Cycle 1
Health 2025-08-07 · Fire 2025-08-07
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pensacola, FL
Willowbrooke Court At Azalea Trace
5-star overall rating with 5-star inspections
10100 Hillview Dr, Pensacola, FL
(850) 478-5200
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
24
Certified beds
Average residents
9
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1983-08-20
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
1.21
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.10
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.90
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.74
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.38
CMS adjusted RN staffing hours
Adjusted total hours
5.57
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
16%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,017
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0161
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.04
Baseline 17.80% · Performance 18.63% · Measure score 6.04 · Achievement 6.04 · Improvement 0
Healthcare-associated infections
4.85
Baseline 5.19% · Performance 6.39% · Measure score 4.85 · Achievement 4.85 · Improvement 0
Total nurse turnover
7.42
Baseline 43.64% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 4.98
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 | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 5.94% · Lower 95% interval 6.38% |
| Discharge to community | 58.01% |
50.57%
7.4 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 57.3% · Lower 95% interval 49.69% |
| 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 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 52.94% |
53.69%
0.8 pts worse
|
Numerator 27 · Denominator 51 |
| Discharge mobility score | 25.49% |
50.94%
25.4 pts worse
|
Numerator 13 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 4.29% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 2.42% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 124 |
| Staff flu vaccination coverage | 91.97% |
42%
50 pts better
|
Numerator 126 · Denominator 137 |
| Discharge function score | 58.82% |
56.45%
2.4 pts better
|
Numerator 30 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 92.86% |
96.28%
3.4 pts worse
|
Numerator 26 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 25.93% |
25.2%
0.7 pts better
|
Numerator 7 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.5% |
94.3%
10.8 pts worse
|
81.7%
1.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 86.1% · Q3 80.0% · Q4 74.2% · 4Q avg 83.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.2% |
9.3%
21.9 pts worse
|
12.0%
19.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.2% · Observed 28.0% · Expected 10.0% · 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 | 83.3% |
94.7%
11.4 pts worse
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
26.2%
7.1 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 16.0% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-03 · Fire 2023-05-03
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-05-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-05-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-05-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-24
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement Services, Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Retirement-Life Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Retirement-Life Communities 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
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
Nearby options
Other facilities in reach
#1
Arcadia Health And Rehabilitation Center
Pensacola, FL
5-star overall rating with 5-star inspections
#2
Aviata At University Hills
Pensacola, FL
3-star overall rating with 2-star inspections with $39,545 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Solaris Healthcare Pensacola
Pensacola, FL
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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