01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-08 | 3 | 2024-05-30 | 7 |
| Cycle 2 | 2024-05-30 | 3 | 2023-05-11 | 1 |
| Cycle 3 | 2023-05-11 | 0 | 2020-01-08 | 3 |
CMS CCN 3453262026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willowbrooke Court Sc Ctr At Matthews Glen
740 Pavilion View Drive · Matthews, NC 28105 · Mecklenburg County
Certified beds15CMS provider file
Recent citation rows17current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
17 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-07-08 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-07-252025-07-08 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-07-252025-07-08 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-07-252024-05-30 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-06-272024-05-30 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-272024-05-30 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-272024-05-30 · FIREK0161Severity D · isolated; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has date of correction · 2024-08-102024-05-30 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-08-102024-05-30 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-08-102024-05-30 · FIREK0345Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-08-102024-05-30 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-08-102024-05-30 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-08-102024-05-30 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-08-102023-05-11 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-07-072020-01-08 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2020-02-212020-01-08 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2020-02-212020-01-08 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2020-02-2103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ACTS ACQUISITION AND DEVELOPMENT COMPANY LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/2003
- ACTS ALLIANCE MANAGEMENT LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS COMMUNITIES OF MARYLAND, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2019
- ACTS LEGACY FOUNDATION, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS RETIREMENT SERVICES, INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/24/2009
- ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS SIGNATURE COMMUNITY SERVICES INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/24/2009
- BONITA SPRINGS RETIREMENT VILLAGE INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/01/2024
- MEASE LIFE INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2023
- ACTS RETIREMENT-LIFE COMMUNITIES INCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 11/01/1988
- ALLMOND, SUSANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2017
- BROD, KATHRYNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/15/2024
- CALLAWAY, WARRENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/30/2022
- CHAMBERLAIN, LINDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- CHRISTIANSEN, KARENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2020
- DETWEILER, HAROLDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2009
- ESTERHAI, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/01/1996
- GERNER, ELRICIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2009
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.67per resident day
RN hours0.92per resident day
Weekend nurse hours4.36per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Matthews ledger →