Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 1.03 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk about this facility
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 245255.
At a glance
CMS research snapshot
CMS overall rating
2 of 5 CMS stars2/5CMS health inspection rating
2 of 5 CMS stars2/5CMS staffing rating
4 of 5 CMS stars4/5CMS quality-measure rating
3 of 5 CMS stars3/5CMS ownership-change history
No attached CMS ownership-change event.
These are CMS star ratings, not Trust Hub ratings. Missing evidence is shown as not reported, not as zero.
Quality & care evidence
What CMS reports about quality
- MDS quality observations: 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
- FAIRVIEW BETHESDA HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
Operators
- BENEDICTINE HEALTH SYSTEMOrganization · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- BENEDICTINE HEALTH SYSTEMOrganization · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
Managers
- ROBINSON, FRANKIndividual owner · CURRENTCONTRACTED MANAGING EMPLOYEE
- ROBINSON, FRANKIndividual owner · UNKNOWNCONTRACTED MANAGING EMPLOYEE
Enrollment organizations
No resolved CMS/PECOS relationships in this category.
Historical ownership observations
Historical
No resolved CMS/PECOS relationships in this category.
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
- FAIRVIEW BETHESDA HOSPITALOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
Ownership change history
CMS ownership-change records
No CMS ownership-change event is currently attached to this profile in the Trust Hub research graph. That is not proof that ownership never changed.
Source freshness
How current each evidence family is
- nursing-home-mds-quality-measures
- 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
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
- 93
- Ownership descriptor
- Non 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
- 6512201700CMS Provider Information
CMS designations
Special Focus and abuse-icon status
This CMS Certification Number appears in the latest CMS Nursing Home Provider Information extract of currently listed nursing homes.
Not currently SFF or candidate
CMS does not currently identify this nursing home as a Special Focus Facility or candidate in the loaded Provider Information extract.
CMS field value: (blank). Observed Aug 1, 2026.
CMS abuse-icon designation
CMS does not currently apply its abuse-icon designation to this facility in the loaded Provider Information extract.
CMS field value: N. Observed Aug 1, 2026.
MDS quality measures
Individual CMS quality measures
These MDS quality measures are individual CMS-published scores. They are not the CMS quality-measure star rating.
MDS source release 2026-08-01.
View individual MDS measures
- Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (Long Stay): 95.785441
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 95.522388
- Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 1.915709 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who have depressive symptoms (Long Stay): 7.272727
- Percentage of long-stay residents who lose too much weight (Long Stay): 2.202643
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 7.755102
- Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 15.094340 · 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): 22.368493 · 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): 19.213974 · 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): 2.298851 · 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): 29.173845
- Percentage of long-stay residents with pressure ulcers (Long Stay): 2.919505 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 89.100817
- Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 1.376147 · 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): 79.279279
Fire-safety citations
CMS fire-safety citations
These are fire-safety citations, not health deficiencies and not a count of fires.
- 2026-03-05 · tag 0351 · scope/severity F — Install an approved automatic sprinkler system.
- 2026-03-05 · tag 0541 · scope/severity F — Install properly constructed and protected linen or trash chutes.
- 2026-03-05 · tag 0918 · scope/severity F — Have generator or other power source capable of supplying service within 10 seconds.
- 2025-01-16 · tag 0351 · scope/severity F — Install an approved automatic sprinkler system.
- 2025-01-16 · tag 0311 · scope/severity F — Have an enclosure around a vertical opening shaft.
- 2025-01-16 · tag 0541 · scope/severity F — Install properly constructed and protected linen or trash chutes.
- 2023-11-30 · tag 0353 · scope/severity D — Inspect, test, and maintain automatic sprinkler systems.
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on Mar 5, 2026 cited 8 deficiencies.
View inspection evidenceOwnership
CMS-published records list 11 ownership or control parties.
