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CMS nursing home

THE NORTH SHORE ESTATES LLC

DULUTH, MN

CMS CCN 2454832186282341Listed 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 245483.

At a glance

CMS research snapshot

CMS overall rating

2 of 5 CMS stars

CMS health inspection rating

2 of 5 CMS stars

CMS staffing rating

4 of 5 CMS stars

CMS quality-measure rating

2 of 5 CMS stars

CMS ownership-change history

No attached CMS ownership-change event.

These are CMS star ratings, not Trust Hub ratings. Missing evidence is shown as not reported, not as zero.

Quality & care evidence

What CMS reports about quality

  • MDS quality observations: 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

  • AREM, JEFFREYIndividual owner5% OR GREATER DIRECT OWNERSHIP INTEREST14% ownership interest
  • HALPERT, MARCIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST23% ownership interest
  • HML LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST12% ownership interest
  • JAFFA, NOAMIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST14% ownership interest
  • LEGUM, JOSHUAIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST23% ownership interest
  • MUENCZ, JEFFREYIndividual owner5% OR GREATER INDIRECT OWNERSHIP INTEREST12% ownership interest
  • NIJ LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST14% ownership interest
  • SPARTAN HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST23% ownership interest
  • STERN, WILLIAMIndividual owner5% OR GREATER DIRECT OWNERSHIP INTEREST15% ownership interest
  • YAZOMA HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST23% ownership interest

Operators

  • MONARCH HEALTHCARE OPERATING IV LLCOrganization · CURRENTOPERATIONAL/MANAGERIAL CONTROL
  • MONARCH HEALTHCARE OPERATING IV LLCOrganization · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL

Managers

  • LEGUM, JOSHUAIndividual owner · CURRENTW-2 MANAGING EMPLOYEE
  • LEGUM, JOSHUAIndividual owner · UNKNOWNW-2 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

  • AREM, JEFFREYIndividual owner · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST14% ownership interest
  • HALPERT, MARCIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST23% ownership interest
  • HML LLCOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST12% ownership interest
  • JAFFA, NOAMIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST14% ownership interest
  • LEGUM, JOSHUAIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST23% ownership interest
  • MUENCZ, JEFFREYIndividual owner · UNKNOWN5% OR GREATER INDIRECT OWNERSHIP INTEREST12% ownership interest
  • NIJ LLCOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST14% ownership interest
  • SPARTAN HEALTHCARE LLCOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST23% ownership interest
  • STERN, WILLIAMIndividual owner · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST15% ownership interest
  • YAZOMA HOLDINGS, LLCOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST23% 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

CMS overall

2 of 5 CMS stars

Health inspection

2 of 5 CMS stars

Staffing

4 of 5 CMS stars

Quality-measure

2 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
70
Ownership descriptor
For profit - Partnership
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
2186282341Verified public information · checked Aug 2026

CMS designations

Special Focus and abuse-icon status

This CMS Certification Number appears in the latest CMS Nursing Home Provider Information extract of currently listed nursing homes.

Not currently SFF or candidate

CMS does not currently identify this nursing home as a Special Focus Facility or candidate in the loaded Provider Information extract.

CMS field value: (blank). Observed Aug 1, 2026.

CMS abuse-icon designation

CMS does not currently apply its abuse-icon designation to this facility in the loaded Provider Information extract.

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

MDS quality measures

Individual CMS quality measures

These MDS quality measures are individual CMS-published scores. They are not the CMS quality-measure star rating.

MDS source release 2026-08-01.

View individual MDS measures
  • Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (Long Stay): 99.530516
  • Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 100.000000
  • Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 2.347418 · CMS uses this measure in the quality-measure star rating
  • Percentage of long-stay residents who have depressive symptoms (Long Stay): 6.629834
  • Percentage of long-stay residents who lose too much weight (Long Stay): 5.142857
  • Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 22.727273
  • Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 14.754098 · 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): 26.012431 · 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): 16.374269 · 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): 7.506665 · CMS uses this measure in the quality-measure star rating
  • Percentage of long-stay residents with a urinary tract infection (Long Stay): 2.358491 · 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): 28.651067
  • Percentage of long-stay residents with pressure ulcers (Long Stay): 5.171843 · CMS uses this measure in the quality-measure star rating
  • Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 100.000000
  • Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 0.000000 · 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): 96.078431

Fire-safety citations

CMS fire-safety citations

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

  • 2026-02-12 · tag 0211 · scope/severity F — Keep aisles, corridors, and exits free of obstruction in case of emergency.
  • 2026-02-12 · tag 0741 · scope/severity F — Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
  • 2026-02-12 · tag 0345 · scope/severity D — Have approved installation, maintenance and testing program for fire alarm systems.
  • 2026-02-12 · tag 0355 · scope/severity D — Properly select, install, inspect, or maintain portable fire extinguishes.
  • 2026-02-12 · tag 0753 · scope/severity D — Have restrictions on the use of highly flammable decorations.
  • 2026-02-12 · tag 0225 · scope/severity C — Have stairways and smokeproof enclosures used as exits that meet safety requirements.
  • 2025-03-20 · tag 0353 · scope/severity F — Inspect, test, and maintain automatic sprinkler systems.
  • 2025-03-20 · tag 0372 · scope/severity F — Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
  • 2025-03-20 · tag 0541 · scope/severity F — Install properly constructed and protected linen or trash chutes.
  • 2025-03-20 · tag 0712 · scope/severity F — Have simulated fire drills held at unexpected times.
  • 2025-03-20 · tag 0741 · scope/severity F — Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
  • 2025-03-20 · 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 0.62 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership & operation

