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)
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
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
Staffing
Hours and turnover
RN hours / resident day
1.39
Registered nurse staffing
LPN hours / resident day
0.64
Licensed practical nurse staffing
Aide hours / resident day
2.19
Nurse aide staffing
Weekend hours
3.87
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 20.1% |
26.6%
6.5 pts better
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
Acts Retirement Services, Inc
5% Or Greater Indirect Ownership Interest · Organization
Acts Communities Of Maryland, Inc.
Operational/Managerial Control · Organization
Acts Communities Of Maryland, Inc.
5% Or Greater Mortgage 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
Athen, Michael
Operational/Managerial Control · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Forrest, Anne
Corporate Director · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Grant, Jonathan
Operational/Managerial Control · Individual
Grant, Jonathan
Corporate Officer · Individual
Kelly, Michael
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Neary, Anne
Corporate Director · Individual
Paquette, Ellen
Corporate Director · Individual
Valdivia, Peggy
Operational/Managerial Control · Individual
Valdivia, Peggy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Autumn Lake Healthcare At Birch Manor
Sykesville, MD
3-star overall rating with 3-star inspections with 23 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Copper Ridge Nursing And Assisted Living Center
Sykesville, MD
1-star overall rating with 2-star inspections with abuse icon flag with 21 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Chapel Hill Nursing Center
Randallstown, MD
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
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