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)
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
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
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.32
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.09
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.44
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.57
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,070
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0154
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.33
Baseline 20.25% · Performance 19.89% · Measure score 3.33 · Achievement 3.33 · Improvement 0.61
Healthcare-associated infections
4.75
Baseline 6.99% · Performance 6.42% · Measure score 4.75 · Achievement 4.75 · Improvement 2.38
Total nurse turnover
10
Baseline 22.73% · Performance 13.95% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.01% |
10.72%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 16.96% · Lower 95% interval 10.25% |
| Discharge to community | 71.68% |
50.57%
21.1 pts better
|
Better than the National Rate · Eligible stays 92 · Observed rate 69.57% · Lower 95% interval 62.4% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 63.27% |
53.69%
9.6 pts better
|
Numerator 31 · Denominator 49 |
| Discharge mobility score | 55.1% |
50.94%
4.2 pts better
|
Numerator 27 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 5.45% |
2.29%
3.2 pts worse
|
Numerator 3 · Denominator 55 · Adjusted rate 6.24% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 3.28% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 6.02% |
8.2%
2.2 pts worse
|
Numerator 8 · Denominator 133 |
| Staff flu vaccination coverage | 93.33% |
42%
51.3 pts better
|
Numerator 112 · Denominator 120 |
| Discharge function score | 75.51% |
56.45%
19.1 pts better
|
Numerator 37 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 46.15% |
25.2%
20.9 pts better
|
Numerator 12 · Denominator 26 |
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 · 4Q avg 100.0% |
| 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 · 4Q avg 4.3% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 7.7% |
| 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 · 4Q avg 20.0% |
| 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 · 4Q avg 6.1% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 3.1% · Used in QM five-star |
| 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 · 4Q avg 7.5% · Used in QM five-star |
| 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 · 4Q avg 2.8% · Used in QM five-star |
| 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 · 4Q avg 4.4% · Used in QM five-star |
| 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 · 4Q avg 25.4% |
| 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 · 4Q avg 6.5% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · Adjusted 6.8% · Observed 5.8% · Expected 9.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
| 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 · Adjusted 22.3% · Observed 17.3% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Inc
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Inc
5% Or Greater Mortgage Interest · Organization
Acts Retirement-Life Communities Management, LLC
Operational/Managerial Control · Organization
Ahern, Susan
Operational/Managerial Control · Individual
Ahern, Susan
Corporate Officer · Individual
Allmond, Susan
Corporate Director · Individual
Allmond, Susan
Corporate Officer · Individual
Brod, Kathryn
Corporate Director · Individual
Callaway, Warren
Corporate Director · Individual
Chamberlain, Linda
Corporate Director · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Glynn, James
Corporate Director · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Greer, Jason
Corporate Director · Individual
Kelly, Michael
Corporate Director · Individual
Lammers, John
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Lawson, Daniel
Corporate Officer · Individual
Mashner, Marvin
Corporate Director · Individual
Mashner, Marvin
Corporate Officer · Individual
Middlebrooks, Daniel
Corporate Director · Individual
Reichard, Dawn
Corporate Director · Individual
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#3
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