Willowbrooke Court SC Ctr at Matthews Glen
740 Pavilion View Drive, Matthews, NC 28105 · Mecklenburg County · 15 certified beds · avg 14 residents/day · certified since Sep 6, 1990
Part of chain: ACTS RETIREMENT-LIFE COMMUNITIES (27 facilities, chain avg rating 4.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (6)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 8, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 8, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 8, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| May 30, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (3 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 3 | 0 | D |
| 2025 | 3 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.32 | 4.01 | 3.95 | top 9% in North Carolina; top 9% in the U.S. |
| Registered Nurse hours | 1.05 | 0.64 | 0.69 | top 10% in North Carolina; top 14% in the U.S. |
| Weekend total nurse staffing | 4.96 | 3.56 | 3.50 | top 8% in North Carolina; top 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.73 | 0.41 | 0.48 | top 9% in North Carolina; top 14% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 49.0 | 45.8 | — |
| RN turnover (%) | 0.0 | 45.7 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.67, RN 0.92, weekend 4.36. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: —/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Acts Acquisition and Development Company LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2003 |
| Acts Alliance Management LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/31/2022 |
| Acts Communities of Maryland, INC. | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2019 |
| Acts Legacy Foundation, INC. | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/31/2022 |
| Acts Retirement Services, INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/24/2009 |
| Acts Retirement-Life Communities Management, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/31/2022 |
| Acts Signature Community Services INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/24/2009 |
| Bonita Springs Retirement Village INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 11/01/2024 |
| Mease Life INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 10/01/2023 |
| Acts Management Services, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2012 |
| Acts Management Services, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 07/21/2025 |
| Acts Retirement-Life Communities INC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 11/01/1988 |
| Acts Retirement-Life Communities INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2012 |
| Acts Retirement-Life Communities INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/1988 |
| Acts Retirement-Life Communities Management, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/31/2022 |
| Acts Retirement-Life Communities Management, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/21/2025 |
| Ahern, Susan | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2020 |
| Ahern, Susan | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Ahern, Susan | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2020 |
| Allmond, Susan | Individual | Corporate Director | NOT APPLICABLE | 01/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Royal Park Rehabilitation & Health Center | 0.0 mi | Matthews, NC | ★★☆☆☆ | 2/5 | |
| Matthews Health & Rehab Center | 2.1 mi | Matthews, NC | ★★☆☆☆ | 2/5 | |
| Lake Park Nursing and Rehabilitation Center | 4.2 mi | Indian Trail, NC | ★★★★☆ | 3/5 | |
| Brookdale Carriage Club Providence | 5.3 mi | Charlotte, NC | ★★★★★ | 5/5 | |
| Sardis Oaks | 6.3 mi | Charlotte, NC | ★★★☆☆ | 3/5 | |
| Redwood Health & Rehab | 6.8 mi | Charlotte, NC | ★★★☆☆ | 3/5 | |
| White Oak Manor - Charlotte | 7.0 mi | Charlotte, NC | ★☆☆☆☆ | 1/5 | |
| Pelican Health Randolph LLC | 7.1 mi | Charlotte, NC | ★☆☆☆☆ | 2/5 | |
| Wilora Lake Healthcare | 7.3 mi | Charlotte, NC | ★★☆☆☆ | 2/5 | abuse |
| Clear Creek Nursing & Rehabilitation Center | 7.5 mi | Mint Hill, NC | ★★☆☆☆ | 2/5 | |
| The Sharon at Southpark | 8.2 mi | Charlotte, NC | ★★★★☆ | 4/5 | |
| Briar Creek Health Center | 8.6 mi | Charlotte, NC | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 345326.