Cycle 1
Health 2025-07-29 · Fire 2024-09-03
4 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hockessin, DE
Willowbrooke Court At Cokesbury Village
5-star overall rating with 4-star inspections with 4 recent health deficiencies
726 Loveville Road, Hockessin, DE
(302) 234-4444
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
10
Certified beds
Average residents
5
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1978-10-16
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
1.24
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
1.00
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
1.84
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
1.39
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,511
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.78
Baseline 19.08% · Performance 19.68% · Measure score 3.78 · Achievement 3.78 · Improvement 0
Healthcare-associated infections
0.91
Baseline 5.46% · Performance 7.56% · Measure score 0.91 · Achievement 0.91 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
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 | 13.3% |
10.72%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 17.65% · Lower 95% interval 8.72% |
| Discharge to community | 67.25% |
50.57%
16.7 pts better
|
Better than the National Rate · Eligible stays 55 · Observed rate 69.09% · Lower 95% interval 55.68% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 84.21% |
95.27%
11.1 pts worse
|
Numerator 32 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 20 · Denominator 30 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 15 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 7.89% |
2.29%
5.6 pts worse
|
Numerator 3 · Denominator 38 · Adjusted rate 7.62% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 4.88% |
8.2%
3.3 pts worse
|
Numerator 6 · Denominator 123 |
| Staff flu vaccination coverage | 97.83% |
42%
55.8 pts better
|
Numerator 135 · Denominator 138 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 21 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
83.5%
7.6 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 91.3% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
11.2%
3.8 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.1% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
21.5%
5.5 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 12.1% · Expected 18.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-03 · Fire 2023-10-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-10-03 · Fire 2021-10-21
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-29
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-09-12
F · Potential for more than minimal harm
2024-09-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-03
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 2024-10-23
F · Potential for more than minimal harm
2023-10-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-03
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-03
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 2023-11-30
D · Potential for more than minimal harm
2023-10-03
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 2023-11-30
Penalties and ownership
What sits behind the stars
Ownership
Acts Management Services, Inc.
Operational/Managerial Control · 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 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
Regal Heights Healthcare & Rehab Center
Hockessin, DE
2-star overall rating with 2-star inspections with abuse icon flag with $140,261 in total fines with 20 recent health deficiencies
#2
Complete Care At Brackenville LLC
Hockessin, DE
5-star overall rating with 4-star inspections with $16,801 in total fines with 8 recent health deficiencies
#3
Pike Creek Nursing & Rehabilitation Center
Wilmington, DE
1-star overall rating with 1-star inspections with Special Focus status with $484,596 in total fines with 30 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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