WILLOW POINT REHABILITATION AND NURSING CENTER

KANSAS CITY, KS

CMS provider ID 175135CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

1 of 5 CMS stars

Health inspection

1 of 5 CMS stars

Staffing

3 of 5 CMS stars

Quality-measure

2 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
45
Ownership descriptor
For profit - Corporation
Medicare participation
Yes
Medicaid participation
Yes

Facility information

Contact

CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.

Phone
9133340200Verified 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 3-star staffing rating for this facility.

RN staffing was 0.64 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership

CMS-published records list 28 ownership or control parties.

CMS records show an ownership change effective December 2025.

View ownership evidence

Chain context

CMS groups this facility with a chain covering 347 facilities across 17 states or territories.

View chain evidence
Enforcement record

CMS records show a $15,421 fine in the loaded enforcement dataset.

View enforcement evidence →

Ownership & operation

Ownership & Operation

Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.

Ownership type
For profit - CorporationCMS
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

Explore ownership network →

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
28
Organizations shown
11
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: Sep 16, 2025

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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
  • EPPERSON, KAREN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Dec 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
  • LEWIS, CORWIN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 1, 2026

    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
  • MOUNT SUNFLOWER HEALTH HOLDINGS LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Dec 1, 2025

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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
  • STANDARD BEARER HEALTHCARE OP, LP

    Organization · ADP OF THE SNF

    Association date reported to CMS: Dec 1, 2025

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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
  • BURNAM, SOON

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Sep 16, 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
  • GATEWAY HEALTHCARE LLC

    Organization · DIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Sep 16, 2025

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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
  • THE ENSIGN GROUP INC

    Organization · INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Dec 1, 2025

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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
  • JORGENSEN, DAVID

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Dec 8, 2025

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

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Nov 13, 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
  • PORT, BARRY

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Nov 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
    View official CMS source
  • LEWIS, CORWIN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Feb 1, 2026

    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
  • BURNAM, SOON

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Sep 16, 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
  • EPPERSON, KAREN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Dec 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
  • LEWIS, CORWIN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 1, 2026

    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
  • ENSIGN SERVICES, INC.

    Organization · ADP OF THE SNF

    Association date reported to CMS: Sep 16, 2025

    Other facilities connected through this exact CMS organization identity: 2 across KS, TX.

    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
  • EPPERSON, KAREN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Dec 1, 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
    View official CMS source
  • LEWIS, CORWIN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 1, 2026

    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
  • MOUNT SUNFLOWER HEALTH HOLDINGS LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Dec 1, 2025

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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
  • STANDARD BEARER HEALTHCARE OP, LP

    Organization · ADP OF THE SNF

    Association date reported to CMS: Dec 1, 2025

    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
    View official CMS source
  • BURNAM, SOON

    Individual · CORPORATE OFFICER

    Published ownership percentage: 0%

    Association date reported to CMS: Sep 16, 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
    View official CMS source
  • GATEWAY HEALTHCARE LLC

    Organization · DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Sep 16, 2025

    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
    View official CMS source
  • THE ENSIGN GROUP INC

    Organization · INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Dec 1, 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
    View official CMS source
  • LEWIS, CORWIN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Feb 1, 2026

    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
  • BURNAM, SOON

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Sep 16, 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
    View official CMS source
  • EPPERSON, KAREN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Dec 1, 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
    View official CMS source
  • LEWIS, CORWIN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 1, 2026

    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
  • HICKORY CREEK HEALTHCARE LLC

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 0 across KS.

