CCN 215137

Willowbrooke CT Skilled Care CTR at Bayleigh Chase

501 DUTCHMAN'S LANE, Easton, MD 21601 · Talbot County

Phone: (410) 822-8888
Ownership: Non profit - Corporation
Certified beds: 99
Residents per day: 61.0
Health citations: 31
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 4 · short-stay 5.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.93; 2.12; 2.32
LPN/LVN: 0.62; 0.91; 0.86
Registered nurse: 1.04; 0.84; 0.69
Total nurse staff: 3.59; 3.87; 3.86
Weekend total: 3.25; 3.47; 3.42
Weekend RN: 0.82; 0.63; 0.48

Adjusted total nurse hours: 4.05. Adjusted RN hours: 1.17. Case-mix total: 3.40. Case-mix index: 1.244.

Total nursing staff turnover: 24.5%. RN turnover: 33.3%. Administrators who left: 2.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: March 25, 2026. Health deficiencies counted in cycle 1: 8. Cycle 1 total health score: 36.

Cycle 2 standard survey: January 17, 2025. Cycle 2/3 health deficiencies: 12. Total weighted health survey score: 71.75.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 31 citations for this home, including 1 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

March 25, 2026

8 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F585	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F697	Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026
F849	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 30, 2026

January 17, 2025

12 citations

Tag	What CMS cited	Scope and severity	Status
F600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	J: isolated, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · February 27, 2025
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · February 27, 2025
F730	Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F867	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F835	Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F943	Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F697	Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025

July 12, 2019

11 citations

Tag	What CMS cited	Scope and severity	Status
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F727	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F623	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F640	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F761	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019
F923	Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 31, 2019

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
CMS flags this provider as a continuing care retirement community.
Chain name in the file: Acts Retirement-Life Communities (27 facilities). Chain average overall rating: 4.9.
Legal business name: Acts Communities of Maryland, INC..
First approved for Medicare and Medicaid services: January 26, 1982.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Willowbrooke CT Skilled Care CTR at Bayleigh Chase?

Willowbrooke CT Skilled Care CTR at Bayleigh Chase has an overall rating of 4 out of 5. The health inspection rating is 4, staffing is 4, and the quality measure rating is 4.

How many health citations does CMS list for Willowbrooke CT Skilled Care CTR at Bayleigh Chase?

The Health Deficiencies file lists 31 health citations for this home. 1 are coded immediate jeopardy (J, K, or L) and 1 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Willowbrooke CT Skilled Care CTR at Bayleigh Chase?

CMS reports 3.59 total nurse hours per resident per day, including 1.04 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

January 17, 2025

12 citations

Tag	What CMS cited	Scope and severity	Status
F600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	J: isolated, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · February 27, 2025
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · February 27, 2025
F730	Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F867	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F835	Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F943	Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F697	Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 27, 2025