Staffing
CMS publishes a 3-star staffing rating for this facility.
RN staffing was 0.80 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceFacility record
THE GUARDIAN CENTER has 123 certified beds in BROCKTON, Massachusetts. The CMS overall rating is 1 of 5, compared with the Massachusetts average of 3.0. The CMS health inspection rating is 2 of 5, compared with the Massachusetts average of 3.0. The CMS staffing rating is 3 of 5. The latest standard health survey on Apr 30, 2025 lists 7 deficiencies, compared with the Massachusetts average of 6.4. Total nurse staffing is 3.29 hours per resident day in 2026Q1, compared with the Massachusetts average of 3.87.
Nearby facilities
- ALLIANCE HEALTH AT WEST ACRES BROCKTON
- BROCKTON POST ACUTE CARE BROCKTON
- CHAMPION REHABILITATION AND NURSING CENTER BROCKTON
- St Joseph Manor Health Care Inc BROCKTON
- BAY PATH AT DUXBURY NURSING & REHABILITATION CTR DUXBURY
- Cardigan Nursing & Rehabilitation Center SCITUATE
- COLONY CENTER FOR HEALTH AND REHABILITATION ABINGTON
- HANNAH B G SHAW HOME MIDDLEBORO
- HARBOR HOUSE NURSING & REHABILITATION CENTER HINGHAM
- LIFE CARE CENTER OF PLYMOUTH PLYMOUTH
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 225382.
At a glance
CMS research snapshot
CMS overall rating
1 of 5
CMS health inspection rating
2 of 5
CMS staffing rating
3 of 5
CMS quality-measure rating
1 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.
Current owners
- CHAPLER, YAAKOVIndividual ownerGENERAL PARTNERSHIP INTEREST
- STEINBERG, MOSHEIndividual ownerGENERAL PARTNERSHIP INTEREST
Operators
- AL-MADI, SAMIIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- ASAKER, BAHIGEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- CHAPLER, YAAKOVIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- STEINBERG, MOSHEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- TWOMAGNETS LLCOrganization · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- ZRAIZAA G, NANCYIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- AL-MADI, SAMIIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- ASAKER, BAHIGEIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- CHAPLER, YAAKOVIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- STEINBERG, MOSHEIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- TWOMAGNETS LLCOrganization · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- ZRAIZAA G, NANCYIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
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.
UNKNOWN
- CHAPLER, YAAKOVIndividual owner · UNKNOWNGENERAL PARTNERSHIP INTEREST
- STEINBERG, MOSHEIndividual owner · UNKNOWNGENERAL PARTNERSHIP INTEREST
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
- 123
- Ownership descriptor
- For profit - Limited Liability company
- 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
- 5085876556Verified 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.
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): 96.782842
- 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): 6.166220 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who have depressive symptoms (Long Stay): 0.906344
- Percentage of long-stay residents who lose too much weight (Long Stay): 1.587302
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 14.199396
- Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 20.093458 · 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): 33.591566 · 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): 33.219178 · 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): 1.811912 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a urinary tract infection (Long Stay): 1.404494 · 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): 22.352080
- Percentage of long-stay residents with pressure ulcers (Long Stay): 2.325367 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 65.641026
- Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 1.960784 · 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): 92.380952
Fire-safety citations
CMS fire-safety citations
These are fire-safety citations, not health deficiencies and not a count of fires.
- 2025-04-30 · tag 0006 · scope/severity F — Conduct risk assessment and an All-Hazards approach.
- 2025-04-30 · tag 0013 · scope/severity F — Develop Emergency Preparedness policies and procedures.
- 2025-04-30 · tag 0020 · scope/severity F — Establish policies and procedures including evacuation.
- 2025-04-30 · tag 0022 · scope/severity F — Establish policies and procedures for sheltering.
- 2025-04-30 · tag 0025 · scope/severity F — Create arrangements with other facilities to receive patients.
- 2025-04-30 · tag 0030 · scope/severity F — List the names and contact information of those in the facility.
- 2025-04-30 · tag 0031 · scope/severity F — Provide emergency officials' contact information.
- 2025-04-30 · tag 0041 · scope/severity F — Implement emergency and standby power systems.
