Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.44 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.44 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Sep 26, 2025 cited 35 deficiencies.
View inspection evidenceCMS-published records list 41 ownership or control parties.
CMS records show an ownership change effective August 2022.
View ownership evidenceCMS groups this facility with a chain covering 7 facilities across 1 states or territories.
View chain evidenceCMS records show a $26,685 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
7 currently connected nursing homes share this CMS organization identity with KEY HEALTH MANAGEMENT LLC.
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
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.
Organization · 5% OR GREATER MORTGAGE INTEREST
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 1, 2023
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MD.
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · CORPORATE OFFICER
Association date reported to CMS: Aug 1, 2022
Organization · DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Aug 1, 2022
Organization · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 2022
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 2022
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 1, 2023
Organization · 5% OR GREATER MORTGAGE INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Aug 1, 2022
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 1, 2023
Organization · ADP OF THE SNF
Association date reported to CMS: Jun 12, 2025
Other facilities connected through this exact CMS organization identity: 0 across MD.
Organization · ADP OF THE SNF
Association date reported to CMS: Jun 12, 2025
Other facilities connected through this exact CMS organization identity: 0 across MD.
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
CMS classifications: Management services company
Other facilities connected through this exact CMS organization identity: 6 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 0 across MD.
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 1 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Individual · CORPORATE OFFICER
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2022
Organization · DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Aug 1, 2022
CMS classifications: Parent company, Holding company
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2022
Organization · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 1 across MD.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 2022
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 2022
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 1, 2023
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across MD.
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.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 767 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 7 | 1.6 | 1.9 |
| Mon Jun | 7 | 1.6 | 1.9 |
| Fri May | 7 | 1.6 | 1.9 |
| Wed Apr | 7 | 1.6 | 1.9 |
| Sun Mar | 7 | 1.6 | 1.4 |
| Sun Feb | 7 | 1.6 | 1.4 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Past Non-Compliance (Feb 24, 2026)
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: Past Non-Compliance (Feb 24, 2026)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 25, 2025)
Give the resident's representative the ability to exercise the resident's 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 (Nov 11, 2025)
Ensure that residents are fully informed and understand their health status, care and treatments.
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 11, 2025)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 (Dec 25, 2025)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 25, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
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 11, 2025)
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
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 (Nov 11, 2025)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
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 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 11, 2025)
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 (Dec 25, 2025)
Provide activities to meet all resident's needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 25, 2025)
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 11, 2025)
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 25, 2025)
Observe each nurse aide's job performance and give regular training.
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 25, 2025)
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
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 11, 2025)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 25, 2025)
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 (Dec 25, 2025)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 25, 2025)
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 (Dec 25, 2025)
Provide or get specialized rehabilitative services as required for a resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
Hire a qualified full-time social worker in a facility with more than 120 beds.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2025)
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 11, 2025)
Provide and implement an infection prevention and control program.
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 25, 2025)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 25, 2025)
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 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 25, 2025)
Keep all essential equipment working safely.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 25, 2025)
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 25, 2025)
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
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 (Dec 25, 2025)
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement 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 (Dec 25, 2025)
Provide training in compliance and ethics.
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 25, 2025)
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 (Jul 25, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 25, 2025)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 25, 2025)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 24, 2023)
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 (Sep 24, 2023)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 19, 2023)
Ensure that residents are fully informed and understand their health status, care and treatments.
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 16, 2023)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 19, 2023)
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 16, 2023)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 (Dec 19, 2023)
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 (Dec 19, 2023)
Respond appropriately to all alleged violations.
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 16, 2023)
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 19, 2023)
Assure that each resident’s assessment is updated at least once every 3 months.
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 19, 2023)
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 (Dec 19, 2023)
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 19, 2023)
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 (Oct 16, 2023)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 19, 2023)
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 16, 2023)
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 19, 2023)
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 19, 2023)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS scope/severity 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 (Oct 16, 2023)
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 19, 2023)
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 (Dec 19, 2023)
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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 (Dec 19, 2023)
Keep all essential equipment working safely.
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 (Dec 19, 2023)
Put firmly secured handrails on each side of hallways.
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 (Oct 16, 2023)
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
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 (Oct 16, 2023)
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 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 16, 2023)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 16, 2023)
Provide activities to meet all resident's needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 16, 2023)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity 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 19, 2023)
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 (Dec 19, 2023)
Ensure medication error rates are not 5 percent or greater.
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 19, 2023)
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 (Oct 16, 2023)
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 (Oct 16, 2023)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity L: Widespread; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Dec 19, 2023)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 19, 2023)
Hire a qualified full-time social worker in a facility with more than 120 beds.
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 (Oct 16, 2023)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in 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 (Oct 16, 2023)
Make sure that a working call system is available in each resident's bathroom and bathing area.
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 16, 2023)
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 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 16, 2023)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 (Mar 28, 2019)
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 (Mar 28, 2019)
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 (Mar 28, 2019)
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 (Mar 28, 2019)
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 (Mar 28, 2019)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 28, 2019)
Penalties & enforcement
Published fine amount: $26,685.00
Payment denial length: 49 days
Published fine amount: $160,325.00
Questions to ask
Facility history
13 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
2 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
CMS recorded a $26,685 civil monetary penalty.
CMS · Recorded event date · View related evidence
35 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
CMS recorded a $160,325 civil monetary penalty.
CMS · Recorded event date · View related evidence
14 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
CMS recorded a Medicare payment denial lasting 49 days.
CMS · Recorded event date · View related evidence
23 deficiencies were recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
An ownership change was recorded. New organization: 11974 EDGEHILL TERRACE OPCO LLC.
AXIS HEALTH AT MANOKIN OPCO LLC → 11974 EDGEHILL TERRACE OPCO LLC
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 2 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).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.355 | 2.872 |
| RN categories | 0.518 | 0.231 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.015 lower than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.28 | 0.462 | 0.543 | 2.174 | 0% | 91 |
| 2025Q3 | 3.428 | 0.449 | 0.663 | 2.214 | 0% | 92 |
| 2025Q4 | 3.324 | 0.45 | 0.635 | 1.985 | 0% | 92 |
| 2026Q1 | 3.215 | 0.435 | 0.667 | 1.917 | 0% | 90 |
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
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.