Willowbrooke Court SC Ctr at Matthews Glen
Non profit - Corporation
15 Beds
ACTS RETIREMENT-LIFE COMMUNITIES
Data: November 2025
Trust Grade
90/100
#76 of 417 in NC
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Willowbrooke Court SC Center at Matthews Glen has an excellent Trust Grade of A, indicating a high level of quality care and satisfaction. Ranked #76 out of 417 facilities in North Carolina, they are in the top half of the state, and locally, they hold the #2 position out of 29 in Mecklenburg County, meaning there is only one better option nearby. The facility's performance has been stable, with three concerns reported in both 2024 and 2025, and they have a commendable staffing situation, boasting a perfect 5/5 star rating and zero turnover, well below the state average. Notably, there have been no fines, which is a positive indicator of compliance. However, there are some areas of concern, such as expired food found in the kitchen, a failure to perform daily treatment for a resident’s skin condition, and a medication error rate exceeding the acceptable limit, which could pose risks to residents.
- Trust Score
- A
- In North Carolina
- #76/417
- Safety Record
- Low Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most North Carolina facilities.
- Skilled Nurses ✓ Good
- Each resident gets 70 minutes of Registered Nurse (RN) attention daily — more than 97% of North Carolina nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ○ Average
- 6 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
90/100
Top 18%
No red flags
3 → 3 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 3 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Chain: ACTS RETIREMENT-LIFE COMMUNITIES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 6 deficiencies on record
Jul 2025
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews with the resident, staff and Medical Doctor (MD), the facility failed to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews with the resident, staff and Medical Doctor (MD), the facility failed to ensure treatment for a non-pressure related area of skin impairment was completed daily per the standing order for 1 of 1 sampled resident (Resident #5) reviewed for skin conditions.
The findings included:
Resident #5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and Parkinsonism (brain condition that cause slowed movements, stiffness and tremors).
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. He had impairment on one side of the upper and lower extremities, no skin issues and had a pressure-reducing device for the bed. Resident #5 required partial/moderate assistance with standing and bed/chair transfers and supervision or touching assistance with toilet transfers.
A review of Resident #5's care plan dated 06/02/25 revealed Resident #5 had potential/actual impairment to skin integrity related to fragile skin. Interventions included to use caution when transferring or moving Resident #5 to prevent striking his arms, legs and hands against any sharp or hard surface.
A staff progress note written by Nurse #1 dated 07/01/25 at 9:47 PM revealed Resident #5's family member stated that while assisting Resident #5 to the toilet, he accidentally sustained an abrasion to the right shin (front of the leg below the knee). Nurse #1 assessed Resident #5's shin and noted the area was bleeding from a small skin tear. Nurse #1 noted the area was cleaned with normal saline (sterile solution of salt and water) and dressed with a triple antibiotic ointment and gauze bandage.
Review of the facility's Standing Orders for Treatment revealed in part, staff may use the following standing orders for the onset of specified symptoms or condition and the nurse will document the assessment of the symptoms and effectiveness of the measures instituted. The standing orders for treatment of skin tears noted: cleanse with normal saline and 4 x 4 gauze, pat dry with 4 x 4 gauze, approximate with thin adhesive bandages (if applicable) and cover with an adhesive border island dressing (specify size). Apply sterile gauze or self-adherent wrap that secures dressing (as needed). Change daily until healed. May use a triple antibiotic ointment, observe for redness and drainage.
Review of Resident #5's Treatment Administration Record (TAR) for the period 07/01/25 through 07/08/25 revealed no treatment order for daily dressing changes to Resident #5's right shin.
During an observation and interview on 07/07/25 at 11:14 AM, Resident #5 was sitting in his wheelchair in his room watching TV. On the upper right shin was a 4 x 4 bordered gauze bandage with Nurse #2's name and the date of 07/05/25 written in red ink. Resident #5 stated he was not sure exactly how the injury happened but it wasn't painful and staff had been very good to provide treatment and change the bandage.
During an observation on 07/08/25 at 9:57 AM, Resident #5 was in his room sleeping soundly while seated in his wheelchair. On the upper right shin was a 4 x 4 bordered gauze bandage with Nurse #2's name and the date of 07/05/25 written in red ink.
During interviews on 07/08/25 at 9:13 AM and 10:10 AM, Nurse #3 revealed she had noticed the bandage on Resident #5's shin but when she reviewed his TAR, there were no orders for treatment. She confirmed the bandage on Resident #5's shin was dated 07/05/25. Nurse #3 explained that when initiating standing orders, the nurse was supposed to enter the treatment orders on the resident's TAR to be completed daily until healed and the orders were usually entered to be completed on the evening shift (3:00 PM to 11:00 PM).
