Willowbrooke Court At Country House ratings, inspections, staffing, and fines

1

How this home got 5 stars

The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.

Health inspections

starting point

Everything starts from what state inspectors found on site. This is a ranking against other homes in Delaware.
Staffing

no change (already 5)

Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
Quality measures

no change (already 5)

Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
Overall

5 of 5

Matches the rating CMS publishes on Care Compare.

2

Where it sits among Delaware homes

Willowbrooke Court At Country House carries 2 inspection points. That is fewer than 95% of Delaware's 43 rated homes.

Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Delaware: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.

5★ 0–20 pts
4★ 20–57 pts
3★ 57–80 pts
2★ 80–139.25 pts
1★ over 139.25 pts

Bars show every rated home in Delaware by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.

3

What inspectors found

5 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.

One resident or a fewA patternWidespread

Immediate jeopardyResidents at risk of serious injury or death

J 0 50 pts

K 0 100 pts

L 0 150 pts

Actual harmA resident was hurt

G 0 20 pts

H 0 35 pts

I 0 45 pts

Potential for harmNo one was hurt, but could have been

D 3 4 pts

E 1 8 pts

F 1 16 pts

Minimal harmPaperwork-level problems

A 0 0 pts

B 0 0 pts

C 0 0 pts

Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.

Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.

No citation on record at the harm or immediate-jeopardy level.

Everything else, by area of care

Resident Rights1D

D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
February 26, 2025 · Standard · F623 · Corrected April 24, 2025

Quality of Life and Care1D

D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
February 26, 2025 · Complaint · F684 · Corrected April 24, 2025

Nutrition and Dietary1F

F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
February 9, 2024 · Standard · F812 · Corrected March 18, 2024

Resident Assessment and Care Planning1E

E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
February 9, 2024 · Standard · F842 · Corrected March 18, 2024

Nursing and Physician Services1D

D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
February 9, 2024 · Standard · F712 · Corrected March 18, 2024

Inspection history

2026-03-23
0 health deficiencies · 0 fire-safety deficiencies
No concentrated health issue counts in this cycle.
2025-02-26
2 health deficiencies · 0 fire-safety deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2024-02-09
3 health deficiencies · 1 fire-safety deficiencies
Top issue: Nursing and Physician Services (1 deficiency)

4

Nursing time per resident, per day

Each resident here gets about 4 h 29 min of nursing staff time a day, 1 h 27 min of it from a registered nurse.

This home

4 h 29 min

Delaware average

4 h 29 min

U.S. average

3 h 54 min

Registered nurse
Licensed practical nurse
Nurse aide

Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.

5

Resident outcomes

Quality measures compared with state and national averages. Most come from assessments the home itself reports.

Measure	This home	State	U.S.
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.3 pts better	96.8%	84.5%	82.3%
Percentage of short-stay residents who had an outpatient emergency department visit7.6 pts better	3.2%	10.8%	11.8%
Percentage of short-stay residents who newly received an antipsychotic medication0.9 pts better	0.0%	0.9%	1.5%
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine11.6 pts better	100.0%	88.4%	80.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission6.9 pts worse	29.6%	22.7%	23.4%

·

Who owns and runs it

55 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.

