WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT

CHESTERTOWN, MD · 38 beds · Non profit - Corporation

82 Trust Score
Grade: B+ LOW Risk → Stable

Red Flags

  • 1 citation(s) at the highest severity level — immediate risk to residents

Green Flags

  • 4-star health inspection rating
  • 5-star staffing rating
  • Below-average deficiency count (5 vs 19 state avg)
  • Above-average RN staffing (1.61 hrs vs 0.81 state avg)
  • Low staff turnover (21%)

Quick Facts

★★★★★
CMS Overall
★★★★☆
Health Inspection
5
0.3x state avg
Deficiencies
$15,440
Fines (3-yr)
★★★★★
Staffing

Violation Timeline

February 22, 2024

20 deficiencyies
F0625 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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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.

F0726 Potential Harm Scope/Severity: E

Nursing and Physician Services Deficiencies

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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.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0759 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure medication error rates are not 5 percent or greater.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0609 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

F0610 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Respond appropriately to all alleged violations.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0689 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0740 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

F0625 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

Show details

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.

F0726 Potential Harm Scope/Severity: E

Nursing and Physician Services Deficiencies

Show details

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.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

Show details

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.

F0759 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

Show details

Ensure medication error rates are not 5 percent or greater.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

Show details

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.

F0609 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Show details

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

F0610 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Show details

Respond appropriately to all alleged violations.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0689 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0740 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

See full violation history →

Staffing

1.61
RN hrs/res/day
0.88
LPN hrs/res/day
2.35
CNA hrs/res/day
3.83
Weekend hrs/res/day
21%
Total nurse turnover
17%
RN turnover

A nurse checks on each resident roughly every 4.9 hours on average.

Fines & Penalties

  • Fine Feb 22, 2024
    $15,440
Total $15,440

Ownership

Non profit - Corporation Chain: ACTS RETIREMENT-LIFE COMMUNITIES
  • ACTS COMMUNITIES OF MARYLAND, INC.

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Organization
  • ACTS MANAGEMENT SERVICES, INC.

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Organization
  • ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Organization
  • AHERN, SUSAN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Individual
  • CHRISTIANSEN, KAREN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Individual
  • FOX, GLENN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Individual
  • GRANT, GERALD

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Individual
  • GRANT, JONATHAN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Individual
  • KURZ, STELLAH

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    Individual
  • VALDIVIA, PEGGY

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Individual
  • CHRISTIANSEN, KAREN

    CORPORATE DIRECTOR

    Since since 12/31/2022

    Individual
  • DETWEILER, HAROLD

    CORPORATE DIRECTOR

    Since since 12/31/2022

    Individual
  • FORREST, ANNE

    CORPORATE DIRECTOR

    Since since 12/31/2022

    Individual
  • GRANT, GERALD

    CORPORATE DIRECTOR

    Since since 12/31/2022

    Individual
  • KELLY, MICHAEL

    CORPORATE DIRECTOR

    Since since 12/31/2022

    Individual
  • LAWSON, DANIEL

    CORPORATE DIRECTOR

    Since since 12/31/2022

    Individual
  • NEARY, ANNE

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual
  • PAQUETTE, ELLEN

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual
  • AHERN, SUSAN

    CORPORATE OFFICER

    Since since 12/31/2022

    Individual
  • CHRISTIANSEN, KAREN

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual
  • FOX, GLENN

    CORPORATE OFFICER

    Since since 12/31/2022

    Individual
  • GRANT, GERALD

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual
  • GRANT, JONATHAN

    CORPORATE OFFICER

    Since since 12/31/2022

    Individual
  • VALDIVIA, PEGGY

    CORPORATE OFFICER

    Since since 12/31/2022

    Individual

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