During a phone interview on 07/08/25 at 10:48 AM, Nurse #1 revealed on 07/01/25 she was informed by the Nurse Aide that Resident #5's family member had reported the wheelchair had scraped Resident #5's shin when the family member had assisted Resident #5 to the bathroom. Nurse #1 stated upon assessment, the area had some bleeding but was not an open wound so she initiated the standing orders for skin tears. Nurse #1 stated once the standing orders where initiated, the nurse was responsible for entering the order on the resident's TAR so that treatments would be completed daily until the area was healed. Nurse #1 stated she thought she had entered the treatment order on Resident #5's TAR and it was an oversight.
An unsuccessful telephone attempt was made for an interview with Nurse #2 on 07/08/25 at 10:43 AM.
During an interview on 07/08/25 at 11:38 AM with the Director of Nursing present, the Registered Nurse (RN) Supervisor explained once standing orders were initiated for Resident #5, the nurse should have entered the treatment orders on the TAR so that nurses would know to check/change the dressing daily until healed.
During an interview on 07/08/25 at 2:07 PM, the Administrator stated she would expect for nurses to follow the standing orders for treatment and enter the orders on the resident's TAR when initiated so that nurses could document that the treatment was being done.
During a phone interview on 07/08/25 at 3:54 PM, the Medical Doctor (MD) stated he was not sure of the facility's protocol but would have expected for staff to follow the standing order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, the facility failed to discard expired food and milk available for use in 1 of 2 walk-in refrigerators (produce refrigerator) in the main kitchen and 1 of 2...
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Based on observations and staff interviews, the facility failed to discard expired food and milk available for use in 1 of 2 walk-in refrigerators (produce refrigerator) in the main kitchen and 1 of 2 nourishment refrigerators. This practice had the potential to affect the food served to residents.
The findings included:
1. During the initial tour of the main kitchen on 7/7/25 from 10:20 AM to 10:45 AM with the Lead Chef, an observation of the walk-in produce refrigerator revealed a box of red and green bell peppers. There were four red bell peppers and three green bell peppers inside the box. Three of the four red bell peppers were covered with gray and white fuzz. There was no date on the box. The Lead Chef went through the box and discarded three of the red bell peppers that had fuzz.
An interview with the Lead Chef on 7/7/25 at 10:45 AM revealed the shelf life of the bell peppers varied and depended on when they received it from their supplier. He stated that he couldn't say for sure how long they lasted because he wasn't the one who received the bell peppers, but they must have been in the produce refrigerator for at least a week. The Lead Chef stated that he saw one red bell pepper that had fuzz this morning, and he had to cut around the bell pepper to serve for the breakfast meal. He said he didn't see the other red bell peppers with fuzz, but they should have been discarded.
An interview with the Dietary Manager on 7/8/25 at 1:18 PM revealed the bell peppers should have been inspected for fuzz whenever they received them from the suppliers, and daily by the chef before starting service.
An interview with the Administrator on 7/8/25 at 4:15 PM revealed she was not sure how the expired bell peppers were left in the produce refrigerator, but that she would have expected them to be discarded.
2. An observation of one of the nourishment refrigerators with the Lead Chef on 7/7/25 at 11:15 AM revealed a gallon of regular milk with a best if used by date of 7/3/25. The gallon had about ¾ of milk left in the bottle. The Lead Chef removed the expired gallon of milk and brought it to the attention of Dietary Aide #1.
An interview with the Lead Chef on 7/7/25 at 11:15 AM revealed both nursing and the dietary aides were responsible for checking the nourishment refrigerators for expired food and drink items. The Lead Chef stated the nurse aides more frequently used the nourishment refrigerators if residents needed snacks or drinks.
During an interview with Dietary Aide #1 on 7/7/25 at 11:18 AM, she stated that she had looked in the nourishment refrigerator, but she didn't really check the expiration dates on the food and drink items inside. She further stated that she had just came in at 10:00 AM, and that the nourishment refrigerator was supposed to be checked by Dietary Aide #2 who came in at 7:00 AM.
An interview with Dietary Aide #2 on 7/7/25 at 11:20 AM revealed she cleaned the nourishment station every morning before breakfast service, and she tried to check the food and drink items in the nourishment refrigerators as well. She stated that she didn't notice the expired gallon of milk inside the nourishment refrigerator, but she didn't think it got served to the residents this morning because they normally got the individual packs of milk.