- 2025-04-30 · tag 0211 · scope/severity F — Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 2025-04-30 · tag 0311 · scope/severity F — Have an enclosure around a vertical opening shaft.
- 2025-04-30 · tag 0241 · scope/severity D — Have correct number of accessible exits for each story.
- 2025-04-30 · tag 0004 · scope/severity F — Develop and maintain an Emergency Preparedness Program (EP).
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 Apr 30, 2025 cited 7 deficiencies.
View inspection evidenceOwnership
CMS-published records list 15 ownership or control parties.
View ownership evidenceOwnership & operation
Ownership & Operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
- Ownership type
- For profit - Limited Liability companyCMS
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 12 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
- 15
- Organizations shown
- 3
- Individuals shown
- 12
- Latest ownership source update
- Aug 1, 2026
CMS-published ownership and control parties
ASAKER, BAHIGE
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 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
BONADIO & CO LLP
Organization · ADP OF THE SNF
Association date reported to CMS: Aug 1, 2022
Other facilities connected through this exact CMS organization identity: 0 across MA.
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
TWOMAGNETS LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Mar 17, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
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
ZRAIZAA G, NANCY
Individual · ADP OF THE SNF
Association date reported to CMS: Aug 1, 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
CHAPLER, YAAKOV
Individual · GENERAL PARTNERSHIP INTEREST
Association date reported to CMS: Aug 1, 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
STEINBERG, MOSHE
Individual · GENERAL PARTNERSHIP INTEREST
Association date reported to CMS: Aug 1, 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
AL-MADI, SAMI
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 1, 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
CHAPLER, YAAKOV
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Aug 1, 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
STEINBERG, MOSHE
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Aug 1, 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
AL-MADI, SAMI
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 1, 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
ASAKER, BAHIGE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 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
CHAPLER, YAAKOV
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 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
STEINBERG, MOSHE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 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
TWOMAGNETS LLC
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 10, 2023
Other facilities connected through this exact CMS organization identity: 0 across MA.
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
ZRAIZAA G, NANCY
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Aug 1, 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
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
- Jun 10, 2026
- 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
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:58798:ccn:225382
Jun 10, 2026 — Health Complaint — 1 linked finding
F0580 — Resident Rights Deficiencies
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 (Jul 16, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163873:ccn:225382
Dec 10, 2025 — Health Complaint — 2 linked findings
F0580 — Resident Rights Deficiencies
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 (Jan 12, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163874:ccn:225382
F0842 — Resident Assessment and Care Planning Deficiencies
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 (Jan 12, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163875:ccn:225382
Apr 30, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 30, 2025 — Health Standard — 7 linked findings
F0550 — Resident Rights Deficiencies
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 (Jun 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163878:ccn:225382
F0551 — Resident Rights Deficiencies
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 (Jun 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163880:ccn:225382
F0658 — Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
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 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163879:ccn:225382
F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such 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 (Jun 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163881:ccn:225382
F0759 — Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163882:ccn:225382
F0865 — Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163876:ccn:225382
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163877:ccn:225382
Apr 23, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 23, 2024 — Health Standard — 7 linked findings
F0558 — Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163884:ccn:225382
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 D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163885:ccn:225382
F0658 — Resident 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: Deficient, Provider has date of correction (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163886:ccn:225382
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163887:ccn:225382
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 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 (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163883:ccn:225382
F0848 — Administration Deficiencies
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163889:ccn:225382
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163888:ccn:225382
Nov 10, 2022 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Nov 10, 2022 — Health Standard — 45 linked findings
F0550 — Resident Rights Deficiencies
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163900:ccn:225382
F0551 — Resident Rights Deficiencies
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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163910:ccn:225382
F0552 — Resident Rights Deficiencies
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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163911:ccn:225382
F0565 — Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163901:ccn:225382
F0578 — Resident 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 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163912:ccn:225382
F0580 — Resident Rights Deficiencies
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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163913:ccn:225382
F0582 — Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163934:ccn:225382
F0583 — Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163914:ccn:225382
F0607 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163915:ccn:225382
F0609 — Freedom 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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163916:ccn:225382
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
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 (Feb 23, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163917:ccn:225382
