Willow Brooke Ct Skilled Care Ctr at Heron Point
501 Campus Avenue · Chestertown, MD · 21620 · 4107787300
38 certified beds Non profit - Corporation Chain: Acts Retirement-Life Communities Part of a CCRC
- Inspection results have improved across recent cycles.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 5 of 5 Inspections: 5 of 5 Staffing: 4 of 5 Quality measures: not rated
| Total nurse hours / resident-day | 3.48 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.33 | 0.55–0.75 |
| Weekend hours / resident-day | 3.21 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $15,440 |
Inspection citations (26 in the current record)
-
Potential for harm · F December 11, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 31, 2026 · Nutrition and Dietary
-
Immediate jeopardy · J February 23, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 13, 2023 · Quality of Life and Care
-
Potential for harm · D 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.
Corrected April 8, 2024 · Resident Rights
-
Potential for harm · E February 23, 2024
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.
Corrected April 8, 2024 · Nursing and Physician Services
-
Potential for harm · D 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.
Corrected April 8, 2024 · Pharmacy Service
-
Potential for harm · D February 23, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected April 8, 2024 · Pharmacy Service
-
Potential for harm · D February 23, 2024
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.
Corrected April 8, 2024 · Pharmacy Service
-
Potential for harm · E February 23, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 8, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E February 23, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 8, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D February 23, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 8, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D February 23, 2024 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected April 8, 2024 · Quality of Life and Care
-
Potential for harm · D April 9, 2019
Give the resident's representative the ability to exercise the resident's rights.
Corrected May 24, 2019 · Resident Rights
-
Potential for harm · D April 9, 2019
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected May 24, 2019 · Resident Rights
-
Potential for harm · D April 9, 2019
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected May 24, 2019 · Resident Rights
-
Potential for harm · D April 9, 2019
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected May 24, 2019 · Resident Rights
-
Potential for harm · E April 9, 2019
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected May 24, 2019 · Resident Assessment and Care Planning
-
Potential for harm · E April 9, 2019
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected May 24, 2019 · Resident Assessment and Care Planning
-
Potential for harm · E April 9, 2019
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected May 24, 2019 · Resident Assessment and Care Planning
-
Potential for harm · D April 9, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 24, 2019 · Quality of Life and Care
-
Potential for harm · E April 9, 2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 24, 2019 · Quality of Life and Care
-
Potential for harm · D April 9, 2019
Provide safe, appropriate pain management for a resident who requires such services.
Corrected May 24, 2019 · Quality of Life and Care
-
Potential for harm · E April 9, 2019
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected May 24, 2019 · Quality of Life and Care
-
Potential for harm · D April 9, 2019
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected May 24, 2019 · Pharmacy Service
-
Potential for harm · E April 9, 2019
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.
Corrected May 24, 2019 · Pharmacy Service
-
Potential for harm · D April 9, 2019
Provide routine and 24-hour emergency dental care for each resident.
Corrected May 24, 2019 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 23, 2024 | Fine | $15,440 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data — this one leads its area. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 215235 · certified since November 7, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.