Cycle 1
Health 2025-07-08 · Fire 2024-05-30
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Matthews, NC
Willowbrooke Court SC Ctr at Matthews Glen
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
740 Pavilion View Drive, Matthews, NC
(704) 845-6220
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
15
Certified beds
Average residents
8
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1990-09-06
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.97
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
1.95
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
5.51
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,865
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.17
Baseline 17.26% · Performance 19.96% · Measure score 3.17 · Achievement 3.17 · Improvement 0
Healthcare-associated infections
5.30
Baseline 5.49% · Performance 6.25% · Measure score 5.30 · Achievement 5.30 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.6% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 2.25% · Lower 95% interval 5.11% |
| Discharge to community | 62.2% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 90 · Observed rate 60% · Lower 95% interval 52.4% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 50 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 72.5% |
53.69%
18.8 pts better
|
Numerator 29 · Denominator 40 |
| Discharge mobility score | 55% |
50.94%
4.1 pts better
|
Numerator 22 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | 6.25% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 3.28% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 0.98% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 205 |
| Staff flu vaccination coverage | 93.28% |
42%
51.3 pts better
|
Numerator 222 · Denominator 238 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 30 · Denominator 40 |
| Transfer of health information to provider | 81.82% |
95.95%
14.1 pts worse
|
Numerator 18 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 13 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
79.9%
11.6 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 96.2% · Q3 89.4% · Q4 87.0% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
13.2%
3.9 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 14.8% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.5%
1.4 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.9% · Q3 0.0% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
78.1%
18.2 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.9%
4.4 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 14.8% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2023-05-11
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-05-11 · Fire 2020-01-08
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-05-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-05-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-05-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-05-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-10
D · Potential for more than minimal harm
2023-05-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-07
E · Potential for more than minimal harm
2020-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-08
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-25
C · Minimal harm
2025-07-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-25
D · Potential for more than minimal harm
2024-05-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-05-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-27
Penalties and ownership
What sits behind the stars
Ownership
Acts Retirement-Life Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Inc
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Inc
5% Or Greater Mortgage Interest · Organization
Acts Retirement-Life Communities Management, LLC
Operational/Managerial Control · Organization
Ahern, Susan
Operational/Managerial Control · Individual
Ahern, Susan
Corporate Officer · Individual
Allmond, Susan
Corporate Director · Individual
Allmond, Susan
Corporate Officer · Individual
Brod, Kathryn
Corporate Director · Individual
Callaway, Warren
Corporate Director · Individual
Chamberlain, Linda
Corporate Director · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Detweiler, Harold
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Glynn, James
Corporate Director · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Greer, Jason
Corporate Director · Individual
Kelly, Michael
Corporate Director · Individual
Lammers, John
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Lawson, Daniel
Corporate Officer · Individual
Mashner, Marvin
Corporate Director · Individual
Mashner, Marvin
Corporate Officer · Individual
Middlebrooks, Daniel
Corporate Director · Individual
Reichard, Dawn
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Royal Park Rehabilitation & Health Center
Matthews, NC
2-star overall rating with 2-star inspections with $52,201 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Matthews Health & Rehab Center
Matthews, NC
1-star overall rating with 1-star inspections with $82,703 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Lake Park Nursing and Rehabilitation Center
Indian Trail, NC
3-star overall rating with 2-star inspections with $44,005 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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