Cycle 1
Health 2024-11-22 · Fire 2024-11-22
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Adamstown, MD
Willowbrooke Ct Skilled Care Buckingham's Choice
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3200 Baker Circle, Adamstown, MD
(301) 644-1636
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
42
Certified beds
Average residents
25
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
2000-03-18
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.48
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
1.35
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.61
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
9%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,276
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0133
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.42
Baseline 22.55% · Performance 20.93% · Measure score 2.42 · Achievement 1.07 · Improvement 2.42
Healthcare-associated infections
5.02
Baseline 6.34% · Performance 6.34% · Measure score 5.02 · Achievement 5.02 · Improvement 0
Total nurse turnover
10
Baseline 36.00% · Performance 21.74% · Measure score 10 · Achievement 10 · Improvement 9
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 | 12.19% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 13.11% · Lower 95% interval 8.09% |
| Discharge to community | 60.43% |
50.57%
9.9 pts better
|
Better than the National Rate · Eligible stays 105 · Observed rate 60% · Lower 95% interval 51.29% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 49 |
| Discharge self-care score | 34.29% |
53.69%
19.4 pts worse
|
Numerator 12 · Denominator 35 |
| Discharge mobility score | 48.57% |
50.94%
2.4 pts worse
|
Numerator 17 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 8.16% |
2.29%
5.9 pts worse
|
Numerator 4 · Denominator 49 · Adjusted rate 7.58% |
| Healthcare-associated infections requiring hospitalization | 6.34% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 14 · Denominator 98 |
| Staff flu vaccination coverage | 96.48% |
42%
54.5 pts better
|
Numerator 137 · Denominator 142 |
| Discharge function score | 45.71% |
56.45%
10.7 pts worse
|
Numerator 16 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 75% |
25.2%
49.8 pts better
|
Numerator 18 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.3
0.8 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.9%
8.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 4.8% · Q4 0.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.7%
0.1 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
16.1%
8.2 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
15.3%
9.7 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
22.9%
8.6 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.7%
1 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 2.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
25.4%
10.2 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 24.5% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 14.5% |
6.3%
8.2 pts worse
|
5.1%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 9.7% · Q4 10.8% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.4%
21.6 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 | 16.6% |
9.9%
6.7 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 14.0% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.3%
1.8 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.6%
19.4 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 | 16.8% |
21.2%
4.4 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 14.0% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-19 · Fire 2019-08-19
14 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-06-22 · Fire 2018-06-22
10 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-07
D · Potential for more than minimal harm
2019-08-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-09-30
D · Potential for more than minimal harm
2019-08-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-09-30
B · Minimal harm
2019-08-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-09-30
D · Potential for more than minimal harm
2018-06-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-08-09
C · Minimal harm
2018-06-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-07-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-22
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 2024-12-13
E · Potential for more than minimal harm
2024-11-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-22
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 2024-12-13
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
F · Potential for more than minimal harm
2019-08-19
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 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
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 2019-10-17
D · Potential for more than minimal harm
2019-08-19
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 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
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 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-17
E · Potential for more than minimal harm
2018-06-22
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 2018-08-31
D · Potential for more than minimal harm
2018-06-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-06-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-06-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-06-22
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 2018-08-31
D · Potential for more than minimal harm
2018-06-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-08-31
C · Minimal harm
2018-06-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2018-08-31
C · Minimal harm
2018-06-22
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 2018-08-31
C · Minimal harm
2018-06-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2018-08-31
C · Minimal harm
2018-06-22
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 2018-08-31
Penalties and ownership
What sits behind the stars
Ownership
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
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Desmarais, Normand
Corporate Director · 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
Grimmel, Eric
Operational/Managerial Control · 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
Frederick Crossing Of Journey
Frederick, MD
3-star overall rating with 2-star inspections with abuse icon flag with $13,538 in total fines with 22 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Autumn Lake Healthcare At Braddock Heights
Frederick, MD
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Northampton Manor Nursing And Rehabilitation Cente
Frederick, MD
1-star overall rating with 1-star inspections with $16,562 in total fines with 34 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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