Easton, MD

Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase

2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

501 Dutchman's Lane, Easton, MD

(410) 822-8888

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

99

Certified beds

Average residents

60

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Acts Retirement-Life Communities

Operator or chain grouping

Approved since

1982-01-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.96

Registered nurse staffing

LPN hours / resident day

0.66

Licensed practical nurse staffing

Aide hours / resident day

2.02

Nurse aide staffing

Weekend hours

3.32

Weekend nurse staffing

RN turnover

12%

Annual RN turnover

Total nurse turnover

21%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.9
1.3
0.4 pts better
1.9
1 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.7
1.2
0.5 pts worse
1.8
0.1 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 97.0%
91.9%
5.1 pts better
93.4%
3.6 pts better
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 5.0%
2.3%
2.7 pts worse
3.3%
1.7 pts worse
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 7.7%
5.7%
2 pts worse
5.4%
2.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 26.1%
16.1%
10 pts worse
19.6%
6.5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 23.4%
15.3%
8.1 pts worse
16.7%
6.7 pts worse
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 13.0%
26.6%
13.6 pts better
16.3%
3.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 22.4%
22.9%
0.5 pts better
14.9%
7.5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.5%
0.7%
0.8 pts worse
1.0%
0.5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 1.0%
1.5%
0.5 pts better
1.7%
0.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 20.5%
25.4%
4.9 pts better
19.8%
0.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 11.0%
6.3%
4.7 pts worse
5.1%
5.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 89.0%
78.4%
10.6 pts better
81.7%
7.3 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 16.2%
9.9%
6.3 pts worse
12.0%
4.2 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.3%
1.3 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 89.4%
80.6%
8.8 pts better
79.7%
9.7 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.2%
21.2%
1 pts better
23.9%
3.7 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-17 · Fire 2025-01-17

7 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

11 fire-safety deficiencies

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

Cycle 2 Health 2019-07-12 · Fire 2019-07-12

16 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2018-02-21 · Fire 2018-02-21

15 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-17

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-03-20

F · Potential for more than minimal harm 2025-01-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-20

F · Potential for more than minimal harm 2025-01-17

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-20

F · Potential for more than minimal harm 2025-01-17

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-03-20

F · Potential for more than minimal harm 2025-01-17

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-03-20

E · Potential for more than minimal harm 2025-01-17

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-03-20

E · Potential for more than minimal harm 2025-01-17

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-03-20

E · Potential for more than minimal harm 2025-01-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-01-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-01-17

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-01-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-03-20

F · Potential for more than minimal harm 2019-07-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-10-15

F · Potential for more than minimal harm 2019-07-12

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2019-10-15

F · Potential for more than minimal harm 2019-07-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2019-10-15

F · Potential for more than minimal harm 2019-07-12

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2019-10-15

F · Potential for more than minimal harm 2019-07-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2019-10-15

E · Potential for more than minimal harm 2019-07-12

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2019-10-15

E · Potential for more than minimal harm 2019-07-12

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-10-15

E · Potential for more than minimal harm 2019-07-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-10-15

D · Potential for more than minimal harm 2019-07-12

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-10-15

D · Potential for more than minimal harm 2019-07-12

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2019-10-15

D · Potential for more than minimal harm 2019-07-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-10-15

D · Potential for more than minimal harm 2019-07-12

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-10-15

D · Potential for more than minimal harm 2019-07-12

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2019-10-15

F · Potential for more than minimal harm 2018-02-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-03-27

F · Potential for more than minimal harm 2018-02-21

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2018-03-27

D · Potential for more than minimal harm 2018-02-21

K163 · Construction Deficiencies

Fire Safety

Install noncombustible or limited-combustible interior walls.

