Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 1.09 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk about this facility
CMS nursing home
OAKLAND PARK COMMUNITIES, INC.
THIEF RIVER FALLS, MN
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 245592.
At a glance
CMS research snapshot
CMS overall rating
1 of 5 CMS stars1/5CMS health inspection rating
2 of 5 CMS stars2/5CMS staffing rating
4 of 5 CMS stars4/5CMS quality-measure rating
1 of 5 CMS stars1/5CMS 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
- BIRCHEM, JAMESIndividual owner5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
- BIRCHEM, JAMESIndividual owner5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
- BIRCHEM, KATHLEENIndividual owner5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
- BIRCHEM, KATHLEENIndividual owner5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
Operators
No resolved CMS/PECOS relationships in this category.
Managers
- CASTILLON, ADINAIndividual owner · CURRENTW-2 MANAGING EMPLOYEE
- CASTILLON, ADINAIndividual owner · CURRENTW-2 MANAGING EMPLOYEE
- CASTILLON, ADINAIndividual owner · UNKNOWNW-2 MANAGING EMPLOYEE
- CASTILLON, ADINAIndividual owner · UNKNOWNW-2 MANAGING EMPLOYEE
Enrollment organizations
- OAKLAND PARK COMMUNITIES, INCOrganization · CURRENTMedicare-enrolled legal organization
- OAKLAND PARK COMMUNITIES, INCOrganization · UNKNOWNMedicare-enrolled legal organization
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
- BIRCHEM, JAMESIndividual owner · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
- BIRCHEM, JAMESIndividual owner · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
- BIRCHEM, KATHLEENIndividual owner · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST50% ownership interest
- BIRCHEM, KATHLEENIndividual owner · 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
- 35
- Ownership descriptor
- For profit - Individual
- 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
- 2186811675Verified 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.
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 1588652259 · enrollment O20070717000249
- NPI 1588652259 · enrollment O20070717000249
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): 100.000000
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 97.058824
- Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 4.838710 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who have depressive symptoms (Long Stay): 3.603604
- Percentage of long-stay residents who lose too much weight (Long Stay): 4.597701
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 8.888889
- Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 23.958333 · 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): 25.819185 · 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): 34.567901 · 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): 3.144902 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a urinary tract infection (Long Stay): 7.563025 · 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): 23.319070
- Percentage of long-stay residents with pressure ulcers (Long Stay): 2.760970 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 87.878788
- Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 2.777778 · 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): 9
Fire-safety citations
CMS fire-safety citations
These are fire-safety citations, not health deficiencies and not a count of fires.
- 2025-12-31 · tag 0226 · scope/severity F — Have horizontal exits used in accordance with safety requirements.
- 2025-12-31 · tag 0920 · scope/severity D — Ensure proper usage of power strips and extension cords.
- 2025-12-31 · tag 0372 · scope/severity F — Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 2025-12-31 · tag 0712 · scope/severity F — Have simulated fire drills held at unexpected times.
- 2025-12-31 · tag 0353 · scope/severity F — Inspect, test, and maintain automatic sprinkler systems.
- 2025-12-31 · tag 0291 · scope/severity D — Install emergency lighting that can last at least 1 1/2 hours.
- 2025-12-31 · tag 0346 · scope/severity D — Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 2025-12-31 · tag 0354 · scope/severity D — Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 2025-12-31 · tag 0912 · scope/severity D — Have power receptacles that are properly grounded.
- 2025-12-31 · tag 0918 · scope/severity D — Have generator or other power source capable of supplying service within 10 seconds.
- 2025-12-31 · tag 0761 · scope/severity F — To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 2025-01-30 · tag 0015 · scope/severity F — Address subsistence needs for staff and patients.
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 Dec 31, 2025 cited 5 deficiencies.
View inspection evidenceOwnership
CMS-published records list 11 ownership or control parties.
