Cycle 1
Health 2024-10-24 · Fire 2024-10-24
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Vero Beach, FL
Willowbrooke Court At Indian River Estates
5-star overall rating with 4-star inspections with $18,330 in total fines with 2 recent health deficiencies
2440 Citrus Blossom Cir, Vero Beach, FL
(772) 562-8700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
13
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1987-11-25
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
1.14
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.38
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.68
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.21
CMS adjusted RN staffing hours
Adjusted total hours
5.09
CMS adjusted total nurse staffing hours
Case-mix index
1.28
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
425
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0225
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.34
Baseline 16.93% · Performance 19.42% · Measure score 4.34 · Achievement 4.34 · Improvement 0
Healthcare-associated infections
6.73
Baseline 6.48% · Performance 5.82% · Measure score 6.73 · Achievement 6.73 · Improvement 3.92
Total nurse turnover
10
Baseline 23.08% · Performance 9.84% · Measure score 10 · Achievement 10 · Improvement 9
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 | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 9.72% · Lower 95% interval 8% |
| Discharge to community | 57.15% |
50.57%
6.6 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 54.7% · Lower 95% interval 48.35% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 1.15% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 87 |
| Discharge self-care score | 49.18% |
53.69%
4.5 pts worse
|
Numerator 30 · Denominator 61 |
| Discharge mobility score | 60.66% |
50.94%
9.7 pts better
|
Numerator 37 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 5.75% |
2.29%
3.5 pts worse
|
Numerator 5 · Denominator 87 · Adjusted rate 7.25% |
| Healthcare-associated infections requiring hospitalization | 5.82% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 3.06% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 1.6% |
8.2%
6.6 pts worse
|
Numerator 3 · Denominator 187 |
| Staff flu vaccination coverage | 89.91% |
42%
47.9 pts better
|
Numerator 196 · Denominator 218 |
| Discharge function score | 55.74% |
56.45%
0.7 pts worse
|
Numerator 34 · Denominator 61 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 32.08% |
25.2%
6.9 pts better
|
Numerator 17 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
94.3%
5.5 pts worse
|
81.7%
7.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 89.9% · Q3 86.5% · Q4 87.0% · 4Q avg 88.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
9.3%
2.5 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.1% · Expected 10.1% · 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 | 97.1% |
94.7%
2.4 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
26.2%
2.8 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 23.5% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-07
D · Potential for more than minimal harm
2022-03-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-04-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-24
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-11-24
D · Potential for more than minimal harm
2024-10-24
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-11-24
F · Potential for more than minimal harm
2023-08-03
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 2023-08-10
D · Potential for more than minimal harm
2022-03-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-05-01
D · Potential for more than minimal harm
2022-03-31
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 2022-05-01
D · Potential for more than minimal harm
2022-03-31
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 2022-05-01
D · Potential for more than minimal harm
2022-03-31
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-05-01
D · Potential for more than minimal harm
2022-03-31
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 2022-05-01
D · Potential for more than minimal harm
2022-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-01
D · Potential for more than minimal harm
2022-03-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-05-01
Penalties and ownership
What sits behind the stars
$18,330
2023-08-03
Fine
Fine · fine $18,330
Fine
Ownership
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 Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Esterhai, John
Corporate Officer · 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
Palm Garden Of Vero Beach
Vero Beach, FL
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Sea Breeze Rehab And Nursing Center
Vero Beach, FL
3-star overall rating with 3-star inspections with $7,456 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Vero Beach Care Center
Vero Beach, FL
1-star overall rating with 1-star inspections with $15,774 in total fines with 23 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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