WILLOWBROOKE COURT SKILLED CENTER AT MANOR HOUSE

SEAFORD, DE · 15 beds · Non profit - Corporation

100 Trust Score
Grade: A+ LOW Risk → Stable

Red Flags

  • ⚠ 1 citation(s) where residents suffered actual harm

Green Flags

  • ✓ 5-star health inspection rating
  • ✓ 5-star staffing rating
  • ✓ Below-average deficiency count (3 vs 14 state avg)
  • ✓ No fines or penalties on record
  • ✓ Above-average RN staffing (1.57 hrs vs 1.04 state avg)

Quick Facts

★★★★★
CMS Overall
★★★★★
Health Inspection
3
0.2x state avg
Deficiencies
$0
Fines (3-yr)
★★★★★
Staffing

Violation Timeline

May 5, 2025

1 deficiency
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.

June 2, 2024

2 deficiencyies
F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0757 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure each resident’s drug regimen must be free from unnecessary drugs.

June 20, 2023

2 deficiencyies
F0550 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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.

November 4, 2021

13 deficiencyies
F0550 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

F0585 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

F0636 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0688 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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

F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0756 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

F0812 Potential Harm Scope/Severity: E

Nutrition and Dietary Deficiencies

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Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0842 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

See full violation history →

Staffing

1.57
RN hrs/res/day
0.71
LPN hrs/res/day
2.44
CNA hrs/res/day
4.25
Weekend hrs/res/day
N/A
Total nurse turnover
N/A
RN turnover

A nurse checks on each resident roughly every 5.1 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

Non profit - Corporation Chain: ACTS RETIREMENT-LIFE COMMUNITIES

  • ACTS RETIREMENT-LIFE COMMUNITIES INC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 07/01/2014

    100% Organization

  • ACTS MANAGEMENT SERVICES, INC.

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 07/01/2014

    Organization

  • ACTS RETIREMENT-LIFE COMMUNITIES INC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 07/01/2014

    Organization

  • ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/31/2022

    Organization

  • AHERN, SUSAN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2020

    Individual

  • CHRISTIANSEN, KAREN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 07/01/2014

    Individual

  • FOX, GLENN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2017

    Individual

  • GRANT, GERALD

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 05/04/2017

    Individual

  • ALLMOND, SUSAN

    CORPORATE DIRECTOR

    Since since 01/01/2015

    Individual

  • BROD, KATHRYN

    CORPORATE DIRECTOR

    Since since 02/15/2024

    Individual

  • CALLAWAY, WARREN

    CORPORATE DIRECTOR

    Since since 03/30/2022

    Individual

  • CHAMBERLAIN, LINDA

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual

  • CHRISTIANSEN, KAREN

    CORPORATE DIRECTOR

    Since since 01/01/2020

    Individual

  • DETWEILER, HAROLD

    CORPORATE DIRECTOR

    Since since 11/01/2009

    Individual

  • ESTERHAI, JOHN

    CORPORATE DIRECTOR

    Since since 05/01/1996

    Individual

  • GERNER, ELRIC

    CORPORATE DIRECTOR

    Since since 04/01/2009

    Individual

  • GLYNN, JAMES

    CORPORATE DIRECTOR

    Since since 01/01/2023

    Individual

  • GRANT, GERALD

    CORPORATE DIRECTOR

    Since since 05/04/2017

    Individual

  • GREER, JASON

    CORPORATE DIRECTOR

    Since since 03/30/2022

    Individual

  • KELLY, MICHAEL

    CORPORATE DIRECTOR

    Since since 02/11/2020

    Individual

  • LAMMERS, JOHN

    CORPORATE DIRECTOR

    Since since 12/15/2020

    Individual

  • LAWSON, DANIEL

    CORPORATE DIRECTOR

    Since since 06/11/2019

    Individual

  • MASHNER, MARVIN

    CORPORATE DIRECTOR

    Since since 01/01/1991

    Individual

  • MIDDLEBROOKS, DANIEL

    CORPORATE DIRECTOR

    Since since 01/01/2023

    Individual

  • REICHARD, DAWN

    CORPORATE DIRECTOR

    Since since 06/01/2025

    Individual

  • AHERN, SUSAN

    CORPORATE OFFICER

    Since since 01/01/2020

    Individual

  • ALLMOND, SUSAN

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual

  • CHRISTIANSEN, KAREN

    CORPORATE OFFICER

    Since since 05/25/2010

    Individual

  • FOX, GLENN

    CORPORATE OFFICER

    Since since 01/01/2017

    Individual

  • GERNER, ELRIC

    CORPORATE OFFICER

    Since since 01/01/2010

    Individual

  • GRANT, GERALD

    CORPORATE OFFICER

    Since since 06/01/2005

    Individual

  • LAWSON, DANIEL

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual

  • MASHNER, MARVIN

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual

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