View ownership evidenceEnforcement record
CMS records show a $26,685 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 - IndividualCMS
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 10 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
- 1
- Individuals shown
- 10
- Latest ownership source update
- Aug 17, 2026
CMS-published ownership and control parties
BIRCHEM, JAMES
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Mar 1, 2017
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
BIRCHEM, KATHLEEN
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Mar 1, 2007
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
BIRCHEM, JAMES
Individual · CORPORATE DIRECTOR
Association date reported to CMS: May 31, 2007
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
BIRCHEM, KATHLEEN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: May 31, 2007
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
CASTILLON, ADINA
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jan 30, 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
BIRCHEM, JAMES
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Mar 1, 2017
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
BIRCHEM, KATHLEEN
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Mar 1, 2007
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
BIRCHEM, JAMES
Individual · CORPORATE DIRECTOR
Association date reported to CMS: May 31, 2007
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
BIRCHEM, KATHLEEN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: May 31, 2007
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
CASTILLON, ADINA
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jan 30, 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
OAKLAND PARK COMMUNITIES, INC
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
What this means
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Inspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- Feb 19, 2026
- Survey type
- Health Complaint
- Linked findings
- 3
- Highest linked CMS classification
- G — Isolated; Actual harm that is not immediate jeopardy
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:68006:ccn:245592
Feb 19, 2026 — Health Complaint — 3 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 (Mar 16, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190072:ccn:245592
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 (Jan 26, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190071:ccn:245592
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
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 16, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190073:ccn:245592
Dec 31, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 31, 2025 — Health Standard — 5 linked findings
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 date of correction (Jan 31, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190074:ccn:245592
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 date of correction (Jan 31, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190075:ccn:245592
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 (Jan 31, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190076:ccn:245592
F0881 — Infection Control Deficiencies
Implement a program that monitors antibiotic use.
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 31, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190077:ccn:245592
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 (Jan 31, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190078:ccn:245592
Jul 17, 2025 — Health Complaint — 1 linked finding
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 (Jul 2, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190079:ccn:245592
Jan 30, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jan 30, 2025 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jan 30, 2025 — Health Standard — 12 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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190085:ccn:245592
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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190086:ccn:245592
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190087:ccn:245592
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 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190088:ccn:245592
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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190080:ccn:245592
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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190089:ccn:245592
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 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190091:ccn:245592
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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190092:ccn:245592
F0851 — Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190081:ccn:245592
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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190082:ccn:245592
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190083:ccn:245592
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 (Feb 28, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190084:ccn:245592
Mar 21, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Mar 21, 2024 — Health Standard — 7 linked findings
F0637 — Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 17, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190096:ccn:245592
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 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190097:ccn:245592
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 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190098:ccn:245592
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 (Apr 8, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190099:ccn:245592
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 (Apr 8, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190093:ccn:245592
F0883 — Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190094:ccn:245592
F0920 — Environmental Deficiencies
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
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 1, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:190095:ccn:245592
Tags appearing across inspections
- F0689 appears in 3 linked inspections.
- F0580 appears in 2 linked inspections.
- F0880 appears in 2 linked inspections.
- F0883 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Dec 30, 2025
Published fine amount: $26,685.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:7122:ccn:245592
Fine — Jul 17, 2025
Published fine amount: $17,345.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 245592
- Source record locator
- csv-row:7121:ccn:245592
Questions to ask
Questions generated from the evidence above
- CMS records show F0689 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0580 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 F0883 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Dec 30, 2025. What changes were made after that enforcement action?
Facility history
Facility History
9 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded3 deficiencies were recorded. That includes 1 higher-severity deficiency.
- RN staffing increasedRN staffing increased from 0.90 to 1.03 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
- Civil monetary penalty recordedCMS recorded a $26,685 civil monetary penalty.
2026
- Complaint inspection recorded
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
2025
- RN staffing increased
RN staffing increased from 0.90 to 1.03 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
0.90 → 1.03
CMS · Reported in a source release · View related evidence
- Health inspection completed
5 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $26,685 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $17,345 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
1 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Health inspection completed
12 deficiencies were recorded. That includes 1 higher-severity deficiency.
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
2024
- Health inspection completed
7 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).
- Total nursing
- 3.782 reported hours per resident day
- RN categories
- 1.09 reported hours per resident day
- LPN/LVN categories
- 0.193 reported hours per resident day
- CNA
- 1.825 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 4.019 | 3.194 |
| RN categories | 1.303 | 0.562 |
Contract staff accounted for 4.4% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.065 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 | 3.867 | 0.912 | 0.355 | 2.081 | 0% | 91 |
| 2025Q3 | 3.793 | 0.9 | 0.37 | 1.859 | 2.1% | 92 |
| 2025Q4 | 3.799 | 1.025 | 0.267 | 1.933 | 4.5% | 92 |
| 2026Q1 | 3.782 | 1.09 | 0.193 | 1.825 | 4.4% | 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 1-star overall rating.
- CMS reports a 2-star health inspection rating.
- CMS reports a 4-star staffing rating.
- CMS reports a 1-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.
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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
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
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
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.
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