SNF
Willowbrooke Court SC Ctr at Matthews Glen
CCN: 345326 · Matthews, NC 28105 · Mecklenburg County
CCRC
Overview
- Address
- 740 Pavilion View Drive, Matthews, NC 28105
- Phone
- 7048456220
- Certified beds
- 15
- Avg daily residents
- 8 (55% of beds filled)
- Ownership
- Non-profit corporation
- Provider type
- Medicare
- Medicare/Medicaid since
- 1990-09-06
- Setting
- Urban
5 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 4.97 | 3.48 | 5.51 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 1.06 | 0.61 | 1.17 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 1.08 | 0.77 | 1.20 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.83 | 2.10 | 3.14 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 2.14 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 1.95 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
4.71
hrs / resident / day
RN (weekend)
0.85
hrs / resident / day
Total nurse (adjusted, weekend)
5.23
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Resident acuity
Nursing Case-Mix Index
1.23
higher acuity than avg
Case-Mix Index Ratio
0.89
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-07-08 | 3 | 3 | 0 | 12 | 1 | 12 |
| Cycle 2/3 (prior) | 2024-05-30 | 3 | 3 | 0 | 12 | 1 | 12 |
Total weighted health score
12.0
lower is better
Deficiencies (6)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
1 A/B/C No actual harm — minor
5 D/E/F Actual harm — potential for minor
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2025-07-08 | 2025-07-25 |
| 0732 | Post nurse staffing information every day. | C | 2025-07-08 | 2025-07-25 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2025-07-08 | 2025-07-25 |
| 0759 | Ensure medication error rates are not 5 percent or greater. | D | 2024-05-30 | 2024-06-27 |
| 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. | D | 2024-05-30 | 2024-06-27 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2024-05-30 | 2024-06-27 |
Financial Health (FY 2023)
Operating performance
Operating Margin
18.4%
Total Margin
21.8%
Occupancy Rate
87.3%
Cost per Resident Day
$77
Revenue & costs
Net Patient Revenue
$43.9M
Total Costs
$2.2M
Net Income
$10.0M
Balance sheet
Total Assets
$238.4M
Total Liabilities
$98.4M
Fund Balance
$140.0M
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: ACTS RETIREMENT-LIFE COMMUNITIES
- Chain ID
9- Facilities in chain
- 26
- Legal business name
- ACTS RETIREMENT-LIFE COMMUNITIES INC
Chain-average star ratings (for peer context)
Overall
4.8
Health
4.3
Staffing
4.7
QM
4.6
Owner / manager organizations (5)
| Organization | Role | Association |
|---|---|---|
| ACTS RETIREMENT-LIFE COMMUNITIES INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 11/01/1988 |
| ACTS MANAGEMENT SERVICES, INC. | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2012 |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2012 |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | since 12/31/2022 |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | 5% OR GREATER MORTGAGE INTEREST | since 11/01/1988 |
Owner / manager individuals (29)
| Name | Role | Association |
|---|---|---|
| AHERN, SUSAN | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| CHRISTIANSEN, KAREN | OPERATIONAL/MANAGERIAL CONTROL | since 05/25/2010 |
| FOX, GLENN | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2017 |
| GRANT, GERALD | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2005 |
| ALLMOND, SUSAN | CORPORATE DIRECTOR | since 01/01/2017 |
| BROD, KATHRYN | CORPORATE DIRECTOR | since 02/15/2024 |
| CALLAWAY, WARREN | CORPORATE DIRECTOR | since 03/30/2022 |
| CHAMBERLAIN, LINDA | CORPORATE DIRECTOR | since 01/01/2025 |
| CHRISTIANSEN, KAREN | CORPORATE DIRECTOR | since 01/01/2020 |
| DETWEILER, HAROLD | CORPORATE DIRECTOR | since 11/01/2009 |
| ESTERHAI, JOHN | CORPORATE DIRECTOR | since 05/01/1996 |
| GERNER, ELRIC | CORPORATE DIRECTOR | since 04/01/2009 |
| GLYNN, JAMES | CORPORATE DIRECTOR | since 01/01/2023 |
| GRANT, GERALD | CORPORATE DIRECTOR | since 05/04/2017 |
| GREER, JASON | CORPORATE DIRECTOR | since 03/30/2022 |
| KELLY, MICHAEL | CORPORATE DIRECTOR | since 02/11/2020 |
| LAMMERS, JOHN | CORPORATE DIRECTOR | since 12/15/2020 |
| LAWSON, DANIEL | CORPORATE DIRECTOR | since 06/11/2019 |
| MASHNER, MARVIN | CORPORATE DIRECTOR | since 01/01/1991 |
| MIDDLEBROOKS, DANIEL | CORPORATE DIRECTOR | since 01/01/2023 |
| REICHARD, DAWN | CORPORATE DIRECTOR | since 06/01/2025 |
| AHERN, SUSAN | CORPORATE OFFICER | since 01/01/2020 |
| ALLMOND, SUSAN | CORPORATE OFFICER | since 01/01/2025 |
| CHRISTIANSEN, KAREN | CORPORATE OFFICER | since 05/25/2010 |
| FOX, GLENN | CORPORATE OFFICER | since 01/01/2017 |
Showing 25 of 29 individuals. Full list in CSV.
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- Yes
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 111 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $77 | metrics.cost_per_resident_day |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicare Day Share (%) | 3.6% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $9,972,017 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $43,905,171 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 87.3% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | 18.4% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $238,418,276 | metrics.total_assets |
| Cost Report | Total Costs ($) | $2,200,159 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $140,044,522 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $98,373,754 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | 21.8% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 1.19989 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 3.14202 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 1.17226 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 5.51417 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 5.22886 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | 27 | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 8.3 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.77204 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.09823 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.60854 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.47880 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.06620 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 4.3 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 4.8 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.6 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 4.7 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 9 | Chain ID |
| Provider Information | Chain Name | ACTS RETIREMENT-LIFE COMMUNITIES | Chain Name |
| Provider Information | City/Town | Matthews | City/Town |
| Provider Information | CMS Certification Number (CCN) | 345326 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | Y | Continuing Care Retirement Community |
| Provider Information | County/Parish | Mecklenburg | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1990-09-06 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | 22 | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 4 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 35.1143 | Latitude |
| Provider Information | Legal Business Name | ACTS RETIREMENT-LIFE COMMUNITIES INC | Legal Business Name |
| Provider Information | Location | 740 Pavilion View Drive,Matthews,NC,28105 | Location |
| Provider Information | Long-Stay QM Rating | — | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | 2 | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -80.694 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | — | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 15 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 26 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.23238 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.89456 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 5 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Corporation | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 740 Pavilion View Drive | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Willowbrooke Court SC Ctr at Matthews Glen | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 590 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 12 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 0 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 3 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-07-08 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 12 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 3 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 3 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-05-30 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 12 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 0 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 12 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 3 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.84679 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | — | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | 27 | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 2.13737 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 1.08114 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.83105 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 1.95058 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 1.05624 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 4.96842 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 5 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 5 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | NC | State |
| Provider Information | Telephone Number | 7048456220 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 4.71135 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | — | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | 27 | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 12.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 28105 | ZIP Code |