Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE

EASTON, MD · 99 certified beds · Last Life Safety survey January 17, 2025

CMS Certification Number 215137 · first certified January 1982

Ownership

Operated by ACTS RETIREMENT-LIFE COMMUNITIES · Non profit - Corporation

Ownership changed March 31, 2020 (change of ownership)to WILLOWBROOKE COURT SKILLED CARE CENTER AT BAYLEIGH CHASE from BAYLEIGH CHASE INC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within MD

32 citations — more than 78% 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

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 11 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: June 2026 to December 2029. This facility’s last Life Safety survey was January 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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7 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)

5 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 32 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.
F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	32
Median facility in MD	22
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
February 21, 2018	8
July 12, 2019	13
January 17, 2025	11

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	3	2025-01-17
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2025-01-17
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2025-01-17
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2025-01-17
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2025-01-17
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	2	2025-01-17
K-0363	Install corridor and hallway doors that block smoke.	2	2019-07-12
K-0923	Have proper medical gas storage and administration areas.	2	2025-01-17

What the citations cover

Citations by CMS category

Smoke Deficiencies 11
Gas, Vacuum, and Electrical Systems Deficiencies 7
Egress Deficiencies 6
Miscellaneous Deficiencies 4
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	11
Gas, Vacuum, and Electrical Systems Deficiencies	7
Egress Deficiencies	6
Miscellaneous Deficiencies	4
Services Deficiencies	3
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 17, 2025 — 11 citations

Citations issued on January 17, 2025
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (March 20, 2025)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (March 20, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 20, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 20, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 20, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 20, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (March 20, 2025)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (March 20, 2025)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (March 20, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 20, 2025)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (March 20, 2025)

July 12, 2019 — 13 citations

Citations issued on July 12, 2019
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (October 15, 2019)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (October 15, 2019)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 15, 2019)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 15, 2019)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (October 15, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 15, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 15, 2019)
K-0500	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (October 15, 2019)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (October 15, 2019)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 15, 2019)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 15, 2019)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Deficient, Provider has date of correction (October 15, 2019)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 15, 2019)

February 21, 2018 — 8 citations

Citations issued on February 21, 2018
Tag	What the surveyor checks	Status
K-0163	Install noncombustible or limited-combustible interior walls.	Deficient, Provider has date of correction (March 27, 2018)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (March 27, 2018)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (March 27, 2018)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (March 27, 2018)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 27, 2018)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (March 27, 2018)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (March 27, 2018)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (March 27, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.