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CMS nursing home

VILLAS AT BRYN MAWR LLC

MINNEAPOLIS, MN

CMS CCN 2452036123774723Listed in the current CMS nursing-home directoryCMS source updated August 1, 2026

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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 245203.

At a glance

CMS research snapshot

CMS overall rating

1 of 5 CMS stars

CMS health inspection rating

1 of 5 CMS stars

CMS staffing rating

4 of 5 CMS stars

CMS quality-measure rating

4 of 5 CMS stars

CMS ownership-change history

CMS has published 1 ownership-change record for this provider.

CMS Special Focus Facility

CMS currently identifies Special Focus Facility or candidate status in the loaded Provider Information extract. That is a CMS designation, not a Trust Hub watchlist.

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: Available
  • PBJ staffing records: Available
  • Inspection evidence: Available
  • Fire-safety evidence: Available

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

  • HALPERT, MARCIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST32% ownership interest
  • HALPERT, MARCIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • JAFFA, NOAMIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST16% ownership interest
  • JAFFA, NOAMIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • LEGUM, JOSHUAIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • LEGUM, JOSHUAIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • MONARCH HEALTHCARE OPERATING XII LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
  • MONARCH HEALTHCARE OPERATING XII LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
  • NIJ LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST14% ownership interest
  • NIJ LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • SPARTAN HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • SPARTAN HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST32% ownership interest
  • STERN, WILLIAMIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • STERN, WILLIAMIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • WBS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST22% ownership interest
  • WBS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • YAZOMA HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • YAZOMA HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST

Operators

  • HALPERT, MARCIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL32% ownership interest
  • HALPERT, MARCIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
  • HALPERT, MARCIndividual owner · HISTORICALOPERATIONAL/MANAGERIAL CONTROL32% ownership interest
  • HALPERT, MARCIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL32% ownership interest
  • HALPERT, MARCIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL

Managers

  • LEGUM, JOSHUAIndividual owner · CURRENTCONTRACTED MANAGING EMPLOYEE26% ownership interest
  • LEGUM, JOSHUAIndividual owner · CURRENTCONTRACTED MANAGING EMPLOYEE
  • LEGUM, JOSHUAIndividual owner · HISTORICALCONTRACTED MANAGING EMPLOYEE26% ownership interest
  • LEGUM, JOSHUAIndividual owner · UNKNOWNCONTRACTED MANAGING EMPLOYEE
  • LEGUM, JOSHUAIndividual owner · UNKNOWNCONTRACTED MANAGING EMPLOYEE26% ownership interest

Enrollment organizations

  • VILLAS AT BRYN MAWR LLCOrganization · CURRENTMedicare-enrolled legal organization
  • VILLAS AT BRYN MAWR LLCOrganization · UNKNOWNMedicare-enrolled legal organization
Historical ownership observations

Historical

  • HALPERT, MARCIndividual owner · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST32% ownership interest
  • JAFFA, NOAMIndividual owner · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST16% ownership interest
  • LEGUM, JOSHUAIndividual owner · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • MONARCH HEALTHCARE OPERATING XII LLCOrganization · HISTORICAL5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
  • NIJ LLCOrganization · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST14% ownership interest
  • SPARTAN HEALTHCARE LLCOrganization · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST32% ownership interest
  • STERN, WILLIAMIndividual owner · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • WBS HOLDINGS LLCOrganization · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST22% ownership interest
  • YAZOMA HOLDINGS, LLCOrganization · HISTORICAL5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
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

  • HALPERT, MARCIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST32% ownership interest
  • HALPERT, MARCIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • JAFFA, NOAMIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST16% ownership interest
  • JAFFA, NOAMIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • LEGUM, JOSHUAIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • LEGUM, JOSHUAIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • MONARCH HEALTHCARE OPERATING XII LLCOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
  • MONARCH HEALTHCARE OPERATING XII LLCOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
  • NIJ LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • NIJ LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST14% ownership interest
  • SPARTAN HEALTHCARE LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST32% ownership interest
  • SPARTAN HEALTHCARE LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • STERN, WILLIAMIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • STERN, WILLIAMIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest
  • WBS HOLDINGS LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST22% ownership interest
  • WBS HOLDINGS LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • YAZOMA HOLDINGS, LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST
  • YAZOMA HOLDINGS, LLCOrganization · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST26% ownership interest

Ownership change history

CMS ownership-change records

CMS publishes Change of Ownership records for this nursing home.

