Home › North Carolina › Mecklenburg County › Willowbrooke Court Sc Ctr at Matthews Glen
Willowbrooke Court Sc Ctr at Matthews Glen
740 Pavilion View Drive, Matthews, NC 28105 · CMS Certification Number (CCN) 345326
At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 6 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 0 from complaints)
- Fire safety citations
- 11
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- July 8, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.9 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★★ 5 of 5 | 2.7 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.3 | 3.6 |
| Long-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | July 8, 2025 | 3 | 3 | 0 |
| Cycle 2 | May 30, 2024 | 3 | 3 | 0 |
CMS weighted health inspection score: 12 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
6 health citations across 2 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 8, 2025: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/25/2025 |
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/25/2025 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/25/2025 |
May 30, 2024: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/27/2024 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/27/2024 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/27/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
11 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/30/2024 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/30/2024 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/30/2024 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/30/2024 | D | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/30/2024 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/30/2024 | D | K-0222 | 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. Egress Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/30/2024 | D | K-0161 | Use approved construction type or materials. Construction Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2024 |
| 05/11/2023 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/07/2023 |
| 01/08/2020 | E | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/21/2020 |
| 01/08/2020 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/21/2020 |
| 01/08/2020 | D | K-0222 | 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. Egress Deficiencies | Deficient, Provider has date of correction Corrected 02/21/2020 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.67 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.92 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 1.02 | Not published | Not published |
| Nurse aide hours per resident per day | 2.72 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 4.36 | Not published | Not published |
| RN hours per resident per day, weekends | 0.73 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | 49 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Acts Retirement-Life Communities INC
- Ownership type
- Non profit - Corporation
- Chain
- Acts Retirement-Life Communities (27 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 15
- Average residents per day
- 13.9
- Participates in
- Medicare
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- September 6, 1990
- County/parish
- Mecklenburg
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
54 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| ACTS ACQUISITION AND DEVELOPMENT COMPANY LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS ALLIANCE MANAGEMENT LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS COMMUNITIES OF MARYLAND, INC. | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS LEGACY FOUNDATION, INC. | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT SERVICES, INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS SIGNATURE COMMUNITY SERVICES INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BONITA SPRINGS RETIREMENT VILLAGE INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MEASE LIFE INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ALLMOND, SUSAN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BROD, KATHRYN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CALLAWAY, WARREN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHAMBERLAIN, LINDA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DETWEILER, HAROLD | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ESTERHAI, JOHN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GERNER, ELRIC | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GLYNN, JAMES | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GREER, JASON | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KELLY, MICHAEL | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAMMERS, JOHN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAWSON, DANIEL | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MASHNER, MARVIN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MIDDLEBROOKS, DANIEL | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| REICHARD, DAWN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| AHERN, SUSAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ALLMOND, SUSAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, GLENN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GERNER, ELRIC | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAWSON, DANIEL | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MASHNER, MARVIN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ACTS MANAGEMENT SERVICES, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AHERN, SUSAN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, GLENN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ACTS MANAGEMENT SERVICES, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BAKER TILLY ADVISORY GROUP LP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BAKER TILLY US LLP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| U.S. BANK | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AHERN, SUSAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CLEMENTS, THAD | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FLEMING, SHACANA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, GLENN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Willowbrooke Court Sc Ctr at Matthews Glen. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.