Cycle 1
Health 2025-02-26 · Fire 2025-02-26
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, DE
Willowbrooke Court At Country House
5-star overall rating with 5-star inspections with 2 recent health deficiencies
4830 Kennett Pike, Wilmington, DE
(302) 654-5101
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
14
Certified beds
Average residents
6
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1967-01-01
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
1.32
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.89
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
1.73
CMS adjusted RN staffing hours
Adjusted total hours
5.08
CMS adjusted total nurse staffing hours
Case-mix index
1.04
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
2,020
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.27
Composite VBP score used to determine payment impact.
Payment multiplier
1.0068
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.62
Performance 18.83% · Measure score 5.62 · Achievement 5.62 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.83
Performance 6.39% · Measure score 4.83 · Achievement 4.83 · This facility did not have sufficient data to calculate a baseline period measure result.
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 | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 71 · Observed rate 8.45% · Lower 95% interval 6.73% |
| Discharge to community | 69.85% |
50.57%
19.3 pts better
|
Better than the National Rate · Eligible stays 62 · Observed rate 74.19% · Lower 95% interval 58.61% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 62.86% |
53.69%
9.2 pts better
|
Numerator 22 · Denominator 35 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 20 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 46 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 2.27% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 6.59% |
8.2%
1.6 pts worse
|
Numerator 6 · Denominator 91 |
| Staff flu vaccination coverage | 95.65% |
42%
53.7 pts better
|
Numerator 110 · Denominator 115 |
| Discharge function score | 80% |
56.45%
23.5 pts better
|
Numerator 28 · Denominator 35 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 76.92% |
25.2%
51.7 pts better
|
Numerator 20 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
83.5%
13.6 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.2% · Q4 90.5% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.2%
5.1 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.9% · Expected 10.7% · 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 · Q1 0.0% · Q2 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 | 100.0% |
83.1%
16.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
21.5%
0.8 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 20.6% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-04-26 · Fire 2022-04-26
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-26
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 2025-04-24
D · Potential for more than minimal harm
2025-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-24
F · Potential for more than minimal harm
2024-02-09
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 2024-03-18
E · Potential for more than minimal harm
2024-02-09
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 2024-03-18
D · Potential for more than minimal harm
2024-02-09
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-03-18
D · Potential for more than minimal harm
2022-04-26
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 2022-06-24
Penalties and ownership
What sits behind the stars
Ownership
Acts Retirement-Life Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Management Services, Inc.
Operational/Managerial Control · 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
Stonegates
Greenville, DE
4-star overall rating with 3-star inspections with $48,696 in total fines with 5 recent health deficiencies
#2
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
#3
Excelcare At Wilmington LLC
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with $38,290 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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