Staffing
CMS publishes a 5-star staffing rating for this facility.
RN staffing was 3.15 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceFacility record
WESTERN MD HOSPITAL CENTER has 63 certified beds in HAGERSTOWN, Maryland. The CMS overall rating is 5 of 5, compared with the Maryland average of 3.1. The CMS health inspection rating is 3 of 5, compared with the Maryland average of 2.8. The CMS staffing rating is 5 of 5. The latest standard health survey on Dec 2, 2025 lists 7 deficiencies, compared with the Maryland average of 12.1. CMS records a fine of $8,018 dated Jun 4, 2024. CMS records a fine of $16,042 dated Jun 4, 2024. Total nurse staffing is 7.40 hours per resident day in 2026Q1, compared with the Maryland average of 3.89.
Nearby facilities
- COFFMAN NURSING HOME HAGERSTOWN
- COMPLETE CARE AT HAGERSTOWN HAGERSTOWN
- CREEKSIDE CENTER FOR REHABILITATION AND NURSING HAGERSTOWN
- Hagerstown Healthcare Center HAGERSTOWN
- JULIA MANOR NURSING AND REHABILITATION CENTER HAGERSTOWN
- Fahrney-Keedy Memorial Home BOONSBORO
- HOMEWOOD LIVING WILLIAMSPORT WILLIAMSPORT
- SOUTH MOUNTAIN REHAB CENTER BOONSBORO
- WILLIAMSPORT HEALTH AND REHABILITATION CENTER WILLIAMSPORT
Independent research from official CMS public records. No paid ranking. No Trust Hub quality score.
Research this nursing home using CMS and federal public records. CMS Certification Number 215110.
At a glance
CMS research snapshot
CMS overall rating
5 of 5
CMS health inspection rating
3 of 5
CMS staffing rating
5 of 5
CMS quality-measure rating
5 of 5
CMS ownership-change history
No attached CMS ownership-change event.
These are CMS star ratings, not Trust Hub ratings. Missing evidence is shown as not reported, not as zero.
Quality & care evidence
What CMS reports about quality
- MDS quality observations are in the CMS extract.
- PBJ staffing records are in the CMS extract.
- Inspection evidence is in the CMS extract.
- Fire-safety evidence is in the CMS extract.
Staffing, inspections, and fire safety are separate CMS evidence families below.
Ownership & management
Who CMS/PECOS connects to this nursing home
Current ownership uses CURRENT OWNED_BY evidence only. UNKNOWN is not a former owner.
Operators
- COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAUOrganization · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- EDMONDS, KELLYIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAUOrganization · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- EDMONDS, KELLYIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
Managers
- BROY-STEVENSON, NEDINAIndividual owner · CURRENTW-2 MANAGING EMPLOYEE
- EDMONDS, KELLYIndividual owner · CURRENTW-2 MANAGING EMPLOYEE
- WATTS, WAYNEIndividual owner · CURRENTW-2 MANAGING EMPLOYEE
- BROY-STEVENSON, NEDINAIndividual owner · UNKNOWNW-2 MANAGING EMPLOYEE
- EDMONDS, KELLYIndividual owner · UNKNOWNW-2 MANAGING EMPLOYEE
- WATTS, WAYNEIndividual owner · UNKNOWNW-2 MANAGING EMPLOYEE
Enrollment organizations
- COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAUOrganization · CURRENTMedicare-enrolled legal organization
- COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAUOrganization · UNKNOWNMedicare-enrolled legal organization
Ownership observations with UNKNOWN status
These relationships were observed in an older snapshot. UNKNOWN does not mean former owner, previous owner, or that ownership ended.
Ownership change history
CMS ownership-change records
No CMS ownership-change event is currently attached to this profile in the Trust Hub research graph. That is not proof that ownership never changed.
Source freshness
How current each evidence family is
- nursing-home-mds-quality-measures
- STALE · source as of 2026-08-01
- nursing-home-provider-information
- STALE · source as of 2026-08-01
- skilled-nursing-facility-all-owners
- AGING · source as of 2026-08-17
- skilled-nursing-facility-change-of-ownership
- CURRENT · source as of 2026-08-24
Profile generated 2026-11-03. That timestamp is not CMS evidence freshness.
Methodology
How Trust Hub researches this provider
- CMS is the source for national nursing-home evidence.
- Trust Hub does not create the CMS star ratings.
- Ownership evidence does not measure care quality.
- CMS CHOW records document reported ownership-change events.
- Missing evidence is not interpreted as zero.
- UNKNOWN ownership history is not interpreted as divestiture.
- Ownership evidence is not a quality measure.
- Missing evidence is not a zero score.
- CMS ratings are CMS ratings, not Trust Hub ratings.
- UNKNOWN ownership does not prove an owner left.
