Willow Brooke Ct Skilled Care Ctr at Heron Point
501 Campus Avenue, Chestertown, MD 21620 · Kent County · (410) 778-7300
38 certified beds, about 2 residents a day · Non profit - Corporation · Medicare and Medicaid since 1991
Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
5 of 5
Staffing
5 of 5
Quality measures
Not rated
CMS note: Not enough data available to calculate a star rating.
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215235 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on December 11, 2025, inspectors cited 1 health deficiency (the Maryland average is 17, the national average 9.2).
Of 26 health citations since April 2019, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $15,440 in the last three years; the largest was $15,440, and the latest is dated February 23, 2024.
Nurses and nurse aides worked 4.75 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 1.76 of those hours.
CMS links it to Acts Retirement-Life Communities, an affiliated group of 27 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1504/19
1002/24
112/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
9E
1F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 1 citation
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This was found to be evident during the observation of the kitchen during the recertification survey. This practice had the potential to affect all residents consuming food and beverage prepared and provided by the facility's kitchen.
February 23, 2024Standard inspection, Complaint inspection · 10 citations
- E 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.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 4 out of 5 GNAs (GNA #6, #7, #8, #9, & #10) reviewed for competencies skill evaluations.
- D 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.
Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to have an effective system in place to ensure that residents and resident representatives are notified in writing of the bed hold policy at the time of discharge/transfer to the hospital. This was found to be evident for 2 (Resident #14 and Resident #183) of 3 residents reviewed for hospitalizations during the investigative portion of the annual survey.
- D 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.
Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to limit the timeframe for a PRN (as needed) psychotropic medications to 14 days. This was evident for 1 resident (Resident #11) out of 5 residents investigated for medication regimen review during the annual survey.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to ensure the medication error rate was 5% or less. This was found to be evident for the medication administration observation during the annual survey.
- D 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.
Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to ensure medication was stored properly. This was found to be evident for 1 out of 2 medication carts observed during the annual survey.
- J Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure a safe environment for a resident diagnosed with a major depressive disorder. This was found to be evident for 1 (Resident #178) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance.
- E Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on the facility's documentation review and staff interview, it was determined the facility failed to report allegations of abuse and injury of an unknown source to the local enforcement agency. This was found to be evident for 4 (residents # 7, #13, #181, & #11) out of 5 residents reviewed for abuse.
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on review of Facility Reported Incidents (FRI) and interview with staff, it was determined that the facility failed to complete a thorough investigation. This was evident for 6 (Resident #3, #4, #5, #21, #7, and #13) out of 13 residents investigated for Facility Reported Incidents.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record review, observation, and staff interview it was determined that the facility staff failed to ensure residents' care plans were followed. This was evident for 1 (#16) out of 29 residents who were part of the survey sample.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure a resident with major depressive disorder receive proper care and treatment. This was found to be evident for 1 (resident #178) out of 1 resident reviewed for behavioral health.
April 9, 2019Standard inspection · 15 citations
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review, observation, and staff interview, it was determined the facility staff failed to complete the required annual MDS assessments, admission assessment and 5 day assessments within the required timeframes. This was evident for 4 of 25 residents reviewed for MDS completion.
- E Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility staff failed to complete the required quarterly MDS assessments within the required timeframes. This was evident for 14 of 25 residents reviewed for MDS complettion.
- E PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to assess Resident (#19) for PASRR. This was evident for 1 out of 1 resident selected for review of the PASRR process and 31 out of 31 residents selected for review during the annual survey process.
- E Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide Residents (#4, #11 and #17)an environment free from potential accidents. This was evident for 3 of 3 residents selected for review of accidents during the survey process and 3 of 25 residents selected for review during the annual survey process.
- E Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to complete Preadmission Screening and Resident Review (PASARR) for residents. The facility failed to complete certifications of incapacity to make medical decisions for resident before having healthcare agents make medical decisons. This was evident for 25 of 25 residents reviewed for PASARR's and 2 of 2 residents (#26 and #12) reviewed for dementia during the annual survey process.
- E 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.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to conduct an AIMS assessment for Resident (#12 and #16) in a timely manner. This was evident for 2 of 5 residents selected for unnecessary medication review and 2 of 25 residents selected for review during the annual survey process.
- D Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed honor a resident's (#26) designation of a health care representative as named in their Advanced Directive. This was evident for 1 of 1 resident selected for review of choices during the annual survey process.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to promote Resident (#6's) self-determination. This was evident for 1 of 25 residents selected for review of self-determination during the survey process.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify Resident (#5's) responsible party of a change in medication and failed to notify the CRNP/physician when holding medications for Resident (#27). This was evident for 1 of 25 residents selected for review of notification of change during the annual survey process.