    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

Ownership changes reported in CMS enrollment records

  1. CHANGE OF OWNERSHIPMEDICALODGES INC to HICKORY CREEK 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
    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 enrollment records show a change of ownership effective Dec 1, 2025. What operational or leadership changes followed that event?
  • CMS records connect ENSIGN SERVICES, INC. to 3 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
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul3473.22.7
Mon Jun3423.22.4
Fri May3383.22.4
Wed Apr3343.22.4
Sun Mar3293.22.7
Sun Feb3243.22.7

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 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
Oct 24, 2024
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
175135
Source record locator
csv-row:48257:ccn:175135
View official CMS source
Oct 24, 2024Fire Safety Standard 0 linked findings

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

Oct 24, 2024Health Complaint 0 linked findings

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

Oct 24, 2024Health Standard 0 linked findings

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

Apr 10, 2024Health Complaint 1 linked finding
  • F0744Quality of Life and Care Deficiencies

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    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 24, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127864:ccn:175135
    View official CMS source
Mar 11, 2024Health Complaint 1 linked finding
  • F0609Freedom 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 15, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127865:ccn:175135
    View official CMS source
Feb 20, 2024Health Complaint 1 linked finding
  • F0609Freedom 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 J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Past Non-Compliance (Feb 19, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127866:ccn:175135
    View official CMS source
May 4, 2023Fire Safety Standard 0 linked findings

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

May 4, 2023Health Standard 24 linked findings
  • F0561Resident Rights Deficiencies

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127850:ccn:175135
    View official CMS source
  • F0582Resident Rights Deficiencies

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127851:ccn:175135
    View official CMS source
  • F0600Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127841:ccn:175135
    View official CMS source
  • F0655Resident 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 date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127852:ccn:175135
    View official CMS source
  • F0660Resident Assessment and Care Planning Deficiencies

    Plan the resident's discharge to meet the resident's goals and needs.

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

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127853:ccn:175135
    View official CMS source
  • F0661Resident Assessment and Care Planning Deficiencies

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127854:ccn:175135
    View official CMS source
  • F0676Quality of Life and Care Deficiencies

    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127855:ccn:175135
    View official CMS source
  • F0677Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

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

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127845:ccn:175135
    View official CMS source
  • F0679Quality of Life and Care Deficiencies

    Provide activities to meet all resident's needs.

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

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127846:ccn:175135
    View official CMS source
  • F0686Quality 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 (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127856:ccn:175135
    View official CMS source
  • 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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127842:ccn:175135
    View official CMS source
  • F0690Quality of Life and Care Deficiencies

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127857:ccn:175135
    View official CMS source
  • F0692Quality of Life and Care Deficiencies

    Provide enough food/fluids to maintain a resident's health.

    CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127843:ccn:175135
    View official CMS source
  • F0695Quality 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 (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127858:ccn:175135
    View official CMS source
  • F0732Nursing and Physician Services Deficiencies

    Post nurse staffing information every day.

    CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127863:ccn:175135
    View official CMS source
  • F0744Quality of Life and Care Deficiencies

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127859:ccn:175135
    View official CMS source
  • F0756Pharmacy Service Deficiencies

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127860:ccn:175135
    View official CMS source
  • F0757Pharmacy Service Deficiencies

    Ensure each resident’s drug regimen must be free from unnecessary 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 (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127861:ccn:175135
    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 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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127847:ccn:175135
    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 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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127844:ccn:175135
    View official CMS source
  • F0865Administration Deficiencies

    Have a plan that describes the process for conducting QAPI and QAA activities.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127848:ccn:175135
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

    CMS scope/severity L: Widespread; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Jun 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127840:ccn:175135
    View official CMS source
  • F0883Infection Control Deficiencies

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127849:ccn:175135
    View official CMS source
  • F0887Infection Control Deficiencies

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

    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 1, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127862:ccn:175135
    View official CMS source
Oct 13, 2021Fire Safety Standard 0 linked findings

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

Oct 13, 2021Health Standard 20 linked findings
  • F0558Resident 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127874:ccn:175135
    View official CMS source
  • F0561Resident Rights Deficiencies

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127875:ccn:175135
    View official CMS source
  • F0584Resident 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127871:ccn:175135
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

    Correction status: Deficient, Provider has date of correction (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127876:ccn:175135
    View official CMS source
  • F0661Resident Assessment and Care Planning Deficiencies

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

    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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127877:ccn:175135
    View official CMS source
  • F0677Quality 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127878:ccn:175135
    View official CMS source
  • F0686Quality 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127879:ccn:175135
    View official CMS source
  • F0688Quality 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 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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127872:ccn:175135
    View official CMS source
  • F0690Quality of Life and Care Deficiencies

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127880:ccn:175135
    View official CMS source
  • F0693Quality of Life and Care Deficiencies

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127881:ccn:175135
    View official CMS source
  • F0695Quality 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127882:ccn:175135
    View official CMS source
  • F0725Nursing 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 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127867:ccn:175135
    View official CMS source
  • F0732Nursing and Physician Services Deficiencies

    Post nurse staffing information every day.

    CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127886:ccn:175135
    View official CMS source
  • F0755Pharmacy 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 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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127873:ccn:175135
    View official CMS source
  • F0756Pharmacy Service Deficiencies

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    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 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127883:ccn:175135
    View official CMS source
  • F0757Pharmacy Service Deficiencies

    Ensure each resident’s drug regimen must be free from unnecessary 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127884:ccn:175135
    View official CMS source
  • F0758Pharmacy Service Deficiencies

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

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

    Correction status: Deficient, Provider has date of correction (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127885:ccn:175135
    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 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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127868:ccn:175135
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

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

    Correction status: Deficient, Provider has date of correction (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127869:ccn:175135
    View official CMS source
  • F0881Infection Control Deficiencies

    Implement a program that monitors antibiotic use.

    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 (Nov 21, 2021)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:127870:ccn:175135
    View official CMS source

Tags appearing across inspections

  • F0561 appears in 2 linked inspections.
  • F0609 appears in 2 linked inspections.
  • F0661 appears in 2 linked inspections.
  • F0677 appears in 2 linked inspections.
  • F0686 appears in 2 linked inspections.
  • F0690 appears in 2 linked inspections.
  • F0695 appears in 2 linked inspections.
  • F0732 appears in 2 linked inspections.
  • F0744 appears in 2 linked inspections.
  • F0756 appears in 2 linked inspections.
  • F0757 appears in 2 linked inspections.
  • F0812 appears in 2 linked inspections.
  • F0880 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • FineFeb 20, 2024

    Published fine amount: $15,421.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    175135
    Source record locator
    csv-row:5198:ccn:175135
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show F0561 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 F0661 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0677 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0686 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0690 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 F0732 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0744 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0756 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0757 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0812 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 Feb 20, 2024. What changes were made after that enforcement action?

Facility history

Facility History

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

What changed recently?

  • Total nurse staffing decreasedTotal nurse staffing decreased from 4.04 to 3.76 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
  • Ownership change recordedAn ownership change was recorded. New organization: HICKORY CREEK HEALTHCARE LLC.

2025

  1. Total nurse staffing decreased

    Total nurse staffing decreased from 4.04 to 3.76 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.

    4.043.76

    CMS · Reported in a source release · View related evidence

  2. Ownership change recorded

    An ownership change was recorded. New organization: HICKORY CREEK HEALTHCARE LLC.

    MEDICALODGES INCHICKORY CREEK HEALTHCARE LLC

    CMS · Recorded event date · View related evidence

  3. Total nurse staffing decreased

    Total nurse staffing decreased from 4.37 to 4.04 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

    4.374.04

    CMS · Reported in a source release · View related evidence

2024

  1. Health inspection completed

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

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

  3. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  4. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  5. Civil monetary penalty recorded

    CMS recorded a $15,421 civil monetary penalty.

    CMS · Recorded event date · View related evidence

  6. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

2023

  1. Health inspection completed

    24 deficiencies were recorded. That includes 4 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

2021

  1. Health inspection completed

    20 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 3 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
3.853
reported hours per resident day
RN categories
0.641
reported hours per resident day
LPN/LVN categories
0.669
reported hours per resident day
CNA
1.703
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.073.318
RN categories0.7570.355

Contract staff accounted for 4.1% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.064 lower 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
2025Q24.3650.790.4662.47823.7%91
2025Q34.0370.7140.3892.3338.3%92
2025Q43.7620.7050.2762.06312.3%92
2026Q13.8530.6410.6691.7034.1%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 1-star overall rating.
  • CMS reports a 1-star health inspection rating.
  • CMS reports a 3-star staffing rating.
  • CMS reports a 2-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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    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
    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
    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.