Staffing
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.30 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
- 80
- Ownership descriptor
- For profit - Limited Liability company
- 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
- 5152853070Verified 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 Jun 10, 2025 cited 8 deficiencies.
View inspection evidenceOwnership
CMS-published records list 30 ownership or control parties.
CMS records show an ownership change effective August 2024.
View ownership evidenceChain context
CMS groups this facility with a chain covering 347 facilities across 17 states or territories.
View chain evidenceEnforcement record
CMS records show a $85,810 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 - Limited Liability companyCMS
- Chain
- THE ENSIGN GROUPCMS identifies this facility as part of the THE ENSIGN GROUP chain.
- Related facilities
- 135Current CMS organization identity
- Ownership changes
- 1 recordedCMS enrollment records
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 4 CMS-reported ownership organizations
- CMS reports 17 individual ownership interests
- a CMS chain / common-control group
- recorded ownership-change events
Related facilities
135 currently connected nursing homes share this CMS organization identity with THE ENSIGN GROUP INC.
- Average CMS overall rating
- 3.3 stars across 133 reporting facilities
- CMS monetary penalties
- 59 of 135 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 25 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 21 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 86 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $2,435,931
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
- 30
- Organizations shown
- 13
- Individuals shown
- 17
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
ENSIGN SERVICES INC
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across IA.
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
OCONNER, MICHAEL
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 20, 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
SKYWALK HEALTH HOLDINGS LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across IA.
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
STANDARD BEARER HEALTHCARE OP, LP
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across IA.
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
THE ENSIGN GROUP INC
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across IA.
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
TIMM, DIRK
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 5, 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
BURNAM, SOON
Individual · CORPORATE OFFICER
Association date reported to CMS: Apr 17, 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
GATEWAY HEALTHCARE LLC
Organization · DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Apr 17, 2024
Other facilities connected through this exact CMS organization identity: 0 across IA.
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
THE ENSIGN GROUP INC
Organization · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Apr 17, 2025
Other facilities connected through this exact CMS organization identity: 0 across IA.
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 · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Jun 2, 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
KEETCH, CHAD
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Jun 2, 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
PORT, BARRY
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Jun 5, 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
BURNAM, SOON
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Apr 17, 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
OCONNER, MICHAEL
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Aug 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
TIMM, DIRK
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Aug 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
TIMM, DIRK
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 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: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 106 across CA, IA, ID, KS, NE, NV, SC, TN, TX, UT, WA, WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
OCONNER, MICHAEL
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 20, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
SKYWALK HEALTH HOLDINGS LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 0 across IA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
STANDARD BEARER HEALTHCARE OP, LP
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 35 across CA, IA, ID, KS, SC, TX, UT, WA, WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
THE ENSIGN GROUP INC
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2024
Other facilities connected through this exact CMS organization identity: 134 across CA, IA, ID, KS, NE, NV, OR, SC, TN, TX, UT, WA, WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
TIMM, DIRK
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 5, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
BURNAM, SOON
Individual · CORPORATE OFFICER
Published ownership percentage: 0%
Association date reported to CMS: Apr 17, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
GATEWAY HEALTHCARE LLC
Organization · DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Apr 17, 2024
Other facilities connected through this exact CMS organization identity: 32 across IA, KS, NE, WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
THE ENSIGN GROUP INC
Organization · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Apr 17, 2025
Other facilities connected through this exact CMS organization identity: 134 across CA, IA, ID, KS, NE, NV, OR, SC, TN, TX, UT, WA, WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
BURNAM, SOON
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Apr 17, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
OCONNER, MICHAEL
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Aug 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
TIMM, DIRK
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Aug 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
TIMM, DIRK
Individual · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Aug 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
TERRACE HILL HEALTHCARE LLC
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across IA.
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
Ownership changes reported in CMS enrollment records
- CHANGE OF OWNERSHIPDSM HEALTHCARE MANAGEMENT to TERRACE HILL HEALTHCARE LLC
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility Change of Ownership
- CMS dataset identifier
- f557a6ed-95b3-4a22-8433-4175db2dec1c
- 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 enrollment records show a change of ownership effective Aug 1, 2024. What operational or leadership changes followed that event?