- CHOW records are CMS transaction records, not Trust Hub judgments or sales.
CMS overview
CMS rating overview
No proprietary TrustHub score. These ratings are published separately by CMS. How CMS ratings and facility records are read
- CMS certified beds
- 63
- Ownership descriptor
- Government - State
- 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
- 3017454200Verified public information · checked Aug 2026
CMS designations
Special Focus and abuse-icon status
This CMS Certification Number appears in the latest CMS Nursing Home Provider Information extract of currently listed nursing homes.
Not currently SFF or candidate
CMS does not currently identify this nursing home as a Special Focus Facility or candidate in the loaded Provider Information extract.
CMS field value: (blank). Observed Aug 1, 2026.
CMS abuse-icon designation
CMS does not currently apply its abuse-icon designation to this facility in the loaded Provider Information extract.
CMS field value: N. Observed Aug 1, 2026.
Enrollment identity
Medicare enrollment organization NPI associated with this CMS Certification Number
These identifiers come from CMS SNF enrollment records linked to this CCN. They are not a substitute for the CMS Certification Number.
- NPI 1154302693 · enrollment O20060105000627
- NPI 1154302693 · enrollment O20060105000627
MDS quality measures
Individual CMS quality measures
These MDS quality measures are individual CMS-published scores. They are not the CMS quality-measure star rating.
MDS source release 2026-08-01.
View individual MDS measures
- Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (Long Stay): 94.818653
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 100.000000
- Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 1.554404 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who have depressive symptoms (Long Stay): 0.735294
- Percentage of long-stay residents who lose too much weight (Long Stay): 1.554404
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 35.751295
- Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 33.802817 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who were physically restrained (Long Stay): 0.000000
- Percentage of long-stay residents whose ability to walk independently worsened (Long Stay): 0.000000 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents whose need for help with daily activities has increased (Long Stay): 6.250000 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a catheter inserted and left in their bladder (Long Stay): 0.000000 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a urinary tract infection (Long Stay): 0.518135 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with new or worsened bowel or bladder incontinence (Long Stay): 14.644517
- Percentage of long-stay residents with pressure ulcers (Long Stay): 5.162227 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 9
- Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 9 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (Short Stay): 9
Fire-safety citations
CMS fire-safety citations
These are fire-safety citations, not health deficiencies and not a count of fires.
- 2025-12-02 · tag 0271 · scope/severity E — Have exits that are accessible at all times.
- 2025-12-02 · tag 0004 · scope/severity F — Develop and maintain an Emergency Preparedness Program (EP).
- 2025-12-02 · tag 0162 · scope/severity F — Have a combustible roofing system that meets safety standards.
- 2025-12-02 · tag 0345 · scope/severity F — Have approved installation, maintenance and testing program for fire alarm systems.
- 2025-12-02 · tag 0353 · scope/severity F — Inspect, test, and maintain automatic sprinkler systems.
- 2025-12-02 · tag 0907 · scope/severity F — Ensure medical gas and vacuum systems have documented maintenance programs.
- 2025-12-02 · tag 0914 · scope/severity F — Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 2025-12-02 · tag 0918 · scope/severity F — Have generator or other power source capable of supplying service within 10 seconds.
- 2025-12-02 · tag 0223 · scope/severity E — Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 2025-12-02 · tag 0281 · scope/severity E — Install proper backup exit lighting.
- 2025-12-02 · tag 0293 · scope/severity E — Have properly located and lighted "Exit" signs.
- 2025-12-02 · tag 0362 · scope/severity E — Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
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 Dec 2, 2025 cited 7 deficiencies.
View inspection evidenceOwnership
CMS-published records list 9 ownership or control parties.
View ownership evidenceEnforcement record
CMS records show a $8,018 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
- Government - StateCMS
- Related facilities
- 3Current CMS organization identity
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 7 individual ownership interests
Related facilities
3 currently connected nursing homes share this CMS organization identity with COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAU.
- Average CMS overall rating
- 4.3 stars across 3 reporting facilities
- CMS monetary penalties
- 3 of 3 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 1 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 1 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 1 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $131,996
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
- 9
- Organizations shown
- 2
- Individuals shown
- 7
- Latest ownership source update
- Aug 17, 2026
CMS-published ownership and control parties
BROY-STEVENSON, NEDINA
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jul 15, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
DEVILBISS, KELLY
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 22, 2018
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
EDMONDS, KELLY
Individual · CORPORATE OFFICER
Association date reported to CMS: Sep 27, 2005
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAU
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 1966
Other facilities connected through this exact CMS organization identity: 0 across MD.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
EDMONDS, KELLY
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 14, 2005
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
BROY-STEVENSON, NEDINA
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jul 15, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
EDMONDS, KELLY
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jan 22, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
WATTS, WAYNE
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Dec 5, 2022
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAU
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 2 across MD.
