Willowbrooke Court at Cokesbury Village
Hockessin, Delaware · CCN 085017
11 surveys since 2010, and no finding has been recorded at harm level.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 49
- Surveys
- 11
- Harm or worse
- 0
- Immediate jeopardy
- 0
No finding on record has been cited at harm level or above.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 10
- Ownership
- Non profit - Corporation
- Chain
- ACTS RETIREMENT-LIFE COMMUNITIES
- County
- New Castle
- Medicare-certified since
- 1978
CMS ratings
- Overall
- 5
- Health inspection
- 4
- Staffing
- 5
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=11, floor 20).
Last survey on record
Jul 29, 2025
468 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.96 | 4.66 |
| Registered-nurse hours per resident day | 1.34 | — |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D763.6% | E19.1% | F327.3% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F6351×
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
- F7561×
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- F7581×
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.
- F8421×
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
In the surveyor’s words
From the most serious findings on record at Willowbrooke Court at Cokesbury Village, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF882Jul 29, 2025
Based on interview, the facility failed to designate an onsite Infection Control Preventionist at the facility from 6/3/25 to 7/13/25. Findings include:7/28/25 1:30 pm - During an interview, E2 (DON) stated [E7] is working from home. I started on 7/14/25. I have a certification for Infection Prevention training.7/28/25 1:50 pm - During an interview, E7 (ADON, Infection Preventionist) stated, I have been working from home since 6/3/25. I will be back on 7/30/25.7/29/25 11:35 am - During an interview, E2 stated, I don't know that anyone was here between 6/3/25 and 7/13/25 that has an Infection Preventionist certification.7/29/25 2:00 pm - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit… […]
- No harm, potential for more than minimal, widespreadF812Sep 3, 2024
Based on observation, interview, and review of other facility documentation it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 8/28/24 9:30 AM thru 9:45 AM - An initial observation of the facility kitchen revealed the following: -Dry food storage area: uncovered graham cracker crumbs. -Walk in refrigerator: unlabeled pies, a large unlabeled casserole, uncovered potatoes and carrots. -Walk in freezer: an unidentified frozen portion of meat was stored in the freezer. […]
- No harm, potential for more than minimal, widespreadF812Oct 3, 2023
Based on observation and interview, it was determined that the facility failed to ensure that food was stored and prepared in a sanitary manner. Findings include: The initial kitchen tour on 9/28/23 from 9:00 AM - 9:45 AM revealed that two moldy boxes of strawberries were found in the walk-in refrigerator. 10/3/23 2:44 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (ED) and E5 (DAL).
- No harm, potential for more than minimal, patternF880Sep 3, 2024
Based on record review and interview, it was determined that for two (R1and R109) out of three residents reviewed for infection control, the facility failed to establish and maintain an infection control program using enhanced barrier precautions. For R1, the presence of an indwelling feeding tube was criteria for Enhanced Barrier Precautions (EBP). R109 was admitted with PICC (percutaneously inserted central catheter) line and was diagnosed as colonized with enterococcus faecium VRE; both of which are criteria for EBP. Also the facility line listing did not specify the name of the pathogen. […]
- No harm, potential for more than minimal, isolatedF883Jul 29, 2025
Based on record review and interview, it was determined that for one (R5) out of five residents reviewed for infection control, the facility failed to offer and document pneumococcal immunization. Findings include: The facility policy dated 2023 and titled, COVID-19, Influenza, and Pneumococcal Education and Consent for Residents included, . Upon admission the licensed nurse will obtain consent from the resident or legal responsible party using the COVID-19, Influenza, or Pneumococcal Vaccine Consent Form. This form will then be stored in the residents' primary care electronic health record. […]
Read 20 findings in full →The most serious and the most recent: 20 of 49 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 29, 2025Standard4 findings
- Sep 3, 2024Standard3 findings
- Oct 3, 2023Standard4 findings
- Jun 3, 2019Standard4 findings
- Apr 20, 2017Standard1 finding
- Apr 25, 2016Standard6 findings
- Feb 25, 2015Standard4 findings
- Mar 28, 2014Standard6 findings
Show the 3 earlier surveys
- Mar 5, 2013—9 findings
- Oct 11, 2011—4 findings
- May 25, 2010—4 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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