WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT

501 CAMPUS AVENUE
CHESTERTOWN, MD, 21620
4107787300
CCN: 215235
5
Overall
4
Health
5
Staffing
Quality
ChainACTS RETIREMENT-LIFE COMMUNITIES
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
CHRISTIANSEN, KARENCORPORATE DIRECTORNOT APPLICABLE
PAQUETTE, ELLENCORPORATE DIRECTORNOT APPLICABLE
NEARY, ANNECORPORATE DIRECTORNOT APPLICABLE
LAWSON, DANIELCORPORATE DIRECTORNOT APPLICABLE
KELLY, MICHAELCORPORATE DIRECTORNOT APPLICABLE
GRANT, GERALDCORPORATE DIRECTORNOT APPLICABLE
FORREST, ANNECORPORATE DIRECTORNOT APPLICABLE
DETWEILER, HAROLDCORPORATE DIRECTORNOT APPLICABLE
VALDIVIA, PEGGYCORPORATE OFFICERNOT APPLICABLE
AHERN, SUSANCORPORATE OFFICERNOT APPLICABLE
CHRISTIANSEN, KARENCORPORATE OFFICERNOT APPLICABLE
FOX, GLENNCORPORATE OFFICERNOT APPLICABLE
GRANT, GERALDCORPORATE OFFICERNOT APPLICABLE
GRANT, JONATHANCORPORATE OFFICERNOT APPLICABLE
CHRISTIANSEN, KARENOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
AHERN, SUSANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
ACTS MANAGEMENT SERVICES, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
ACTS COMMUNITIES OF MARYLAND, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
VALDIVIA, PEGGYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
KURZ, STELLAHOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
GRANT, JONATHANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
GRANT, GERALDOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FOX, GLENNOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2024-02-23Fine$15K
Health Deficiencies (31)
2024-02-23 · Health
D
F761 · 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.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F758 · 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.
D
F740 · Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
E
F726 · 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.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F656 · 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.
D
F625 · 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.
E
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
E
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2019-04-09 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F790 · Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
E
F758 · 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.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
E
F745 · Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
E
F638 · Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
E
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F580 · 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.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
D
F551 · Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
2017-11-06 · Health
D
F514 · Administration Deficiencies
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
C
F456 · Environmental Deficiencies
Keep all essential equipment working safely.
C
F441 · Environmental Deficiencies
Have a program that investigates, controls and keeps infection from spreading.
D
F431 · Pharmacy Service Deficiencies
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
D
F329 · Pharmacy Service Deficiencies
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
D
F309 · Quality of Life and Care Deficiencies
Provide necessary care and services to maintain or improve the highest well being of each resident .
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
5.48
3.68
RN Hrs/Resident/Day
1.82
0.54
LPN Hrs/Resident/Day
1.00
0.81
CNA Hrs/Resident/Day
2.66
2.33
PT Hrs/Resident/Day
2.02
0.12
Data as of 2026-03-01