Cycle 1
Health 2025-03-27 · Fire 2025-03-27
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Media, PA
Willowbrooke Court-Granite
5-star overall rating with 5-star inspections with 9 fire-safety deficiencies in the latest cycle
1343 West Baltimore Pike, Media, PA
(610) 358-0510
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
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
1987-07-17
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
1.37
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.07
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
1.38
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.53
CMS adjusted RN staffing hours
Adjusted total hours
4.42
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
2,415
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.89
Composite VBP score used to determine payment impact.
Payment multiplier
1.0039
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.18
Baseline 18.57% · Performance 19.50% · Measure score 4.18 · Achievement 4.18 · Improvement 0
Healthcare-associated infections
5.80
Baseline 5.85% · Performance 6.10% · Measure score 5.80 · Achievement 5.80 · 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 | 12.02% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 16.33% · Lower 95% interval 8.14% |
| Discharge to community | 66.34% |
50.57%
15.8 pts better
|
Better than the National Rate · Eligible stays 41 · Observed rate 68.29% · Lower 95% interval 53.99% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 52.17% |
53.69%
1.5 pts worse
|
Numerator 12 · Denominator 23 |
| Discharge mobility score | 30.43% |
50.94%
20.5 pts worse
|
Numerator 7 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 0% · Lower 95% interval 2.6% |
| Staff COVID-19 vaccination coverage | 3.62% |
8.2%
4.6 pts worse
|
Numerator 5 · Denominator 138 |
| Staff flu vaccination coverage | 90.78% |
42%
48.8 pts better
|
Numerator 128 · Denominator 141 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 12 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 85.0% |
68.9%
16.1 pts better
|
81.7%
3.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 85.0% · Q3 96.0% · Q4 83.3% · 4Q avg 85.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
9.8%
1.3 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.4% · Expected 9.7% · 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 · 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 | 100.0% |
68.7%
31.3 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 | 12.7% |
23.1%
10.4 pts better
|
23.9%
11.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 11.1% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
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 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-30
E · Potential for more than minimal harm
2024-04-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-04-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-24
E · Potential for more than minimal harm
2023-05-11
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-05-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-05-11
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 2023-06-02
D · Potential for more than minimal harm
2023-05-11
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 2023-06-02
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 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
Fair Acres Geriatric Center
Lima, PA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Willowbrooke Court Skd Care Center At Lima Estates
Lima, PA
5-star overall rating with 5-star inspections
#3
Hcc At White Horse Village
Newtown Square, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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