Cycle 1
Health 2025-03-27 · Fire 2025-03-27
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Boca Raton, FL
Willowbrooke Court Skilled Care Center - Edgewater
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
23305 Blue Water Circle, Boca Raton, FL
(561) 368-5600
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
60
Certified beds
Average residents
18
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1984-11-07
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 0.73 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.23
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.51
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
7%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,023
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0161
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.27% · Performance 21.69% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.79
Baseline 6.33% · Performance 6.10% · Measure score 5.79 · Achievement 5.79 · Improvement 1.16
Total nurse turnover
10
Baseline 21.67% · Performance 6.25% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
8.61
Baseline 5.16 hours · Performance 5.53 hours · Measure score 8.61 · Achievement 8.61 · Improvement 5.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.54% |
10.72%
3.8 pts worse
|
Worse than the National Rate · Eligible stays 150 · Observed rate 16.67% · Lower 95% interval 11.23% |
| Discharge to community | 72.4% |
50.57%
21.8 pts better
|
Better than the National Rate · Eligible stays 126 · Observed rate 69.05% · Lower 95% interval 63.96% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 92 · Denominator 92 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 92 |
| Discharge self-care score | 78.48% |
53.69%
24.8 pts better
|
Numerator 62 · Denominator 79 |
| Discharge mobility score | 58.23% |
50.94%
7.3 pts better
|
Numerator 46 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 1.11% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 2.47% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 0.68% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 148 |
| Staff flu vaccination coverage | 87.26% |
42%
45.3 pts better
|
Numerator 137 · Denominator 157 |
| Discharge function score | 82.28% |
56.45%
25.8 pts better
|
Numerator 65 · Denominator 79 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 71.11% |
25.2%
45.9 pts better
|
Numerator 32 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
2.1
1.8 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
2.6%
0.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
5.9%
5.2 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.7% |
15.7%
12 pts better
|
19.6%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
11.7%
3.2 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.7% |
9.8%
6.1 pts better
|
14.9%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
0.8%
4 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.6% |
12.5%
3.9 pts better
|
19.8%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.1%
1.2 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
9.3%
5 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.0% · Expected 10.4% · 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 | 100.0% |
94.7%
5.3 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 | 27.4% |
26.2%
1.2 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 21.8% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-01
F · 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 2025-05-01
F · Potential for more than minimal harm
2025-03-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-12-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-14
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 2024-01-12
D · Potential for more than minimal harm
2022-08-04
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-09-03
D · Potential for more than minimal harm
2022-08-04
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 2022-09-03
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 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
Stratford Court Of Boca Raton
Boca Raton, FL
5-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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
#3
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
Jump out