View ownership evidenceEnforcement record
CMS records show a $51,948 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
- Non profit - CorporationCMS
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 1 CMS-reported ownership organization
- CMS reports 9 individual ownership interests
Ownership
Who CMS records show is connected to this facility
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
- Reported party records
- 11
- Organizations shown
- 2
- Individuals shown
- 9
- Latest ownership source update
- Aug 1, 2026
CMS-published ownership and control parties
FAIRVIEW BETHESDA HOSPITAL
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jul 1, 2005
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
ROBINSON, FRANK
Individual · CONTRACTED MANAGING EMPLOYEE
Association date reported to CMS: Jul 9, 2021
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
CARLEY, GERALD
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 2, 2018
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
FOUSSARD, WILLIAM
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 24, 2010
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
GRZYWINSKI, JOAN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 13, 2014
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
KSEPKA, DAWN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 13, 2013
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
LUNDBERG, JONATHAN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Mar 1, 2018
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
BERGIEN, TRICIA
Individual · CORPORATE OFFICER
Association date reported to CMS: Nov 16, 2016
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
BRUHN, JENNIFER
Individual · CORPORATE OFFICER
Association date reported to CMS: Nov 25, 2019
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
RYMANOWSKI, KEVIN
Individual · CORPORATE OFFICER
Association date reported to CMS: Jul 1, 2005
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
BENEDICTINE HEALTH SYSTEM
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2005
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
What this means
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Questions to ask
- CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
Inspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- Mar 5, 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
- 245255
- Source record locator
- csv-row:65742:ccn:245255
Mar 5, 2026 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Mar 5, 2026 — Health Standard — 8 linked findings
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 (Apr 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185034:ccn:245255
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 date of correction (Apr 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185035:ccn:245255
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 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 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185036:ccn:245255
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 (Apr 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185037:ccn:245255
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185038:ccn:245255
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 (Apr 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185039:ccn:245255
F0756 — Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity 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 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185040:ccn:245255
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 14, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185041:ccn:245255
Nov 18, 2025 — Health Complaint — 1 linked finding
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 (Dec 10, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185042:ccn:245255
May 15, 2025 — Health Complaint — 6 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 G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Past Non-Compliance (May 12, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185043:ccn:245255
F0725 — Nursing and Physician Services Deficiencies
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 G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 17, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185044:ccn:245255
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 (Jun 17, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185046:ccn:245255
F0810 — Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
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 17, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185047:ccn:245255
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 17, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185048:ccn:245255
F0867 — Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 17, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185045:ccn:245255
Jan 16, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jan 16, 2025 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jan 16, 2025 — Health Standard — 5 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 (Feb 25, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185053:ccn:245255
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 25, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185055:ccn:245255
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 (Feb 25, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185058:ccn:245255
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 (Feb 25, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185051:ccn:245255
F0919 — Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 25, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185059:ccn:245255
Dec 5, 2024 — 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 J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Past Non-Compliance (Dec 3, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185060:ccn:245255
Aug 27, 2024 — Health Complaint — 4 linked findings
F0580 — Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 1, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185061:ccn:245255
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 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 1, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185062:ccn:245255
F0803 — Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Oct 1, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185064:ccn:245255
F0908 — Environmental Deficiencies
Keep all essential equipment working 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 (Oct 1, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185063:ccn:245255
Aug 8, 2024 — Health Complaint — 1 linked finding
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 (Aug 12, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185065:ccn:245255
Jul 11, 2024 — Health Complaint — 3 linked findings
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 date of correction (Aug 7, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185068:ccn:245255
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 7, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185066:ccn:245255
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: Deficient, Provider has date of correction (Aug 7, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185067:ccn:245255
May 22, 2024 — Health Complaint — 4 linked findings
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 (Jul 17, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185070:ccn:245255
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 (Jul 17, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185071:ccn:245255
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 17, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185072:ccn:245255
F0804 — Nutrition and Dietary Deficiencies
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 (Jul 17, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185069:ccn:245255
Nov 30, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Nov 30, 2023 — Health Standard — 3 linked findings
F0690 — Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185074:ccn:245255
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 (Jan 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185075:ccn:245255
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 (Jan 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:185073:ccn:245255
Tags appearing across inspections
- F0684 appears in 3 linked inspections.
- F0689 appears in 3 linked inspections.
- F0755 appears in 3 linked inspections.
- F0584 appears in 2 linked inspections.
- F0880 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — May 15, 2025
Published fine amount: $51,948.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:6910:ccn:245255
Fine — Dec 5, 2024
Published fine amount: $17,083.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:6909:ccn:245255
Payment Denial — May 22, 2024
Payment denial length: 4 days
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245255
- Source record locator
- csv-row:6911:ccn:245255
Questions to ask
Questions generated from the evidence above
- CMS records show F0684 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0689 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0755 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 F0880 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated May 15, 2025. What changes were made after that enforcement action?
Facility history
Facility History
15 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- RN staffing increasedRN staffing increased from 0.88 to 1.03 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
- Health inspection completed8 deficiencies were recorded.
- Civil monetary penalty recordedCMS recorded a $79,920 civil monetary penalty.
2026
- RN staffing increased
RN staffing increased from 0.88 to 1.03 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
0.88 → 1.03
CMS · Reported in a source release · View related evidence
- Health inspection completed
8 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $79,920 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
6 deficiencies were recorded. That includes 2 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
- Health inspection completed
5 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2024
- Complaint inspection recorded
1 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $16,801 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
3 deficiencies were recorded. That includes 2 higher-severity deficiencies.
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).
- Total nursing
- 3.841 reported hours per resident day
- RN categories
- 1.031 reported hours per resident day
- LPN/LVN categories
- 0.828 reported hours per resident day
- CNA
- 1.969 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 4.075 | 3.263 |
| RN categories | 1.147 | 0.744 |
Contract staff accounted for 20% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.149 higher than the prior loaded quarter.
Staffing over time
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.789 | 0.852 | 0.913 | 1.99 | 9.1% | 91 |
| 2025Q3 | 3.85 | 0.883 | 0.929 | 2.007 | 13% | 92 |
| 2025Q4 | 3.886 | 0.882 | 0.93 | 2.042 | 19.7% | 92 |
| 2026Q1 | 3.841 | 1.031 | 0.828 | 1.969 | 20% | 90 |
Questions to ask
- PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
- PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 2-star overall rating.
- CMS reports a 2-star health inspection rating.
- CMS reports a 4-star staffing rating.
- CMS reports a 3-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
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Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Health deficiencies and facility history
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
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Ownership parties, organization connections, and ownership history
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.