An interview with Nurse Aide #1 on 7/7/25 at 12:03 PM revealed the dietary aides normally gave them a heads up if any of the food and drink items in the nourishment refrigerators were expiring. She stated that she didn't look at the expiration date on the jug of milk before she poured some on a bowl of cereal and served it to one of the residents this morning.
An interview with the Dietary Manager on 7/8/25 at 1:18 PM revealed both the dietary aides and nursing were supposed to check the nourishment refrigerators for expired food and drink items.
An interview with the Administrator on 7/8/25 at 4:15 PM revealed she was not sure how the expired milk was left in the nourishment refrigerator, but it should have been discarded.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 32 of 72 days reviewed (01/01/25, 01/02/25,...
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Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 32 of 72 days reviewed (01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/07/25, 01/08/25, 01/10/25, 01/12/25, 01/18/25, 01/21/25, 01/26/25, 02/07/25, 02/09/25, 02/15/25, 02/20/25, 02/21/25, 02/24/25, 02/25/25, 02/27/25, 02/28/25, 03/01/25, 03/03/25, 03/05/25, 03/06/25, 03/07/25, 03/09/25, 03/14/25, 03/15/25, 03/21/25, 03/24/25, and 03/29/25).
Findings included:
Review of the facility's daily nurse staffing sheet revealed spaces to indicate the name of the unit, resident census each shift, and the number of staff and hours worked for Registered Nurse (RN), Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) for each 8-hour shift: day shift (7:00 AM to 3:00 PM), evening shift (3:00 PM to 11:00 PM) and night shift (11:00 PM to 7:00 AM). The facility's 24-hour day started on the night shift.
a. The nursing staff time clock report revealed a LPN clocked in at 3:22 PM on 12/31/25 and clocked out on 8:03 AM on 01/01/25. The daily nurse staffing sheets dated 01/01/25 and 01/02/25 revealed there was no LPN on the night shifts.
b. The nursing staff time clock report revealed a LPN clocked in at 3:05 PM on 01/02/25 and clocked out on 8:04 AM on 01/03/25. The daily nurse staffing sheets dated 01/02/25 and 01/03/25 revealed there was no LPN on the night shifts.
c. The nursing staff time clock report revealed a LPN clocked in at 3:00 PM on 01/03/25 and clocked out at 7:35 AM on 01/04/25. The daily nurse staffing sheets dated 01/03/25 and 01/04/25 revealed there was no LPN on the night shifts.
d. The nursing staff time clock reports revealed one RN clocked in at 3:15 PM on 01/04/25 and clocked out at 12:01 AM on 01/05/25 and one RN clocked in at 3:54 PM on 01/04/25 and clocked out at 7:44 AM on 01/05/25. The daily nurse staffing sheet dated 01/04/25 revealed there was only one RN on the evening shift.
e. The nursing staff time clock reports revealed one LPN clocked in at 2:06 PM on 01/07/25 and clocked out at 8:06 AM on 01/08/25. The daily nursing staffing sheets dated 01/07/25 and 01/08/25 revealed there was no LPN on the night shifts.
f. The nursing staff time clock reports revealed one CNA clocked in at 2:53 PM and clocked out at 11:15 PM on 01/10/25 and one CNA clocked in at 2:53 PM on 01/10/25 and clocked out at 7:37 AM on 01/11/25. The daily nursing staffing sheet dated 01/10/25 revealed there was only one CNA on the evening shift.
g. The nursing staff time clock reports revealed one RN clocked in at 6:40 AM and clocked out at 11:45 PM on 01/12/25 and one RN clocked in at 7:06 PM on 01/12/25 and clocked out at 7:26 AM on 01/13/25. The daily nursing staffing sheet for 01/12/25 revealed there was only one RN on the evening shift.
h. The nursing staff time clock reports revealed on 01/18/25 one CNA clocked in at 7:31 AM and clocked out at 3:13 PM and one CNA clocked in at 7:11 AM and clocked out at 1:12 PM. The daily nursing staffing sheet for 01/18/25 revealed there was only one CNA on the day shift.
i. The nursing staff time clock reports revealed one RN clocked in at 2:40 PM on 01/18/25 and clocked out at 12:21 AM on 01/19/25 and one RN clocked in at 2:52 PM on 01/18/25 and clocked out at 8:46 AM on 01/19/25. The daily nursing staffing sheet for 01/18/25 revealed there was only one RN on the evening shift.