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify the responsible party in writing of a Resident's (#26) transfer to the hospital. This was evident for 1 of 1 residents reviewed for hospitalizations.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to provide an environment to promote the highest well-being for Residents (#11, #12 and #27). This was evident for 3 of 25 residents selected for review of well-being during the annual survey process.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Residents (#16). This was evident for 1 of 2 resident selected for pain assessment and 1 of 25 residents selected for review during the annual survey.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Resident (#5). This was evident for 1 of 5 residents selected for unnecessary medication review during the annual survey process.
- D Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on review of a medical record and staff interview, it was determined the facility staff failed to take steps to ensure that a resident received dental services as ordered by the resident's physician. This was evident for 1 (Resident #12) of 4 residents reviewed during an annual recertification survey for dental services and 1 out of 25 selected for review during the annual survey process.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#16). This was evident for 1 of 25 residents selected for medical record review during the annual survey process.
Fire safety inspections
14 fire safety citations on file: 4 on December 11, 2025, 6 on February 23, 2024, 4 on April 9, 2019.
Every fire safety citation14 citations
- F Have approved installation, maintenance and testing program for fire alarm systems.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Have proper medical gas storage and administration areas.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- D Have exits that are accessible at all times.
- D Provide properly protected cooking facilities.
- D Have simulated fire drills held at unexpected times.
- D Have generator or other power source capable of supplying service within 10 seconds.
- F Meet other general requirements that are deficient.
- F Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| February 23, 2024 | Fine | $15,440 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.75 | 3.87 | 3.86 |
| Registered nurses | 1.76 | 0.84 | 0.69 |
| All nursing staff on weekends | 4.12 | 3.47 | 3.42 |
| Nurse aides | 2.22 | ||
| Licensed practical nurses | 0.77 | ||
| Nursing staff turnover (share who left in a year) | not reported | 40.2% | 45.8% |
| Registered nurse turnover | not reported | 38.7% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.08 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.00 on weekdays and 4.12 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.83 in April to June 2025 to 4.75 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.75 | 1.76 | 5.00 | 4.12 | 0.0% | 0 of 63 | 2 |
| Oct to Dec 2025 | 3.48 | 1.33 | 3.58 | 3.21 | 0.0% | 0 of 87 | 2 |
| Jul to Sep 2025 | 5.48 | 1.82 | 5.93 | 4.33 | 0.0% | 0 of 92 | 3 |
| Apr to Jun 2025 | 2.83 | 0.93 | 3.09 | 2.19 | 0.0% | 0 of 71 | 2 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Maryland, Jan to Mar 2026 | 3.73 | 0.74 | 3.88 | 3.34 | 8.0% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Maryland | US |
|---|---|---|---|
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.1 | 1.6 |
Owners and operators
Legal business name: ACTS COMMUNITIES OF MARYLAND, INC.. CMS links this home to Acts Retirement-Life Communities, a group of 27 nursing homes averaging 4.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Acts Acquisition and Development Company LLC | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Alliance Management LLC | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Legacy Foundation, Inc. | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Retirement Services, Inc | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Signature Community Services Inc | Indirect ownership interest | Organization | 12/31/2022 | |
| Bonita Springs Retirement Village Inc | Indirect ownership interest | Organization | 11/01/2024 | |
| Mease Life Inc | Indirect ownership interest | Organization | 10/01/2023 | |
| Christiansen, Karen | Corporate director | Individual | 12/31/2022 | |
| Detweiler, Harold | Corporate director | Individual | 12/31/2022 | |
| Forrest, Anne | Corporate director | Individual | 12/31/2022 | |
| Grant, Gerald | Corporate director | Individual | 12/31/2022 | |
| Kelly, Michael | Corporate director | Individual | 12/31/2022 | |
| Lawson, Daniel | Corporate director | Individual | 12/31/2022 | |
| Neary, Anne | Corporate director | Individual | 01/01/2025 | |
| Paquette, Ellen | Corporate director | Individual | 01/01/2025 | |
| Ahern, Susan | Corporate officer | Individual | 12/31/2022 | |
