Sykesville, MD

Willowbrooke Court Skilled Care Center Fairhaven

4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

7200 Third Avenue, Sykesville, MD

(410) 795-8800

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

79

Certified beds

Average residents

41

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Acts Retirement-Life Communities

Operator or chain grouping

Approved since

1981-01-05

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

1.39

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

0.64

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.19

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

4.22

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

2.03

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

3.87

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

1.14

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.27

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

1.55

CMS adjusted RN staffing hours

Adjusted total hours

4.73

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

42%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

587

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

66.94

Composite VBP score used to determine payment impact.

Payment multiplier

1.0206

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.53

Baseline 21.43% · Performance 18.40% · Measure score 6.53 · Achievement 6.53 · Improvement 6.37

Healthcare-associated infections

7.14

Baseline 6.06% · Performance 5.70% · Measure score 7.14 · Achievement 7.14 · Improvement 2.89

Total nurse turnover

7.11

Baseline 38.33% · Performance 34.62% · Measure score 7.11 · Achievement 7.11 · Improvement 2.26

Adjusted total nurse staffing

5.99

Baseline 4.68 hours · Performance 4.78 hours · Measure score 5.99 · Achievement 5.99 · Improvement 0.40

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 12.08%
10.72%
1.4 pts worse
No Different than the National Rate · Eligible stays 100 · Observed rate 13% · Lower 95% interval 7.47%
Discharge to community 68.35%
50.57%
17.8 pts better
Better than the National Rate · Eligible stays 79 · Observed rate 69.62% · Lower 95% interval 57.63%
Medicare spending per beneficiary 0.93
1.02
0.1 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 61 · Denominator 61
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 61
Discharge self-care score 71.15%
53.69%
17.5 pts better
Numerator 37 · Denominator 52
Discharge mobility score 44.23%
50.94%
6.7 pts worse
Numerator 23 · Denominator 52
Pressure ulcers or injuries, new or worsened 1.64%
2.29%
0.7 pts better
Numerator 1 · Denominator 61 · Adjusted rate 1.68%
Healthcare-associated infections requiring hospitalization 5.7%
7.12%
1.4 pts better
No Different than the National Rate · Eligible stays 54 · Observed rate 0% · Lower 95% interval 2.82%
Staff COVID-19 vaccination coverage 1.87%
8.2%
6.3 pts worse
Numerator 2 · Denominator 107
Staff flu vaccination coverage 89.93%
42%
47.9 pts better
Numerator 134 · Denominator 149
Discharge function score 59.62%
56.45%
3.2 pts better
Numerator 31 · Denominator 52
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 31 · Denominator 31
Resident COVID-19 vaccinations up to date 31.43%
25.2%
6.2 pts better
Numerator 11 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.3
1.3
2 pts worse
1.9
1.4 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.5 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.5
1.2
0.3 pts worse
1.8
0.3 pts better
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 83.9%
91.9%
8 pts worse
93.4%
9.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 85.7% · Q3 86.2% · Q4 81.8% · 4Q avg 83.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
96.6%
3.4 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury 2.5%
2.3%
0.2 pts worse
3.3%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 6.1% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.0%
21.4%
21.4 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 5.0%
5.7%
0.7 pts better
5.4%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.0% · Q4 10.7% · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 18.3%
16.1%
2.2 pts worse
19.6%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 23.1% · Q4 16.7% · 4Q avg 18.3%
Percentage of long-stay residents who received an antipsychotic medication 2.4%
15.3%
12.9 pts better
16.7%
14.3 pts better
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 4.0% · 4Q avg 2.4% · 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 20.1%
26.6%
6.5 pts better
16.3%
3.8 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 20.6%
22.9%
2.3 pts better
14.9%
5.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 17.4% · Q3 23.1% · Q4 16.7% · 4Q avg 20.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.8%
0.7%
3.1 pts worse
1.0%
2.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 6.2% · Q4 5.3% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.6%
1.5%
1.1 pts worse
1.7%
0.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 3.6% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 19.5%
25.4%
5.9 pts better
19.8%
0.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 29.7% · Q3 20.1% · Q4 8.2% · 4Q avg 19.5%
Percentage of long-stay residents with pressure ulcers 3.3%
6.3%
3 pts better
5.1%
1.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.0% · Q3 3.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 78.3%
78.4%
0.1 pts worse
81.7%
3.4 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 77.5% · Q3 72.5% · Q4 76.2% · 4Q avg 78.3%
Percentage of short-stay residents who had an outpatient emergency department visit 13.4%
9.9%
3.5 pts worse
12.0%
1.4 pts worse
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.1% · Expected 10.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.9%
1.3%
0.4 pts better
1.6%
0.7 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 87.8%
80.6%
7.2 pts better
79.7%
8.1 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 24.8%
21.2%
3.6 pts worse
23.9%
0.9 pts worse
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 20.7% · Expected 19.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-18 · Fire 2025-07-18

