Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.89 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceCMS 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
- 131
- 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
- 5749369981Verified 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 Feb 7, 2025 cited 7 deficiencies.
View inspection evidenceOwnership
CMS-published records list 22 ownership or control parties.
View ownership evidenceChain context
CMS groups this facility with a chain covering 14 facilities across 1 states or territories.
View chain evidenceOwnership & 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
- Chain
- MILLER'S MERRY MANORCMS identifies this facility as part of the MILLER'S MERRY MANOR chain.
- Related facilities
- 35Current CMS organization identity
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 1 CMS-reported ownership organization
- CMS reports 11 individual ownership interests
- a CMS chain / common-control group
Related facilities
35 currently connected nursing homes share this CMS organization identity with JOHNSON MEMORIAL HOSPITAL.
- Average CMS overall rating
- 2.9 stars across 35 reporting facilities
- CMS monetary penalties
- 7 of 35 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 1 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 1 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 22 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $191,480
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
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
- 22
- Organizations shown
- 11
- Individuals shown
- 11
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
JOHNSON MEMORIAL HOSPITAL
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 1, 2012
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
LUMENT FINANCE TRUST INC
Organization · 5% OR GREATER MORTGAGE INTEREST
Association date reported to CMS: Nov 1, 2014
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
FORVIS MAZARS LLP
Organization · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2023
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
HOLM, BYRON
Individual · ADP OF THE SNF
Association date reported to CMS: Nov 10, 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
MILLER'S HEALTH SYSTEMS INC
Organization · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2013
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
MILLER'S MERRY MANOR PLYMOUTH LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2012
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
MMM-INVEST INC
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2012
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
ZEHR, BRYAN
Individual · ADP OF THE SNF
Association date reported to CMS: Nov 10, 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
BOYLE, PATRICK
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Nov 8, 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
DUNKLE, DAVID
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Mar 1, 2019
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
BOYLE, PATRICK
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
DECOLA, ROBERT
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
DUNKLE, DAVID
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
FORVIS MAZARS LLP
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2023
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
HAUG, LORI
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
HOLM, BYRON
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
JOHNSON MEMORIAL HOSPITAL
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2012
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
MILLER'S HEALTH SYSTEMS INC
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2013
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
ROBINSON, TINA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
THERACARE INC
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across IN.
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
ZEHR, BRYAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 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
JOHNSON MEMORIAL HOSPITAL
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 34 across IN.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility Enrollments
- CMS dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Jul 27, 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?
- CMS records connect JOHNSON MEMORIAL HOSPITAL to 35 facilities. Which policies and staffing decisions are managed centrally versus locally?
Chain context
CMS groups this facility with MILLER'S MERRY MANOR
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 352 is a grouping identifier, not a legal organization.
- Facilities
- 14
- States and territories
- 1
- Average overall rating
- 3.5
- Average staffing rating
- 3.3
- Average total nurse HPRD
- 3.8
- Total fines
- 1
CMS-published history
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 14 | 3.5 | 3.3 |
| Mon Jun | 14 | 3.7 | 3.2 |
| Fri May | 14 | 3.7 | 3.2 |
| Wed Apr | 14 | 3.8 | 3.2 |
| Sun Mar | 14 | 4 | 3.2 |
| Sun Feb | 14 | 3.9 | 3.2 |
Questions to ask
- CMS groups facilities in 1 states or territories under this chain. Which operational policies are set at the chain level?
- CMS reports 1 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- Feb 7, 2025
- Survey type
- Fire Safety Standard
- Linked findings
- 0
- Highest linked CMS classification
- No linked health-deficiency finding in the loaded record
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:39739:ccn:155102
Feb 7, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Feb 7, 2025 — Health Standard — 7 linked findings
F0567 — Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108410:ccn:155102
F0580 — Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108412:ccn:155102
F0679 — Quality of Life and Care Deficiencies
Provide activities to meet all resident's 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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108413:ccn:155102
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108411:ccn:155102
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108414:ccn:155102
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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108415:ccn:155102
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 (Mar 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108416:ccn:155102
Apr 23, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 23, 2024 — Health Standard — 10 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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108418:ccn:155102
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108419:ccn:155102
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108420:ccn:155102
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108421:ccn:155102
F0679 — Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108417:ccn:155102
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108422:ccn:155102
F0692 — Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108423:ccn:155102
F0700 — Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108424:ccn:155102
F0759 — Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108425:ccn:155102
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 (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108426:ccn:155102
Feb 24, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Feb 24, 2023 — Health Standard — 3 linked findings
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 (Mar 17, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108427:ccn:155102
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 (Mar 17, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108428:ccn:155102
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 (Mar 17, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 155102
- Source record locator
- csv-row:108429:ccn:155102
Tags appearing across inspections
- F0684 appears in 3 linked inspections.
- F0657 appears in 2 linked inspections.
- F0679 appears in 2 linked inspections.
- F0880 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Questions generated from the evidence above
- CMS records show F0684 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0657 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0679 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0880 in 2 inspections in the available record. What changes has the facility made to address this issue?
Facility history
Facility History
4 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- RN staffing decreasedRN staffing decreased from 0.95 to 0.80 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
2025
- RN staffing decreased
RN staffing decreased from 0.95 to 0.80 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
0.95 → 0.80
CMS · Reported in a source release · View related evidence
- Health inspection completed
7 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2024
- Health inspection completed
10 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2023
- Health inspection completed
3 deficiencies were recorded.
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
- 4.137 reported hours per resident day
- RN categories
- 0.886 reported hours per resident day
- LPN/LVN categories
- 0.583 reported hours per resident day
- CNA
- 2.57 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 4.402 | 3.483 |
| RN categories | 1.008 | 0.585 |
Contract staff accounted for 15.6% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.084 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 | 4.159 | 0.955 | 0.618 | 2.459 | 18.8% | 91 |
| 2025Q3 | 4.204 | 0.951 | 0.671 | 2.472 | 18.8% | 92 |
| 2025Q4 | 4.128 | 0.802 | 0.73 | 2.493 | 16.4% | 92 |
| 2026Q1 | 4.137 | 0.886 | 0.583 | 2.57 | 15.6% | 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.
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These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
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- CMS reports a 3-star health inspection rating.
- CMS reports a 4-star staffing rating.
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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
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
Skilled Nursing Facility Enrollments
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Nursing Home Chain Performance Measures
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 97ecfad1-d3f1-4d42-b774-d74661d830bc
- Coverage
- Wed Jul
- Source updated
- Aug 12, 2026
- Retrieved
- Aug 16, 2026
- Supports
- CMS chain context, performance, and monthly 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.
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