Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

A+
Grade
78
Score
CMS Ratings
18.7/22
Staffing Quality
23.3/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate5.0%
38
Total Beds
2
Occupied
36
Available

Basic Information

Address:

501 CAMPUS AVENUE

CHESTERTOWN, MD 21620

Number of Beds:

38

Estimated Occupancy:

5% (~36 available)

Chain:

ACTS RETIREMENT-LIFE COMMUNITIES

Quality Ratings

Overall Rating:5/5 Stars
Health Inspection:5/5 Stars
Staffing Rating:5/5 Stars
Quality Measures:Not Rated

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

215235

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Above Average

This Facility

1.76

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Above Average

This Facility

4.75

hours

National Avg

3.89

hours

Breakdown:

RN: 1.76hLPN: 0.77hAide: 2.22h

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Critical Deficiencies Found

This facility has 2 deficiency citations involving actual harm to residents. Review these carefully before making a decision.

Total Deficiencies

62

Inspections

3

Critical

2

Feb 23, 2024 - Health Survey

20 deficiencies cited

Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Apr 8, 2024From Complaint
Medium - PatternTag F0625

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0726

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0758

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Apr 8, 2024
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Apr 8, 2024From Complaint
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 13, 2023From Complaint
Medium - PatternTag F0656

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.

Corrected: Apr 8, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Apr 8, 2024From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Apr 8, 2024From Complaint
Medium - PatternTag F0761

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0761

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0625

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0726

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0758

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.

Corrected: Apr 8, 2024
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Apr 8, 2024
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Apr 8, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Apr 8, 2024From Complaint
Medium - PatternTag F0656

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.

Corrected: Apr 8, 2024From Complaint
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 13, 2023From Complaint

Apr 9, 2019 - Health Survey

30 deficiencies cited

Medium - PatternTag F0638

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected: May 24, 2019
Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: May 24, 2019
Medium - PatternTag F0561

Resident Rights Deficiencies

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
Medium - PatternTag F0580

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.

Corrected: May 24, 2019
Medium - PatternTag F0623

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.

Corrected: May 24, 2019
Medium - PatternTag F0636

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.

Corrected: May 24, 2019
Medium - PatternTag F0638

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected: May 24, 2019
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: May 24, 2019
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: May 24, 2019
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: May 24, 2019
Medium - PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: May 24, 2019
Medium - PatternTag F0756

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.

Corrected: May 24, 2019
Medium - PatternTag F0758

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.

Corrected: May 24, 2019
Medium - PatternTag F0790

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Corrected: May 24, 2019
Medium - PatternTag F0842

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.

Corrected: May 24, 2019
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: May 24, 2019
Medium - PatternTag F0580

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.

Corrected: May 24, 2019
Medium - PatternTag F0623

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.

Corrected: May 24, 2019
Medium - PatternTag F0636

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.

Corrected: May 24, 2019
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: May 24, 2019
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: May 24, 2019
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: May 24, 2019
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: May 24, 2019
Medium - PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: May 24, 2019
Medium - PatternTag F0756

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.

Corrected: May 24, 2019
Medium - PatternTag F0758

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.

Corrected: May 24, 2019
Medium - PatternTag F0790

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Corrected: May 24, 2019
Medium - PatternTag F0842

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.

Corrected: May 24, 2019
Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: May 24, 2019
Medium - PatternTag F0561

Resident Rights Deficiencies

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

Nov 6, 2017 - Health Survey

12 deficiencies cited

Medium - PatternTag F0514

Administration Deficiencies

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Corrected: Jan 31, 2018
Low - IsolatedTag F0456

Environmental Deficiencies

Keep all essential equipment working safely.

Corrected: Jan 31, 2018
Low - IsolatedTag F0441

Environmental Deficiencies

Have a program that investigates, controls and keeps infection from spreading.

Corrected: Jan 31, 2018
Medium - PatternTag F0431

Pharmacy Service Deficiencies

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Corrected: Jan 31, 2018
Medium - PatternTag F0329

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.

Corrected: Jan 31, 2018
Medium - PatternTag F0309

Quality of Life and Care Deficiencies

Provide necessary care and services to maintain or improve the highest well being of each resident .

Corrected: Jan 31, 2018
Low - IsolatedTag F0456

Environmental Deficiencies

Keep all essential equipment working safely.

Corrected: Jan 31, 2018
Medium - PatternTag F0514

Administration Deficiencies

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Corrected: Jan 31, 2018
Medium - PatternTag F0309

Quality of Life and Care Deficiencies

Provide necessary care and services to maintain or improve the highest well being of each resident .

Corrected: Jan 31, 2018
Medium - PatternTag F0329

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.

Corrected: Jan 31, 2018
Medium - PatternTag F0431

Pharmacy Service Deficiencies

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Corrected: Jan 31, 2018
Low - IsolatedTag F0441

Environmental Deficiencies

Have a program that investigates, controls and keeps infection from spreading.

Corrected: Jan 31, 2018

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

1 penalty in the past 3 years

Total fines: $15,440

FineFebruary 23, 2024

$15,440

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

High CMS Rating
5 out of 5 stars from Medicare
👨‍⚕
Above Average RN Staffing
1.76 RN hours per resident/day (national avg: 0.64)
🛏
Beds Available
Approximately 36 beds potentially available
🏢
Part of Healthcare Chain
ACTS RETIREMENT-LIFE COMMUNITIES

Frequently Asked Questions

What is the quality rating for WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT?

WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT has an overall CMS rating of 5 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT has 38 certified beds. The facility averages 2 residents per day, with an occupancy rate of approximately 5%.

What type of ownership does this facility have?

This facility is non profit - corporation owned. It is part of the ACTS RETIREMENT-LIFE COMMUNITIES network.

How can I contact WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT?

You can call WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT at (410)778-7300. The facility is located at 501 CAMPUS AVENUE, CHESTERTOWN, MD 21620.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

Important Considerations for This Facility

Based on this facility's data, we recommend reading these guides to understand what to look for:

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