Cycle 1
Health 2025-12-17 · Fire 2024-11-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Columbus, NC
Willowbrooke Court SC Ctr at Tryon Estates
5-star overall rating with 5-star inspections
619 Laurel Lake Drive, Columbus, NC
(828) 894-5500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
16
Certified beds
Average residents
9
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1994-06-03
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
1.63
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.15
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.70
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.83
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 6.16% |
| Discharge to community | 71.57% |
50.57%
21 pts better
|
Better than the National Rate · Eligible stays 38 · Observed rate 78.95% · Lower 95% interval 54.74% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 13 · Denominator 20 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 6 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 90.16% |
42%
48.2 pts better
|
Numerator 110 · Denominator 122 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 12 · Denominator 20 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
79.9%
10.7 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 90.0% · Q3 92.9% · Q4 100.0% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.4% |
13.2%
6.2 pts worse
|
12.0%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 15.0% · Expected 8.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
78.1%
18.6 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.6% |
22.9%
17.7 pts worse
|
23.9%
16.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.6% · Observed 25.0% · Expected 14.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-20 · Fire 2023-09-08
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-09-08 · Fire 2022-04-07
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-17
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
White Oak Manor - Tryon
Tryon, NC
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Autumn Care of Saluda
Saluda, NC
2-star overall rating with 2-star inspections with abuse icon flag with $16,801 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hendersonville Health and Rehabilitation
Flat Rock, NC
5-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
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