Southridge Specialty Care

Marshalltown, IA

CMS provider ID 165209CMS source updated July 29, 2026

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CMS overview

CMS overall

Health inspection

Staffing

Quality-measure

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: 82
Ownership descriptor: Non 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: 6417524553Verified 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.

Staffing

CMS publishes a 4-star staffing rating for this facility.

RN staffing was 0.72 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Inspections

The latest standard inspection on May 29, 2025 cited 2 deficiencies.

View inspection evidence

Ownership

CMS-published records list 25 ownership or control parties.

View ownership evidence

Chain context

CMS groups this facility with a chain covering 43 facilities across 1 states or territories.

View chain evidence

Enforcement record

CMS records show a 25-day payment denial 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: Non profit - CorporationCMS
Chain: CARE INITIATIVESCMS identifies this facility as part of the CARE INITIATIVES chain.
Related facilities: 43Current CMS organization identity

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

1 CMS-reported ownership organization
CMS reports 21 individual ownership interests
a CMS chain / common-control group

Related facilities

43 currently connected nursing homes share this CMS organization identity with CARE INITIATIVES.

Average CMS overall rating: 3 stars across 43 reporting facilities
CMS monetary penalties: 19 of 43 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties: 4 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement: 4 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections: 31 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines: $861,207

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: 25
Organizations shown: 4
Individuals shown: 21
Latest ownership source update: Jul 27, 2026

CMS-published ownership and control parties

CARE INITIATIVES
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Mar 1, 2014
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
View official CMS source
COMPUTERSHARE CORPORATE TRUST COMPANY, NA
Organization · 5% OR GREATER MORTGAGE INTEREST
Association date reported to CMS: Jan 1, 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
View official CMS source
COMPUTERSHARE CORPORATE TRUST COMPANY, NA
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 14, 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
View official CMS source
GIJIMA, DESIRE
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 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
View official CMS source
SPINA, DYLAN
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 14, 2025
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
BEAL, MICHAEL
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2020
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
View official CMS source
BOWEN, LANE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2021
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
View official CMS source
CAROTHERS, MARY JANE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2023
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
View official CMS source
CHILDS, KEVIN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Apr 1, 2023
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
View official CMS source
CORLESS, PETER
Individual · CORPORATE DIRECTOR
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
View official CMS source
KREIN, KEITH
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 29, 2022
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
View official CMS source
RUST, ELIZABETH
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2023
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
View official CMS source
STURM, DENISE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2021
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
View official CMS source
UPMEYER, LINDA
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 29, 2022
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
View official CMS source
BEAL, MICHAEL
Individual · CORPORATE OFFICER
Association date reported to CMS: Jun 1, 2020
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
View official CMS source
DIXON, DAVID
Individual · CORPORATE OFFICER
Association date reported to CMS: Jun 1, 2016
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
View official CMS source
DRAKE, EMILY
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 4, 2023
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
View official CMS source
GILYARD, TANYA
Individual · CORPORATE OFFICER
Association date reported to CMS: May 23, 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
View official CMS source
KUHN, JERAMY
Individual · CORPORATE OFFICER
Association date reported to CMS: Jun 25, 2008
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
View official CMS source
MCDYER, JESSICA
Individual · CORPORATE OFFICER
Association date reported to CMS: Feb 22, 2023
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
View official CMS source
VOLM, JOHANNA
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 1, 2021
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
View official CMS source
GIJIMA, DESIRE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 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
View official CMS source
MAHLER, CARLA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 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
View official CMS source
SPINA, DYLAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 24, 2023
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
View official CMS source
CARE INITIATIVES
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 42 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
View official CMS source

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 CARE INITIATIVES to 43 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with CARE INITIATIVES

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 106 is a grouping identifier, not a legal organization.

