Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.59 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceDERBY HEALTH & REHABILITATION, LLC
Also known publicly as Derby Health & Rehab
DERBY, KS
CMS overview
CMS rating overview
No proprietary TrustHub score. These ratings are published separately by CMS.
How CMS describes these ratings
- CMS overall rating
- The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
- Health inspection rating
- The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
- Staffing rating
- The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
- Quality-measure rating
- The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
- CMS certified beds
- 74
- 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
- 3167192400Verified public information · checked Aug 2026
- Also known publicly as
- Derby Health & RehabVerified public information · checked Aug 2026
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on Mar 11, 2026 cited 2 deficiencies.
View inspection evidenceOwnership
CMS-published records list 33 ownership or control parties.
View ownership evidenceOwnership & operation
Ownership & Operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
- Ownership type
- For profit - CorporationCMS
- Related facilities
- 4Current CMS organization identity
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 12 CMS-reported ownership organizations
- CMS reports 18 individual ownership interests
Related facilities
4 currently connected nursing homes share this CMS organization identity with AXIOM HEALTHCARE ALLIANCE, LLC.
- Average CMS overall rating
- 4.3 stars across 4 reporting facilities
- CMS monetary penalties
- 1 of 4 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 0 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 0 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 2 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $8,827
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
- 33
- Organizations shown
- 15
- Individuals shown
- 18
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
AXIOM HEALTHCARE ALLIANCE, LLC
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Sep 1, 2020
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
AXIOM CONSULTING LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 9%
Association date reported to CMS: Jul 7, 2015
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
DENNIS L. ROSS POD TO TRUSTEE OF DENNIS L. ROSS LIVING TRUST U/A 4/4/1
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5%
Association date reported to CMS: Sep 1, 2020
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
EVANS, ROGER
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 6%
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
HERMES, FREDERICK
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 9%
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
LAKIN, GREGORY
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 11%
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
LILLIE, MATTHEW
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 8%
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
MATT LILLIE INVESTMENTS, INC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 8%
Association date reported to CMS: Sep 1, 2020
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
ROGER EVANS REVOCABLE TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 6%
Association date reported to CMS: Sep 1, 2020
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
ROSS, ANN
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5%
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
ROSS, DENNIS
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5%
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
WICHITA WELLNESS INC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 11%
Association date reported to CMS: Sep 1, 2020
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
BECNEL, CHANCE
Individual · CORPORATE OFFICER
Association date reported to CMS: Sep 1, 2020
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
KRUSE, BRENDA
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 22, 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
AXIOM HEALTHCARE SERVICES LLC
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 23, 2009
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
HERMES, FREDERICK
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Oct 9, 2009
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
AXIOM HEALTHCARE ALLIANCE, LLC
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Sep 1, 2020
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 3 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
AXIOM CONSULTING LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 8.76%
Association date reported to CMS: Jul 7, 2015
Other facilities connected through this exact CMS organization identity: 3 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
DENNIS L. ROSS POD TO TRUSTEE OF DENNIS L. ROSS LIVING TRUST U/A 4/4/1
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.38%
Association date reported to CMS: Sep 1, 2020
Other facilities connected through this exact CMS organization identity: 3 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
EVANS, ROGER
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.65%
Association date reported to CMS: Sep 1, 2020
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
HERMES, FREDERICK
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 8.76%
Association date reported to CMS: Sep 1, 2020
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
LAKIN, GREGORY
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 10.97%
Association date reported to CMS: Sep 1, 2020
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
LILLIE, MATTHEW
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 7.9%
Association date reported to CMS: Sep 1, 2020
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
MATT LILLIE INVESTMENTS, INC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 7.9%
Association date reported to CMS: Sep 1, 2020
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 3 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
ROGER EVANS REVOCABLE TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.65%
Association date reported to CMS: Sep 1, 2020
Other facilities connected through this exact CMS organization identity: 3 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
ROSS, ANN
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.38%
Association date reported to CMS: Sep 1, 2020
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
ROSS, DENNIS
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.38%
Association date reported to CMS: Sep 1, 2020
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
WICHITA WELLNESS INC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 10.97%
Association date reported to CMS: Sep 1, 2020
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 3 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
BECNEL, CHANCE
Individual · CORPORATE OFFICER
Association date reported to CMS: Sep 1, 2020
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
KRUSE, BRENDA
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 22, 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
AXIOM HEALTHCARE SERVICES LLC
Organization · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Oct 23, 2009
CMS classifications: Management services company
Other facilities connected through this exact CMS organization identity: 3 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
HERMES, FREDERICK
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Oct 9, 2009
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
DERBY HEALTH & REHABILITATION
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
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 AXIOM HEALTHCARE ALLIANCE, LLC to 4 facilities. Which policies and staffing decisions are managed centrally versus locally?
