Your report for Willow Brooke Ct Skilled Care Ctr at Heron Point
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MarylandAbove 76% of peers219 rated homes · average 3.1★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point4★+1.2 vs MD avg
- StaffingCan add or remove a star5★+1.9 vs MD avg
- Quality measuresCan add or remove a star—
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles4★Above 67% of peersMD avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 87% of peersMD avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments—No dataMD avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff5.48hrsTop 3%MD avg3.90Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only1.82hrsTop 3%MD avg0.83Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better21%Top 8%MD avg41%RN turnover17%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$15,440Above only 32% of peersMD avg$24,026Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthNov 2017 – Feb 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Feb 23, 2024Cycle 1worst J · immediate jeopardy$15,440
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jul 13, 2023
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Apr 8, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Apr 8, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Apr 8, 2024
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 8, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Apr 8, 2024
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Apr 8, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Apr 8, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Apr 8, 2024
Apr 9, 2019Cycle 2worst E · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 24, 2019
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected May 24, 2019
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 24, 2019
- F551Give the resident's representative the ability to exercise the resident's rights.Resident RightsD · isolatedCorrected May 24, 2019
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected May 24, 2019
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 24, 2019
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareE · patternCorrected May 24, 2019
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 24, 2019
- F758Implement 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.Pharmacy ServiceE · patternCorrected May 24, 2019
- F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareD · isolatedCorrected May 24, 2019
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 24, 2019
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected May 24, 2019
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningE · patternCorrected May 24, 2019
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected May 24, 2019
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected May 24, 2019
Nov 6, 2017Cycle 3worst D · no actual harm
- Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.Pharmacy ServiceD · isolatedCorrected Jan 31, 2018
- F309Provide necessary care and services to maintain or improve the highest well being of each resident .Quality of Life and CareD · isolatedCorrected Jan 31, 2018
- F431Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.Pharmacy ServiceD · isolatedCorrected Jan 31, 2018
- F441Have a program that investigates, controls and keeps infection from spreading.EnvironmentalC · widespreadCorrected Jan 31, 2018
- F908Keep all essential equipment working safely.EnvironmentalC · widespreadCorrected Jan 31, 2018
- F514Keep accurate, complete and organized clinical records on each resident that meet professional standards.AdministrationD · isolatedCorrected Jan 31, 2018
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined5.48hrs
- Registered nursesRN hours only1.82hrs
- Licensed practical nursesLPN hours1.00hrs
- Nurse aidesCNA hours2.66hrs
- Weekend nursingAll staff on Saturdays and Sundays4.33hrs
- Maryland average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better21%Top 8%MD avg 41%
- RN turnoverRegistered nurses only17%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy38 certified beds · ~3 residents a day7%Lowest tier among peersMD avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $15,440In fines
- 1Fine
- 0Payment denials
- $24,026MD avg in fines
Actions on record
- Feb 23, 2024Civil money penalty$15,440
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Acts Retirement-Life Communities26 facilities in the chain4.8★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- Acts Communities of Maryland, INC.
- Acts Management Services, INC.
- Acts Retirement-Life Communities Management, LLC
- Susan Ahern
- Karen Christiansen
- Glenn Fox
- Gerald Grant
- Jonathan Grant
- +2 more
- Karen Christiansen
- Harold Detweiler
- Anne Forrest
- Gerald Grant
- Michael Kelly
- Daniel Lawson
- Anne Neary
- Ellen Paquette
- Susan Ahern
- Karen Christiansen
- Glenn Fox
- Gerald Grant
- Jonathan Grant
- Peggy Valdivia
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 215235 · 501 CAMPUS AVENUE, CHESTERTOWN, MD, 21620.
- Percentiles compare this facility with every rated nursing home in Maryland and Kent County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









