Cycle 1
Health 2025-05-01 · Fire 2025-05-01
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Boca Raton, FL
Willowbrooke Court At St Andrews Estates
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6152 N Verde Trail, Boca Raton, FL
(561) 487-5200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
89
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1979-06-13
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
1.22
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.26
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
936
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.96
Composite VBP score used to determine payment impact.
Payment multiplier
1.0169
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.17
Baseline 21.80% · Performance 19.57% · Measure score 4.17 · Achievement 4.01 · Improvement 4.17
Healthcare-associated infections
3.51
Baseline 8.76% · Performance 7.25% · Measure score 3.51 · Achievement 1.96 · Improvement 3.51
Total nurse turnover
10
Baseline 16.13% · Performance 17.86% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
7.10
Baseline 4.82 hours · Performance 5.10 hours · Measure score 7.10 · Achievement 7.10 · Improvement 2.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 6.32% · Lower 95% interval 6.04% |
| Discharge to community | 62.74% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 79 · Observed rate 59.49% · Lower 95% interval 52.76% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.33% |
95.27%
3.1 pts better
|
Numerator 59 · Denominator 60 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 60 |
| Discharge self-care score | 65.79% |
53.69%
12.1 pts better
|
Numerator 25 · Denominator 38 |
| Discharge mobility score | 52.63% |
50.94%
1.7 pts better
|
Numerator 20 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 4 · Denominator 60 · Adjusted rate 7.85% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0.69% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 145 |
| Staff flu vaccination coverage | 86.08% |
42%
44.1 pts better
|
Numerator 167 · Denominator 194 |
| Discharge function score | 71.05% |
56.45%
14.6 pts better
|
Numerator 27 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 40.54% |
25.2%
15.3 pts better
|
Numerator 15 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
97.8%
17.4 pts worse
|
93.4%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 95.2% · Q3 97.4% · Q4 91.7% · 4Q avg 80.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.0% |
99.2%
15.2 pts worse
|
95.5%
11.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
2.6%
2.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.8% · Q3 5.3% · Q4 5.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.9%
0.1 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 3.2% · Q3 0.0% · Q4 6.7% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
15.7%
0.6 pts worse
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 18.2% · Q3 22.6% · Q4 13.3% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
9.8%
3.6 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 4.3% · Q3 4.5% · Q4 4.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.3% |
11.7%
4.6 pts worse
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
9.8%
8.5 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 22.6% · Q3 24.1% · Q4 10.7% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long 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 long-stay residents with a urinary tract infection | 7.2% |
0.8%
6.4 pts worse
|
1.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.5% · Q3 7.9% · Q4 8.3% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.0% |
12.5%
0.5 pts better
|
19.8%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 10.0% · Q3 10.3% · Q4 19.1% · 4Q avg 12.0% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
5.1%
5.3 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.5% · Q3 9.1% · Q4 6.8% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.1% |
94.3%
26.2 pts worse
|
81.7%
13.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.2% · Q2 76.2% · Q3 76.9% · Q4 69.4% · 4Q avg 68.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
9.3%
7.3 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 14.1% · Expected 9.5% · 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 | 75.6% |
94.7%
19.1 pts worse
|
79.7%
4.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
26.2%
0.5 pts better
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 18.3% · Expected 17.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-29
D · Potential for more than minimal harm
2024-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-08
D · Potential for more than minimal harm
2022-09-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-09-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-01
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 2025-05-31
D · Potential for more than minimal harm
2025-05-01
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 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
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 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-01-25
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 2024-02-08
D · Potential for more than minimal harm
2024-01-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-25
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 2024-02-08
D · Potential for more than minimal harm
2024-01-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-08
D · Potential for more than minimal harm
2022-09-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
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 2022-10-09
D · Potential for more than minimal harm
2022-09-09
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
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 2022-10-09
Penalties and ownership
What sits behind the stars
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
Legacy At Boca Raton Rehabilitation And Nursing Ce
Boca Raton, FL
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Encore At Boca Raton Rehabilitation And Nursing Ce
Boca Raton, FL
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Boca Circle Rehabilitation Center
Boca Raton, FL
2-star overall rating with 2-star inspections with $31,736 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out