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
Staffing
Hours and turnover
RN hours / resident day
1.82
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
2.66
Nurse aide staffing
Weekend hours
4.33
Weekend nurse staffing
RN turnover
17%
Annual RN turnover
Total nurse turnover
21%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
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
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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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