Cycle 1
Health 2021-04-08 · Fire 2021-04-08
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Spanish Fort, AL
Willowbrooke Ct Skilled Care Ctr Westminster Vlg
5-star overall rating with 3-star inspections with 1 recent health deficiencies
500 Spanish Fort Blvd, Spanish Fort, AL
(251) 626-7007
Overall
5 / 5
CMS overall stars
Health inspections
3 / 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
7
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1983-07-07
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 0.64 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
1.38
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
1.34
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.65
CMS adjusted RN staffing hours
Adjusted total hours
5.68
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,896
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.16
Baseline 23.20% · Performance 22.17% · Measure score 1.16 · Achievement 0 · Improvement 1.16
Healthcare-associated infections
4.56
Baseline 9.68% · Performance 7.31% · Measure score 4.56 · Achievement 1.76 · Improvement 4.56
Total nurse turnover
2.81
Baseline 52.38% · Performance 52.17% · Measure score 2.81 · Achievement 2.81 · Improvement 0
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 | 12.45% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 14.89% · Lower 95% interval 9.24% |
| Discharge to community | 52.07% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 48.65% · Lower 95% interval 42.91% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 89.47% |
95.27%
5.8 pts worse
|
Numerator 34 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 80% |
53.69%
26.3 pts better
|
Numerator 20 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.31% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 5.1% |
8.2%
3.1 pts worse
|
Numerator 5 · Denominator 98 |
| Staff flu vaccination coverage | 88.55% |
42%
46.5 pts better
|
Numerator 116 · Denominator 131 |
| Discharge function score | 72% |
56.45%
15.5 pts better
|
Numerator 18 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
84.3%
14.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.3% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
11.5%
7.3 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 3.3% · Expected 8.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.1%
0.6 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.3%
19.7 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 | 28.7% |
24.5%
4.2 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 20.0% · Expected 16.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-02-14 · Fire 2019-02-14
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2018-03-01 · Fire 2018-03-01
8 health deficiencies
Top issue: Administration (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-02-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-03-21
E · Potential for more than minimal harm
2019-02-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-03-22
E · Potential for more than minimal harm
2019-02-14
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2019-03-27
E · Potential for more than minimal harm
2019-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-27
D · Potential for more than minimal harm
2019-02-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-03-15
E · Potential for more than minimal harm
2018-03-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-04-10
D · Potential for more than minimal harm
2018-03-01
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 2018-04-10
D · Potential for more than minimal harm
2018-03-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-04-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2021-04-08
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 2021-05-13
F · Potential for more than minimal harm
2019-02-14
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 2019-03-15
F · Potential for more than minimal harm
2018-03-01
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 2018-04-04
E · Potential for more than minimal harm
2018-03-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-04-04
E · Potential for more than minimal harm
2018-03-01
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 2018-04-04
E · Potential for more than minimal harm
2018-03-01
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-04-04
E · Potential for more than minimal harm
2018-03-01
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2018-04-04
E · Potential for more than minimal harm
2018-03-01
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2018-04-04
D · Potential for more than minimal harm
2018-03-01
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 2018-04-04
C · Minimal harm
2018-03-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-04-04
Penalties and ownership
What sits behind the stars
Ownership
Acts Retirement Services, Inc
5% Or Greater Indirect Ownership Interest · Organization
Acts Retirement-Life Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities 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
Allmond, Susan
Corporate Director · Individual
Allmond, Susan
Corporate Officer · Individual
Brod, Kathryn
Corporate Director · Individual
Callaway, Warren
Corporate Director · Individual
Chamberlain, Linda
Corporate Director · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Glynn, James
Corporate Director · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Greer, Jason
Corporate Director · Individual
Kelly, Michael
Corporate Director · Individual
Lammers, John
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Lawson, Daniel
Corporate Officer · Individual
Mashner, Marvin
Corporate Director · Individual
Mashner, Marvin
Corporate Officer · Individual
Middlebrooks, Daniel
Corporate Director · Individual
Reichard, Dawn
Corporate Director · Individual
Varden, Kevin
Operational/Managerial Control · Individual
Webb, Gloryana
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Eastern Shore Rehabilitation And Health Center
Daphne, AL
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Arabella Health And Wellness Of Fairhope
Fairhope, AL
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Allen Health And Rehabilitation
Mobile, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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