Show ownership list

Name	Role	Share	Homes
Acts Acquisition And Development Company LLC	Indirect Ownership Interest · Organization	0%	25 facilities
Acts Alliance Management LLC	Indirect Ownership Interest · Organization	0%	25 facilities
Acts Communities Of Maryland, Inc.	Indirect Ownership Interest · Organization	0%	25 facilities
Acts Legacy Foundation, Inc.	Indirect Ownership Interest · Organization	0%	25 facilities
Acts Management Services, Inc.	Indirect Ownership Interest · Organization	0%	27 facilities
Acts Management Services, Inc.	Operational/Managerial Control · Organization	0%	27 facilities
Acts Management Services, Inc.	Adp Of The SNF · Organization	0%	27 facilities
Acts Retirement Services, Inc	Indirect Ownership Interest · Organization	0%	26 facilities
Acts Retirement-Life Communities Inc	Operational/Managerial Control · Organization	0%	22 facilities
Acts Retirement-Life Communities Inc	Adp Of The SNF · Organization	0%	22 facilities
Acts Retirement-Life Communities Management, LLC	Indirect Ownership Interest · Organization	0%	27 facilities
Acts Retirement-Life Communities Management, LLC	Operational/Managerial Control · Organization	0%	27 facilities
Acts Retirement-Life Communities Management, LLC	Adp Of The SNF · Organization	0%	27 facilities
Acts Signature Community Services Inc	Indirect Ownership Interest · Organization	0%	25 facilities
Ahern, Susan	Corporate Officer · Individual	0%	27 facilities
Ahern, Susan	Operational/Managerial Control · Individual	0%	27 facilities
Ahern, Susan	Adp Of The SNF · Individual	0%	27 facilities
Allmond, Susan	Corporate Director · Individual	0%	23 facilities
Allmond, Susan	Corporate Officer · Individual	0%	23 facilities
Baker Tilly Advisory Group LP	Adp Of The SNF · Organization	0%	83 facilities
Baker Tilly Us Llp	Adp Of The SNF · Organization	0%	75 facilities
Bonita Springs Retirement Village Inc	Indirect Ownership Interest · Organization	0%	25 facilities
Brod, Kathryn	Corporate Director · Individual	0%	24 facilities
Callaway, Warren	Corporate Director · Individual	0%	21 facilities
Chamberlain, Linda	Corporate Director · Individual	0%	22 facilities
Christiansen, Karen	Corporate Director · Individual	0%	27 facilities
Christiansen, Karen	Corporate Officer · Individual	0%	27 facilities
Christiansen, Karen	Operational/Managerial Control · Individual	0%	27 facilities
Christiansen, Karen	Adp Of The SNF · Individual	0%	27 facilities
Detweiler, Harold	Corporate Director · Individual	0%	25 facilities
Esterhai, John	Corporate Director · Individual	0%	21 facilities
Fox, Glenn	Corporate Officer · Individual	0%	27 facilities
Fox, Glenn	Operational/Managerial Control · Individual	0%	27 facilities
Fox, Glenn	Adp Of The SNF · Individual	0%	27 facilities
Gerner, Elric	Corporate Director · Individual	0%	24 facilities
Gerner, Elric	Corporate Officer · Individual	0%	24 facilities
Glynn, James	Corporate Director · Individual	0%	23 facilities
Grant, Gerald	Corporate Director · Individual	0%	29 facilities
Grant, Gerald	Corporate Officer · Individual	0%	29 facilities
Grant, Gerald	Operational/Managerial Control · Individual	0%	29 facilities
Grant, Gerald	Adp Of The SNF · Individual	0%	29 facilities
Greenwalt, Jennifer	Adp Of The SNF · Individual	0%	1 facilities
Greer, Jason	Corporate Director · Individual	0%	21 facilities
Janney, Brian	Adp Of The SNF · Individual	0%	3 facilities
Kelly, Michael	Corporate Director · Individual	0%	30 facilities
Lammers, John	Corporate Director · Individual	0%	21 facilities
Lawson, Daniel	Corporate Director · Individual	0%	25 facilities
Lawson, Daniel	Corporate Officer · Individual	0%	25 facilities
Mashner, Marvin	Corporate Director · Individual	0%	23 facilities
Mashner, Marvin	Corporate Officer · Individual	0%	23 facilities
Mease Life Inc	Indirect Ownership Interest · Organization	0%	25 facilities
Middlebrooks, Daniel	Corporate Director · Individual	0%	21 facilities
Reichard, Dawn	Corporate Director · Individual	0%	21 facilities
U.s. Bank	Trustee Of The SNF · Organization	0%	42 facilities
U.s. Bank	Adp Of The SNF · Organization	0%	42 facilities

·

Fire safety

1 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.

Emergency Preparedness1E

E
Establish staff and initial training requirements.
February 9, 2024 · E37 · Corrected March 18, 2024

·

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