Ledgewood Manor

WINDHAM, ME

CMS provider ID 205137CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

3 of 5 CMS stars

Health inspection

3 of 5 CMS stars

Staffing

3 of 5 CMS stars

Quality-measure

3 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
60
Ownership descriptor
For profit - Individual
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
2078922261Verified 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 0.65 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing 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 - IndividualCMS

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • CMS reports 20 individual ownership interests

Ownership

Who CMS records show is connected to this facility

These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.

Reported party records
25
Organizations shown
5
Individuals shown
20
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • BENNETT, EDISON

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 51%

    Association date reported to CMS: Feb 11, 1980

    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
  • BENNETT, JEAN

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 49%

    Association date reported to CMS: Feb 11, 1980

    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
  • BENNETT, EDISON

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jul 29, 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
  • CADIGAN, CATHARINE

    Individual · ADP OF THE SNF

    Association date reported to CMS: Oct 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jul 14, 2025

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

    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
  • BENNETT, NATHANIEL

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Feb 22, 2015

    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
  • BROWN, JESSICA

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: May 31, 2021

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

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jan 1, 1980

    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
  • BENNETT, NATHANIEL

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 22, 2015

    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
  • BROWN, JESSICA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: May 31, 2021

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

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Oct 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Dec 3, 2018

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

    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
  • BENNETT, EDISON

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 51%

    Association date reported to CMS: Feb 11, 1980

    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
  • BENNETT, JEAN

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 49%

    Association date reported to CMS: Feb 11, 1980

    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
  • BENNETT, EDISON

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jul 29, 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
  • CADIGAN, CATHARINE

    Individual · ADP OF THE SNF

    Association date reported to CMS: Oct 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jul 14, 2025

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

    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
  • BENNETT, NATHANIEL

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Feb 22, 2015

    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
  • BROWN, JESSICA

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: May 31, 2021

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • BENNETT, EDISON

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Published ownership percentage: 100%

    Association date reported to CMS: Jan 1, 1980

    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
  • BENNETT, NATHANIEL

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 22, 2015

    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
  • BROWN, JESSICA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: May 31, 2021

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CADIGAN, CATHARINE

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Oct 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Dec 3, 2018

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

    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
  • LEDGEWOOD MANOR INC

    Organization · Medicare-enrolled legal organization

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

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility Enrollments
    CMS dataset identifier
    5f2c306f-3b1c-42cd-b037-187b2ce22126
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source

What this means

Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.

Questions to ask

  • CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?

Inspections & deficiencies

What CMS inspection records show

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

Latest recorded inspection

Date
Apr 29, 2025
Survey type
Health Complaint
Linked findings
1
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
205137
Source record locator
csv-row:55572:ccn:205137
View official CMS source
Apr 29, 2025Health Complaint 1 linked finding
  • F0658Resident Assessment and Care Planning Deficiencies

    Ensure services provided by the nursing facility meet professional standards of quality.

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

    Correction status: Past Non-Compliance (Apr 24, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147212:ccn:205137
    View official CMS source
Feb 26, 2025Fire Safety Standard 0 linked findings

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

Feb 26, 2025Health Standard 10 linked findings
  • F0578Resident Rights Deficiencies

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147202:ccn:205137
    View official CMS source
  • F0623Resident Rights Deficiencies

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147209:ccn:205137
    View official CMS source
  • F0625Resident Rights Deficiencies

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147210:ccn:205137
    View official CMS source
  • F0637Resident Assessment and Care Planning Deficiencies

    Assess the resident when there is a significant change in condition

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147211:ccn:205137
    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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147203:ccn:205137
    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 (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147207:ccn:205137
    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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147204:ccn:205137
    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 (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147208:ccn:205137
    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 (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147205:ccn:205137
    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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Apr 11, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147206:ccn:205137
    View official CMS source
Oct 8, 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 (Nov 8, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147213:ccn:205137
    View official CMS source
Jun 14, 2022Fire Safety Standard 0 linked findings

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

Jun 14, 2022Health Standard 12 linked findings
  • F0567Resident Rights Deficiencies

    Honor the resident's right to manage his or her financial affairs.

