Home / North Carolina / Matthews
Willowbrooke Court Sc Ctr at Matthews Glen
740 Pavilion View Drive, Matthews, NC 28105 · Mecklenburg County · (704) 845-6220
15 certified beds, about 14 residents a day · Non profit - Corporation · Medicare since 1990
CMS Care Compare ratings, data as of September 1, 2026 · CCN 345326 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 8, 2025, inspectors cited 3 health deficiencies (the North Carolina average is 4.7, the national average 9.2).
None of its 6 health citations since May 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.67 hours per resident per day, against 3.85 across North Carolina and 3.86 nationally. Registered nurses accounted for 0.92 of those hours.
CMS links it to Acts Retirement-Life Communities, an affiliated group of 27 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 6 health citations on file.
July 8, 2025Standard inspection · 3 citations
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews, the facility failed to discard expired food and milk available for use in 1 of 2 walk-in refrigerators (produce refrigerator) in the main kitchen and 1 of 2 nourishment refrigerators. This practice had the potential to affect the food served to residents.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record reviews and interviews with the resident, staff and Medical Doctor (MD), the facility failed to ensure treatment for a non-pressure related area of skin impairment was completed daily per the standing order for 1 of 1 sampled resident (Resident #5) reviewed for skin conditions.
- C Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 32 of 72 days reviewed (01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/07/25, 01/08/25, 01/10/25, 01/12/25, 01/18/25, 01/21/25, 01/26/25, 02/07/25, 02/09/25, 02/15/25, 02/20/25, 02/21/25, 02/24/25, 02/25/25, 02/27/25, 02/28/25, 03/01/25, 03/03/25, 03/05/25, 03/06/25, 03/07/25, 03/09/25, 03/14/25, 03/15/25, 03/21/25, 03/24/25, and 03/29/25).
May 30, 2024Standard inspection · 3 citations
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, staff, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 25 opportunities which resulted in an 12% medication error rate. This affected 1 of 3 residents observed for medication administration (Resident #57).
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, record review, and staff and resident interviews the facility failed to store a medication and left it unattended at the bedside for 1 of 1 resident (Resident #5) reviewed for medication storage.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, staff, and Nurse Practitioner (NP) interview the facility failed to wear personal protective equipment (PPE) while administering medications through a peripherally inserted central catheter (PICC line) for a resident requiring Enhanced Barrier Precautions (EBP). This deficit practice occurred for 1 of 2 residents reviewed for EBP (Resident #57).
May 11, 2023Standard inspection · 0 citations
Fire safety inspections
11 fire safety citations on file: 7 on May 30, 2024, 1 on May 11, 2023, 3 on January 8, 2020.
Every fire safety citation11 citations
- D Use approved construction type or materials.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Have approved installation, maintenance and testing program for fire alarm systems.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- D Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Provide properly protected cooking facilities.
- E Have approved installation, maintenance and testing program for fire alarm systems.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Provide properly protected cooking facilities.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | North Carolina | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.67 | 3.85 | 3.86 |
| Registered nurses | 0.92 | 0.62 | 0.69 |
| All nursing staff on weekends | 4.36 | 3.42 | 3.42 |
| Nurse aides | 2.72 | ||
| Licensed practical nurses | 1.02 | ||
| Nursing staff turnover (share who left in a year) | not reported | 49.0% | 45.8% |
| Registered nurse turnover | not reported | 45.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.37 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.80 on weekdays and 4.36 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.23 in April to June 2025 to 4.67 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.67 | 0.92 | 4.80 | 4.36 | 0.0% | 0 of 90 | 14 |
| Oct to Dec 2025 | 4.63 | 0.97 | 4.73 | 4.37 | 0.7% | 0 of 92 | 12 |
| Jul to Sep 2025 | 4.97 | 1.06 | 5.07 | 4.71 | 0.2% | 0 of 92 | 8 |
| Apr to Jun 2025 | 5.23 | 1.17 | 5.36 | 4.90 | 0.5% | 0 of 91 | 10 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| North Carolina, Jan to Mar 2026 | 3.65 | 0.53 | 3.82 | 3.25 | 8.0% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | North Carolina | US |
|---|---|---|---|
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.2 | 1.4 | 1.6 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 10.8 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 14.4 | 12.9 | 12.0 |
Owners and operators
Legal business name: ACTS RETIREMENT-LIFE COMMUNITIES INC. CMS links this home to Acts Retirement-Life Communities, a group of 27 nursing homes averaging 4.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Acts Acquisition and Development Company LLC | Indirect ownership interest | Organization | 01/01/2003 | |
| Acts Alliance Management LLC | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Communities of Maryland, Inc. | Indirect ownership interest | Organization | 04/01/2019 | |
| Acts Legacy Foundation, Inc. | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Retirement Services, Inc | Indirect ownership interest | Organization | 03/24/2009 | |
| Acts Retirement-Life Communities Management, LLC | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Signature Community Services Inc | Indirect ownership interest | Organization | 03/24/2009 | |
| Bonita Springs Retirement Village Inc | Indirect ownership interest | Organization | 11/01/2024 | |