- CMS records connect ENSIGN SERVICES INC to 107 facilities. Which policies and staffing decisions are managed centrally versus locally?
Chain context
CMS groups this facility with THE ENSIGN GROUP
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 507 is a grouping identifier, not a legal organization.
- Facilities
- 347
- States and territories
- 17
- Average overall rating
- 3.2
- Average staffing rating
- 2.7
- Average total nurse HPRD
- 3.7
- Total fines
- 304
CMS-published history
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 347 | 3.2 | 2.7 |
| Mon Jun | 342 | 3.2 | 2.4 |
| Fri May | 338 | 3.2 | 2.4 |
| Wed Apr | 334 | 3.2 | 2.4 |
| Sun Mar | 329 | 3.2 | 2.7 |
| Sun Feb | 324 | 3.2 | 2.7 |
Questions to ask
- CMS groups facilities in 17 states or territories under this chain. Which operational policies are set at the chain level?
- CMS reports 304 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
- May 14, 2026
- Survey type
- Health Complaint
- Linked findings
- 2
- Highest linked CMS classification
- K — Pattern; Immediate jeopardy to resident health or safety
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:44836:ccn:165175
May 14, 2026 — Health Complaint — 2 linked findings
F0726 — Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 (Jun 12, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120208:ccn:165175
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 12, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120207:ccn:165175
Apr 9, 2026 — Health Complaint — 5 linked findings
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 (Apr 29, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120209:ccn:165175
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 (Apr 29, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120210:ccn:165175
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 (Apr 29, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120211:ccn:165175
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
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 (Apr 29, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120212:ccn:165175
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 (Apr 29, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120213:ccn:165175
Oct 27, 2025 — Health Complaint — 5 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 G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120214:ccn:165175
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 (Nov 14, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120215:ccn:165175
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 (Nov 14, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120216:ccn:165175
F0635 — Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 (Nov 14, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120217:ccn:165175
F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management 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 (Nov 14, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120218:ccn:165175
Sep 3, 2025 — Health Complaint — 4 linked findings
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120220:ccn:165175
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 (Sep 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120221:ccn:165175
F0725 — Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120219:ccn:165175
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 (Sep 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120222:ccn:165175
Jun 10, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jun 10, 2025 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jun 10, 2025 — Health Standard — 8 linked findings
F0578 — Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120226:ccn:165175
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 plan of correction (Jun 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120227:ccn:165175
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120228:ccn:165175
F0655 — Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120229:ccn:165175
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120230:ccn:165175
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 plan of correction (Jun 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120231:ccn:165175
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 plan of correction (Jun 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120233:ccn:165175
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 plan of correction (Jun 23, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120225:ccn:165175
Apr 24, 2025 — Health Complaint — 1 linked finding
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 13, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120236:ccn:165175
Mar 20, 2025 — Health Complaint — 4 linked findings
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120237:ccn:165175
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 (Mar 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120238:ccn:165175
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 (Mar 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120239:ccn:165175
F0919 — Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
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 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120240:ccn:165175
Nov 13, 2024 — Health Complaint — 2 linked findings
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 J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Nov 16, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120241:ccn:165175
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 (Nov 16, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120242:ccn:165175
Oct 2, 2024 — Health Complaint — 10 linked findings
F0551 — Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120245:ccn:165175
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120246:ccn:165175
F0642 — Resident Assessment and Care Planning Deficiencies
Ensure a qualified health professional conducts resident assessments.