11 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-06-02 · Fire 2022-06-02

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 3 Health 2018-11-15 · Fire 2018-11-15

14 health deficiencies

Top issue: Nursing and Physician Services (3 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-10-01

F · Potential for more than minimal harm 2025-07-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-01

F · Potential for more than minimal harm 2025-07-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-07-18

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-07-18

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-10-01

F · Potential for more than minimal harm 2022-06-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-02

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-02

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-02

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2022-07-08

E · Potential for more than minimal harm 2018-11-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-12-31

D · Potential for more than minimal harm 2018-11-15

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2018-12-31

C · Minimal harm 2018-11-15

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2019-01-25

C · Minimal harm 2018-11-15

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2019-01-25

C · Minimal harm 2018-11-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2018-12-31

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-07-18

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-09-25

F · Potential for more than minimal harm 2025-07-18

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 2025-09-25

E · Potential for more than minimal harm 2025-07-18

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

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 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-09-25

D · Potential for more than minimal harm 2025-07-18

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-09-25

G · Actual harm 2022-06-02

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 2022-07-01

F · Potential for more than minimal harm 2022-06-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-07-01

E · Potential for more than minimal harm 2022-06-02

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2022-07-27

E · Potential for more than minimal harm 2022-06-02

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-07-27

D · Potential for more than minimal harm 2022-06-02

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 2022-07-01

D · Potential for more than minimal harm 2022-06-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-07-01

D · Potential for more than minimal harm 2022-06-02

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-07-01

E · Potential for more than minimal harm 2018-11-15

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 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

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 2018-12-21

D · Potential for more than minimal harm 2018-11-15

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 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2018-12-21

D · Potential for more than minimal harm 2018-11-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-12-21

Penalties and ownership

What sits behind the stars

Ownership

Acts Communities Of Maryland, Inc.

5% Or Greater Direct Ownership Interest · Organization

100% 4 facilities 2022-12-31
Acts Retirement Services, Inc

5% Or Greater Indirect Ownership Interest · Organization

100% 4 facilities 2022-12-31
Acts Communities Of Maryland, Inc.

Operational/Managerial Control · Organization

0% 4 facilities 2022-12-31
Acts Communities Of Maryland, Inc.

5% Or Greater Mortgage Interest · Organization

0% 4 facilities 2022-12-31
Acts Management Services, Inc.

Operational/Managerial Control · Organization

0% 27 facilities 2022-12-31
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 2025-01-01
Ahern, Susan

Corporate Officer · Individual

0% 27 facilities 2025-01-01
Athen, Michael

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01
Christiansen, Karen

Operational/Managerial Control · Individual

0% 27 facilities 2025-01-01
Christiansen, Karen

Corporate Director · Individual

0% 27 facilities 2025-01-01
Christiansen, Karen

Corporate Officer · Individual

0% 27 facilities 2025-01-01
Detweiler, Harold

Corporate Director · Individual

0% 25 facilities 2025-01-01
Forrest, Anne

Corporate Director · Individual

0% 4 facilities 2025-01-01
Fox, Glenn

Operational/Managerial Control · Individual

0% 27 facilities 2025-01-01
Fox, Glenn

Corporate Officer · Individual

0% 27 facilities 2025-01-01
Grant, Gerald

Operational/Managerial Control · Individual

0% 29 facilities 2025-01-01
Grant, Gerald

Corporate Director · Individual

0% 29 facilities 2025-01-01
Grant, Gerald

Corporate Officer · Individual

0% 29 facilities 2025-01-01
Grant, Jonathan

Operational/Managerial Control · Individual

0% 6 facilities 2025-01-01
Grant, Jonathan

Corporate Officer · Individual

0% 6 facilities 2025-01-01
Kelly, Michael

Corporate Director · Individual

0% 33 facilities 2025-01-01
Lawson, Daniel

Corporate Director · Individual

0% 25 facilities 2025-01-01
Neary, Anne

Corporate Director · Individual

0% 4 facilities 2025-01-01
Paquette, Ellen

Corporate Director · Individual

0% 4 facilities 2025-01-01
Valdivia, Peggy

Operational/Managerial Control · Individual

0% 6 facilities 2025-01-01
Valdivia, Peggy

Corporate Officer · Individual

0% 6 facilities 2025-01-01

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Fines
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Chapel Hill Nursing Center

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1-star overall rating with 2-star inspections with $13,247 in total fines with 12 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle

Overall
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Staffing
4 / 5
Fines
$13,247

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