WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE

EASTON, MD · 99 beds · Non profit - Corporation

16 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • This facility has a substantiated finding of abuse
  • 1 citation(s) at the highest severity level — immediate risk to residents
  • 1 citation(s) where residents suffered actual harm

Green Flags

  • 4-star staffing rating
  • Below-average deficiency count (7 vs 19 state avg)
  • No fines or penalties on record
  • Low staff turnover (21%)

Quick Facts

★★☆☆☆
CMS Overall
★★☆☆☆
Health Inspection
7
0.4x state avg
Deficiencies
$0
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

January 16, 2025

12 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.

F0812 Potential Harm Scope/Severity: F

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.

F0867 Potential Harm Scope/Severity: F

Administration Deficiencies

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

F0600 Immediate Jeopardy Scope/Severity: J

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

F0609 Potential Harm Scope/Severity: D

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: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Respond appropriately to all alleged violations.

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.

F0697 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0730 Potential Harm Scope/Severity: F

Nursing and Physician Services Deficiencies

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

F0835 Potential Harm Scope/Severity: E

Administration Deficiencies

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

F0842 Potential Harm Scope/Severity: D

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.

F0943 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

July 11, 2019

8 deficiencyies
F0623 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

F0640 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0641 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure each resident receives an accurate assessment.

F0657 Potential Harm Scope/Severity: E

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.

F0679 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide activities to meet all resident's needs.

F0689 Potential Harm Scope/Severity: D

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.

F0727 Potential Harm Scope/Severity: E

Nursing and Physician Services Deficiencies

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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.

F0759 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure medication error rates are not 5 percent or greater.

See full violation history →

Staffing

1.03
RN hrs/res/day
0.71
LPN hrs/res/day
2.15
CNA hrs/res/day
3.55
Weekend hrs/res/day
21%
Total nurse turnover
12%
RN turnover

A nurse checks on each resident roughly every 6.2 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

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

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    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
  • 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
  • SHOCKLEY, NICHOLAS

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    Individual
  • VALDIVIA, PEGGY

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    Individual
  • CHRISTIANSEN, KAREN

    CORPORATE DIRECTOR

    Since since 03/31/2020

    Individual
  • DESMARAIS, NORMAND

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual
  • DETWEILER, HAROLD

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual
  • FORREST, ANNE

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual
  • GRANT, GERALD

    CORPORATE DIRECTOR

    Since since 03/31/2020

    Individual
  • KELLY, MICHAEL

    CORPORATE DIRECTOR

    Since since 01/01/2025

    Individual
  • LAWSON, DANIEL

    CORPORATE DIRECTOR

    Since since 01/01/2025

    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 07/15/2021

    Individual
  • CHRISTIANSEN, KAREN

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual
  • FOX, GLENN

    CORPORATE OFFICER

    Since since 03/31/2020

    Individual
  • GRANT, GERALD

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual
  • GRANT, JONATHAN

    CORPORATE OFFICER

    Since since 03/31/2020

    Individual
  • VALDIVIA, PEGGY

    CORPORATE OFFICER

    Since since 01/01/2025

    Individual
  • ACTS COMMUNITIES OF MARYLAND, INC.

    5% OR GREATER MORTGAGE INTEREST

    Since since 12/31/2022

    Organization

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