Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOW BROOKE CT SKILLED CARE CTR AT HERON POINT
CHESTERTOWN, MD · 38 certified beds · Last Life Safety survey December 11, 2025
CMS Certification Number 215235 · first certified November 1991
Ownership
Operated by ACTS RETIREMENT-LIFE COMMUNITIES · Non profit - Corporation
- Ownership changed December 31, 2022 (change of ownership)to WILLOWBROOKE COURT SKILLED CARE CENTER AT HERON POINT from HERON POINT OF CHESTERTOWN INC
Position within MD
14 citations — more than 14% of the 221 certified nursing homes in MD. Compared within MD rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 8 months from now. This facility’s last Life Safety survey was December 2025. Facilities in MD are typically surveyed 17–59 months after the last one (median 30), measured over 283 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in MD | 22 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 9, 2019 | 4 |
| February 23, 2024 | 6 |
| December 11, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-12-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-12-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-12-11 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-02-23 |
| K-0500 | Meet other general requirements that are deficient. | 1 | 2019-04-09 |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | 1 | 2019-04-09 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2024-02-23 |
| K-0271 | Have exits that are accessible at all times. | 1 | 2024-02-23 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 11, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 1, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 1, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 1, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 1, 2026) |
February 23, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 30, 2024) |
April 9, 2019 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (June 13, 2019) |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Deficient, Provider has date of correction (June 13, 2019) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 13, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 13, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.