  1. CMS records show an ownership change effective 2023-01-01.

    CMS type
    CHANGE OF OWNERSHIP
    Buyer legal entity
    VILLAS AT BRYN MAWR LLC
    Seller legal entity
    VILLA AT BRYN MAWR LLC
    Effective date
    2023-01-01

These are CMS transaction records. They are not a Trust Hub quality, stability, or sale judgment.

Source freshness

How current each evidence family is

nursing-home-mds-quality-measures
AGING · source as of 2026-08-01
nursing-home-provider-information
AGING · 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 2026-10-02. 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

CMS overall

1 of 5 CMS stars

Health inspection

1 of 5 CMS stars

Staffing

4 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
105
Ownership descriptor
For profit - Corporation
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
6123774723Verified 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.

Special Focus Facility candidate

CMS currently identifies this nursing home as a Special Focus Facility candidate. Candidate status is not the same as being designated a Special Focus Facility.

CMS field value: SFF Candidate. Observed Aug 1, 2026.

CMS abuse-icon designation

CMS currently applies its abuse-icon designation to this facility. That is CMS's published designation, not a Trust Hub verdict.

CMS field value: Y. Observed Aug 1, 2026.

Enrollment identity

Medicare enrollment organization NPI associated with this CMS Certification Number

These identifiers come from CMS SNF enrollment records linked to this CCN. They are not a substitute for the CMS Certification Number.

  • NPI 1992414429 · enrollment O20221229001007
  • NPI 1992414429 · enrollment O20221229001007

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): 96.111111
  • Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 95.402299
  • Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 2.500000 · CMS uses this measure in the quality-measure star rating
  • Percentage of long-stay residents who have depressive symptoms (Long Stay): 10.191083
  • Percentage of long-stay residents who lose too much weight (Long Stay): 2.058824
  • Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 12.250712
  • Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 23.280423 · 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): 5.284851 · 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): 5.571848 · CMS uses this measure in the quality-measure star rating
  • Percentage of long-stay residents with a catheter inserted and left in their bladder (Long Stay): 0.000000 · CMS uses this measure in the quality-measure star rating
  • Percentage of long-stay residents with a urinary tract infection (Long Stay): 0.833333 · 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): 8.762784
  • Percentage of long-stay residents with pressure ulcers (Long Stay): 2.089903 · CMS uses this measure in the quality-measure star rating
  • Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 72.125436
  • Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 2.631579 · 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): 57.142857

Fire-safety citations

CMS fire-safety citations

These are fire-safety citations, not health deficiencies and not a count of fires.

  • 2026-06-17 · tag 0222 · scope/severity E — Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
  • 2026-06-17 · tag 0321 · scope/severity E — Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
  • 2026-06-17 · tag 0345 · scope/severity E — Have approved installation, maintenance and testing program for fire alarm systems.
  • 2026-06-17 · tag 0355 · scope/severity E — Properly select, install, inspect, or maintain portable fire extinguishes.
  • 2026-06-17 · tag 0372 · scope/severity E — Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
  • 2026-06-17 · tag 0541 · scope/severity E — Install properly constructed and protected linen or trash chutes.
  • 2026-06-17 · tag 0741 · scope/severity E — Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
  • 2026-06-17 · tag 0211 · scope/severity D — Keep aisles, corridors, and exits free of obstruction in case of emergency.
  • 2026-06-17 · tag 0363 · scope/severity D — Install corridor and hallway doors that block smoke.
  • 2026-06-17 · tag 0912 · scope/severity D — Have power receptacles that are properly grounded.
  • 2026-06-17 · tag 0353 · scope/severity C — Inspect, test, and maintain automatic sprinkler systems.
  • 2026-06-17 · tag 0918 · scope/severity F — Have generator or other power source capable of supplying service within 10 seconds.