| Mease Life Inc | Indirect ownership interest | Organization | 10/01/2023 | |
| Acts Retirement-Life Communities Inc | 5% or greater mortgage interest | Organization | 11/01/1988 | |
| Allmond, Susan | Corporate director | Individual | 01/01/2017 | |
| Brod, Kathryn | Corporate director | Individual | 02/15/2024 | |
| Callaway, Warren | Corporate director | Individual | 03/30/2022 | |
| Chamberlain, Linda | Corporate director | Individual | 01/01/2025 | |
| Christiansen, Karen | Corporate director | Individual | 01/01/2020 | |
| Detweiler, Harold | Corporate director | Individual | 11/01/2009 | |
| Esterhai, John | Corporate director | Individual | 05/01/1996 | |
| Gerner, Elric | Corporate director | Individual | 04/01/2009 | |
| Glynn, James | Corporate director | Individual | 01/01/2023 | |
| Grant, Gerald | Corporate director | Individual | 05/04/2017 | |
| Greer, Jason | Corporate director | Individual | 03/30/2022 | |
| Kelly, Michael | Corporate director | Individual | 02/11/2020 | |
| Lammers, John | Corporate director | Individual | 12/15/2020 | |
| Lawson, Daniel | Corporate director | Individual | 06/11/2019 | |
| Mashner, Marvin | Corporate director | Individual | 01/01/1991 | |
| Middlebrooks, Daniel | Corporate director | Individual | 01/01/2023 | |
| Reichard, Dawn | Corporate director | Individual | 06/01/2025 | |
| Ahern, Susan | Corporate officer | Individual | 01/01/2020 | |
| Allmond, Susan | Corporate officer | Individual | 01/01/2025 | |
| Christiansen, Karen | Corporate officer | Individual | 05/25/2010 | |
| Fox, Glenn | Corporate officer | Individual | 01/01/2017 | |
| Gerner, Elric | Corporate officer | Individual | 01/01/2010 | |
| Grant, Gerald | Corporate officer | Individual | 06/01/2005 | |
| Lawson, Daniel | Corporate officer | Individual | 01/01/2025 | |
| Mashner, Marvin | Corporate officer | Individual | 01/01/2025 | |
| Acts Management Services, Inc. | Operational/managerial control | Organization | 01/01/2012 | |
| Acts Retirement-Life Communities Inc | Operational/managerial control | Organization | 01/01/2012 | |
| Acts Retirement-Life Communities Management, LLC | Operational/managerial control | Organization | 12/31/2022 | |
| Ahern, Susan | Operational/managerial control | Individual | 01/01/2020 | |
| Christiansen, Karen | Operational/managerial control | Individual | 05/25/2010 | |
| Fox, Glenn | Operational/managerial control | Individual | 01/01/2017 | |
| Grant, Gerald | Operational/managerial control | Individual | 06/01/2005 | |
| Acts Management Services, Inc. | Adp of the SNF | Organization | 07/21/2025 | |
| Acts Retirement-Life Communities Inc | Adp of the SNF | Organization | 11/01/1988 | |
| Acts Retirement-Life Communities Management, LLC | Adp of the SNF | Organization | 07/21/2025 | |
| Baker Tilly Advisory Group LP | Adp of the SNF | Organization | 02/03/2025 | |
| Baker Tilly Us LLP | Adp of the SNF | Organization | 11/05/2024 | |
| U.s. Bank | Adp of the SNF | Organization | 07/09/2025 | |
| Ahern, Susan | Adp of the SNF | Individual | 01/01/2020 | |
| Christiansen, Karen | Adp of the SNF | Individual | 05/25/2010 | |
| Clements, Thad | Adp of the SNF | Individual | 09/17/2021 | |
| Fleming, Shacana | Adp of the SNF | Individual | 11/13/2020 | |
| Fox, Glenn | Adp of the SNF | Individual | 01/01/2017 | |
| Grant, Gerald | Adp of the SNF | Individual | 06/01/2005 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 2 problems in this area, most recently on May 30, 2024: "Ensure medication error rates are not 5 percent or greater."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 1 problem in this area, most recently on July 8, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 1 problem in this area, most recently on July 8, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 1 problem in this area, most recently on July 8, 2025: "Post nurse staffing information every day."
Other nursing homes nearby
- Royal Park Rehabilitation & Health Center Matthews, 0 mi · 2 of 5 stars · 25 citations
- Matthews Health & Rehab Center Matthews, 2.1 mi · 2 of 5 stars · 20 citations
- Lake Park Nursing and Rehabilitation Center Indian Trail, 4.2 mi · 4 of 5 stars · 22 citations
- Brookdale Carriage Club Providence Charlotte, 5.3 mi · 5 of 5 stars · 11 citations
- Sardis Oaks Charlotte, 6.3 mi · 3 of 5 stars · 16 citations
- Redwood Health & Rehab Charlotte, 6.8 mi · 2 of 5 stars · 18 citations
- White Oak Manor - Charlotte Charlotte, 7.1 mi · 1 of 5 stars · 21 citations
- Pelican Health Randolph LLC Charlotte, 7.1 mi · 1 of 5 stars · 47 citations
North Carolina contacts for a concern about a nursing home
These are the official offices in North Carolina. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: NC Division of Health Service Regulation, Nursing Home Licensure and Certification Section, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: North Carolina Long-Term Care Ombudsman Program. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: NC DHSR Regulated Facilities search (Statements of Deficiencies), where North Carolina publishes its own records on licensed homes.
Common questions
- What is Willowbrooke Court Sc Ctr at Matthews Glen's Medicare star rating?
- CMS rates Willowbrooke Court Sc Ctr at Matthews Glen 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willowbrooke Court Sc Ctr at Matthews Glen get at its last inspection?
- 3 health deficiencies at the standard inspection on July 8, 2025. The North Carolina average is 4.7.
- Has Willowbrooke Court Sc Ctr at Matthews Glen been fined?
- CMS lists no fines in the last three years.
- Does Willowbrooke Court Sc Ctr at Matthews Glen accept Medicaid?
- CMS lists it as "Medicare", so it is not certified for Medicaid.
- Who owns Willowbrooke Court Sc Ctr at Matthews Glen?
- CMS lists 54 owners and managers, and links the home to Acts Retirement-Life Communities. Legal business name: ACTS RETIREMENT-LIFE COMMUNITIES INC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.