j. The nursing staff time clock reports revealed one RN clocked in at 8:33 AM and clocked out at 11:44 PM on 01/21/25 and one RN clocked in at 2:57 PM on 01/21/25 and clocked out at 7:29 AM on 01/22/25. The daily nursing staffing sheet for 01/21/25 revealed there was only one RN on the evening shift.
k. The nursing staff time clock reports revealed one CNA clocked in at 6:53 AM and clocked out at 11:03 PM on 01/26/25 and one CNA clocked in at 2:54 PM on 01/26/25 and clocked out at 7:27 AM on 01/27/25. The daily nursing staffing sheet for 01/26/25 revealed there was only one CNA on the evening shift.
l. The nursing staff time clock report revealed on 02/07/25 a LPN clocked in at 7:09 AM and clocked out at 3:23 PM. The daily nursing staffing sheet for 02/07/25 revealed there was one RN and no LPN on the day shift.
m. The nursing staff time clock reports revealed one CNA clocked in at 6:52 AM and clocked out at 3:25 PM on 02/09/25 and one CNA clocked in at 2:56 PM on 02/09/25 and clocked out at 7:22 AM on 02/10/25. The daily nursing staffing sheet for 02/09/25 revealed there were 1.5 CNAs on the day shift and 1.5 CNAs on the evening shift.
n. The nursing staff time clock reports revealed one RN clocked in at 3:01 PM and clocked out at 11:01 PM on 02/15/25 and one RN clocked in at 3:07 PM on 02/15/25 and clocked out at 7:45 AM on 02/16/25. The daily nursing staffing sheet for 02/15/25 revealed there was only on RN on the evening shift.
o. The nursing staff time clock reports revealed on 02/20/25 one CNA clocked in at 7:30 AM and clocked out at 3:10 PM and one CNA clocked in at 7:03 AM and clocked out at 3:03 PM. The daily nursing staffing sheet for 02/20/25 revealed there were 1.5 CNAs on the day shift.
p. The nursing staff time clock reports revealed one CNA clocked in at 3:16 PM and clocked out at 11:35 PM on 02/21/25 and one CNA clocked in at 2:56 PM on 02/21/25 and clocked out at 7:06 AM on 02/22/25. The daily nursing staffing sheet for 02/21/25 revealed there was only one CNA on the evening shift.
q. The nursing staff time clock reports revealed one CNA clocked in at 2:51 PM and clocked out at 11:50 PM on 02/24/25 and one CNA clocked in at 2:55 PM on 02/24/25 and clocked out at 7:10 AM on 02/25/25. The daily nursing staffing sheet for 02/24/25 revealed there was only one CNA on the evening shift.
r. The nursing staff time clock reports revealed on 02/25/25 one CNA clocked in at 7:24 AM and clocked out at 3:08 PM and one CNA clocked in at 6:47 AM and clocked out at 3:12 PM. The daily nursing staffing sheet for 02/25/25 revealed there was only one CNA on the day shift.
s. The nursing staff time clock reports revealed on 02/27/25 one RN clocked in at 7:00 AM and clocked out at 11:31 PM and one RN clocked in at 2:54 PM and clocked out at 11:38 PM. The daily nursing staffing sheet for 02/27/25 revealed there was only one RN on the evening shift.
t. The nursing staff time clock reports revealed one CNA clocked in at 6:55 AM and clocked out at 3:21 PM on 02/28/25, one CNA clocked in at 7:16 AM and clocked out at 3:30 PM on 02/28/25, one CNA clocked in at 3:56 PM and clocked out at 8:09 PM on 02/28/25, and one CNA clocked in at 2:56 PM on 02/28/25 and clocked out at 7:22 AM on 03/01/25. The daily nursing staffing sheet for 02/28/25 revealed there were 1.5 CNAs on the day shift and 1.5 CNAs on the evening shift.
u. The nursing staff time clock reports revealed on 03/01/25 one CNA clocked in at 7:07 AM and clocked out at 3:24 PM, one CNA clocked in at 7:20 AM and clocked out at 3:18 PM, and one CNA clocked in at 7:00 AM and clocked out at 8:08 PM. The nursing staff time clock reports also revealed one RN clocked in at 3:08 PM on 03/01/25 and clocked out at 12:01 AM on 03/02/25 and one RN clocked in at 3:00 PM on 03/01/25 and clocked out at 7:30 AM on 03/02/25. The daily nursing staffing sheet for 03/01/25 revealed there were only 1.5 CNAs on the day shift and one RN on the evening shift.