Decision guide

What to review

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

Staffing

CMS publishes a 4-star staffing rating for this facility.

RN staffing was 0.68 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership

CMS-published records list 29 ownership or control parties.

CMS records show an ownership change effective January 2023.

View ownership evidence

Chain context

CMS groups this facility with a chain covering 45 facilities across 1 states or territories.

View chain evidence
Enforcement record

CMS records show a $16,720 fine in the loaded enforcement dataset.

View enforcement evidence →

Ownership & operation

Ownership & Operation

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

Ownership type
For profit - CorporationCMS
Chain
MONARCH HEALTHCARE MANAGEMENTCMS identifies this facility as part of the MONARCH HEALTHCARE MANAGEMENT chain.
Related facilities
42Current CMS organization identity
Ownership changes
1 recordedCMS enrollment records

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • 10 CMS-reported ownership organizations
  • CMS reports 18 individual ownership interests
  • a CMS chain / common-control group
  • recorded ownership-change events

Related facilities

42 currently connected nursing homes share this CMS organization identity with SPARTAN HEALTHCARE LLC.

Average CMS overall rating
2.3 stars across 42 reporting facilities
CMS monetary penalties
24 of 42 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
11 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
11 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
36 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$1,381,790

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

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
29
Organizations shown
11
Individuals shown
18
Latest ownership source update
Aug 17, 2026

CMS-published ownership and control parties

  • MONARCH HEALTHCARE OPERATING XII LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 0 across MN.

    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
    View official CMS source
  • HALPERT, MARC

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • JAFFA, NOAM

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • LEGUM, JOSHUA

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • NIJ LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 0 across MN.

    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
    View official CMS source
  • SPARTAN HEALTHCARE LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 0 across MN.

    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
    View official CMS source
  • STERN, WILLIAM

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • WBS HOLDINGS LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 0 across MN.

    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
    View official CMS source
  • YAZOMA HOLDINGS, LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 0 across MN.

    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
    View official CMS source
  • LEGUM, JOSHUA

    Individual · CONTRACTED MANAGING EMPLOYEE

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • JAFFA, NOAM

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • HALPERT, MARC

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • STERN, WILLIAM

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • HALPERT, MARC

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jan 1, 2023

    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
    View official CMS source
  • MONARCH HEALTHCARE OPERATING XII LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 10 across MN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • HALPERT, MARC

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 32%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • JAFFA, NOAM

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 16%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • LEGUM, JOSHUA

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 26%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • NIJ LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 14%

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 40 across MN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • SPARTAN HEALTHCARE LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 32%

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 41 across MN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • STERN, WILLIAM

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 26%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • WBS HOLDINGS LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 22%

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 23 across MN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • YAZOMA HOLDINGS, LLC

    Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 26%

    Association date reported to CMS: Jan 1, 2023

    Other facilities connected through this exact CMS organization identity: 40 across MN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • LEGUM, JOSHUA

    Individual · CONTRACTED MANAGING EMPLOYEE

    Published ownership percentage: 26%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • JAFFA, NOAM

    Individual · CORPORATE DIRECTOR

    Published ownership percentage: 16%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • HALPERT, MARC

    Individual · CORPORATE OFFICER

    Published ownership percentage: 32%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • STERN, WILLIAM

    Individual · CORPORATE OFFICER

    Published ownership percentage: 26%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • HALPERT, MARC

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Published ownership percentage: 32%

    Association date reported to CMS: Jan 1, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source
  • VILLAS AT BRYN MAWR LLC

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 0 across MN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility Enrollments
    CMS dataset identifier
    5f2c306f-3b1c-42cd-b037-187b2ce22126
    Source updated
    Aug 17, 2026
    Retrieved
    Aug 26, 2026
    View official CMS source

Ownership changes reported in CMS enrollment records

  1. CHANGE OF OWNERSHIPVILLA AT BRYN MAWR LLC to VILLAS AT BRYN MAWR LLC
    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility Change of Ownership
    CMS dataset identifier
    f557a6ed-95b3-4a22-8433-4175db2dec1c
    Source updated
    Aug 24, 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.

