Willowbrooke Ct Skilled Care Ctr at Bayleigh Chase
501 Dutchman'S Lane, Easton, MD 21601 · Talbot County · 99 certified beds · avg 61 residents/day · certified since Jan 26, 1982
Abuse citation flag (CMS)
Part of chain: ACTS RETIREMENT-LIFE COMMUNITIES (27 facilities, chain avg rating 4.7★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Jan 17, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Feb 27, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 17, 2025 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 27, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (38)
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 |
|---|---|---|
| Jan 17, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 17, 2025 | ▲ G · Actual harm, 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 |
| Jan 17, 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. |
| Jan 17, 2025 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jan 17, 2025 | D · Potential for harm, one-off | 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 |
| Jan 17, 2025 | D · Potential for harm, one-off | 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 |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jan 17, 2025 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Jan 17, 2025 | 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. · from a complaint |
| Jul 12, 2019 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 12, 2019 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jul 12, 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. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 12, 2019 | 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. |
| Jul 12, 2019 | 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. |
| Jul 12, 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. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. |
| Feb 21, 2018 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 21, 2018 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Feb 21, 2018 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 21, 2018 | E · Potential for harm, repeated | 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. |
| Feb 21, 2018 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 21, 2018 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 21, 2018 | 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. |
| Feb 21, 2018 | E · Potential for harm, repeated | 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 21, 2018 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 21, 2018 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Feb 21, 2018 | 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. |
| Feb 21, 2018 | 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 21, 2018 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 21, 2018 | 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. |
| Feb 21, 2018 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 15 | 0 | E |
| 2019 | 11 | 0 | E |
| 2025 | 12 | 2 | J ▲ |
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)
No fines or payment denials in the published 3-year window.
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) | 4.05 | 3.83 | 3.95 | top 24% in Maryland; top 37% in the U.S. |
| Registered Nurse hours | 1.17 | 0.83 | 0.69 | top 12% in Maryland; top 10% in the U.S. |
| Weekend total nurse staffing | 3.67 | 3.43 | 3.50 | top 24% in Maryland; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.82 | 0.63 | 0.48 | top 18% in Maryland; top 11% in the U.S. |
| Total nursing staff turnover (%) | 24.5 | 40.2 | 45.8 | top 12% in Maryland; top 6% in the U.S. |
| RN turnover (%) | 33.3 | 38.7 | 42.9 | top 34% in Maryland; top 33% in the U.S. |
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 3.59, RN 1.04, weekend 3.25. Staffing rating: 4/5.
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: 4/5 · long-stay residents: 4/5 · short-stay residents: 5/5
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 Communities of Maryland, INC. | Organization | Direct 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 | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/31/2022 |
| Acts Communities of Maryland, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| 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 | 07/15/2021 |
| 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 | 03/31/2020 |
| 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.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "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 does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "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 |
|---|---|---|---|---|---|
| Pines Nursing and Rehab | 0.3 mi | Easton, MD | ★☆☆☆☆ | 1/5 | SFF |
| Mallard Bay Nursing and Rehab | 13.0 mi | Cambridge, MD | ★★☆☆☆ | 1/5 | abuse |
| Autumn Lake Healthcare at Chesapeake Woods | 13.0 mi | Cambridge, MD | ★★★☆☆ | 3/5 | |
| Caroline Nursing and Rehab | 15.4 mi | Denton, MD | ★★☆☆☆ | 2/5 | |
| Denton Nursing and Rehab | 16.7 mi | Denton, MD | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 215137.