01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-11 | 1 | 2025-12-11 | 4 |
| Cycle 2 | 2024-02-23 | 5 | 2024-02-23 | 6 |
| Cycle 3 | 2019-04-09 | 20 | 2019-04-09 | 4 |
CMS CCN 2152352026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willow Brooke Ct Skilled Care Ctr At Heron Point
501 Campus Avenue · Chestertown, MD 21620 · Kent County
Certified beds38CMS provider file
Recent citation rows40current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
40 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-11 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-312025-12-11 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-03-012025-12-11 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-03-012025-12-11 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2026-03-012025-12-11 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2026-03-012024-02-23 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-04-08 · complaint2024-02-23 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-04-08 · complaint2024-02-23 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-082024-02-23 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-04-08 · complaint2024-02-23 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2023-07-13 · complaint2024-02-23 · HEALTHF0726Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-082024-02-23 · HEALTHF0740Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2024-04-08 · complaint2024-02-23 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-082024-02-23 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-04-082024-02-23 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-082024-02-23 · FIREK0271Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2024-03-302024-02-23 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-03-302024-02-23 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-03-302024-02-23 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-03-302024-02-23 · FIREK0712Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-03-302024-02-23 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-03-302019-04-09 · HEALTHF0551Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Correction field: Deficient, Provider has date of correction · 2019-05-242019-04-09 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2019-05-242019-04-09 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2019-05-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-02-23 | Fine | $15,440 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ACTS ACQUISITION AND DEVELOPMENT COMPANY LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS ALLIANCE MANAGEMENT LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS LEGACY FOUNDATION, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS RETIREMENT SERVICES, INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS SIGNATURE COMMUNITY SERVICES INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- BONITA SPRINGS RETIREMENT VILLAGE INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/01/2024
- MEASE LIFE INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2023
- CHRISTIANSEN, KARENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2022
- DETWEILER, HAROLDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2022
- FORREST, ANNEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2022
- GRANT, GERALDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2022
- KELLY, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2022
- LAWSON, DANIELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2022
- NEARY, ANNEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- PAQUETTE, ELLENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- AHERN, SUSANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/31/2022
- CHRISTIANSEN, KARENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2025
- FOX, GLENNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/31/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.75per resident day
RN hours1.76per resident day
Weekend nurse hours4.12per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Chestertown ledger →