Questions to ask

  • CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
  • CMS enrollment records show a change of ownership effective Jan 1, 2023. What operational or leadership changes followed that event?
  • CMS records connect MONARCH HEALTHCARE OPERATING XII LLC to 11 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with MONARCH HEALTHCARE MANAGEMENT

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 361 is a grouping identifier, not a legal organization.

Facilities
45
States and territories
1
Average overall rating
2.3
Average staffing rating
3.7
Average total nurse HPRD
3.5
Total fines
82
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul452.33.7
Mon Jun452.23.5
Fri May452.23.5
Wed Apr452.33.5
Sun Mar452.33.3
Sun Feb452.23.3

Questions to ask

  • CMS groups facilities in 1 states or territories under this chain. Which operational policies are set at the chain level?
  • CMS reports 82 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology

Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.

View official CMS source

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 17, 2026
Survey type
Fire Safety Standard
Linked findings
0
Highest linked CMS classification
No linked health-deficiency finding in the loaded record
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Aug 1, 2026
CMS provider ID
245203
Source record locator
csv-row:65426:ccn:245203
View official CMS source
Jun 17, 2026 — Fire Safety Standard — 0 linked findings

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

Jun 17, 2026 — Health Complaint — 0 linked findings

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

Jun 17, 2026 — Health Standard — 11 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 D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184257:ccn:245203
    View official CMS source
  • F0582 — Resident Rights Deficiencies

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    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 plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184258:ccn:245203
    View official CMS source
  • F0584 — Resident Rights Deficiencies

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

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

    Correction status: Deficient, Provider has plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184259:ccn:245203
    View official CMS source
  • F0605 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

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

    Correction status: Deficient, Provider has plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184260:ccn:245203
    View official CMS source
  • 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184254:ccn:245203
    View official CMS source
  • F0628 — Resident Rights Deficiencies

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

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

    Correction status: Deficient, Provider has plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184261:ccn:245203
    View official CMS source
  • F0641 — Resident 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 plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184262:ccn:245203
    View official CMS source
  • 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 plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184263:ccn:245203
    View official CMS source
  • F0684 — Quality of Life and Care Deficiencies

    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 plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184264:ccn:245203
    View official CMS source
  • F0761 — Pharmacy Service Deficiencies

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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

    Correction status: Deficient, Provider has plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184265:ccn:245203
    View official CMS source
  • 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 plan of correction (Jul 29, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184266:ccn:245203
    View official CMS source
Mar 13, 2026 — Health Complaint — 2 linked findings
  • F0684 — Quality of Life and Care Deficiencies

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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

    Correction status: Deficient, Provider has date of correction (Apr 7, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184268:ccn:245203
    View official CMS source
  • F0692 — Quality 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 (Apr 7, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184269:ccn:245203
    View official CMS source
Feb 27, 2026 — Health Complaint — 1 linked finding
  • F0686 — Quality of Life and Care Deficiencies

    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: Past Non-Compliance

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184270:ccn:245203
    View official CMS source
Sep 29, 2025 — Health Complaint — 1 linked finding
  • F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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

    Correction status: Deficient, Provider has date of correction (Oct 15, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184271:ccn:245203
    View official CMS source
Sep 11, 2025 — Health Complaint — 1 linked finding
  • 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 J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Past Non-Compliance

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184272:ccn:245203
    View official CMS source
Jun 24, 2025 — Health Complaint — 5 linked findings
  • 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 (Jul 18, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184274:ccn:245203
    View official CMS source
  • 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 (Jul 18, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184275:ccn:245203
    View official CMS source
  • 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 J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Past Non-Compliance (Jun 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184273:ccn:245203
    View official CMS source
  • F0742 — Quality of Life and Care Deficiencies

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

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

    Correction status: Deficient, Provider has date of correction (Jul 18, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184276:ccn:245203
    View official CMS source
  • 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 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 18, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184277:ccn:245203
    View official CMS source
Apr 15, 2025 — Health Complaint — 1 linked finding
  • F0692 — Quality 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 (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184278:ccn:245203
    View official CMS source
Mar 27, 2025 — Fire Safety Standard — 0 linked findings

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

Mar 27, 2025 — Health Complaint — 0 linked findings

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

Mar 27, 2025 — Health Standard — 14 linked findings
  • F0576 — Resident Rights Deficiencies

    Ensure residents have reasonable access to and privacy in their use of communication methods.