v. The nursing staff time clock reports revealed on 03/03/25 one CNA clocked in at 6:53 AM and clocked out at 3:11 PM and one CNA clocked in at 7:25 AM and clocked out at 3:11 PM. The daily nursing staffing sheet for 03/03/25 revealed there were only 1.5 CNAs on the day shift.
w. The nursing staff time clock reports revealed on 03/05/25 one CNA clocked in at 6:53 AM and clocked out at 8:00 PM and one CNA clocked in at 7:00 AM and clocked out at 3:15 PM. The daily nursing staffing sheet for 03/05/25 revealed there were only 1.5 CNAs on the day shift.
x. The nursing staff time clock reports revealed one CNA clocked in at 3:33 PM and clocked out at 11:40 PM on 03/06/25, one CNA clocked in at 4:17 PM and clocked out at 11:02 PM on 03/06/25, and one CNA clocked in at 3:02 PM on 03/06/25 and clocked out at 7:01 AM on 03/07/25. The daily nursing staffing sheet for 03/06/25 there was only one CNA on the evening shift.
y. The nursing staff time clock reports revealed one CNA clocked in at 3:17 PM and clocked out at 11:38 PM on 03/07/25 and one CNA clocked in at 2:56 PM on 03/07/25 and clocked out at 7:10 AM on 03/08/25. The daily nursing staffing sheet for 03/07/25 revealed there was only one CNA on the evening shift.
z. The nursing staff time clock reports revealed one CNA clocked in at 6:52 AM and clocked out at 10:28 PM on 03/09/25 and one CNA clocked in at 2:56 PM on 03/09/25 and clocked out at 7:15 AM on 03/10/25. The daily staffing sheet for 03/09/25 revealed there was only one CNA on the evening shift.
aa. The nursing staff time clock reports revealed one LPN clocked in at 3:14 PM on 03/14/25 and clocked out at 7:58 AM on 03/15/25 and one RN clocked in at 10:51 PM on 03/14/25 and clocked out at 7:21 AM on 03/15/25. The daily nursing staffing sheets for 03/14/25 and 03/15/25 revealed there was only one RN and no LPN on the night shifts.
bb. The nursing staff time clock reports revealed one CNA clocked in at 3:08 PM and clocked out at 11:13 PM on 03/21/25 and one CNA clocked in at 2:55 PM on 03/21/25 and clocked out at 7:13 AM on 03/22/25. The daily nursing staffing sheet for 03/21/25 revealed there was only one CNA on the evening shift.
cc. The nursing staff time clock reports revealed one CNA clocked in at 2:58 PM and clocked out at 11:13 PM on 03/24/25 and one CNA clocked in at 2:54 PM on 03/24/25 and clocked out at 7:13 AM on 03/25/25. The daily nursing staffing sheet for 03/24/25 revealed there was only one CNA on the evening shift.
dd. The nursing staff time clock reports revealed one CNA clocked in at 2:57 PM and clocked out at 11:10 PM on 03/29/25 and one CNA clocked in at 3:02 PM on 03/29/25 and clocked out at 7:11 AM on 03/30/25. The daily nursing staffing sheet for 03/29/25 revealed there was only one CNA on the evening shift.
During an interview on 07/08/25 at 2:49 PM, the Health Services Coordinator revealed the daily nursing staffing sheets were filled out and posted by the evening shift nurse. The Health Services Coordinator explained around the first part of the year (2025) the former receptionist was updating the daily nursing staffing sheets as needed but currently she (Health Services Coordinator) was the person responsible for updating the nurse staffing sheets when they were collected daily.
During an interview on 07/08/25 at 3:32 PM, the Administrator revealed the Administrative Assistant who works along side the Health Services Coordinator will be the person responsible for updating the daily nursing staffing sheets but she was currently learning the process. The Administrator stated the daily nursing staffing sheets should be updated as needed to reflect the actual nursing staff that worked each shift.
May 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, record review, staff, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 25 opp...
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Based on observations, record review, staff, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 25 opportunities which resulted in an 12% medication error rate. This affected 1 of 3 residents observed for medication administration (Resident #57).
Findings included:
1a. A Physician's order dated 5/21/24 read Ceftriaxone sodium (antibiotic) intravenous solution reconstituted 2 grams (gm), use 2 gm intravenously (IV) in the morning for sepsis until 6/27/24.
A Physician's order dated 5/21/24 read Heparin (blood thinner) lock flush solution 10 units/ milliliter (ml), use 5 ml intravenously in the morning for after medication administration until 6/28/24, use SASH: saline flush, administer medication, saline flush, heparin flush.