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

    Correction status: Deficient, Provider has date of correction (Jun 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147224:ccn:205137
    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 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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147220:ccn:205137
    View official CMS source
  • F0645Resident Assessment and Care Planning Deficiencies

    PASARR screening for Mental disorders or Intellectual Disabilities

    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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147221:ccn:205137
    View official CMS source
  • F0657Resident Assessment and Care Planning Deficiencies

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    CMS scope/severity 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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147217:ccn:205137
    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 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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147218:ccn:205137
    View official CMS source
  • F0868Administration Deficiencies

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Jun 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147225:ccn:205137
    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 (Jun 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147214:ccn:205137
    View official CMS source
  • F0882Infection Control Deficiencies

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147215:ccn:205137
    View official CMS source
  • F0883Infection Control Deficiencies

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

    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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147222:ccn:205137
    View official CMS source
  • F0886Infection Control Deficiencies

    Perform COVID19 testing on residents and staff.

    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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147216:ccn:205137
    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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147223:ccn:205137
    View official CMS source
  • F0947Nursing and Physician Services Deficiencies

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

    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 29, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147219:ccn:205137
    View official CMS source
Oct 31, 2019Fire Safety Standard 0 linked findings

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

Oct 31, 2019Health Standard 9 linked findings
  • F0623Resident Rights Deficiencies

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147233:ccn:205137
    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 (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147228:ccn:205137
    View official CMS source
  • F0657Resident Assessment and Care Planning Deficiencies

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    CMS scope/severity 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 (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147227:ccn:205137
    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 (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147229:ccn:205137
    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 K: Pattern; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147226:ccn:205137
    View official CMS source
  • F0692Quality of Life and Care Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147230:ccn:205137
    View official CMS source
  • F0730Nursing and Physician Services Deficiencies

    Observe each nurse aide's job performance and give regular training.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147234:ccn:205137
    View official CMS source
  • F0838Administration Deficiencies

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

    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 (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147231:ccn:205137
    View official CMS source
  • F0883Infection Control Deficiencies

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

    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 (Dec 31, 2019)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    205137
    Source record locator
    csv-row:147232:ccn:205137
    View official CMS source

Tags appearing across inspections

  • F0623 appears in 2 linked inspections.
  • F0656 appears in 2 linked inspections.
  • F0657 appears in 2 linked inspections.
  • F0689 appears in 2 linked inspections.
  • F0812 appears in 2 linked inspections.
  • F0883 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 F0623 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0656 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0657 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0689 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 F0883 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

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

What changed recently?

  • Complaint inspection recorded1 deficiency was recorded.

2025

  1. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    10 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

2022

  1. Health inspection completed

    12 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2019

  1. Health inspection completed

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

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 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
4.042
reported hours per resident day
RN categories
0.654
reported hours per resident day
LPN/LVN categories
0.461
reported hours per resident day
CNA
2.799
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.1383.805
RN categories0.7070.523

Contract staff accounted for 31.6% of reported nursing hours included in this quarter calculation.

PBJ reports zero combined RN-category hours on 1 day with a positive MDS census in this quarter.

Reported RN-category hours per resident day were 0.136 higher than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q24.2920.4760.7583.05922.2%91
2025Q34.1050.5180.7082.78723.4%92
2026Q14.0420.6540.4612.79931.6%90

Questions to ask

  • PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
  • PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
Source
Centers for Medicare & Medicaid Services (CMS)
Dataset
Payroll Based Journal Daily Nurse Staffing
CMS dataset ID
7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter
2026Q1
Coverage
Jan 1, 2026Mar 31, 2026
Days represented
90 (90 with positive MDS census)
CMS source updated
Jul 29, 2026
Calculation version
pbj-quarter-ratio-of-sums-v1

Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.

View official CMS PBJ source

What we can verify today

Current Provider Information facts

These measures come from the current successfully ingested CMS Nursing Home Provider Information release.

  • CMS reports a 3-star overall rating.
  • CMS reports a 3-star health inspection rating.
  • CMS reports a 3-star staffing rating.
  • CMS reports a 3-star quality-measure rating.

Planned evidence layers

Additional public-source research

These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.

  • Chain / portfolio intelligence

Trust participation

See something that needs correction?

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

How corrections work

Source register

See where this record came from

Provider Information
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
4pq5-n9py
Source updated
Jul 29, 2026
Retrieved
Aug 14, 2026
Supports
Overview, facility facts, and CMS ratings
View official CMS source
Inspection Dates
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
svdt-c123
Source updated
Jul 1, 2026
Retrieved
Aug 14, 2026
Supports
Inspections and facility history
View official CMS source
Health Deficiencies
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
r5ix-sfxw
Source updated
Jul 1, 2026
Retrieved
Aug 14, 2026
Supports
Health deficiencies and facility history
View official CMS source
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
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.