Cycle 1
Health 2024-02-23 · Fire 2024-02-23
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chestertown, MD
Willow Brooke Ct Skilled Care Ctr At Heron Point
5-star overall rating with 4-star inspections with $15,440 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
501 Campus Avenue, Chestertown, MD
(410) 778-7300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
3
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1991-11-07
CMS approved date
Coverage
Medicare + Medicaid
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
1.82
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.48
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
2.82
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
1.13
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
2.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.61
CMS adjusted RN staffing hours
Adjusted total hours
4.85
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.21% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 16.67% · Lower 95% interval 8.12% |
| Discharge to community | 58.84% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 59.46% · Lower 95% interval 46.96% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 82.61% |
95.27%
12.7 pts worse
|
Numerator 19 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.1% |
8.2%
2.1 pts worse
|
Numerator 5 · Denominator 82 |
| Staff flu vaccination coverage | 88.57% |
42%
46.6 pts better
|
Numerator 93 · Denominator 105 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0 |
1.3
1.3 pts better
|
1.9
1.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 56.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.2
1.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 34.7 · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.4%
21.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-09 · Fire 2019-04-09
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2017-11-06 · Fire 2017-11-06
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-30
F · Potential for more than minimal harm
2024-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-23
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-30
F · Potential for more than minimal harm
2019-04-09
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-06-13
F · Potential for more than minimal harm
2019-04-09
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2019-06-13
F · Potential for more than minimal harm
2019-04-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-06-13
F · Potential for more than minimal harm
2019-04-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-13
D · Potential for more than minimal harm
2017-11-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2017-11-08
D · Potential for more than minimal harm
2017-11-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2017-11-08
Inspection history
Recent health citations
J · Immediate jeopardy
2024-02-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-13
E · Potential for more than minimal harm
2024-02-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-02-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-02-23
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-08
E · Potential for more than minimal harm
2019-04-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2019-05-24
E · Potential for more than minimal harm
2019-04-09
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-05-24
E · Potential for more than minimal harm
2019-04-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-05-24
E · Potential for more than minimal harm
2019-04-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-05-24
E · Potential for more than minimal harm
2019-04-09
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-05-24
E · Potential for more than minimal harm
2019-04-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-05-24
D · Potential for more than minimal harm
2017-11-06
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2018-01-31
D · Potential for more than minimal harm
2017-11-06
F329 · Pharmacy Service Deficiencies
Health
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Corrected 2018-01-31
D · Potential for more than minimal harm
2017-11-06
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2018-01-31
D · Potential for more than minimal harm
2017-11-06
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2018-01-31
C · Minimal harm
2017-11-06
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2018-01-31
C · Minimal harm
2017-11-06
F456 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-01-31
Penalties and ownership
What sits behind the stars
$15,440
2024-02-23
Fine
Fine · fine $15,440
Fine
Ownership
Acts Communities Of Maryland, Inc.
Operational/Managerial Control · Organization
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Management, LLC
Operational/Managerial Control · Organization
Ahern, Susan
Operational/Managerial Control · Individual
Ahern, Susan
Corporate Officer · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Forrest, Anne
Corporate Director · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Grant, Jonathan
Operational/Managerial Control · Individual
Grant, Jonathan
Corporate Officer · Individual
Kelly, Michael
Corporate Director · Individual
Kurz, Stellah
Operational/Managerial Control · Individual
Lawson, Daniel
Corporate Director · Individual
Neary, Anne
Corporate Director · Individual
Paquette, Ellen
Corporate Director · Individual
Valdivia, Peggy
Operational/Managerial Control · Individual
Valdivia, Peggy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Chestertown Nursing And Rehab
Chestertown, MD
1-star overall rating with 1-star inspections with abuse icon flag with $3,418 in total fines with 41 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Resorts At Chester River Manor Corp
Chestertown, MD
4-star overall rating with 4-star inspections with 16 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Complete Care at Corsica Hills LLC
Centreville, MD
2-star overall rating with 2-star inspections with abuse icon flag with $55,564 in total fines with 6 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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