Chestertown Nursing and Rehab
Chestertown · 0.5 mi · 92 beds
Citations0Substantiated0
Willow Brooke CT Skilled Care CTR at Heron Point
501 CAMPUS AVENUE, Chestertown, MD, 21620
Nursing home38 licensed beds0 citations on record
2 more within 6 milesOpen in Maps
Has this facility been cited?
Yes. Federal inspectors cited 1 deficiency against Willow Brooke CT Skilled Care CTR at Heron Point in Chestertown, Maryland at its most recent standard inspection on 2025-12-11. 1 finding has been recorded at the immediate-jeopardy level, the most serious CMS uses, meaning a resident was placed in immediate danger. Medicare has fined it 1 time, totalling $15,440. Medicare rates it 5 out of 5 overall.
5 / 5Medicare overall rating
38certified beds
1deficiencies at the last inspection
1immediate-jeopardy findings on record
0actual-harm findings on record
1federal fines, $15,440
What the inspectors found
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
Immediate jeopardyA resident was placed in immediate danger. The most serious band CMS uses.1
Actual harmA resident was harmed, but not placed in immediate danger.0
Potential for more than minimal harmNo resident was harmed, but the failing could have caused it.25
Potential for minimal harmThe least serious band.0
Most recentFEDDDDJEEDDEEEEEEDDD
The last 20 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2025-12-11 · standard survey · No actual harm, potential for more than minimal harm
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.
Nursing and Physician Services Deficiencies · F0726 · 2024-02-23 · standard survey · No actual harm, potential for more than minimal harm
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.
Resident Rights Deficiencies · F0625 · 2024-02-23 · standard survey · No actual harm, potential for more than minimal harm
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.
Pharmacy Service Deficiencies · F0758 · 2024-02-23 · standard survey · No actual harm, potential for more than minimal harm
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · F0759 · 2024-02-23 · standard survey · No actual harm, potential for more than minimal harm
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.
Pharmacy Service Deficiencies · F0761 · 2024-02-23 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2024-02-23 · from a complaint · Immediate jeopardy to resident health or safety
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0609 · 2024-02-23 · from a complaint · No actual harm, potential for more than minimal harm
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0610 · 2024-02-23 · from a complaint · No actual harm, potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · F0656 · 2024-02-23 · from a complaint · No actual harm, potential for more than minimal harm
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies · F0740 · 2024-02-23 · from a complaint · No actual harm, potential for more than minimal harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies · F0636 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies · F0638 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · F0645 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · F0745 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
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.
Pharmacy Service Deficiencies · F0758 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Give the resident's representative the ability to exercise the resident's rights.
Resident Rights Deficiencies · F0551 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · F0561 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · F0580 · 2019-04-09 · standard survey · No actual harm, potential for more than minimal harm
Medicare’s own rating
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
OverallCombines the three below5 of 5
Health inspectionBased on the last three inspection cycles5 of 5
StaffingNurse hours per resident, adjusted for how sick residents are5 of 5
Quality measuresResident outcomes reported by the home—
Nurse hours per resident per dayReported by the home to CMS4.74709
Penalties
What Medicare has fined this home
FinesCivil money penalties imposed by CMS1
Total fined$15,440
Payment denials and other penaltiesMedicare refusing to pay for new admissions is the usual one1
Ownership
Who owns Willow Brooke CT Skilled Care CTR at Heron Point
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| ACTS ACQUISITION AND DEVELOPMENT COMPANY LLC | Organization | NOT APPLICABLE | since 12/31/2022 |
| ACTS ALLIANCE MANAGEMENT LLC | Organization | NOT APPLICABLE | since 12/31/2022 |
| ACTS LEGACY FOUNDATION, INC. | Organization | NOT APPLICABLE | since 12/31/2022 |
| ACTS RETIREMENT SERVICES, INC | Organization | NOT APPLICABLE | since 12/31/2022 |
| ACTS SIGNATURE COMMUNITY SERVICES INC | Organization | NOT APPLICABLE | since 12/31/2022 |
| BONITA SPRINGS RETIREMENT VILLAGE INC | Organization | NOT APPLICABLE | since 11/01/2024 |
| MEASE LIFE INC | Organization | NOT APPLICABLE | since 10/01/2023 |
| CHRISTIANSEN, KAREN | Individual | NOT APPLICABLE | since 12/31/2022 |
| DETWEILER, HAROLD | Individual | NOT APPLICABLE | since 12/31/2022 |
| FORREST, ANNE | Individual | NOT APPLICABLE | since 12/31/2022 |
| GRANT, GERALD | Individual | NOT APPLICABLE | since 12/31/2022 |
| KELLY, MICHAEL | Individual | NOT APPLICABLE | since 12/31/2022 |
Part of the ACTS RETIREMENT-LIFE COMMUNITIES group.
Nearby
Other licensed providers within six miles
Listed by distance. Nobody paid to appear here and the order is not for sale.
Resorts at Chester River Manor Corp
Chestertown · 0.6 mi · 98 beds
Citations0Substantiated0
Contact
Ask Willow Brooke CT Skilled Care CTR at Heron Point a question
This page has not been claimed, so messages sent here would reach nobody. Call them instead — we take no commission either way, so we have no reason to steer you anywhere.
Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 215235.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction