Willowbrooke Court SC Ctr at Matthews Glen
740 Pavilion View Drive, Matthews, NC 28105
Willowbrooke Court SC Ctr at Matthews Glen is a nursing home in Matthews, North Carolina. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (704) 845-6220
- Last standard health inspection
- August 19, 2026 (2 months ago)
- Certified beds
- 15
- Residents per day, on average
- 13
- Ownership type
- Non profit - Corporation
- Legal business name
- Acts Retirement-Life Communities INC
- Chain
- Acts Retirement-Life Communities
- Takes part in
- Medicare
Fewer health citations than the North Carolina average (7 vs 18).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on August 19, 2026
CMS lists this as a standard inspection.
Citation F0575. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
CMS lists it as corrected on September 11, 2026.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
3 citations
Health inspection on July 8, 2025
CMS lists this as a standard inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 25, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 25, 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on July 25, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 7.3 to 5.5 hours per resident per day.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5.
3 citations
Health inspection on May 30, 2024
CMS lists this as a standard inspection.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 27, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 27, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 27, 2024.
7 citations
Fire safety inspection on May 30, 2024
CMS lists this as a standard inspection.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on August 10, 2024.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 10, 2024.
CMS has cited this home for K0222 2 times since 2020.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 10, 2024.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 10, 2024.
CMS has cited this home for K0345 2 times since 2020.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on August 10, 2024.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on August 10, 2024.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 10, 2024.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Fire safety inspection on May 11, 2023
CMS lists this as a standard inspection.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 7, 2023.
CMS has cited this home for K0324 2 times since 2020.
3 citations
Fire safety inspection on January 8, 2020
CMS lists this as a standard inspection.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 21, 2020.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 21, 2020.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 21, 2020.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ACTS ACQUISITION AND DEVELOPMENT COMPANY LLCIndirect ownership interest · not applicable · since 01/01/2003
- ACTS ALLIANCE MANAGEMENT LLCIndirect ownership interest · not applicable · since 12/31/2022
- ACTS COMMUNITIES OF MARYLAND, INC.Indirect ownership interest · not applicable · since 04/01/2019
- ACTS LEGACY FOUNDATION, INC.Indirect ownership interest · not applicable · since 12/31/2022
- ACTS RETIREMENT SERVICES, INCIndirect ownership interest · not applicable · since 03/24/2009
- ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLCIndirect ownership interest · not applicable · since 12/31/2022
- ACTS SIGNATURE COMMUNITY SERVICES INCIndirect ownership interest · not applicable · since 03/24/2009
- BONITA SPRINGS RETIREMENT VILLAGE INCIndirect ownership interest · not applicable · since 11/01/2024
- MEASE LIFE INCIndirect ownership interest · not applicable · since 10/01/2023
- ACTS MANAGEMENT SERVICES, INC.Operational/managerial control · not applicable · since 01/01/2012
- ACTS RETIREMENT-LIFE COMMUNITIES INCOperational/managerial control · not applicable · since 01/01/2012
- ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLCOperational/managerial control · not applicable · since 12/31/2022
- AHERN, SUSANOperational/managerial control · not applicable · since 01/01/2020
- CHRISTIANSEN, KARENOperational/managerial control · not applicable · since 05/25/2010
- FOX, GLENNOperational/managerial control · not applicable · since 01/01/2017
- GRANT, GERALDOperational/managerial control · not applicable · since 06/01/2005
Questions
When was Willowbrooke Court SC Ctr at Matthews Glen last inspected?
CMS lists August 19, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Willowbrooke Court SC Ctr at Matthews Glen have?
CMS lists 7 health citations since May 30, 2024. CMS also calls these deficiencies.
Has Willowbrooke Court SC Ctr at Matthews Glen been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Willowbrooke Court SC Ctr at Matthews Glen?
Its CMS overall star rating is 5 of 5.
Is Willowbrooke Court SC Ctr at Matthews Glen a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.