An observation and interview were made on 5/30/24 at 8:50 AM of Nurse #1 preparing Resident #57's medication. She removed a 10 milliliter (ml) normal saline (NS) flush and a heparin 5 units/ ml 5 ml flush from her medication cart. She then proceeded to take a bag of IV ceftriaxone (an IV antibiotic), IV tubing, the NS flush, and the heparin flush into Resident #57's room. Nurse #1 was observed to hang the bag of IV ceftriaxone sodium 2gm on the IV pole. She primed the IV tubing at Resident #57's bedside. Nurse #1 then cleaned the connection cap of the PICC line lumen with an alcohol swab. Nurse #1 opened the heparin flush from its packaging and connected the heparin flush to Resident #57's PICC line connection cap. Nurse #1 was stopped before she flushed Resident #57's PICC line with the heparin flush. Nurse #1 went back to her medication cart to review the flush orders for Resident #57's PICC line. After reviewing the PICC line flush orders on Resident #57's medication administration record (MAR), Nurse #1 said she was supposed to flush Resident #57's PICC line using the SASH (saline- administer medication-saline-heparin) method. She said she should have flushed the PICC line using a normal saline flush. Nurse #1 said she was nervous and got confused.
1b. Another observation was made on 5/30/24 at 9:45 AM of Nurse #1 disconnecting Resident #57's IV and flushing his PICC line. Nurse #1 was observed to take a NS 10 ml flush and a Heparin 5 unit/ml 5 ml flush from her medication cart and into Resident #57's room. She was observed to disconnect the IV tubing from Resident #57's PICC line. She cleaned the PICC line connection cap with an alcohol swab. She then held up an opened heparin flush to indicate which flush she intended to use first to flush Resident #57's PICC line, she did not connect the flush to the PICC line connection cap. Nurse #1 was stopped. She then proceeded to flush the PICC line with the 10 ml normal saline flush, followed by the 5 ml heparin flush. Nurse #1 said she was nervous and forgot which flush she was supposed to use first.
An interview was conducted with the Director of nursing on 5/30/24 at 9:55 AM. She said Nurse #1 should have flushed Resident #57's PICC line using the SASH method. She said Nurse #1 had received training on IV administration, which included flushing of IV devices. She said she was not sure why Nurse #1 failed to flush Resident #57 PICC line correctly, except that she was nervous.
An interview was conducted with the NP on 5/30/24 at 11:00 AM. She said there would probably be no adverse effect from using heparin to flush the PICC line before administering medication through the PICC line. She said Nurse #1 should have followed protocol and flushed the PICC line as ordered using the SASH method.
An interview was conducted with the pharmacist on 5/30/24 at 11:19 AM. The Pharmacist said there was no adverse reaction between heparin and ceftriaxone. She said there would not be an adverse effect to the resident. The Pharmacist said that the heparin flush dose was not enough to be absorbed systemically and adversely affect the resident, even if the resident received other anticoagulant medications.
An interview was conducted with the Administrator on 5/30/24 at 11:56 AM. The Administrator said she expected Nurse #1 to follow the protocol for flushing of PICC lines and that Nurse #1 should have followed the physician's orders.
2. A Physician's order dated 5/22/24 read Voltaren External Gel (topical analgesic) 1% (Diclofenac Sodium (Topical)) Apply to right shoulder topically three times a day for osteoarthritis, apply 2 grams (gm) to right shoulder three times daily.
An observation was made on 5/30/24 at 8:58 AM of Nurse #1 preparing and administering Resident #57's medications. She was observed to squeeze a quarter sized amount of Voltaren 1% gel onto her gloved hand four separate times and applied the gel to Resident #57's left lower back, right lower back, left side, and right shoulder.
An interview was conducted with Nurse #1 on 5/30/24 at 9:32 AM. She stated had never measured Voltaren gel for administration. Nurse #1 said she was not aware that Voltaren gel was supposed to be measured or that there was a dose card to measure the grams to be administered. She said she should have only applied the Voltaren gel to Resident #57 right shoulder as it was ordered. She said she applied the Voltaren gel to other areas because Resident #57 had requested it.
An interview was conducted with the Director of Nursing (DON) on 5/30/24 at 9:55 AM. The DON said she had spoken to the pharmacy, and they confirmed Voltaren gel should be measured using a dosing card before being applied. She said she did not know why there was not a dose measuring card for Resident #57's Voltaren gel. She said the dose measuring card could have fallen out of the package or accidentally been thrown away. The DON stated that not measuring the Voltaren gel was a medication error. She said Nurse #1 should have only applied the Voltaren gel to Resident #57's right shoulder as specified in the order. She could not say why Nurse #1 applied the Voltaren gel to other areas.
