Fox, Glenn

Operational/Managerial Control · Individual

0% 27 facilities 2017-01-01

Fox, Glenn

Corporate Officer · Individual

0% 27 facilities 2017-01-01

Gerner, Elric

Corporate Director · Individual

0% 24 facilities 2009-04-01

Gerner, Elric

Corporate Officer · Individual

0% 24 facilities 2010-01-01

Glynn, James

Corporate Director · Individual

0% 21 facilities 2023-01-01

Grant, Gerald

Operational/Managerial Control · Individual

0% 29 facilities 2009-01-26

Grant, Gerald

Corporate Director · Individual

0% 29 facilities 2017-05-04

Grant, Gerald

Corporate Officer · Individual

0% 29 facilities 2014-08-01

Greer, Jason

Corporate Director · Individual

0% 19 facilities 2022-03-30

Kelly, Michael

Corporate Director · Individual

0% 33 facilities 2020-02-11

Lammers, John

Corporate Director · Individual

0% 21 facilities 2020-12-15

Lawson, Daniel

Corporate Director · Individual

0% 25 facilities 2019-06-11

Lawson, Daniel

Corporate Officer · Individual

0% 25 facilities 2025-01-01

Mashner, Marvin

Corporate Director · Individual

0% 23 facilities 2009-01-26

Mashner, Marvin

Corporate Officer · Individual

0% 23 facilities 2025-01-01

Middlebrooks, Daniel

Corporate Director · Individual

0% 19 facilities 2023-01-01

Reichard, Dawn

Corporate Director · Individual

0% 19 facilities 2025-06-01

Nearby options

Other facilities in reach

#1

Majestic Oaks Rehabilitation And Nursing Center

Warminster, PA

1-star overall rating with 1-star inspections with $35,175 in total fines with 21 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

Overall: 1 / 5
Health: 1 / 5
Staffing: 4 / 5
Fines: $35,175

#2