Cycle 1
Health 2025-03-27 · Fire 2025-03-27
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rock Hill, SC
Willow Brooke Court At Park Pointe Village
5-star overall rating with 4-star inspections with 2 recent health deficiencies
3025 Chesbrough Blvd, Rock Hill, SC
(803) 980-8605
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
16
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
2001-04-25
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing
LPN hours / resident day
0.78
Licensed practical nurse staffing
Aide hours / resident day
2.48
Nurse aide staffing
Weekend hours
3.87
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.5%
9.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.0%
3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.9%
2.9 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.8% |
6.2%
3.4 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
20.4%
1.5 pts better
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
16.3%
0.9 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.0% |
14.9%
5.1 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.6% |
12.4%
16.2 pts worse
|
14.9%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.7%
2.3 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.6%
0.8 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
17.2%
12 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.8%
5.8 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
79.8%
17.3 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
14.1%
1 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.0%
22 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
24.7%
3.3 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-31 · Fire 2021-12-31
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-31
F · Potential for more than minimal harm
2021-12-31
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-01-26
D · Potential for more than minimal harm
2021-12-31
F849 · Administration Deficiencies
Health
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.
Corrected 2022-01-26
Penalties and ownership
What sits behind the stars
Ownership
Acts Retirement-Life Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Inc
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Inc
5% Or Greater Mortgage Interest · Organization
Acts Retirement-Life Communities Management, LLC
Operational/Managerial Control · Organization
Ahern, Susan
Operational/Managerial Control · Individual
Ahern, Susan
Corporate Officer · Individual
Allmond, Susan
Corporate Director · Individual
Allmond, Susan
Corporate Officer · Individual
Brod, Kathryn
Corporate Director · Individual
Callaway, Warren
Corporate Director · Individual
Chamberlain, Linda
Corporate Director · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Glynn, James
Corporate Director · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Greer, Jason
Corporate Director · Individual
Kelly, Michael
Corporate Director · Individual
Lammers, John
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Lawson, Daniel
Corporate Officer · Individual
Mashner, Marvin
Corporate Director · Individual
Mashner, Marvin
Corporate Officer · Individual
Middlebrooks, Daniel
Corporate Director · Individual
Reichard, Dawn
Corporate Director · Individual
Nearby options
Other facilities in reach
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PruittHealth- Rock Hill
Rock Hill, SC
3-star overall rating with 3-star inspections with $23,989 in total fines with 1 recent health deficiencies
#2
White Oak Manor - Rock Hill
Rock Hill, SC
4-star overall rating with 3-star inspections with $7,446 in total fines with 3 recent health deficiencies
#3
Rock Hill Post Acute Care Center
Rock Hill, SC
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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