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
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
4.32
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.44
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
5.51
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,060
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0155
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.41
Baseline 18.19% · Performance 19.39% · Measure score 4.41 · Achievement 4.41 · Improvement 0
Healthcare-associated infections
5.71
Baseline 6.00% · Performance 6.13% · Measure score 5.71 · Achievement 5.71 · Improvement 0
Total nurse turnover
7.99
Baseline 47.62% · Performance 31.03% · Measure score 7.99 · Achievement 7.99 · Improvement 6.78
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 8.22% · Lower 95% interval 7.23% |
| Discharge to community | 63.04% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 68 · Observed rate 64.71% · Lower 95% interval 54.2% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 55.17% |
53.69%
1.5 pts better
|
Numerator 16 · Denominator 29 |
| Discharge mobility score | 48.28% |
50.94%
2.7 pts worse
|
Numerator 14 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.13% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 0% · Lower 95% interval 2.82% |
| Staff COVID-19 vaccination coverage | 2.15% |
8.2%
6 pts worse
|
Numerator 2 · Denominator 93 |
| Staff flu vaccination coverage | 86.4% |
42%
44.4 pts better
|
Numerator 108 · Denominator 125 |
| Discharge function score | 62.07% |
56.45%
5.6 pts better
|
Numerator 18 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
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 · 4Q avg 100.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 2.8% |
| 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 · 4Q avg 18.9% |
| 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 · 4Q avg 17.2% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 20.0% · Used in QM five-star |
| 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 · 4Q avg 28.6% · Used in QM five-star |
| 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 · 4Q avg 3.0% · Used in QM five-star |
| 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 · 4Q avg 2.4% · Used in QM five-star |
| 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 · 4Q avg 29.2% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 93.1% · Q3 95.7% · Q4 100.0% · 4Q avg 97.1% |
| 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 · Adjusted 15.1% · Observed 13.3% · Expected 9.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
| 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 · Adjusted 21.4% · Observed 16.7% · Expected 18.6% · Used in QM five-star |
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
#1
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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