Brio of Johnston, LLC

Johnston, IA

CMS provider ID 165624CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

3 of 5 CMS stars

Health inspection

3 of 5 CMS stars

Staffing

4 of 5 CMS stars

Quality-measure

4 of 5 CMS stars

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
36
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
5152532501CMS Provider Information

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 1.00 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Chain context

CMS groups this facility with a chain covering 10 facilities across 1 states or territories.

View chain evidence
Enforcement record

CMS records show a $6,923 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
WESLEYLIFECMS identifies this facility as part of the WESLEYLIFE chain.
Related facilities
6Current CMS organization identity

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • 2 CMS-reported ownership organizations
  • CMS reports 22 individual ownership interests
  • a CMS chain / common-control group

Related facilities

6 currently connected nursing homes share this CMS organization identity with WESLEYLIFE.

Average CMS overall rating
3.5 stars across 6 reporting facilities
CMS monetary penalties
3 of 6 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
1 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
1 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
4 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$73,335

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
27
Organizations shown
5
Individuals shown
22
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • WESLEYLIFE

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Mar 26, 2018

    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
  • ALBERTSON, KERMIT

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2018

    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
  • GILROY, ABBEY

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 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
  • HOEKSEMA, NICOLE

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Mar 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
  • RASMUSSEN, CHAD

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2011

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • RUCH, ROBERT

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2003

    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
  • STOUT, DAVID

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2011

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • TAYLOR, CHRISTINA

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2018

    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
  • WATSON, SUSAN

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2014

    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
  • FLANAGAN, CRAIG

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jul 1, 2019

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • KRETZINGER, ROBERT

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Apr 27, 2007

    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
  • KRETZINGER, ROBERT

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 27, 2007

    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
  • WESLEY RETIREMENT SERVICES INC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Mar 26, 2018

    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
  • WESLEYLIFE

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Mar 26, 2018

    Other facilities connected through this exact CMS organization identity: 5 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
    View official CMS source
  • ALBERTSON, KERMIT

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2018

    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
    View official CMS source
  • GILROY, ABBEY

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2016

    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
    View official CMS source
  • HOEKSEMA, NICOLE

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Mar 1, 2021

    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
    View official CMS source
  • RASMUSSEN, CHAD

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2011

    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
    View official CMS source
  • RUCH, ROBERT

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2003

    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
    View official CMS source
  • STOUT, DAVID

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2011

    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
    View official CMS source
  • TAYLOR, CHRISTINA

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2018

    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
    View official CMS source
  • WATSON, SUSAN

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2014

    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
    View official CMS source
  • FLANAGAN, CRAIG

    Individual · CORPORATE OFFICER

    Published ownership percentage: 100%

    Association date reported to CMS: Jul 1, 2019

    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
    View official CMS source
  • KRETZINGER, ROBERT

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Apr 27, 2007

    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
    View official CMS source
  • KRETZINGER, ROBERT

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 27, 2007

    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
    View official CMS source
  • WESLEY RETIREMENT SERVICES INC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Published ownership percentage: 100%

    Association date reported to CMS: Mar 26, 2018

    Other facilities connected through this exact CMS organization identity: 7 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
    View official CMS source
  • BRIO OF JOHNSTON 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
    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 WESLEYLIFE to 6 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with WESLEYLIFE

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 561 is a grouping identifier, not a legal organization.

Facilities
10
States and territories
1
Average overall rating
3.9
Average staffing rating
4.4
Average total nurse HPRD
4.3
Total fines
5
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul103.94.4
Mon Jun1044.4
Fri May103.94.4
Wed Apr103.94.4
Sun Mar113.84.1
Sun Feb113.64.1

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 5 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
Apr 9, 2026
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
165624
Source record locator
csv-row:47934:ccn:165624
View official CMS source
Apr 9, 2026Fire Safety Standard 0 linked findings

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

Apr 9, 2026Health Standard 5 linked findings
  • F0689Quality 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 28, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127098:ccn:165624
    View official CMS source
  • F0760Pharmacy 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 28, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127099:ccn:165624
    View official CMS source
  • F0761Pharmacy Service Deficiencies

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Apr 28, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127100:ccn:165624
    View official CMS source
  • F0812Nutrition and Dietary Deficiencies

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    CMS scope/severity 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 24, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127101:ccn:165624
    View official CMS source
  • F0880Infection 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 (Apr 28, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127102:ccn:165624
    View official CMS source
Mar 13, 2025Fire Safety Standard 0 linked findings

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

Mar 13, 2025Health Standard 2 linked findings
  • F0741Quality of Life and Care Deficiencies

    Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

    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 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127103:ccn:165624
    View official CMS source
  • F0761Pharmacy Service Deficiencies

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Apr 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127104:ccn:165624
    View official CMS source
Jun 19, 2024Health Complaint 1 linked finding
  • F0689Quality 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 (Jul 18, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127105:ccn:165624
    View official CMS source
Apr 25, 2024Fire Safety Standard 0 linked findings

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

Apr 25, 2024Health Standard 3 linked findings
  • F0658Resident 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 (May 11, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127106:ccn:165624
    View official CMS source
  • F0727Nursing and Physician Services Deficiencies

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

    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 11, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127107:ccn:165624
    View official CMS source
  • F0880Infection 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 11, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127108:ccn:165624
    View official CMS source
Sep 14, 2023Health Complaint 1 linked finding
  • F0689Quality 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 K: Pattern; Immediate jeopardy to resident health or safety.

    Correction status: Past Non-Compliance (Apr 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:127109:ccn:165624
    View official CMS source
Sep 14, 2023Infection Control 0 linked findings

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

Tags appearing across inspections

  • F0689 appears in 3 linked inspections.
  • F0761 appears in 2 linked inspections.
  • F0880 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • FineSep 14, 2023

    Published fine amount: $6,923.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    165624
    Source record locator
    csv-row:5157:ccn:165624
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show F0689 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0761 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 show a monetary penalty dated Sep 14, 2023. What changes were made after that enforcement action?

Facility history

Facility History

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

What changed recently?

  • Health inspection completed5 deficiencies were recorded.
  • RN staffing decreasedRN staffing decreased from 1.48 to 0.98 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

2026

  1. Health inspection completed

    5 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2025

  1. RN staffing decreased

    RN staffing decreased from 1.48 to 0.98 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

    1.480.98

    CMS · Reported in a source release · View related evidence

  2. Total nurse staffing decreased

    Total nurse staffing decreased from 4.86 to 4.54 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

    4.864.54

    CMS · Reported in a source release · View related evidence

  3. Health inspection completed

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    3 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2023

  1. Complaint inspection recorded

    1 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  2. Civil monetary penalty recorded

    CMS recorded a $6,923 civil monetary penalty.

    CMS · Recorded event date · View related evidence

  3. Infection-control inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    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
4.569
reported hours per resident day
RN categories
1
reported hours per resident day
LPN/LVN categories
0.865
reported hours per resident day
CNA
1.731
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.754.115
RN categories1.1130.717

Contract staff accounted for 0.1% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.033 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
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q24.8581.4810.5021.7385.6%91
2025Q34.5440.9830.6931.8451.1%92
2025Q44.5870.9670.7921.9451%92
2026Q14.56910.8651.7310.1%90

Questions to ask

  • PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
  • PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
Source
Centers for Medicare & Medicaid Services (CMS)
Dataset
Payroll Based Journal Daily Nurse Staffing
CMS dataset ID
7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter
2026Q1
Coverage
Jan 1, 2026Mar 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 3-star overall rating.
  • CMS reports a 3-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.

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

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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
    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 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
    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

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