Corrected 2018-03-27

D · Potential for more than minimal harm 2018-02-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2018-03-27

D · Potential for more than minimal harm 2018-02-21

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2018-03-27

D · Potential for more than minimal harm 2018-02-21

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 2018-03-27

D · Potential for more than minimal harm 2018-02-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2018-03-27

D · Potential for more than minimal harm 2018-02-21

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2018-03-27

Inspection history

Recent health citations

J · Immediate jeopardy 2025-01-17

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 2025-02-27

G · Actual harm 2025-01-17

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 2025-02-27

F · Potential for more than minimal harm 2025-01-17

F730 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2025-02-27

F · Potential for more than minimal harm 2025-01-17

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 2025-02-27

F · Potential for more than minimal harm 2025-01-17

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-02-27

E · Potential for more than minimal harm 2025-01-17

F835 · Administration Deficiencies

Health

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

Corrected 2025-02-27

E · Potential for more than minimal harm 2025-01-17

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-17

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 2025-02-27

D · Potential for more than minimal harm 2025-01-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-17

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-17

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-17

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 2025-02-27

E · Potential for more than minimal harm 2019-07-12

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 2019-08-31

E · Potential for more than minimal harm 2019-07-12

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2019-08-31

D · Potential for more than minimal harm 2019-07-12

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 2019-08-31

D · Potential for more than minimal harm 2019-07-12

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2019-08-31

D · Potential for more than minimal harm 2019-07-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-08-31

D · Potential for more than minimal harm 2019-07-12

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2019-08-31

D · Potential for more than minimal harm 2019-07-12

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 2019-08-31

D · Potential for more than minimal harm 2019-07-12

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2019-08-31

D · Potential for more than minimal harm 2019-07-12

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 2019-08-31

D · Potential for more than minimal harm 2019-07-12

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 2019-08-31

D · Potential for more than minimal harm 2019-07-12

F923 · Environmental Deficiencies

Health

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected 2019-08-31

E · Potential for more than minimal harm 2018-02-21

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 2018-04-30

E · Potential for more than minimal harm 2018-02-21

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2018-04-30

E · Potential for more than minimal harm 2018-02-21

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 2018-04-30

E · Potential for more than minimal harm 2018-02-21

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 2018-04-30

E · Potential for more than minimal harm 2018-02-21

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 2018-04-30

E · Potential for more than minimal harm 2018-02-21

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2018-04-30

E · Potential for more than minimal harm 2018-02-21

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 2018-04-30

E · Potential for more than minimal harm 2018-02-21

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2018-04-30

E · Potential for more than minimal harm 2018-02-21

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2018-04-30

D · Potential for more than minimal harm 2018-02-21

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2018-04-30

D · Potential for more than minimal harm 2018-02-21

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 2018-04-30

D · Potential for more than minimal harm 2018-02-21

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2018-04-30

D · Potential for more than minimal harm 2018-02-21

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-04-30

D · Potential for more than minimal harm 2018-02-21

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2018-04-30

D · Potential for more than minimal harm 2018-02-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-04-30

Penalties and ownership

What sits behind the stars

Ownership

Acts Communities Of Maryland, Inc.

Operational/Managerial Control · Organization

0% 4 facilities 2025-01-01
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

Corporate Officer · Individual

0% 27 facilities 2021-07-15
Christiansen, Karen

Operational/Managerial Control · Individual

0% 27 facilities 2022-12-31
Christiansen, Karen

Corporate Director · Individual

0% 27 facilities 2020-03-31
Christiansen, Karen

Corporate Officer · Individual

0% 27 facilities 2025-01-01
Clemes, George

Operational/Managerial Control · Individual

0% 1 facilities 2025-02-06
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 2022-12-31
Fox, Glenn

Corporate Officer · Individual

0% 27 facilities 2020-03-31
Grant, Gerald

Operational/Managerial Control · Individual

0% 29 facilities 2022-12-31
Grant, Gerald

Corporate Director · Individual

0% 29 facilities 2020-03-31
Grant, Gerald

Corporate Officer · Individual

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

Operational/Managerial Control · Individual

0% 6 facilities 2022-12-31
Grant, Jonathan

Corporate Officer · Individual

0% 6 facilities 2020-03-31
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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Pines Nursing And Rehab

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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $24,088 in total fines with 75 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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4-star overall rating with 4-star inspections with $50,879 in total fines with 12 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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#3

Mallard Bay Nursing And Rehab

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1-star overall rating with 1-star inspections with 48 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

Overall
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Staffing
1 / 5
Fines
$0

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