WACHUSETT MANOR

GARDNER, MA

CMS provider ID 225533CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

3 of 5 CMS stars

Health inspection

3 of 5 CMS stars

Staffing

2 of 5 CMS stars

Quality-measure

4 of 5 CMS stars

No proprietary TrustHub score. These ratings are published separately by CMS.

How CMS describes these ratings
CMS overall rating
The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
Health inspection rating
The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
Staffing rating
The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
Quality-measure rating
The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
CMS certified beds
96
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
9786325477Verified public information · checked Aug 2026

Decision guide

What to review

Factual evidence to examine before you decide. These summaries are not a score or recommendation.

Staffing

CMS publishes a 2-star staffing rating for this facility.

RN staffing was 0.43 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership & operation

Ownership & Operation

Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.

Ownership type
For profit - Limited Liability companyCMS

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • CMS reports 5 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
5
Organizations shown
0
Individuals shown
5
Latest ownership source update
Jul 1, 2026

CMS-published ownership and control parties

  • MAJEKODUNMI, AKINDELE

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jul 10, 2025

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

    Individual · ADP OF THE SNF

    Association date reported to CMS: Apr 8, 2025

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

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Aug 14, 2023

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

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jan 1, 2025

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

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Aug 14, 2023

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

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.

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
Sep 26, 2025
Survey type
Fire Safety Standard
Linked findings
0
Highest linked CMS classification
No linked health-deficiency finding in the loaded record
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Jul 1, 2026
CMS provider ID
225533
Source record locator
csv-row:59447:ccn:225533
View official CMS source
Sep 26, 2025Fire Safety Standard 0 linked findings

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

Sep 26, 2025Health Standard 5 linked findings
  • F0580Resident 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 (Oct 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166711:ccn:225533
    View official CMS source
  • F0585Resident Rights Deficiencies

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    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 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166712:ccn:225533
    View official CMS source
  • F0628Resident Rights Deficiencies

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

    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 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166710:ccn:225533
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

    Correction status: Deficient, Provider has date of correction (Oct 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166713:ccn:225533
    View official CMS source
  • F0880Infection 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 (Oct 7, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166714:ccn:225533
    View official CMS source
Jun 24, 2025Health Complaint 2 linked findings
  • F0580Resident 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: Past Non-Compliance (Jun 19, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166715:ccn:225533
    View official CMS source
  • F0658Resident Assessment and Care Planning Deficiencies

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

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

    Correction status: Past Non-Compliance (Jun 19, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166716:ccn:225533
    View official CMS source
Aug 13, 2024Fire Safety Standard 0 linked findings

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

Aug 13, 2024Health Standard 9 linked findings
  • F0584Resident Rights Deficiencies

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

    Correction status: Deficient, Provider has date of correction (Sep 4, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166719:ccn:225533
    View official CMS source
  • F0641Resident Assessment and Care Planning Deficiencies

    Ensure each resident receives an accurate assessment.

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

    Correction status: Deficient, Provider has date of correction (Aug 27, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166725:ccn:225533
    View official CMS source
  • F0658Resident Assessment and Care Planning Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Sep 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166720:ccn:225533
    View official CMS source
  • F0695Quality of Life and Care Deficiencies

    Provide safe and appropriate respiratory care for a resident when needed.

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

    Correction status: Deficient, Provider has date of correction (Sep 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166721:ccn:225533
    View official CMS source
  • F0699Quality of Life and Care Deficiencies

    Provide care or services that was trauma informed and/or culturally competent.

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

    Correction status: Deficient, Provider has date of correction (Aug 21, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166722:ccn:225533
    View official CMS source
  • F0791Quality of Life and Care Deficiencies

    Provide or obtain dental services for each resident.

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

    Correction status: Deficient, Provider has date of correction (Sep 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166723:ccn:225533
    View official CMS source
  • F0880Infection Control Deficiencies

    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 (Sep 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166717:ccn:225533
    View official CMS source
  • F0921Environmental Deficiencies

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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

    Correction status: Deficient, Provider has date of correction (Aug 13, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166724:ccn:225533
    View official CMS source
  • F0925Environmental Deficiencies

    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 (Sep 15, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166718:ccn:225533
    View official CMS source
May 16, 2023Fire Safety Standard 0 linked findings

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

May 16, 2023Health Standard 26 linked findings
  • F0550Resident Rights Deficiencies

    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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166735:ccn:225533
    View official CMS source
  • F0580Resident 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166736:ccn:225533
    View official CMS source
  • F0637Resident Assessment and Care Planning Deficiencies

    Assess the resident when there is a significant change in condition

    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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166737:ccn:225533
    View official CMS source
  • F0640Resident Assessment and Care Planning Deficiencies

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

    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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166738:ccn:225533
    View official CMS source
  • F0641Resident Assessment and Care Planning Deficiencies

    Ensure each resident receives an accurate assessment.