An interview was conducted with the NP on 5/30/24 at 11:00 AM. She said Nurse #1 should have measured the Voltaren gel before administering the medication. She said Nurse #1 should follow the physician's orders and should have only administered the Voltaren gel to Resident #57's right shoulder as specified in the order.
An interview was conducted on 5/30/24 at 11:19 AM with the Pharmacist. She stated Voltaren gel should be measured using a dosage card before being applied. The Pharmacist stated that there was a maximum daily dose for Voltaren gel of 32 gm for the entire body. She stated if the maximum daily dosage was exceeded there could be adverse reactions. The Pharmacist explained Voltaren gel was a non-steroid anti-inflammatory (NSAID) medication. The Pharmacist said anytime an NSAID was used with an anticoagulant medication, there was always a labeled risk of an increased risk of bruising and bleeding. The Pharmacist stated with Voltaren gel being a topical medication the risk of it being absorbed systemically and causing an adverse effect was low.
An interview conducted on 5/30/24 at 11:56 AM with the Administrator. She said the nurse should follow physician orders when administering medications. She said Nurse #1 should have measured the Voltaren gel before administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and resident interviews the facility failed to store a medication and left it un...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and resident interviews the facility failed to store a medication and left it unattended at the bedside for 1 of 1 resident (Resident #5) reviewed for medication storage.
The findings included:
Resident #5 was admitted to facility on 5/9/24 with diagnosis that included constipation.
A review of the Resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact.
A review of Resident #5's physician order dated 5/25/2024 revealed he was ordered Senna S Oral Tablet 8.6-50 milligrams (MG). The order continued to give 2 tablets by mouth one time a day for constipation and hold for loose stool.
There was no self-administration assessment for any medication in Resident #5's medical record.
Review of Resident #5's medical record revealed no care plan for self-administration of medications.
On 5/29/24 at 9:29 AM an observation and interview was conducted with Resident #5 in his room. During the interview with Resident #5 was observed to knock over a napkin that contained an orange round pill off his bedside table. The pill was observed to fall to the floor. Resident #5 indicated the orange round pill was from the morning, and it was for his constipation. Resident #5 further indicated he liked to finish his breakfast prior to taking his medication for constipation. He stated that he took the rest of his morning medication but took his constipation pill later.
An interview on 5/29/24 at 9:32 AM with Nurse #1 revealed Resident #5 wanted his stool softener after eating breakfast. Nurse #1 indicated she had left the Senna S Oral tablet on Resident #5's bedside table on purpose so he could take it after breakfast. Nurse #1 also indicated this was a consistent morning routine for Resident #5. An observation with Nurse #1 of Resident #5's Medication Administration Record (MAR) revealed it had been signed on 5/29/24 prior to Resident #5 taking the pill.
On 5/29/24 at 2:34 PM the Nurse Supervisor indicated that a nurse should stand and observe a resident taking their medication before leaving the room. The Nursing Supervisor further indicated Nurse #1 should not have left Resident #5's medication at bedside. The MAR should not have been signed due to Resident #5 not consuming the Senna S Oral tablet.
An interview was conducted with the Director of Nursing (DON) on 5/29/24 at 3:02 PM. The DON stated Resident #5 should have been observed taking his medication before Nurse #1 left the room. Medication should not be left for residents to take at their discretion. The DON further stated when a resident wanted to take a medication later than the time ordered, the nurse should not sign off on the MAR. The nurse should hold the pill and come back when the resident requests.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, and Nurse Practitioner (NP) interview the facility failed to wear personal protecti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, and Nurse Practitioner (NP) interview the facility failed to wear personal protective equipment (PPE) while administering medications through a peripherally inserted central catheter (PICC line) for a resident requiring Enhanced Barrier Precautions (EBP). This deficit practice occurred for 1 of 2 residents reviewed for EBP (Resident #57).
Findings included:
Review of the facility's policy and procedure revised on 3/2023, entitled Policy and procedures guidelines for isolation precautions read in part:
Enhanced Barrier Precautions (EBP) are used as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). This precaution expands on the use of PPE and refers to the use of gown and gloves during high-contact resident care activities. That provides opportunities for transfer of MDROs to staff hands and clothing. EBP will be applied to resident with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Implementation- High-contact care activities that require gown and glove use for Enhanced Barrier Precautions include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ ventilator.
