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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

1.37

Registered nurse staffing

LPN hours / resident day

0.55

Licensed practical nurse staffing

Aide hours / resident day

2.62

Nurse aide staffing

Weekend hours

4.33

Weekend nurse staffing

RN turnover

8%

Annual RN turnover

Total nurse turnover

7%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

0% 27 facilities 2012-01-01
Acts Retirement-Life Communities Inc

Operational/Managerial Control · Organization

0% 19 facilities 2012-01-01
Acts Retirement-Life Communities Management, LLC

Operational/Managerial Control · Organization

0% 25 facilities 2022-12-31
Ahern, Susan

Operational/Managerial Control · Individual

0% 27 facilities 2020-01-01
Ahern, Susan

Corporate Officer · Individual

0% 27 facilities 2020-01-01
Allmond, Susan

Corporate Director · Individual

0% 23 facilities 2015-01-01
Allmond, Susan

Corporate Officer · Individual

0% 23 facilities 2025-01-01
Brod, Kathryn

Corporate Director · Individual

0% 22 facilities 2024-02-15
Callaway, Warren

Corporate Director · Individual

0% 19 facilities 2022-03-30
Chamberlain, Linda

Corporate Director · Individual

0% 20 facilities 2025-01-01
Christiansen, Karen

Operational/Managerial Control · Individual

0% 27 facilities 2009-01-26
Christiansen, Karen

Corporate Director · Individual

0% 27 facilities 2009-01-26
Christiansen, Karen

Corporate Officer · Individual

0% 27 facilities 2010-05-25
Detweiler, Harold

Corporate Director · Individual

0% 25 facilities 2009-01-26
Esterhai, John

Corporate Director · Individual

0% 21 facilities 1996-05-01
Fox, Glenn

Operational/Managerial Control · Individual

0% 27 facilities 2017-01-01
Fox, Glenn

Corporate Officer · Individual

0% 27 facilities 2017-01-01
Gerner, Elric

Corporate Director · Individual

0% 24 facilities 2009-04-01
Gerner, Elric

Corporate Officer · Individual

0% 24 facilities 2010-01-01
Glynn, James

Corporate Director · Individual

0% 21 facilities 2023-01-01
Grant, Gerald

Operational/Managerial Control · Individual

0% 29 facilities 2009-01-26
Grant, Gerald

Corporate Director · Individual

0% 29 facilities 2009-01-26
Grant, Gerald

Corporate Officer · Individual

0% 29 facilities 2005-06-01
Greer, Jason

Corporate Director · Individual

0% 19 facilities 2022-03-30
Kelly, Michael

Corporate Director · Individual

0% 33 facilities 2020-02-11
Lammers, John

Corporate Director · Individual

0% 21 facilities 2020-12-15
Lawson, Daniel

Corporate Director · Individual

0% 25 facilities 2019-06-11
Lawson, Daniel

Corporate Officer · Individual

0% 25 facilities 2025-01-01
Mashner, Marvin

Corporate Director · Individual

0% 23 facilities 1991-01-01
Mashner, Marvin

Corporate Officer · Individual

0% 23 facilities 2025-01-01
Middlebrooks, Daniel

Corporate Director · Individual

0% 19 facilities 2023-01-01
Reichard, Dawn

Corporate Director · Individual

0% 19 facilities 2025-06-01

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