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
- Aug 17, 2026
- Retrieved
- Aug 26, 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 COMPTROLLER OF MARYLAND CENTRAL PAYROLL BUREAU to 3 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
- Dec 2, 2025
- Survey type
- Fire Safety Standard
- Linked findings
- 0
- Highest linked CMS classification
- No linked health-deficiency finding in the loaded record
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:56311:ccn:215110
Dec 2, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 2, 2025 — Health Standard — 7 linked findings
F0567 — Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151219:ccn:215110
F0605 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151220:ccn:215110
F0686 — Quality 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 (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151221:ccn:215110
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 (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151223:ccn:215110
F0801 — Nutrition and Dietary Deficiencies
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151217:ccn:215110
F0812 — Nutrition 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 (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151218:ccn:215110
F0921 — Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151222:ccn:215110
Jun 4, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jun 4, 2024 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jun 4, 2024 — Health Standard — 15 linked findings
F0559 — Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 31, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151233:ccn:215110
F0584 — Resident 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 (Aug 9, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151234:ccn:215110
F0622 — Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 (Aug 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151237:ccn:215110
F0623 — Resident 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 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 (Oct 31, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151238:ccn:215110
F0677 — Quality 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 (Aug 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151239:ccn:215110
F0726 — Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 (Aug 30, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151242:ccn:215110
F0757 — Pharmacy 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 (Sep 11, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151244:ccn:215110
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 (Sep 11, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151246:ccn:215110
F0791 — Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151247:ccn:215110
F0812 — Nutrition 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 (Aug 9, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151226:ccn:215110
F0838 — Administration 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 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 (Sep 3, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151227:ccn:215110
F0843 — Administration Deficiencies
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
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 (Oct 31, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151228:ccn:215110
F0867 — Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 (Oct 31, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151249:ccn:215110
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 (Aug 21, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151232:ccn:215110
F0909 — Environmental Deficiencies
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 (Aug 9, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151229:ccn:215110
May 24, 2019 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
May 24, 2019 — Health Standard — 4 linked findings
F0623 — Resident 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 (Jul 29, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151253:ccn:215110
F0624 — Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 29, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151252:ccn:215110
F0656 — Resident 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 29, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151251:ccn:215110
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity 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 (Jul 29, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:151250:ccn:215110
Tags appearing across inspections
- F0623 appears in 2 linked inspections.
- F0812 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Jun 4, 2024
Published fine amount: $8,018.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:5961:ccn:215110
Fine — Jun 4, 2024
Published fine amount: $16,042.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 215110
- Source record locator
- csv-row:5962:ccn:215110
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 F0812 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Jun 4, 2024. What changes were made after that enforcement action?
Facility history
Facility History
9 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Total nurse staffing increasedTotal nurse staffing increased from 6.49 to 7.40 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
- Health inspection completed7 deficiencies were recorded.
2026
- Total nurse staffing increased
Total nurse staffing increased from 6.49 to 7.40 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
6.49 → 7.40
CMS · Reported in a source release · View related evidence
- RN staffing increased
RN staffing increased from 2.39 to 3.15 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
2.39 → 3.15
CMS · Reported in a source release · View related evidence
2025
- Health inspection completed
7 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- RN staffing increased
RN staffing increased from 1.65 to 2.35 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
1.65 → 2.35
CMS · Reported in a source release · View related evidence
2024
- Civil monetary penalty recorded
CMS recorded a $16,042 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
- Health inspection completed
15 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $8,018 civil monetary penalty.
CMS · Recorded event date · View related evidence
2019
- Health inspection completed
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 5 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
- 7.404 reported hours per resident day
- RN categories
- 3.151 reported hours per resident day
- LPN/LVN categories
- 1.098 reported hours per resident day
- CNA
- 3.155 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 7.664 | 6.763 |
| RN categories | 3.321 | 2.734 |
Contract staff accounted for 10.3% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.762 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 | 6.547 | 1.649 | 1.639 | 3.259 | 12.2% | 91 |
| 2025Q3 | 6.484 | 2.346 | 1.023 | 3.115 | 10.4% | 92 |
| 2025Q4 | 6.485 | 2.389 | 1.079 | 3.018 | 10.1% | 92 |
| 2026Q1 | 7.404 | 3.151 | 1.098 | 3.155 | 10.3% | 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 3-star health inspection rating.
- CMS reports a 5-star staffing rating.
- CMS reports a 5-star quality-measure rating.
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Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Health deficiencies and facility history
Penalties
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- g6vv-u9sr
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Penalties, enforcement, 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
- Aug 1, 2026
- Retrieved
- Aug 26, 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
- Aug 17, 2026
- Retrieved
- Aug 26, 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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