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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163918:ccn:225382
F0625 — Resident 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 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163919:ccn:225382
F0655 — Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163920:ccn:225382
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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163902:ccn:225382
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 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163921:ccn:225382
F0658 — Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163903:ccn:225382
F0675 — Quality of Life and Care Deficiencies
Honor each resident's preferences, choices, values and beliefs.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163890:ccn:225382
F0679 — Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163904:ccn:225382
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163891:ccn:225382
F0685 — Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing 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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163922:ccn:225382
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163905:ccn:225382
F0690 — Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163923:ccn:225382
F0695 — Quality 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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163924:ccn:225382
F0698 — Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such 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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163925:ccn:225382
F0711 — Nursing and Physician Services Deficiencies
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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163926:ccn:225382
F0712 — Nursing and Physician Services Deficiencies
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163927:ccn:225382
F0740 — Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163892:ccn:225382
F0755 — Pharmacy 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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163906:ccn:225382
F0756 — Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163907:ccn:225382
F0757 — Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163908:ccn:225382
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163928:ccn:225382
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 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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163909:ccn:225382
F0790 — Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care 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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163929:ccn:225382
F0825 — Quality of Life and Care Deficiencies
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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163930:ccn:225382
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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163893:ccn:225382
F0842 — Resident Assessment and Care Planning Deficiencies
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 (Feb 21, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163931:ccn:225382
F0849 — Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 (Dec 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163932:ccn:225382
F0865 — Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163894:ccn:225382
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 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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163895:ccn:225382
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163896:ccn:225382
F0886 — Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163933:ccn:225382
F0888 — Infection Control Deficiencies
Ensure staff are vaccinated for COVID-19
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163897:ccn:225382
F0944 — Administration Deficiencies
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163898:ccn:225382
F0946 — Administration Deficiencies
Provide training in compliance and ethics.
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 21, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 225382
- Source record locator
- csv-row:163899:ccn:225382
Tags appearing across inspections
- F0580 appears in 3 linked inspections.
- F0658 appears in 3 linked inspections.
- F0550 appears in 2 linked inspections.
- F0551 appears in 2 linked inspections.
- F0656 appears in 2 linked inspections.
- F0758 appears in 2 linked inspections.
- F0761 appears in 2 linked inspections.
- F0842 appears in 2 linked inspections.
- F0865 appears in 2 linked inspections.
- F0868 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 F0580 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0658 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0550 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0551 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 F0758 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0761 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0842 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0865 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0868 in 2 inspections in the available record. What changes has the facility made to address this issue?
Facility history
Facility History
6 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Total nurse staffing decreasedTotal nurse staffing decreased from 3.58 to 3.32 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
- Complaint inspection recorded2 deficiencies were recorded.
2025
- Total nurse staffing decreased
Total nurse staffing decreased from 3.58 to 3.32 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
3.58 → 3.32
CMS · Reported in a source release · View related evidence
- RN staffing decreased
RN staffing decreased from 1.01 to 0.87 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
1.01 → 0.87
CMS · Reported in a source release · View related evidence
- Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Health inspection completed
7 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2024
- Health inspection completed
7 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2022
- Health inspection completed
45 deficiencies were recorded. That includes 3 higher-severity deficiencies.
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).
- Total nursing
- 3.287 reported hours per resident day
- RN categories
- 0.798 reported hours per resident day
- LPN/LVN categories
- 0.633 reported hours per resident day
- CNA
- 1.856 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.415 | 2.972 |
| RN categories | 0.845 | 0.682 |
Contract staff accounted for 7% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.073 lower 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 | 3.591 | 1.1 | 0.584 | 1.907 | 8.6% | 91 |
| 2025Q3 | 3.58 | 1.007 | 0.551 | 2.022 | 7.9% | 92 |
| 2025Q4 | 3.318 | 0.871 | 0.629 | 1.818 | 6.4% | 92 |
| 2026Q1 | 3.287 | 0.798 | 0.633 | 1.856 | 7% | 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 1-star overall rating.
- CMS reports a 2-star health inspection rating.
- CMS reports a 3-star staffing rating.
- CMS reports a 1-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
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
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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