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
- Mar 11, 2026
- Survey type
- Health Standard
- Linked findings
- 2
- Highest linked CMS classification
- D — Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:50004:ccn:175514
Mar 11, 2026 — Health Standard — 2 linked findings
F0628 — Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 11, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133843:ccn:175514
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 11, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133844:ccn:175514
Apr 29, 2025 — Health Complaint — 1 linked finding
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity 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 5, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133845:ccn:175514
Apr 30, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 30, 2024 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 30, 2024 — Health Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jul 12, 2023 — Infection Control — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Nov 8, 2022 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Nov 8, 2022 — Health Standard — 4 linked findings
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133853:ccn:175514
F0690 — Quality 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 18, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133854:ccn:175514
F0732 — Nursing 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 18, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133856:ccn:175514
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 18, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 175514
- Source record locator
- csv-row:133855:ccn:175514
May 12, 2021 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Tags appearing across inspections
- F0689 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Questions generated from the evidence above
- CMS records show F0689 in 2 inspections in the available record. What changes has the facility made to address this issue?
Facility history
Facility History
10 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Total nurse staffing increasedTotal nurse staffing increased from 4.74 to 4.99 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
- Health inspection completed2 deficiencies were recorded.
2026
- Total nurse staffing increased
Total nurse staffing increased from 4.74 to 4.99 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
4.74 → 4.99
CMS · Reported in a source release · View related evidence
- RN staffing increased
RN staffing increased from 0.48 to 0.59 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
0.48 → 0.59
CMS · Reported in a source release · View related evidence
- Health inspection completed
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- RN staffing decreased
RN staffing decreased from 0.61 to 0.48 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
0.61 → 0.48
CMS · Reported in a source release · View related evidence
- Total nurse staffing decreased
Total nurse staffing decreased from 5.20 to 4.94 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
5.20 → 4.94
CMS · Reported in a source release · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
2024
- Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
- Health inspection completed
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
2023
- Infection-control inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
2022
- Health inspection completed
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 4 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
- Total nursing
- 4.991 reported hours per resident day
- RN categories
- 0.586 reported hours per resident day
- LPN/LVN categories
- 1.324 reported hours per resident day
- CNA
- 2.493 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 5.31 | 4.201 |
| RN categories | 0.669 | 0.38 |
Contract staff accounted for 3.5% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.103 higher than the prior loaded quarter.
Staffing over time
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 5.202 | 0.671 | 1.322 | 2.565 | 12.6% | 91 |
| 2025Q3 | 4.943 | 0.613 | 1.261 | 2.44 | 7.9% | 92 |
| 2025Q4 | 4.745 | 0.482 | 1.339 | 2.363 | 4.9% | 92 |
| 2026Q1 | 4.991 | 0.586 | 1.324 | 2.493 | 3.5% | 90 |
Questions to ask
- PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
- PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 5-star overall rating.
- CMS reports a 5-star health inspection rating.
- CMS reports a 4-star staffing rating.
- CMS reports a 5-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
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Health deficiencies and facility history
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility All Owners
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility Enrollments
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Verified public facility information
- Source organization
- Public facility listing
- Dataset identifier
- commercial-corroboration:public-listing
- Source updated
- Aug 18, 2026
- Retrieved
- Aug 18, 2026
- Supports
- Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
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