Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.79 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.79 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on May 8, 2025 cited 8 deficiencies.
View inspection evidenceCMS-published records list 81 ownership or control parties.
CMS records show an ownership change effective October 2024.
View ownership evidenceCMS groups this facility with a chain covering 89 facilities across 9 states or territories.
View chain evidenceCMS records show a $298,483 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
79 currently connected nursing homes share this CMS organization identity with UAK 2020 IRRV TR.
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER MORTGAGE INTEREST
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 17, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: Feb 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Organization · DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Sep 12, 2024
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 31, 2024
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 31, 2024
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Feb 26, 2025
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Feb 26, 2025
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Jul 22, 2025
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 31, 2024
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Feb 17, 2025
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 31, 2024
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 31, 2024
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Feb 17, 2025
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 31, 2024
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 31, 2024
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 78.6%
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 45 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 20%
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 49 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 21.8%
Association date reported to CMS: Nov 1, 2024
Other facilities connected through this exact CMS organization identity: 77 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 21.8%
Association date reported to CMS: Nov 1, 2024
Other facilities connected through this exact CMS organization identity: 77 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 14.2%
Association date reported to CMS: Nov 1, 2024
Other facilities connected through this exact CMS organization identity: 48 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 56.8%
Association date reported to CMS: Nov 1, 2024
Other facilities connected through this exact CMS organization identity: 49 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 20%
Association date reported to CMS: Nov 1, 2024
Other facilities connected through this exact CMS organization identity: 78 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 14.2%
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 49 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 28.4%
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 48 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · 5% OR GREATER MORTGAGE INTEREST
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 34 across CA, IA, IL, MA, MI, NC, OH, PA.
Organization · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 16, 2025
Other facilities connected through this exact CMS organization identity: 0 across MA.
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 17, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: Feb 11, 2025
Other facilities connected through this exact CMS organization identity: 72 across MA, MD, NH, NJ, PA, RI, VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 77 across FL, MA, MD, NH, NJ, PA, RI, VA.
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 45 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
CMS classifications: Management services company
Other facilities connected through this exact CMS organization identity: 70 across MA, MD, NH, NJ, PA, RI, VA, WA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 77 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 48 across FL, MA, MD, NH, NJ, PA, RI, VA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 49 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 11, 2025
Other facilities connected through this exact CMS organization identity: 78 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 49 across FL, MA, MD, NH, NJ, PA, RI, VA.
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 49 across FL, MA, MD, NH, NJ, PA, RI, VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Jan 13, 2025
Other facilities connected through this exact CMS organization identity: 48 across FL, MA, MD, NH, NJ, PA, RI, VA.
Individual · ADP OF THE SNF
Association date reported to CMS: Oct 31, 2024
Organization · DIRECT OWNERSHIP INTEREST
Published ownership percentage: 1.4%
Association date reported to CMS: Sep 12, 2024
Other facilities connected through this exact CMS organization identity: 24 across FL, MA, MD, NH, NJ, PA, RI, VA.
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 0%
Association date reported to CMS: Oct 31, 2024
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 0%
Association date reported to CMS: Oct 31, 2024
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 31, 2024
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Feb 17, 2025
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 31, 2024
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Oct 31, 2024
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 336 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 89 | 3.1 | 2.3 |
| Mon Jun | 88 | 3 | 2.5 |
| Fri May | 88 | 3 | 2.5 |
| Wed Apr | 84 | 3.1 | 2.5 |
| Sun Mar | 81 | 3 | 2.3 |
| Sun Feb | 80 | 2.9 | 2.3 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
No health-deficiency rows were deterministically linked to this inspection.
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)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 3, 2025)
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 (Jun 3, 2025)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 3, 2025)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with 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 (Jun 3, 2025)
Provide and implement an infection prevention and control program.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 3, 2025)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 3, 2025)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 3, 2025)
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 20, 2025)
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 (Aug 9, 2024)
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 (Aug 9, 2024)
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 (Jun 9, 2024)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
Allow residents to self-administer drugs if determined clinically appropriate.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
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 (Apr 26, 2024)
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 H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
Ensure each resident receives an accurate assessment.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
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 (Apr 24, 2024)
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 G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
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 (Apr 24, 2024)
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 (May 26, 2024)
Provide activities to meet all resident's needs.
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 (Apr 26, 2024)
Ensure the activities program is directed by a qualified professional.
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 (Apr 24, 2024)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
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 (Apr 26, 2024)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
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 (May 26, 2024)
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 (Apr 24, 2024)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 24, 2024)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
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 (Apr 24, 2024)
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 (Apr 26, 2024)
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 (Apr 24, 2024)
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 (Apr 24, 2024)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Apr 24, 2024)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 16, 2023)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 16, 2023)
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 16, 2023)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 16, 2023)
No health-deficiency rows were deterministically linked to this inspection.
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 (Oct 14, 2022)
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 (Oct 14, 2022)
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
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 14, 2022)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
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 (Oct 14, 2022)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 30, 2022)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 30, 2022)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 7, 2022)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
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 F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 14, 2022)
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 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 14, 2022)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
Provide timely, quality laboratory services/tests to meet the needs of residents.
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 14, 2022)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 14, 2022)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 14, 2022)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2022)
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 (Oct 14, 2022)
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 (Oct 14, 2022)
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 (Oct 6, 2022)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 5, 2022)
Perform COVID19 testing on residents and staff.
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 6, 2022)
Penalties & enforcement
Published fine amount: $298,483.00
Payment denial length: 38 days
Questions to ask
Facility history
11 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
RN staffing decreased from 0.93 to 0.83 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
0.93 → 0.83
CMS · Reported in a source release · View related evidence
8 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
An ownership change was recorded. New organization: CAPE COD OPERATOR LLC.
PLEASANT BAY OF BREWSTER REHAB CENTER LLC → CAPE COD OPERATOR LLC
CMS · Recorded event date · View related evidence
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
CMS recorded a $298,483 civil monetary penalty.
CMS · Recorded event date · View related evidence
29 deficiencies were recorded. That includes 5 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
CMS recorded a Medicare payment denial lasting 38 days.
CMS · Recorded event date · View related evidence
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
24 deficiencies were recorded. That includes 3 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 2 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.493 | 3.011 |
| RN categories | 0.867 | 0.61 |
Contract staff accounted for 0.5% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.028 higher than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.585 | 0.93 | 0.697 | 1.958 | 5.5% | 91 |
| 2025Q3 | 3.404 | 0.829 | 0.666 | 1.908 | 0.4% | 92 |
| 2025Q4 | 3.355 | 0.765 | 0.743 | 1.847 | 0.6% | 92 |
| 2026Q1 | 3.354 | 0.793 | 0.681 | 1.88 | 0.5% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.