SNF

WILLOWBROOKE COURT-SOUTHAMPTON

CCN: 395490 · SOUTHAMPTON, PA 18966 · Bucks County

ℹ CCRC

Overview

Address
238 STREET ROAD, SOUTHAMPTON, PA 18966
Phone
2153642550
Certified beds
29
Avg daily residents
21 (73% of beds filled)
Ownership
Non-profit corporation
Provider type
Medicare
Medicare/Medicaid since
1980-12-19
Setting
Urban
5 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 5/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 5/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 5/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 5/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 4/5
Short-Stay Quality Measures ★★★★★ 5/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 3.98 3.24 4.74 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 1.32 0.57 1.57 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.46 0.72 0.55 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 2.20 1.95 2.62 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.78 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.44 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.70
hrs / resident / day
RN (weekend)
1.09
hrs / resident / day
Total nurse (adjusted, weekend)
4.41
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
17.8%
annual
RN turnover
9.1%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.15
near national average
Case-Mix Index Ratio
0.83
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-12-05 0 0 0 0 0 0
Cycle 2/3 (prior) 2025-01-08 0 0 0 0 0 0
Total weighted health score
0.0
lower is better

Financial Health (FY 2023)

Operating performance

Operating Margin
5.2%
Total Margin
9.5%
Occupancy Rate
65.3%
Cost per Resident Day
$50

Revenue & costs

Net Patient Revenue
$23.3M
Total Costs
$1.2M
Net Income
$2.3M

Balance sheet

Total Assets
$44.1M
Total Liabilities
$30.6M
Fund Balance
$13.5M
Current Ratio
0.06

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: ACTS RETIREMENT-LIFE COMMUNITIES

Chain ID
9
Facilities in chain
26
Legal business name
ACTS RETIREMENT-LIFE COMMUNITIES INC
Chain-average star ratings (for peer context)
Overall
4.8
Health
4.3
Staffing
4.7
QM
4.6

Owner / manager organizations (5)

Organization Role Association
ACTS RETIREMENT-LIFE COMMUNITIES INC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 05/01/1997
ACTS MANAGEMENT SERVICES, INC. OPERATIONAL/MANAGERIAL CONTROL since 01/01/2012
ACTS RETIREMENT-LIFE COMMUNITIES INC OPERATIONAL/MANAGERIAL CONTROL since 01/01/2012
ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC OPERATIONAL/MANAGERIAL CONTROL since 12/31/2022
ACTS RETIREMENT-LIFE COMMUNITIES INC 5% OR GREATER MORTGAGE INTEREST since 05/01/1997

Owner / manager individuals (29)

Name Role Association
AHERN, SUSAN OPERATIONAL/MANAGERIAL CONTROL since 01/01/2020
CHRISTIANSEN, KAREN OPERATIONAL/MANAGERIAL CONTROL since 01/26/2009
FOX, GLENN OPERATIONAL/MANAGERIAL CONTROL since 01/01/2017
GRANT, GERALD OPERATIONAL/MANAGERIAL CONTROL since 01/26/2009
ALLMOND, SUSAN CORPORATE DIRECTOR since 01/01/2015
BROD, KATHRYN CORPORATE DIRECTOR since 02/15/2024
CALLAWAY, WARREN CORPORATE DIRECTOR since 03/30/2022
CHAMBERLAIN, LINDA CORPORATE DIRECTOR since 01/01/2025
CHRISTIANSEN, KAREN CORPORATE DIRECTOR since 01/01/2020
DETWEILER, HAROLD CORPORATE DIRECTOR since 01/26/2009
ESTERHAI, JOHN CORPORATE DIRECTOR since 01/26/2009
GERNER, ELRIC CORPORATE DIRECTOR since 04/01/2009
GLYNN, JAMES CORPORATE DIRECTOR since 01/01/2023
GRANT, GERALD CORPORATE DIRECTOR since 05/04/2017
GREER, JASON CORPORATE DIRECTOR since 03/30/2022
KELLY, MICHAEL CORPORATE DIRECTOR since 02/11/2020
LAMMERS, JOHN CORPORATE DIRECTOR since 12/15/2020
LAWSON, DANIEL CORPORATE DIRECTOR since 06/11/2019
MASHNER, MARVIN CORPORATE DIRECTOR since 01/26/2009
MIDDLEBROOKS, DANIEL CORPORATE DIRECTOR since 01/01/2023
REICHARD, DAWN CORPORATE DIRECTOR since 06/01/2025
AHERN, SUSAN CORPORATE OFFICER since 01/01/2020
ALLMOND, SUSAN CORPORATE OFFICER since 01/01/2025
CHRISTIANSEN, KAREN CORPORATE OFFICER since 08/01/2014
FOX, GLENN CORPORATE OFFICER since 01/01/2017

Showing 25 of 29 individuals. Full list in CSV.

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
Yes
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 112 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $50 metrics.cost_per_resident_day
Cost Report Current Ratio 0.06 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicare Day Share (%) 6.7% metrics.medicare_day_share
Cost Report Net Income ($) $2,308,444 metrics.net_income
Cost Report Net Patient Revenue ($) $23,314,091 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 65.3% metrics.occupancy_rate
Cost Report Operating Margin (%) 5.2% metrics.operating_margin
Cost Report Total Assets ($) $44,122,645 metrics.total_assets
Cost Report Total Costs ($) $1,188,959 metrics.total_costs
Cost Report Total Fund Balances ($) $13,536,165 metrics.fund_balance
Cost Report Total Liabilities ($) $30,586,480 metrics.total_liabilities
Cost Report Total Margin (%) 9.5% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.55355 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.61733 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 1.57212 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 4.74299 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 4.41230 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 21.1 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.71896 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 1.95398 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.56670 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.23965 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 2.85541 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 4.3 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 4.8 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.6 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 4.7 Chain Average Staffing Rating
Provider Information Chain ID 9 Chain ID
Provider Information Chain Name ACTS RETIREMENT-LIFE COMMUNITIES Chain Name
Provider Information City/Town SOUTHAMPTON City/Town
Provider Information CMS Certification Number (CCN) 395490 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community Y Continuing Care Retirement Community
Provider Information County/Parish Bucks County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1980-12-19 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 5 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 40.1791 Latitude
Provider Information Legal Business Name ACTS RETIREMENT-LIFE COMMUNITIES INC Legal Business Name
Provider Information Location 238 STREET ROAD,SOUTHAMPTON,PA,18966 Location
Provider Information Long-Stay QM Rating 4 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -75.052 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 29 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 26 Number of Facilities in Chain
Provider Information Number of Fines 0 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.14766 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.83306 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 5 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type Non profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 238 STREET ROAD Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name WILLOWBROOKE COURT-SOUTHAMPTON Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 140 Provider SSA County Code
Provider Information Provider Type Medicare Provider Type
Provider Information QM Rating 5 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 0 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 0 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 0 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 0 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-12-05 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 0 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 0 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 0 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2025-01-08 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 0 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 0 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 0 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 0 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 0 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 1.09415 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 9.1 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.78362 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.46447 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.19616 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.43543 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 1.31914 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.97978 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 5 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 5 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State PA State
Provider Information Telephone Number 2153642550 Telephone Number
Provider Information Total Amount of Fines in Dollars 0.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.70230 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 0 Total Number of Penalties
Provider Information Total nursing staff turnover 17.8 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 0.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 18966 ZIP Code