Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.84 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidencePELICAN POINTE HEALTH AND REHABILITATION CENTER
Also known publicly as Pelican Pointe Health and Rehabilitation
WINDSOR, CO
CMS overview
CMS rating overview
No proprietary TrustHub score. These ratings are published separately by CMS.
How CMS describes these ratings
- CMS overall rating
- The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
- Health inspection rating
- The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
- Staffing rating
- The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
- Quality-measure rating
- The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
- CMS certified beds
- 104
- Ownership descriptor
- For profit - Corporation
- Medicare participation
- Yes
- Medicaid participation
- Yes
Facility information
Contact
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
- Phone
- 9706867474Verified public information · checked Aug 2026
- Also known publicly as
- Pelican Pointe Health and RehabilitationVerified public information · checked Aug 2026
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on Jan 15, 2026 cited 6 deficiencies.
View inspection evidenceOwnership
CMS-published records list 14 ownership or control parties.
View ownership evidenceEnforcement record
CMS records show a $28,780 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Ownership & Operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
- Ownership type
- For profit - CorporationCMS
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 12 individual ownership interests
Ownership
Who CMS records show is connected to this facility
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
- Reported party records
- 14
- Organizations shown
- 2
- Individuals shown
- 12
- Latest ownership source update
- Jul 1, 2026
CMS-published ownership and control parties
CHOHAN, JAMEEL
Individual · ADP OF THE SNF
Association date reported to CMS: Sep 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
ENSIGN SERVICES INC
Organization · ADP OF THE SNF
Association date reported to CMS: Sep 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across CO.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
HRIBAR, KENNETH
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 14, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
SMV PROPERTY HOLDINGS LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Sep 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across CO.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
JORGENSEN, DAVID
Individual · CORPORATE DIRECTOR
Association date reported to CMS: May 24, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
BURNAM, SOON
Individual · CORPORATE OFFICER
Association date reported to CMS: May 24, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
GRAHAM, JOSEPH
Individual · CORPORATE OFFICER
Association date reported to CMS: May 24, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
JORGENSEN, DAVID
Individual · CORPORATE OFFICER
Association date reported to CMS: May 24, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
KEETCH, CHAD
Individual · CORPORATE OFFICER
Association date reported to CMS: Mar 1, 2011
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
SATO, AMI
Individual · CORPORATE OFFICER
Association date reported to CMS: Sep 9, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
CHOHAN, JAMEEL
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Sep 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
BURNAM, SOON
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
CHOHAN, JAMEEL
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
HRIBAR, KENNETH
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 14, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
What this means
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Questions to ask
- CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
Inspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- May 19, 2026
- Survey type
- Health Complaint
- Linked findings
- 3
- Highest linked CMS classification
- G — Isolated; Actual harm that is not immediate jeopardy
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:16591:ccn:065278
May 19, 2026 — Health Complaint — 3 linked findings
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 5, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47277:ccn:065278
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 5, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47278:ccn:065278
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 5, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47279:ccn:065278
Jan 15, 2026 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jan 15, 2026 — Health Standard — 6 linked findings
F0605 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 7, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47280:ccn:065278
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 7, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47281:ccn:065278
F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 7, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47282:ccn:065278
F0698 — Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 7, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47283:ccn:065278
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 7, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47284:ccn:065278
F0881 — Infection Control Deficiencies
Implement a program that monitors antibiotic use.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 7, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47285:ccn:065278
Jul 15, 2025 — Health Complaint — 3 linked findings
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Aug 8, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47286:ccn:065278
F0839 — Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 8, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47287:ccn:065278
F0867 — Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 8, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47288:ccn:065278
Feb 4, 2025 — Health Complaint — 1 linked finding
F0585 — Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47289:ccn:065278
Jun 10, 2024 — Health Complaint — 3 linked findings
F0677 — Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 12, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47307:ccn:065278
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 11, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47308:ccn:065278
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 11, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47309:ccn:065278
Dec 11, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 11, 2023 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 11, 2023 — Health Standard — 16 linked findings
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47301:ccn:065278
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47302:ccn:065278
F0658 — Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47303:ccn:065278
F0660 — Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47304:ccn:065278
F0692 — Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47290:ccn:065278
F0744 — Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47299:ccn:065278
F0761 — Pharmacy Service Deficiencies
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 scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47305:ccn:065278
F0806 — Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47306:ccn:065278
F0838 — Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47291:ccn:065278
F0867 — Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47292:ccn:065278
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47293:ccn:065278
F0883 — Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47294:ccn:065278
F0908 — Environmental Deficiencies
Keep all essential equipment working safely.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47295:ccn:065278
F0943 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47296:ccn:065278
F0944 — Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47297:ccn:065278
F0949 — Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 29, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47298:ccn:065278
Aug 7, 2023 — Health Complaint — 2 linked findings
F0584 — Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 8, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47310:ccn:065278
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 8, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47311:ccn:065278
Aug 25, 2022 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Aug 25, 2022 — Health Standard — 8 linked findings
F0584 — Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47316:ccn:065278
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47312:ccn:065278
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47317:ccn:065278
F0744 — Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47315:ccn:065278
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47318:ccn:065278
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47313:ccn:065278
F0849 — Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47319:ccn:065278
F0925 — Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 28, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:47314:ccn:065278
Tags appearing across inspections
- F0880 appears in 4 linked inspections.
