01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-01 | 8 | 2025-05-01 | 3 |
| Cycle 2 | 2024-01-25 | 5 | 2024-01-25 | 1 |
| Cycle 3 | 2022-09-09 | 4 | 2022-09-09 | 2 |
CMS CCN 1053552026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willowbrooke Court At St Andrews Estates
6152 N Verde Trail · Boca Raton, FL 33433 · Palm Beach County
Certified beds89CMS provider file
Recent citation rows23current CMS citation release
Penalty rows0current 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
23 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-05-01 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-05-01 · HEALTHF0726Severity D · isolated; 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 · 2025-05-312025-05-01 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-05-01 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-05-01 · 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 · 2025-05-312025-05-01 · HEALTHF0812Severity E · pattern; 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 · 2025-05-312025-05-01 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-05-01 · HEALTHF0919Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-05-01 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-05-01 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-05-292025-05-01 · 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 · 2025-05-292024-01-25 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-02-082024-01-25 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-02-082024-01-25 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-02-082024-01-25 · 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 · 2024-02-082024-01-25 · HEALTHF0908Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Keep all essential equipment working safely.
Correction field: Deficient, Provider has date of correction · 2024-02-082024-01-25 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-02-082022-09-09 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2022-10-092022-09-09 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
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: Deficient, Provider has date of correction · 2022-10-092022-09-09 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Correction field: Deficient, Provider has date of correction · 2022-10-092022-09-09 · 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 · 2022-10-092022-09-09 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2022-10-132022-09-09 · 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 · 2022-10-1303 / 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 |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ACTS ACQUISITION AND DEVELOPMENT COMPANY LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/2012
- ACTS ALLIANCE MANAGEMENT LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS COMMUNITIES OF MARYLAND, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2019
- ACTS LEGACY FOUNDATION, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS RETIREMENT SERVICES, INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/24/2009
- 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
- ALLMOND, SUSANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2017
- BROD, KATHRYNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/15/2024
- CALLAWAY, WARRENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/30/2022
- CHAMBERLAIN, LINDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- DETWEILER, HAROLDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/26/2009
- ESTERHAI, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/01/1996
- GERNER, ELRICIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2009
- GLYNN, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- GRANT, GERALDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/26/2009
- GREER, JASONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/30/2022
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 hours4.17per resident day
RN hours1.34per resident day
Weekend nurse hours3.86per resident day
Staff turnover21.4%CMS reported field
06 / LOCAL RECORDS
Open the Boca Raton ledger →Other published facilities nearby
Avante At Boca Raton, Inc.144 beds · CMS overall 1/548 citation rowsBoca Circle Rehabilitation Center120 beds · CMS overall 2/546 citation rowsBoca Raton Rehabilitation Center120 beds · CMS overall 2/533 citation rowsEncore At Boca Raton Rehabilitation And Nursing Ce154 beds · CMS overall 3/551 citation rowsHealth Center At Sinai Residences60 beds · CMS overall 5/510 citation rowsLegacy At Boca Raton Rehabilitation And Nursing Ce180 beds · CMS overall 4/541 citation rowsMenorah House120 beds · CMS overall 3/540 citation rowsStratford Court Of Boca Raton60 beds · CMS overall 5/524 citation rows