Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbrooke Court Sc Ctr At Matthews Glen during CMS and state inspections, most recent first.
Expired bell peppers with visible mold and a gallon of milk past its 'best if used by' date were found in the kitchen and nourishment refrigerators. Staff interviews revealed inconsistent practices in checking for expired items, and expired milk was served to a resident. Both dietary and nursing staff were responsible for monitoring food safety, but expired items were not consistently identified or removed.
A resident with hemiplegia and Parkinsonism developed a skin tear on the shin, which was initially treated according to standing orders. However, nursing staff failed to enter the required daily dressing change order on the TAR, resulting in the dressing not being changed as required. Observations and staff interviews confirmed the lapse in documentation and daily treatment.
The facility did not accurately document daily nurse staffing, with discrepancies found between time clock records and posted staffing sheets for numerous days. Staff including RNs, LPNs, and CNAs who worked specific shifts were not properly recorded, resulting in underreporting or omission of staff on the official records. The process for updating staffing sheets changed hands multiple times, but the documentation remained inconsistent and inaccurate.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate. A nurse made multiple errors, including incorrect PICC line flushing and improper application of Voltaren gel. The nurse did not follow the SASH method for flushing and applied the gel to multiple areas instead of the ordered right shoulder, without measuring the dosage. These actions were confirmed by the DON, NP, and Pharmacist.
A resident's medication was left unattended at the bedside, and the MAR was signed before the medication was consumed. The resident preferred to take the medication after breakfast, but there was no self-administration assessment or care plan in place. The Nurse Supervisor and DON confirmed that proper procedures were not followed.
A nurse failed to wear a gown while administering medications through a PICC line for a resident under Enhanced Barrier Precautions (EBP). Despite being aware of the EBP requirements, the nurse only performed hand hygiene and donned gloves, neglecting to wear a gown. Interviews with facility staff confirmed that the nurse should have followed EBP guidelines.
Expired Food and Milk Not Discarded in Kitchen and Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to discard expired food items in both the main kitchen's walk-in produce refrigerator and a nourishment refrigerator. During a tour of the kitchen, three red bell peppers covered with gray and white fuzz were found in a box without a date, and the Lead Chef admitted to having cut around a pepper with fuzz earlier that morning for meal preparation. The Dietary Manager confirmed that bell peppers should be inspected upon receipt and daily, but this was not consistently done. The Administrator was unaware of how the expired produce remained in the refrigerator. Additionally, a gallon of milk with a 'best if used by' date that had already passed was found in a nourishment refrigerator, with about three-quarters of the milk still present. The Lead Chef and dietary aides acknowledged shared responsibility for checking for expired items, but interviews revealed that expiration dates were not always checked, and the expired milk had been used to serve a resident that morning. The Administrator stated that the expired milk should have been discarded, but was unsure how it was overlooked.
Failure to Document and Complete Daily Skin Tear Treatment per Standing Orders
Penalty
Summary
The facility failed to ensure that treatment for a non-pressure related skin impairment was completed daily according to standing orders for one resident with a skin tear. The resident, who had a history of hemiplegia, hemiparesis, and Parkinsonism, sustained an abrasion to the right shin while being assisted to the toilet by a family member. The injury was initially assessed and treated by a nurse using the facility's standing orders, which required daily dressing changes and documentation on the Treatment Administration Record (TAR) until the area was healed. However, a review of the resident's TAR revealed that no treatment order for daily dressing changes was entered, resulting in the dressing not being changed as required. Observations showed the same bandage remained in place for several days, and interviews with nursing staff confirmed that the standing order had not been properly documented on the TAR. Both the nursing staff and the RN Supervisor acknowledged that the nurse responsible for initiating the standing order should have entered the treatment order on the TAR to ensure daily care was provided and documented.