    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 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184282:ccn:245203
    View official CMS source
  • F0583 — Resident Rights Deficiencies

    Keep residents' personal and medical records private and confidential.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has date of correction (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184293:ccn:245203
    View official CMS source
  • F0638 — Resident Assessment and Care Planning Deficiencies

    Assure that each resident’s assessment is updated at least once every 3 months.

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

    Correction status: Deficient, Provider has date of correction (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184283:ccn:245203
    View official CMS source
  • F0645 — Resident Assessment and Care Planning Deficiencies

    PASARR screening for Mental disorders or Intellectual Disabilities

    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 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184284:ccn:245203
    View official CMS source
  • F0676 — Quality of Life and Care Deficiencies

    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184285:ccn:245203
    View official CMS source
  • F0677 — Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

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

    Correction status: Deficient, Provider has date of correction (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184286:ccn:245203
    View official CMS source
  • F0684 — Quality of Life and Care Deficiencies

    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 (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184280:ccn:245203
    View official CMS source
  • 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 (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184287:ccn:245203
    View official CMS source
  • F0687 — Quality of Life and Care Deficiencies

    Provide appropriate foot care.

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

    Correction status: Deficient, Provider has date of correction (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184288:ccn:245203
    View official CMS source
  • F0688 — Quality of Life and Care Deficiencies

    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 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184289:ccn:245203
    View official CMS source
  • 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 (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184291:ccn:245203
    View official CMS source
  • F0812 — Nutrition and Dietary Deficiencies

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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

    Correction status: Deficient, Provider has date of correction (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184279:ccn:245203
    View official CMS source
  • 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 (Apr 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184292:ccn:245203
    View official CMS source
  • F0921 — Environmental Deficiencies

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

    CMS scope/severity 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 29, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184281:ccn:245203
    View official CMS source
Jan 23, 2025 — Health Complaint — 1 linked finding
  • 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 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 14, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184294:ccn:245203
    View official CMS source
Jan 14, 2025 — Health Complaint — 1 linked finding
  • F0684 — Quality of Life and Care Deficiencies

    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 (Feb 3, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184295:ccn:245203
    View official CMS source
Aug 12, 2024 — Health Complaint — 5 linked findings
  • 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 L: Widespread; Immediate jeopardy to resident health or safety.

    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
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184296:ccn:245203
    View official CMS source
  • F0914 — Environmental Deficiencies

    Provide bedrooms that don't allow residents to see each other when privacy is 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 4, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184297:ccn:245203
    View official CMS source
  • F0941 — Administration Deficiencies

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    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
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184299:ccn:245203
    View official CMS source
  • F0944 — Administration Deficiencies

    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 (Sep 4, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184300:ccn:245203
    View official CMS source
  • F0949 — Administration Deficiencies

    Provide behavior health training consistent with the requirements and as determined by a facility 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 (Sep 4, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184298:ccn:245203
    View official CMS source
May 2, 2024 — Fire Safety Standard — 0 linked findings

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

May 2, 2024 — Health Standard — 9 linked findings
  • F0554 — Resident Rights Deficiencies

    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 (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184303:ccn:245203
    View official CMS source
  • F0584 — Resident Rights Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184304:ccn:245203
    View official CMS source
  • F0677 — Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

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

    Correction status: Deficient, Provider has date of correction (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184305:ccn:245203
    View official CMS source
  • F0693 — Quality of Life and Care Deficiencies

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184306:ccn:245203
    View official CMS source
  • F0699 — Quality 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 (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184307:ccn:245203
    View official CMS source
  • F0732 — Nursing and Physician Services Deficiencies

    Post nurse staffing information every day.