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120247:ccn:165175
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120248:ccn:165175
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 date of correction (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120243:ccn:165175
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120249:ccn:165175
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120250:ccn:165175
F0726 — Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120251:ccn:165175
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120252:ccn:165175
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 (Oct 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120244:ccn:165175
Aug 29, 2024 — Health Complaint — 1 linked finding
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 J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Sep 12, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120253:ccn:165175
Jul 12, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jul 12, 2024 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jul 12, 2024 — Health Standard — 2 linked findings
F0644 — Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 (Jul 23, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120255:ccn:165175
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 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 (Jul 23, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120257:ccn:165175
Jun 3, 2024 — Health Complaint — 4 linked findings
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 (Jun 14, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120259:ccn:165175
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 (Jun 14, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120258:ccn:165175
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 (Jun 14, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120260:ccn:165175
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 (Jun 14, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120261:ccn:165175
Apr 19, 2024 — Health Complaint — 1 linked finding
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120262:ccn:165175
Mar 11, 2024 — Health Complaint — 2 linked findings
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 (Apr 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120264:ccn:165175
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 (Apr 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120263:ccn:165175
Sep 7, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Sep 7, 2023 — Health Standard — 5 linked findings
F0558 — Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each 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 (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120265:ccn:165175
F0623 — Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120266:ccn:165175
F0644 — Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120267:ccn:165175
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 (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120268:ccn:165175
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:120269:ccn:165175
Tags appearing across inspections
- F0689 appears in 5 linked inspections.
- F0684 appears in 4 linked inspections.
- F0658 appears in 3 linked inspections.
- F0550 appears in 2 linked inspections.
- F0580 appears in 2 linked inspections.
- F0600 appears in 2 linked inspections.
- F0609 appears in 2 linked inspections.
- F0644 appears in 2 linked inspections.
- F0657 appears in 2 linked inspections.
- F0688 appears in 2 linked inspections.
- F0695 appears in 2 linked inspections.
- F0698 appears in 2 linked inspections.
- F0726 appears in 2 linked inspections.
- F0760 appears in 2 linked inspections.
- F0880 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Oct 2, 2024
Published fine amount: $85,810.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:4899:ccn:165175
Fine — Aug 29, 2024
Published fine amount: $25,454.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:4896:ccn:165175
Fine — Jul 12, 2024
Published fine amount: $26,374.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:4897:ccn:165175
Fine — Apr 19, 2024
Published fine amount: $28,805.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:4898:ccn:165175
Payment Denial — Apr 19, 2024
Payment denial length: 17 days
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 165175
- Source record locator
- csv-row:4900:ccn:165175
Questions to ask
Questions generated from the evidence above
- CMS records show F0689 in 5 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0684 in 4 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0658 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0550 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0580 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0600 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0609 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0644 in 2 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 F0688 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0695 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0698 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0726 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 F0880 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records include an Immediate Jeopardy-level finding. What corrective actions were taken after that inspection?
- CMS records show a monetary penalty dated Oct 2, 2024. What changes were made after that enforcement action?
Facility history
Facility History
25 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded2 deficiencies were recorded. That includes 1 higher-severity deficiency.
- RN staffing decreasedRN staffing decreased from 0.42 to 0.26 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
2026
- Complaint inspection recorded
2 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
5 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- Complaint inspection recorded
5 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- RN staffing decreased
RN staffing decreased from 0.42 to 0.26 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
0.42 → 0.26
CMS · Reported in a source release · View related evidence
- Complaint inspection recorded
4 deficiencies were recorded.
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
- Health inspection completed
8 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2024
- Complaint inspection recorded
2 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $85,810 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
10 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 1 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
- 3.442 reported hours per resident day
- RN categories
- 0.296 reported hours per resident day
- LPN/LVN categories
- 0.871 reported hours per resident day
- CNA
- 1.808 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.747 | 2.685 |
| RN categories | 0.314 | 0.251 |
Contract staff accounted for 0.3% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.053 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 | 3.292 | 0.423 | 0.71 | 1.575 | 0% | 91 |
| 2025Q3 | 3.3 | 0.262 | 0.688 | 1.773 | 0% | 92 |
| 2025Q4 | 3.337 | 0.243 | 0.724 | 1.891 | 0.1% | 92 |
| 2026Q1 | 3.442 | 0.296 | 0.871 | 1.808 | 0.3% | 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 1-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.
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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
Skilled Nursing Facility All Owners
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 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
Skilled Nursing Facility Change of Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- f557a6ed-95b3-4a22-8433-4175db2dec1c
- 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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