Ownership & Operation

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

Ownership type
For profit - PartnershipCMS

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • 4 CMS-reported ownership organizations
  • 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
14
Organizations shown
5
Individuals shown
9
Latest ownership source update
Aug 1, 2026

CMS-published ownership and control parties

  • AREM, JEFFREY

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 14%

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • HML LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 12%

    Association date reported to CMS: Jul 1, 2016

    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
  • NIJ LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 14%

    Association date reported to CMS: Jul 1, 2016

    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 DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 23%

    Association date reported to CMS: Jul 1, 2016

    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 DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 15%

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • YAZOMA HOLDINGS, LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 23%

    Association date reported to CMS: Jul 1, 2016

    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

    Published ownership percentage: 23%

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • JAFFA, NOAM

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 14%

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • LEGUM, JOSHUA

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 23%

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • MUENCZ, JEFFREY

    Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Published ownership percentage: 12%

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • HALPERT, MARC

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • STERN, WILLIAM

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jul 1, 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
    View official CMS source
  • MONARCH HEALTHCARE OPERATING IV LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jul 1, 2016

    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 · W-2 MANAGING EMPLOYEE

    Association date reported to CMS: Jul 1, 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
    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?

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
Feb 12, 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
245483
Source record locator
csv-row:67362:ccn:245483
View official CMS source
Feb 12, 2026 — Fire Safety Standard — 0 linked findings

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

Feb 12, 2026 — Health Standard — 10 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 (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188845:ccn:245483
    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 date of correction (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188839:ccn:245483
    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 date of correction (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188846:ccn:245483
    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 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 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188847:ccn:245483
    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 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 (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188840:ccn:245483
    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 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 (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188841:ccn:245483
    View official CMS source
  • 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 (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188842:ccn:245483
    View official CMS source
  • F0809 — Nutrition and Dietary Deficiencies

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    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 (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188843:ccn:245483
    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 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 (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188844:ccn:245483
    View official CMS source
  • F0880 — Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

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

    Correction status: Deficient, Provider has date of correction (Mar 18, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188838:ccn:245483
    View official CMS source
Mar 20, 2025 — Fire Safety Standard — 0 linked findings

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

Mar 20, 2025 — Health Standard — 6 linked findings
  • 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 (Apr 9, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188849:ccn:245483
    View official CMS source
  • F0660 — Resident Assessment and Care Planning Deficiencies

    Plan the resident's discharge to meet the resident's goals and needs.

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

    Correction status: Deficient, Provider has date of correction (Apr 9, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188850:ccn:245483
    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 9, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188851:ccn:245483
    View official CMS source
  • F0757 — Pharmacy Service Deficiencies

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

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

    Correction status: Deficient, Provider has date of correction (Apr 9, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188852:ccn:245483
    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 9, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188853:ccn:245483
    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 (Apr 9, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188848:ccn:245483
    View official CMS source
Feb 1, 2024 — Fire Safety Standard — 0 linked findings

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

Feb 1, 2024 — Health Standard — 8 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 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188857:ccn:245483
    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 date of correction (Feb 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188858:ccn:245483
    View official CMS source
  • F0695 — Quality of Life and Care Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Feb 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188859:ccn:245483
    View official CMS source
  • F0698 — Quality of Life and Care Deficiencies

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

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

    Correction status: Deficient, Provider has date of correction (Feb 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188860:ccn:245483
    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 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 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188855:ccn:245483
    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 (Feb 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188856:ccn:245483
    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 (Feb 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188861:ccn:245483
    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 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 (Feb 22, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Aug 1, 2026
    CMS provider ID
    245483
    Source record locator
    csv-row:188854:ccn:245483
    View official CMS source

Tags appearing across inspections

  • F0880 appears in 3 linked inspections.
  • F0554 appears in 2 linked inspections.
  • F0761 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

No penalty records were found for this provider in the currently loaded CMS Penalties dataset.

Questions to ask

Questions generated from the evidence above

  • CMS records show F0880 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0554 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0761 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

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

What changed recently?

  • Health inspection completed10 deficiencies were recorded.

2026

  1. Health inspection completed

    10 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2025

  1. Health inspection completed

    6 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Health inspection completed

    8 deficiencies were recorded.

    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
3.151
reported hours per resident day
RN categories
0.62
reported hours per resident day
LPN/LVN categories
0.47
reported hours per resident day
CNA
1.628
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing3.2822.83
RN categories0.7110.395

Contract staff accounted for 1.7% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.083 lower than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q23.2210.7730.4091.5696.7%91
2025Q33.250.6840.4781.6398.3%92
2025Q43.2640.7030.4571.6644.9%92
2026Q13.1510.620.471.6281.7%90

Questions to ask

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

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

View official CMS PBJ 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 2-star overall rating.
  • CMS reports a 2-star health inspection rating.
  • CMS reports a 4-star staffing rating.
  • CMS reports a 2-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
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
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.