Facilities: 43
States and territories: 1
Average overall rating: 3
Average staffing rating: 3.7
Average total nurse HPRD: 3.3
Total fines: 23

Review CMS chain evidence

CMS-published history

Monthly chain measures
Month	Facilities	Overall rating	Staffing rating
Wed Jul	43	3	3.7
Mon Jun	43	3	3.6
Fri May	43	3.1	3.6
Wed Apr	43	3.1	3.6
Sun Mar	43	3	3.6
Sun Feb	43	2.9	3.6

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 23 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 source

Inspections & deficiencies

What CMS inspection records show

Scope and severity terms below are CMS classifications. They are not a TrustHub score.

Latest recorded inspection

Date: May 29, 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: 165209
Source record locator: csv-row:45087:ccn:165209

View official CMS source

May 29, 2025 — Fire Safety Standard — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

May 29, 2025 — Health Complaint — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

May 29, 2025 — 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 (May 30, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120895:ccn:165209
View official CMS source
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 30, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120899:ccn:165209
View official CMS source

Nov 5, 2024 — Health Complaint — 4 linked findings

F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120900:ccn:165209
View official CMS source
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 (Nov 18, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120901:ccn:165209
View official CMS source
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 (Nov 18, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120902:ccn:165209
View official CMS source
F0791 — Quality of Life and Care Deficiencies
Provide or obtain dental services for 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 (Nov 18, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120903:ccn:165209
View official CMS source

Sep 26, 2024 — Health Complaint — 2 linked findings

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 (Sep 27, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120904:ccn:165209
View official CMS source
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 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 27, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120905:ccn:165209
View official CMS source

Jun 20, 2024 — Fire Safety Standard — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Jun 20, 2024 — Health Complaint — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Jun 20, 2024 — Health Standard — 2 linked findings

F0585 — Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 10, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120908:ccn:165209
View official CMS source
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 (Jul 10, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120906:ccn:165209
View official CMS source

Mar 21, 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 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120909:ccn:165209
View official CMS source
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 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120910:ccn:165209
View official CMS source

Dec 19, 2023 — Health Complaint — 3 linked findings

F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity 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 (Jan 10, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120911:ccn:165209
View official CMS source
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 (Jan 10, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120912:ccn:165209
View official CMS source
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 (Jan 10, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120913:ccn:165209
View official CMS source

May 18, 2023 — Fire Safety Standard — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

May 18, 2023 — Health Standard — 5 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 (Jun 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120914:ccn:165209
View official CMS source
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 (Jun 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120915:ccn:165209
View official CMS source
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 (Jun 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120916:ccn:165209
View official CMS source
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 (Jun 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120917:ccn:165209
View official CMS source
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 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 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:120918:ccn:165209
View official CMS source

Tags appearing across inspections

F0658 appears in 2 linked inspections.
F0697 appears in 2 linked inspections.
F0725 appears in 2 linked inspections.
F0755 appears in 2 linked inspections.
F0842 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

Payment Denial — Sep 26, 2024
Payment denial length: 25 days
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:4927:ccn:165209
View official CMS source
Fine — Sep 26, 2024
Published fine amount: $45,406.00
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
165209
Source record locator
csv-row:4926:ccn:165209
View official CMS source

Questions to ask

Questions generated from the evidence above

CMS records show F0658 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0697 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0725 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0755 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0842 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show a monetary penalty dated Sep 26, 2024. What changes were made after that enforcement action?

Facility history

Facility History

12 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.

What changed recently?

RN staffing increasedRN staffing increased from 0.60 to 0.72 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
Complaint inspection recordedNo linked health-deficiency findings were recorded for this survey.

2026

Mar 2026
RN staffing increased
RN staffing increased from 0.60 to 0.72 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
0.60 → 0.72
CMS · Reported in a source release · View related evidence

2025

May 29
Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
May 29
Health inspection completed
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence

2024

Nov 5
Complaint inspection recorded
4 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Sep 26
Complaint inspection recorded
2 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Sep 26
Medicare payment denial recorded
CMS recorded a Medicare payment denial lasting 25 days.
CMS · Recorded event date · View related evidence
Sep 26
Civil monetary penalty recorded
CMS recorded a $45,406 civil monetary penalty.
CMS · Recorded event date · View related evidence
Jun 20
Health inspection completed
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Jun 20
Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
Mar 21
Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence

2023

Dec 19
Complaint inspection recorded
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
May 18
Health inspection completed
5 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).

