WILLOWBROOKE COURT AT COUNTRY HOUSE

4830 KENNETT PIKE, WILMINGTON, DE 19807 (302) 654-5101
Non profit - Corporation 14 Beds ACTS RETIREMENT-LIFE COMMUNITIES Data: November 2025
Trust Grade
90/100
#12 of 43 in DE
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Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Willowbrooke Court at Country House has an excellent Trust Grade of A, indicating a high level of quality and care. It ranks #12 out of 43 facilities in Delaware, placing it in the top half, and #7 out of 25 in New Castle County, which means there are only six local options better than this facility. The facility shows an improving trend, with the number of issues decreasing from 3 in 2024 to 2 in 2025. Staffing is a notable strength, boasting a perfect 5-star rating and zero turnover, which is significantly better than the state average of 42%, ensuring consistent care from familiar staff members. However, there are some concerns, including incidents where food was not stored properly, and medical records were not fully updated, highlighting areas that need attention despite the overall high quality of care.

Trust Score
A
90/100
In Delaware
#12/43
Top 27%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
3 → 2 violations
Staff Stability
○ Average
Turnover data not reported for this facility.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Delaware facilities.
Skilled Nurses
✓ Good
Each resident gets 83 minutes of Registered Nurse (RN) attention daily — more than 97% of Delaware nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
○ Average
6 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 2 issues

The Good

  • 5-Star Staffing Rating · Excellent nurse staffing levels
  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Chain: ACTS RETIREMENT-LIFE COMMUNITIES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 6 deficiencies on record

Feb 2025 2 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Based on clinical record review and interview, it was determined that for one (R3) out of one resident reviewed for hospitalization, the facility failed to send a copy of a hospital transfer notice to...

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Based on clinical record review and interview, it was determined that for one (R3) out of one resident reviewed for hospitalization, the facility failed to send a copy of a hospital transfer notice to the Office of the State Long-Term Care Ombudsman. Findings include: Review of R3's clinical record revealed: 1/10/25 - R3 was admitted to the facility with multiple diagnoses, including the aftereffects from a fall, heart disease, chronic pain, diabetes and anemia. 1/15/25 - R3 experienced severe stomach pain with diarrhea, and the R3 was sent to the hospital for an evaluation, and was admitted to the hospital. 2/25/25 1:15 PM - During an interview, E1 (NHA) stated that the facility failed to send a copy of the hospital transfer notice the State Long-Term Care Ombudsman for the R3's 1/15/25 hospitalization. 2/26/25 3:30 PM - Findings were reviewed during the exit conference with E1, E2 (DON), E13 (ED) and a representative from the Ombudsman's office.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review, it was determined that for one (R1) out of five residents reviewed for unnecessary medications, the facility failed to ensure that R1's physician order for weekly...

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Based on interview and record review, it was determined that for one (R1) out of five residents reviewed for unnecessary medications, the facility failed to ensure that R1's physician order for weekly blood pressure (BP) monitoring on Mondays was completed. Findings include: Review of R1's clinical record revealed: 5/22/24 - R1 had a physician's order for blood pressure every week on Mondays for diagnosis of high blood pressure. According to the monthly electronic MARs, R1 was receiving the following medications for a diagnosis of high blood pressure from December 1, 2024 through February 18, 2025: - Cardizem daily; - Hydrochlorothiazide daily; and - Atenolol twice a day. Review of the R1's clinical record for the weekly blood pressures revealed that 10 out of 12 scheduled opportunities, R1's blood pressure was not checked per the physician's order. 2/25/25 11:30 AM - During a combined interview with E2 (DON) and E3 (RNAC/Supervisor), finding was reviewed and acknowledged. No further information was provided to the Surveyor. 2/26/25 3:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2, E13 (ED) and a representative from the Ombudsman's office.
Feb 2024 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined that for one (R8) out of five residents reviewed for physician services, the facility failed to ensure the resident was seen for the required ph...

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Based on record review and interview, it was determined that for one (R8) out of five residents reviewed for physician services, the facility failed to ensure the resident was seen for the required physician visits. Findings include: R8's clinicial record revealed: 12/5/23 - R8 was admitted to the facility. Review of R8's clinical record revealed the absence of an initial comprehensive visit by the Physician. 2/8/24 at 2:03 PM - During a combined interview, finding was confirmed with E1 (NHA) and E3 (Regional Clinical Director). 2/9/24 at 3:30 PM - Finding was reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Based on record review and interview it was determined that for one (R4) out of five residents reviewed for clinical records, the facility failed to ensure that R4's medical records were complete and ...