- F0600 appears in 3 linked inspections.
- F0584 appears in 2 linked inspections.
- F0684 appears in 2 linked inspections.
- F0689 appears in 2 linked inspections.
- F0744 appears in 2 linked inspections.
- F0760 appears in 2 linked inspections.
- F0867 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Jul 15, 2025
Published fine amount: $28,780.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:1228:ccn:065278
Fine — Dec 11, 2023
Published fine amount: $30,862.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:1229:ccn:065278
Fine — Nov 20, 2023
Published fine amount: $3,529.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:1226:ccn:065278
Fine — Oct 30, 2023
Published fine amount: $8,469.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 065278
- Source record locator
- csv-row:1227:ccn:065278
Questions to ask
Questions generated from the evidence above
- CMS records show F0880 in 4 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0600 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0584 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0684 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0689 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0744 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0760 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0867 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Jul 15, 2025. What changes were made after that enforcement action?
Facility history
Facility History
14 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded3 deficiencies were recorded. That includes 1 higher-severity deficiency.
- Total nurse staffing decreasedTotal nurse staffing decreased from 3.84 to 3.41 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
- Civil monetary penalty recordedCMS recorded a $28,780 civil monetary penalty.
2026
- Complaint inspection recorded
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Health inspection completed
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- Total nurse staffing decreased
Total nurse staffing decreased from 3.84 to 3.41 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
3.84 → 3.41
CMS · Reported in a source release · View related evidence
- Civil monetary penalty recorded
CMS recorded a $28,780 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
2024
- Complaint inspection recorded
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2023
- Civil monetary penalty recorded
CMS recorded a $30,862 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Health inspection completed
16 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $3,529 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $8,469 civil monetary penalty.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 4 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
- Total nursing
- 3.325 reported hours per resident day
- RN categories
- 0.839 reported hours per resident day
- LPN/LVN categories
- 0.362 reported hours per resident day
- CNA
- 1.982 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.468 | 2.975 |
| RN categories | 0.958 | 0.547 |
Contract staff accounted for 20.1% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.005 higher than the prior loaded quarter.
Staffing over time
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.736 | 0.828 | 0.501 | 2.223 | 27.2% | 91 |
| 2025Q3 | 3.84 | 0.826 | 0.48 | 2.371 | 20.7% | 92 |
| 2025Q4 | 3.414 | 0.834 | 0.436 | 1.931 | 15.4% | 92 |
| 2026Q1 | 3.325 | 0.839 | 0.362 | 1.982 | 20.1% | 90 |
Questions to ask
- PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
- PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 1-star overall rating.
- CMS reports a 1-star health inspection rating.
- CMS reports a 4-star staffing rating.
- CMS reports a 3-star quality-measure rating.
Planned evidence layers
Additional public-source research
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
- Chain / portfolio intelligence
Trust participation
See something that needs correction?
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
See where this record came from
Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Health deficiencies and facility history
Penalties
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- g6vv-u9sr
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Penalties, enforcement, and facility history
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Verified public facility information
- Source organization
- Public facility listing
- Dataset identifier
- commercial-corroboration:public-listing
- Source updated
- Aug 18, 2026
- Retrieved
- Aug 18, 2026
- Supports
- Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.