Inaccurate Daily Nurse Staffing Documentation
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets accurately reflected the nursing staff who worked for 32 out of 72 days reviewed. Record review showed discrepancies between the time clock reports and the posted daily nurse staffing sheets. For multiple dates, staff who had clocked in and worked specific shifts, including RNs, LPNs, and CNAs, were not accurately recorded on the corresponding staffing sheets for those shifts. In several instances, staff worked overnight or across shifts, but their presence was not reflected on the staffing documentation for the relevant shifts or days. The daily nurse staffing sheets were designed to capture the name of the unit, resident census for each shift, and the number and hours worked for RNs, LPNs, and CNAs for each 8-hour shift. However, the review found that the sheets often underreported the actual number of staff present, sometimes omitting entire shifts or misrepresenting the number of staff on duty. For example, there were cases where LPNs or RNs worked night shifts, but the staffing sheets indicated no such staff were present. Similarly, CNAs who worked full or partial shifts were not always listed, or the number of CNAs was inaccurately reported. Interviews with facility staff revealed that the process for updating and posting the daily nurse staffing sheets had changed over time. Initially, the former receptionist was responsible for updating the sheets, but this responsibility later shifted to the Health Services Coordinator. At the time of the survey, the Administrative Assistant was being trained to take over this task. Despite these changes, the staffing sheets were not consistently updated to reflect the actual staff who worked each shift, leading to the identified deficiencies.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12% error rate. This was observed during the administration of medications to a resident. Nurse #1 made multiple errors while administering medications, including incorrect flushing of a PICC line and improper application of a topical analgesic. Specifically, Nurse #1 did not follow the SASH method for flushing the PICC line and was observed to almost use heparin flush instead of normal saline. Additionally, Nurse #1 applied Voltaren gel to multiple areas of the resident's body instead of just the right shoulder as ordered, and did not measure the gel using a dosing card as required. These actions were confirmed through interviews with the Director of Nursing, Nurse Practitioner, and Pharmacist, who all stated that the nurse should have followed the physician's orders and protocols for medication administration. The first deficiency involved the incorrect flushing of the PICC line. Nurse #1 was observed preparing to flush the line with heparin instead of normal saline before administering the IV antibiotic ceftriaxone. Despite being stopped before completing the flush, Nurse #1 admitted to being nervous and confused about the correct procedure. The Director of Nursing confirmed that Nurse #1 had been trained on IV administration, including the SASH method, but failed to follow the protocol. The Nurse Practitioner and Pharmacist both indicated that while no adverse effects were expected from the error, the correct procedure should have been followed. The second deficiency involved the improper application of Voltaren gel. Nurse #1 applied the gel to multiple areas of the resident's body instead of just the right shoulder as ordered. She also did not measure the gel using a dosing card, which is required to ensure the correct dosage. The Director of Nursing and Pharmacist confirmed that the gel should be measured and applied only to the specified area. The Nurse Practitioner reiterated that the nurse should have followed the physician's orders. These actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to store a medication properly and left it unattended at the bedside for a resident who was admitted with a diagnosis that included constipation. The resident was cognitively intact and had a physician's order for Senna S Oral Tablet to be taken once daily for constipation. However, there was no self-administration assessment or care plan for self-administration of medications in the resident's medical record. During an observation, the resident knocked over a napkin containing the medication, which fell to the floor. The resident indicated that he preferred to take the medication after breakfast, and Nurse #1 had left the pill on the bedside table for this purpose. The MAR had been signed before the resident took the pill, indicating a failure to follow proper medication administration procedures. The Nurse Supervisor and the Director of Nursing confirmed that the nurse should have observed the resident taking the medication before leaving the room and should not have signed the MAR until the medication was consumed. The nurse should have held the pill and returned when the resident was ready to take it. This incident highlights a lapse in medication storage and administration protocols, as well as documentation practices within the facility.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) while administering medications through a peripherally inserted central catheter (PICC line) for a resident. Specifically, Nurse #1 did not wear a gown while accessing the PICC line of Resident #57, who had an EBP order in place due to the presence of a double lumen PICC line. The nurse performed hand hygiene and donned gloves but neglected to wear a gown, which is required under EBP guidelines for high-contact care activities involving indwelling medical devices. This lapse was observed during a medication administration procedure on 5/30/24. Interviews with the nurse, Director of Nursing (DON), Infection Preventionist (IP), Nurse Practitioner (NP), and the Administrator confirmed that the nurse should have followed EBP guidelines, which include wearing a gown when accessing the PICC line. The nurse admitted to being aware of the EBP requirements but stated she was nervous and forgot to don the gown. The DON, IP, NP, and Administrator all reiterated that the nurse should have adhered to the EBP protocol to prevent the transmission of multidrug-resistant organisms (MDROs).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Matthews
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Park Rehabilitation & Health Center | 0 mi | ★★★★★ | 8 | 0 |
| Matthews Health & Rehab Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Lake Park Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 11 | 0 |
| Brookdale Carriage Club Providence | 5.3 mi | ★★★★★ | 1 | 0 |
| Sardis Oaks | 6.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.