Inspect a PBJ quarter

Total nursing: 3.647
RN categories: 0.716
LPN/LVN categories: 0.468
CNA: 1.891

Weekday and weekend calculations

2026Q1 reported hours per resident day
Measure	Monday–Friday	Saturday–Sunday
Total nursing	3.835	3.181
RN categories	0.804	0.499

Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.118 higher than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
Quarter	Total nursing	RN categories	LPN/LVN	CNA	Contract share	Days
2025Q2	3.411	0.643	0.464	1.69	0%	91
2025Q3	3.456	0.611	0.48	1.716	0%	92
2025Q4	3.523	0.598	0.532	1.822	0%	92
2026Q1	3.647	0.716	0.468	1.891	0%	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?

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 source

What 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 2-star overall rating.
CMS reports a 2-star health inspection rating.
CMS reports a 4-star staffing rating.
CMS reports a 4-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.

Trust participation

See something that needs correction?

Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.

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How corrections work

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

View official CMS source

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

View official CMS source

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

View official CMS source

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

View official CMS source

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

View official CMS source

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

View official CMS source

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

View official CMS source

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

View official CMS source

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.

How sources work

No paid placements. Facilities cannot pay to rank higher. We cite. You decide.

CMS rating overview

CMS overall

Health inspection

Staffing

Quality-measure

Contact

What to review

Staffing

Inspections

Ownership

Chain context

Ownership & Operation

Who is behind this facility?

Related facilities

Facilities currently connected to this organization

Who CMS records show is connected to this facility

CMS-published ownership and control parties

CARE INITIATIVES

COMPUTERSHARE CORPORATE TRUST COMPANY, NA

COMPUTERSHARE CORPORATE TRUST COMPANY, NA

GIJIMA, DESIRE

SPINA, DYLAN

BEAL, MICHAEL

BOWEN, LANE

CAROTHERS, MARY JANE

CHILDS, KEVIN

CORLESS, PETER

KREIN, KEITH

RUST, ELIZABETH

STURM, DENISE

UPMEYER, LINDA

BEAL, MICHAEL

DIXON, DAVID

DRAKE, EMILY

GILYARD, TANYA

KUHN, JERAMY

MCDYER, JESSICA

VOLM, JOHANNA

GIJIMA, DESIRE

MAHLER, CARLA

SPINA, DYLAN

CARE INITIATIVES

What this means

Questions to ask

CMS groups this facility with CARE INITIATIVES

CMS-published history

Questions to ask

What CMS inspection records show

Latest recorded inspection

F0644 — Resident Assessment and Care Planning Deficiencies

F0880 — Infection Control Deficiencies

F0697 — Quality of Life and Care Deficiencies

F0725 — Nursing and Physician Services Deficiencies

F0755 — Pharmacy Service Deficiencies

F0791 — Quality of Life and Care Deficiencies

F0760 — Pharmacy Service Deficiencies

F0842 — Resident Assessment and Care Planning Deficiencies

F0585 — Resident Rights Deficiencies

F0725 — Nursing and Physician Services Deficiencies

F0658 — Resident Assessment and Care Planning Deficiencies

F0689 — Quality of Life and Care Deficiencies

F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

F0657 — Resident Assessment and Care Planning Deficiencies

F0658 — Resident Assessment and Care Planning Deficiencies

F0684 — Quality of Life and Care Deficiencies

F0697 — Quality of Life and Care Deficiencies

F0755 — Pharmacy Service Deficiencies

F0842 — Resident Assessment and Care Planning Deficiencies

Tags appearing across inspections

CMS penalty records in the loaded three-year dataset

Payment Denial — Sep 26, 2024

Fine — Sep 26, 2024

Questions generated from the evidence above

Facility History

What changed recently?

2026

2025

2024

2023