Deficiency Index

Willow Brooke Court At Park Pointe Village

Rock Hill, South Carolina · CCN 425375

9 surveys since 2012, 1 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
19
Surveys
9
Harm or worse
1
Immediate jeopardy
1
The record, 2012–2025
’12’15’20’25
No harm recordedHarm or worseNot surveyed
Immediate jeopardy1

Findings at the most serious level CMS records.

Beyond CMS’s monthly file7/9

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
20
Ownership
Non profit - Corporation
Chain
ACTS RETIREMENT-LIFE COMMUNITIES
County
York
Medicare-certified since
2001

CMS ratings

Overall
5
Health inspection
5
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=4, floor 20).

Last survey on record

Mar 27, 2025

592 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.815.61
Registered-nurse hours per resident day0.91—
Annual nurse turnover28.1%42.6%

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

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD250.0%E125.0%F125.0%
No harm, potential for minimalA—B—C—
CMS’s current file: 4 of the 19 citations on record.

In the surveyor’s words

From the most serious findings on record at Willow Brooke Court At Park Pointe Village, in the surveyor’s own words.

  • No harm, potential for more than minimal, widespreadF921Dec 31, 2021

    Based on observation, interview, and record of professional reference information, the facility failed to maintain a safe, sanitary, functional environment by assuring that the drainage pipes from the juice bar table and the ice machine were above floor level. In the event of a sewer back-up, drainpipes at or below floor level which do not have an air gap of at least one inch can be contaminated by the dirty sewer liquid backup, creating the potential to affect any of the current ten residents. […]

  • No harm, potential for more than minimal, patternF574Mar 27, 2025

    Based on record review and interviews, the facility failed to ensure residents were informed of their right to have access to names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The facility further failed to ensure residents knew where the above information was located within the facility as revealed by 7 of 7 residents during 1 of 1 resident council meetings. […]

  • No harm, potential for more than minimal, isolatedF655Mar 27, 2025

    Based on review of the facility policy, observation, interviews and review of the facility assessment, the facility failed to complete and implement a Baseline Care Plan within 48 hours of an admission, for Resident (R)218. Findings include: Review of the facility policy titled, Baseline Care Plan, with a revision date of November 2024 revealed, 1. The licensed nurse will develop a baseline care plan in the electronic application under the assessment tab for each resident within 48 hours of a resident's admission. […]

  • No harm, potential for more than minimal, isolatedF849Dec 31, 2021

    Based on interview, record review, and review of facility policy, the facility failed to ensure a coordinated/integrated plan of care was developed for one (Resident (R) 112) of one residents reviewed for Hospice care out of the total census of 10 residents. R112's care plan failed to describe the coordination of care between the facility and the Hospice provider, including which services each party would provide for the resident. Findings include: During an interview on 12/29/21 at 10:27 AM, R112 stated she was not on Hospice care and that I'm just happy here in my chair. Review of R112's printed Admission Record from the electronic medical record (EMR) Profile tab, showed a facility admitted [DATE]. […]

Read 18 findings in full →The most serious and the most recent: 18 of 19 on record.

Every survey on record

FindingsAt actual harm or above

  • Mar 27, 2025Standard2 findings
  • Dec 31, 2021Standard2 findings
  • Nov 20, 2018Standard1 finding
  • Nov 16, 2017Standard3 findings
  • Nov 9, 2016Standard2 findings
  • Sep 17, 2015Standard4 findings
  • Oct 8, 2014Standard and complaint3 findings · 1 harm
  • May 31, 2013—1 finding
Show the 1 earlier survey
  • Mar 7, 2012—1 finding

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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