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Based on record review and interview it was determined that for one (R4) out of five residents reviewed for clinical records, the facility failed to ensure that R4's medical records were complete and readily accessible as evidenced by the failure to upload the attending physician notes in the EMR (electronic medical record). Findings include: 5/21/20 - R4 was admitted to the facility. 1/23/23 - R4 was seen by E6 (MD) for R4's required 60 day visit. 3/27/23 - R4 was seen by E6 for R4's required 60 day visit. 5/6/23 - R4 was seen by E6 for R4's required 60 day visit. 6/26/23 - R4 was seen by E6 for R4's required 60 day visit. 8/28/23 - R4 was seen by E6 for R4's required 60 day visit. 10/23/23 - R4 was seen by E6 for R4's required 60 day visit. 2/8/24 - There was no evidence in R4's EMR of the 1/23/23, 3/27/23, 5/6/23, 6/26/23, 8/28/23 and 10/23/23 encounter or the subsequent progress note by E6. 2/9/24 3:30 PM - Findings were reviewed at the Exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation and interview during the initial kitchen tour, it was determined that the facility failed to ensure food was stored in accordance with professional standards for food service safe...

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Based on observation and interview during the initial kitchen tour, it was determined that the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings include: 2/5/24 from 8:22 AM to 8:35 AM, observation of the kitchen with E1 (NHA) revealed the following: - observed 1/4 tray of cake (vanilla with chocolate icing) and a full tray of sloppy joe were undated in the refrigerator; - observed a full tray of frozen dough that was not covered completely and undated, a plate with two pieces of cooked chicken was uncovered and undated and a clear bag of chicken nuggets was undated in the walk-in freezer. Finding was immediately confirmed with E1 (NHA). 2/9/24 at 3:30 PM - Finding was reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).
Apr 2022 1 deficiency
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected 1 resident

Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required training on abuse, neglect and exploitation was completed f...

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Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required training on abuse, neglect and exploitation was completed for one (E8) out of 12 randomly sampled staff members. Findings include: Review of E8's personnel records revealed: 12/21/21 - The first day of assignment at the facility for E8 (Enrichment Assistant). 4/26/22 at 12:50 PM - In an interview, E1 (NHA) confirmed that E8 did not receive his abuse, neglect and exploitation training. Findings where reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 4/26/22 beginning at 3:15 PM.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade A (90/100). Above average facility, better than most options in Delaware.
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Delaware facilities.
Concerns
  • • No significant concerns identified. This facility shows no red flags across CMS ratings, staff turnover, or federal penalties.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Willowbrooke Court At Country House's CMS Rating?

CMS assigns WILLOWBROOKE COURT AT COUNTRY HOUSE an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Delaware, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Willowbrooke Court At Country House Staffed?

CMS rates WILLOWBROOKE COURT AT COUNTRY HOUSE's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes.

What Have Inspectors Found at Willowbrooke Court At Country House?

State health inspectors documented 6 deficiencies at WILLOWBROOKE COURT AT COUNTRY HOUSE during 2022 to 2025. These included: 6 with potential for harm.

Who Owns and Operates Willowbrooke Court At Country House?

WILLOWBROOKE COURT AT COUNTRY HOUSE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by ACTS RETIREMENT-LIFE COMMUNITIES, a chain that manages multiple nursing homes. With 14 certified beds and approximately 3 residents (about 21% occupancy), it is a smaller facility located in WILMINGTON, Delaware.

How Does Willowbrooke Court At Country House Compare to Other Delaware Nursing Homes?

Compared to the 100 nursing homes in Delaware, WILLOWBROOKE COURT AT COUNTRY HOUSE's overall rating (5 stars) is above the state average of 3.3 and health inspection rating (5 stars) is much above the national benchmark.

What Should Families Ask When Visiting Willowbrooke Court At Country House?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Willowbrooke Court At Country House Safe?

Based on CMS inspection data, WILLOWBROOKE COURT AT COUNTRY HOUSE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Delaware. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Willowbrooke Court At Country House Stick Around?

WILLOWBROOKE COURT AT COUNTRY HOUSE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Willowbrooke Court At Country House Ever Fined?

WILLOWBROOKE COURT AT COUNTRY HOUSE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Willowbrooke Court At Country House on Any Federal Watch List?

WILLOWBROOKE COURT AT COUNTRY HOUSE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

WILLOWBROOKE COURT AT COUNTRY HOUSE

4830 KENNETT PIKE, WILMINGTON, DE 19807 | (302) 654-5101

A
Trust Grade (90/100)
5.0
CMS Rating
6
Deficiencies

Strengths

  • 5-star staffing
  • 5-star quality

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025