Resident #57 was admitted to the facility on [DATE].
Review of Resident #57 active physician orders for May 2024 revealed he had an order for EBP dated 5/21/24. He had an order dated 5/21/24 that read: Double Lumen PICC to left brachial vein inserted 5/20/24.
An observation was completed on 5/28/24 at 12:41 PM and revealed Resident #57 had a double lumen PICC line in place to his left upper arm. There was an EBP sign on the outside of his door. There was a cart with PPE supplies including: gowns, mask, and gloves outside the door of his room.
An observation was completed on 5/30/24 at 8:50 AM of Nurse #1 accessing Resident #57's PICC line prior to administering his intravenous (IV) medication. The nurse performed hand hygiene using hand sanitizer and donned clean gloves. She did not don a gown. Nurse #1 hung the IV medication on the IV pole and primed the IV tubing. She cleaned the PICC line lumen connection cap with an alcohol swab and connected a flush to the PICC line lumen.
An interview was conducted with Nurse #1 on 5/30/24 at 8:58 AM. Nurse #1 stated she was aware that Resident #57 had EBP in place. She explained EPB should be used when providing direct care and changing wound dressings. Nurse #1 stated that if she was providing care for the PICC line or using the PICC line she should use EBP and wear a gown. She stated she had been nervous and forgot to put on the gown.
An interview was performed with the Director of Nursing (DON) on 5/30/24 at 9:55 AM. The DON said Nurse #1 should follow EBP guidelines, which included wearing a gown when she accessed the PICC line to administer medications.
An interview was performed with the Infection Preventionist (IP) on 5/30/24 at 10:50 AM. The IP stated that residents with indwelling medical devices such as PICC lines should have EBP in place. She said if a nurse was using the PICC line or changing the dressing then they should follow EBP, which included wearing a gown and gloves.
An interview was performed with NP on 5/30/24 at 11:00 AM. The NP stated she was aware of EBP being used by the facility. She said Resident #57 had EBP in place for his PICC line and wounds. She stated Nurse #1 should have followed EBP when accessing Resident #57's PICC line.
An interview was performed with the Administrator on 5/30/24 at 11:56 AM. She stated if residents have EBP in place, staff should follow the EBP guidelines when performing procedures. The Administrator said Nurse #1 should have followed EBP guidelines and worn a gown when accessing Resident #57's PICC line. She said Nurse #1 did not follow protocol.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade A (90/100). Above average facility, better than most options in North Carolina.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most North Carolina facilities.
Concerns
- • No significant concerns identified. This facility shows no red flags across CMS ratings, staff turnover, or federal penalties.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Willowbrooke Court Sc Ctr At Matthews Glen's CMS Rating?
CMS assigns Willowbrooke Court SC Ctr at Matthews Glen an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within North Carolina, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Willowbrooke Court Sc Ctr At Matthews Glen Staffed?
CMS rates Willowbrooke Court SC Ctr at Matthews Glen's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes.
What Have Inspectors Found at Willowbrooke Court Sc Ctr At Matthews Glen?
State health inspectors documented 6 deficiencies at Willowbrooke Court SC Ctr at Matthews Glen during 2024 to 2025. These included: 5 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Willowbrooke Court Sc Ctr At Matthews Glen?
Willowbrooke Court SC Ctr at Matthews Glen is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by ACTS RETIREMENT-LIFE COMMUNITIES, a chain that manages multiple nursing homes. With 15 certified beds and approximately 9 residents (about 60% occupancy), it is a smaller facility located in Matthews, North Carolina.
How Does Willowbrooke Court Sc Ctr At Matthews Glen Compare to Other North Carolina Nursing Homes?
Compared to the 100 nursing homes in North Carolina, Willowbrooke Court SC Ctr at Matthews Glen's overall rating (5 stars) is above the state average of 2.8 and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Willowbrooke Court Sc Ctr At Matthews Glen?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Willowbrooke Court Sc Ctr At Matthews Glen Safe?
Based on CMS inspection data, Willowbrooke Court SC Ctr at Matthews Glen has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in North Carolina. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Willowbrooke Court Sc Ctr At Matthews Glen Stick Around?
Willowbrooke Court SC Ctr at Matthews Glen has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Willowbrooke Court Sc Ctr At Matthews Glen Ever Fined?
Willowbrooke Court SC Ctr at Matthews Glen has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Willowbrooke Court Sc Ctr At Matthews Glen on Any Federal Watch List?
Willowbrooke Court SC Ctr at Matthews Glen is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.