| Christiansen, Karen | Corporate officer | Individual | 01/01/2025 | |
| Fox, Glenn | Corporate officer | Individual | 12/31/2022 | |
| Grant, Gerald | Corporate officer | Individual | 01/01/2025 | |
| Grant, Jonathan | Corporate officer | Individual | 12/31/2022 | |
| Valdivia, Peggy | Corporate officer | Individual | 12/31/2022 | |
| Acts Communities of Maryland, Inc. | Operational/managerial control | Organization | 12/31/2022 | |
| Acts Management Services, Inc. | Operational/managerial control | Organization | 12/31/2022 | |
| Acts Retirement-Life Communities Management, LLC | Operational/managerial control | Organization | 12/31/2022 | |
| Ahern, Susan | Operational/managerial control | Individual | 12/31/2022 | |
| Christiansen, Karen | Operational/managerial control | Individual | 12/31/2022 | |
| Fox, Glenn | Operational/managerial control | Individual | 12/31/2022 | |
| Grant, Gerald | Operational/managerial control | Individual | 12/31/2022 | |
| Grant, Jonathan | Operational/managerial control | Individual | 12/31/2022 | |
| Kurz, Stellah | Operational/managerial control | Individual | 01/01/2025 | |
| Valdivia, Peggy | Operational/managerial control | Individual | 12/31/2022 | |
| U.s. Bank | Trustee of the SNF | Organization | 07/09/2025 | |
| Acts Communities of Maryland, Inc. | Adp of the SNF | Organization | 12/31/2022 | |
| Acts Management Services, Inc. | Adp of the SNF | Organization | 02/06/2025 | |
| Acts Retirement-Life Communities Management, LLC | Adp of the SNF | Organization | 02/06/2025 | |
| Baker Tilly Advisory Group LP | Adp of the SNF | Organization | 02/03/2025 | |
| Baker Tilly Us LLP | Adp of the SNF | Organization | 11/05/2024 | |
| U.s. Bank | Adp of the SNF | Organization | 07/10/2025 | |
| Ahern, Susan | Adp of the SNF | Individual | 01/01/2025 | |
| Christiansen, Karen | Adp of the SNF | Individual | 01/01/2025 | |
| Fox, Glenn | Adp of the SNF | Individual | 01/01/2025 | |
| Grant, Gerald | Adp of the SNF | Individual | 01/01/2025 | |
| Grant, Jonathan | Adp of the SNF | Individual | 01/01/2025 | |
| Knaish, Kinan | Adp of the SNF | Individual | 01/01/2025 | |
| Kurz, Stellah | Adp of the SNF | Individual | 01/01/2025 | |
| Valdivia, Peggy | Adp of the SNF | Individual | 01/01/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 7 problems in this area, most recently on February 23, 2024: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on February 23, 2024: "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."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on February 23, 2024: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on February 23, 2024: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
Other nursing homes nearby
- Chestertown Nursing and Rehab Chestertown, 0.5 mi · 1 of 5 stars · 79 citations
- Resorts at Chester River Manor Corp Chestertown, 0.6 mi · 3 of 5 stars · 37 citations
- Complete Care at Corsica Hills LLC Centreville, 11.6 mi · 3 of 5 stars · 36 citations
- Sterling Care Riverside Belcamp, 20 mi · 5 of 5 stars · 41 citations
- Oakwood SNF LLC Middle River, 22.3 mi · 1 of 5 stars · 88 citations
- Citizens Care Center Havre De Grace, 22.6 mi · 5 of 5 stars · 38 citations
- Autumn Lake Healthcare at Riverview Essex, 22.6 mi · 3 of 5 stars · 47 citations
- Franklin Woods Center Baltimore, 24 mi · 4 of 5 stars · 46 citations
Maryland contacts for a concern about a nursing home
These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Maryland Department of Health, Office of Health Care Quality, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Maryland Long-Term Care Ombudsman Program, Maryland Department of Aging, 800-243-3425. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Maryland Health Care Commission, Maryland Quality Reporting, Nursing Homes, where Maryland publishes its own records on licensed homes.
Common questions
- What is Willow Brooke Ct Skilled Care Ctr at Heron Point's Medicare star rating?
- CMS rates Willow Brooke Ct Skilled Care Ctr at Heron Point 5 out of 5 stars overall, with 5 for health inspections, 5 for staffing and no for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willow Brooke Ct Skilled Care Ctr at Heron Point get at its last inspection?
- 1 health deficiency at the standard inspection on December 11, 2025. The Maryland average is 17.
- Has Willow Brooke Ct Skilled Care Ctr at Heron Point been fined?
- Yes. CMS lists 1 fine totaling $15,440 in the last three years.
- Does Willow Brooke Ct Skilled Care Ctr at Heron Point accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Willow Brooke Ct Skilled Care Ctr at Heron Point?
- CMS lists 46 owners and managers, and links the home to Acts Retirement-Life Communities. Legal business name: ACTS COMMUNITIES OF MARYLAND, INC..
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.