Willow Brooke Ct Skilled Care Ctr at Heron Point

Name: Willow Brooke Ct Skilled Care Ctr at Heron Point
Address: 501 CAMPUS AVENUE, Chestertown, MD, 21620, US
Telephone: 4107787300

501 Campus Avenue, Chestertown, MD 21620 · Kent County · 38 certified beds · avg 2 residents/day · certified since Nov 7, 1991

Part of chain: ACTS RETIREMENT-LIFE COMMUNITIES (27 facilities, chain avg rating 4.7★)

5/5

Health inspection rating (on-site)

Serious findings on record

$15,440

Fines, last 3 years

5.91

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Feb 23, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 13, 2023 (Past Non-Compliance)

All citations in the current public record (26)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Dec 11, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 23, 2024	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 23, 2024	E · Potential for harm, repeated	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Feb 23, 2024	D · Potential for harm, one-off	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Feb 23, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Feb 23, 2024	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 23, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 23, 2024	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 23, 2024	E · Potential for harm, repeated	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Feb 23, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Feb 23, 2024	D · Potential for harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Apr 9, 2019	E · Potential for harm, repeated	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Apr 9, 2019	E · Potential for harm, repeated	The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Apr 9, 2019	E · Potential for harm, repeated	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Apr 9, 2019	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 9, 2019	E · Potential for harm, repeated	The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Apr 9, 2019	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not provide routine dental care and 24-hour emergency dental care for residents.
Apr 9, 2019	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (5 → 1).

Year	Citations	Serious (G–L)	Worst severity that year
2019	15	0	E
2024	10	1	J ▲
2025	1	0	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $15,440.

Date	Type	Amount / length
Feb 23, 2024	Fine	$15,440

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Maryland avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.91	3.83	3.95	top 4% in Maryland; top 4% in the U.S.
Registered Nurse hours	2.19	0.83	0.69	top 3% in Maryland; top 1% in the U.S.
Weekend total nurse staffing	5.13	3.43	3.50	top 6% in Maryland; top 5% in the U.S.
Weekend RN hours (not acuity-adjusted)	1.20	0.63	0.48	top 6% in Maryland; top 4% in the U.S.
Total nursing staff turnover (%)	0.0	40.2	45.8	—
RN turnover (%)	0.0	38.7	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.75, RN 1.76, weekend 4.12. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Acts Acquisition and Development Company LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/31/2022
Acts Alliance Management LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/31/2022
Acts Legacy Foundation, INC.	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/31/2022
Acts Retirement Services, INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/31/2022
Acts Signature Community Services INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/31/2022
Bonita Springs Retirement Village INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	11/01/2024
Mease Life INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	10/01/2023
Acts Communities of Maryland, INC.	Organization	Operational/Managerial Control	NOT APPLICABLE	12/31/2022
Acts Communities of Maryland, INC.	Organization	ADP of the SNF	NOT APPLICABLE	12/31/2022
Acts Management Services, INC.	Organization	Operational/Managerial Control	NOT APPLICABLE	12/31/2022
Acts Management Services, INC.	Organization	ADP of the SNF	NOT APPLICABLE	02/06/2025
Acts Retirement-Life Communities Management, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	12/31/2022
Acts Retirement-Life Communities Management, LLC	Organization	ADP of the SNF	NOT APPLICABLE	02/06/2025
Ahern, Susan	Individual	Corporate Officer	NOT APPLICABLE	12/31/2022
Ahern, Susan	Individual	Operational/Managerial Control	NOT APPLICABLE	12/31/2022
Ahern, Susan	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2025
Baker Tilly Advisory Group LP	Organization	ADP of the SNF	NOT APPLICABLE	02/03/2025
Baker Tilly Us LLP	Organization	ADP of the SNF	NOT APPLICABLE	11/05/2024
Christiansen, Karen	Individual	Corporate Director	NOT APPLICABLE	12/31/2022
Christiansen, Karen	Individual	Corporate Officer	NOT APPLICABLE	01/01/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
"If my family member goes to the hospital, how long will you hold their bed, and will we get that in writing?"
"What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Chestertown Nursing and Rehab	0.5 mi	Chestertown, MD	★☆☆☆☆	1/5	abuse
Resorts at Chester River Manor Corp	0.6 mi	Chestertown, MD	★★★☆☆	3/5
Complete Care at Corsica Hills LLC	11.6 mi	Centreville, MD	★★★☆☆	3/5

Compare this facility with the 3 closest →

All facilities in Chestertown →

Facility data as of CMS processing date 2026-08-01. CCN 215235.

The Care File

Visit checklist — Willow Brooke Ct Skilled Care Ctr at Heron Point

501 Campus Avenue, Chestertown, MD 21620 · 4107787300

Health inspection rating 5/5 · CMS overall 5/5· Fines (3y): $15,440

Most serious findings on record:

▲ Feb 23, 2024 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
☐ "If my family member goes to the hospital, how long will you hold their bed, and will we get that in writing?"
☐ "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 215235 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)