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

    Correction status: Deficient, Provider has date of correction (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184309:ccn:245203
    View official CMS source
  • F0812 — Nutrition and Dietary Deficiencies

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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

    Correction status: Deficient, Provider has date of correction (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184301:ccn:245203
    View official CMS source
  • F0880 — Infection 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 (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184302:ccn:245203
    View official CMS source
  • F0883 — Infection 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 (Jun 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184308:ccn:245203
    View official CMS source
Feb 26, 2024 — Health Complaint — 1 linked finding
  • F0686 — Quality of Life and Care Deficiencies

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

    Correction status: Deficient, Provider has date of correction (Mar 8, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:184310:ccn:245203
    View official CMS source

Tags appearing across inspections

  • F0684 appears in 4 linked inspections.
  • F0880 appears in 3 linked inspections.
  • F0584 appears in 2 linked inspections.
  • F0609 appears in 2 linked inspections.
  • F0657 appears in 2 linked inspections.
  • F0677 appears in 2 linked inspections.
  • F0686 appears in 2 linked inspections.
  • F0689 appears in 2 linked inspections.
  • F0692 appears in 2 linked inspections.
  • F0755 appears in 2 linked inspections.
  • F0812 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • Fine — Feb 27, 2026

    Published fine amount: $16,720.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:6874:ccn:245203
    View official CMS source
  • Fine — Aug 12, 2024

    Published fine amount: $35,260.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245203
    Source record locator
    csv-row:6875:ccn:245203
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show F0684 in 4 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 F0584 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0609 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0657 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0677 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0686 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0689 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0692 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0755 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0812 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show a monetary penalty dated Feb 27, 2026. What changes were made after that enforcement action?

Facility history

Facility History

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

What changed recently?

  • Complaint inspection recorded2 deficiencies were recorded. That includes 1 higher-severity deficiency.
  • Civil monetary penalty recordedCMS recorded a $16,720 civil monetary penalty.

2026

  1. Complaint inspection recorded

    2 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    1 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  3. Civil monetary penalty recorded

    CMS recorded a $16,720 civil monetary penalty.

    CMS · Recorded event date · View related evidence

2025

  1. Complaint inspection recorded

    1 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    1 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  3. Complaint inspection recorded

    5 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  4. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  5. Health inspection completed

    14 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  6. Complaint inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    CMS · Recorded event date · View related evidence

  7. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  8. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

    5 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 4 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
2.734
reported hours per resident day
RN categories
0.682
reported hours per resident day
LPN/LVN categories
0.474
reported hours per resident day
CNA
1
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing2.8142.538
RN categories0.7720.459

Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.054 higher 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
2025Q22.5710.6830.5560.9021.1%91
2025Q32.6850.6590.5781.010%92
2025Q42.7890.6280.5991.0090%92
2026Q12.7340.6820.47410%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?
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 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 1-star overall rating.
  • CMS reports a 1-star health inspection rating.
  • CMS reports a 4-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.

  • Home health national spine remains a separate CMS provider class, not this profile.
  • Hospice national spine remains a separate CMS provider class, not this profile.

Trust participation

See something that needs correction?

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

Representation claims are reviewed manually. Live profile-management tools are not yet enabled for this facility.

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
Aug 1, 2026
Retrieved
Aug 26, 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
Aug 1, 2026
Retrieved
Aug 26, 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
Aug 1, 2026
Retrieved
Aug 26, 2026
Supports
Health deficiencies and facility history
View official CMS source
Penalties
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
g6vv-u9sr
Source updated
Aug 1, 2026
Retrieved
Aug 26, 2026
Supports
Penalties, enforcement, and facility history
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
Aug 1, 2026
Retrieved
Aug 26, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Skilled Nursing Facility All Owners
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated
Aug 17, 2026
Retrieved
Aug 26, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Skilled Nursing Facility Enrollments
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
5f2c306f-3b1c-42cd-b037-187b2ce22126
Source updated
Aug 17, 2026
Retrieved
Aug 26, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Skilled Nursing Facility Change of Ownership
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
f557a6ed-95b3-4a22-8433-4175db2dec1c
Source updated
Aug 24, 2026
Retrieved
Aug 15, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Nursing Home Chain Performance Measures
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
97ecfad1-d3f1-4d42-b774-d74661d830bc
Coverage
Wed Jul
Source updated
Aug 12, 2026
Retrieved
Aug 16, 2026
Supports
CMS chain context, performance, and monthly 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.