    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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166739:ccn:225533
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166740:ccn:225533
    View official CMS source
  • F0657Resident Assessment and Care Planning Deficiencies

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

    CMS scope/severity 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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166741:ccn:225533
    View official CMS source
  • F0658Resident Assessment and Care Planning Deficiencies

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

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166726:ccn:225533
    View official CMS source
  • F0679Quality of Life and Care Deficiencies

    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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166742:ccn:225533
    View official CMS source
  • F0685Quality 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166743:ccn:225533
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166732:ccn:225533
    View official CMS source
  • F0692Quality of Life and Care Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166744:ccn:225533
    View official CMS source
  • F0694Quality of Life and Care Deficiencies

    Provide for the safe, appropriate administration of IV fluids 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166745:ccn:225533
    View official CMS source
  • F0695Quality of Life and Care Deficiencies

    Provide safe and appropriate respiratory care for a resident when needed.

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166727:ccn:225533
    View official CMS source
  • F0697Quality 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166746:ccn:225533
    View official CMS source
  • F0700Quality of Life and Care Deficiencies

    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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166747:ccn:225533
    View official CMS source
  • F0712Nursing 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166748:ccn:225533
    View official CMS source
  • F0726Nursing and Physician Services Deficiencies

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166728:ccn:225533
    View official CMS source
  • F0838Administration Deficiencies

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

    CMS scope/severity 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166729:ccn:225533
    View official CMS source
  • F0842Resident 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166749:ccn:225533
    View official CMS source
  • F0868Administration Deficiencies

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

    CMS scope/severity 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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166733:ccn:225533
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

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

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166730:ccn:225533
    View official CMS source
  • F0883Infection Control Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166750:ccn:225533
    View official CMS source
  • F0887Infection Control Deficiencies

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

    CMS scope/severity 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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166734:ccn:225533
    View official CMS source
  • F0888Infection 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 (May 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166731:ccn:225533
    View official CMS source
  • F0909Environmental Deficiencies

    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

    CMS scope/severity 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 23, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    225533
    Source record locator
    csv-row:166751:ccn:225533
    View official CMS source

Tags appearing across inspections

  • F0580 appears in 3 linked inspections.
  • F0658 appears in 3 linked inspections.
  • F0880 appears in 3 linked inspections.
  • F0641 appears in 2 linked inspections.
  • F0656 appears in 2 linked inspections.
  • F0695 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 F0880 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0641 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 F0695 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

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

What changed recently?

  • Health inspection completed5 deficiencies were recorded.

2025

  1. Health inspection completed

    5 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Health inspection completed

    9 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2023

  1. Health inspection completed

    26 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: 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).

Inspect a PBJ quarter
Total nursing
3.285
reported hours per resident day
RN categories
0.434
reported hours per resident day
LPN/LVN categories
0.897
reported hours per resident day
CNA
1.954
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing3.4172.957
RN categories0.480.321

Contract staff accounted for 8% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.034 lower than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q23.4380.371.0342.00518.8%91
2025Q33.420.4230.9462.0519.2%92
2025Q43.3550.4680.9061.9815.7%92
2026Q13.2850.4340.8971.9548%90

Questions to ask

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

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

View official CMS PBJ source

What we can verify today

Current Provider Information facts

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

  • CMS reports a 3-star overall rating.
  • CMS reports a 3-star health inspection rating.
  • CMS reports a 2-star staffing rating.
  • CMS reports a 4-star quality-measure rating.

Planned evidence layers

Additional public-source research

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

  • Chain / portfolio intelligence

Trust participation

See something that needs correction?

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

How corrections work

Source register

See where this record came from

Provider Information
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
4pq5-n9py
Source updated
Jul 29, 2026
Retrieved
Aug 14, 2026
Supports
Overview, facility facts, and CMS ratings
View official CMS source
Inspection Dates
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
svdt-c123
Source updated
Jul 1, 2026
Retrieved
Aug 14, 2026
Supports
Inspections and facility history
View official CMS source
Health Deficiencies
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
r5ix-sfxw
Source updated
Jul 1, 2026
Retrieved
Aug 14, 2026
Supports
Health deficiencies and facility history
View official CMS source
Payroll Based Journal Daily Nurse Staffing
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Coverage
Apr 1, 2025–Mar 31, 2026
Source updated
Jul 29, 2026
Retrieved
Aug 15, 2026
Supports
PBJ staffing cards, history, and transparent calculations
View official CMS source
Ownership
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Verified public facility information
Source organization
Public facility listing
Dataset identifier
commercial-corroboration:public-listing
Source updated
Aug 18, 2026
Retrieved
Aug 18, 2026
Supports
Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
How sources work

No paid placements. Facilities cannot pay to rank higher. We cite. You decide.