Staffing
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.30 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceCMS 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
- 78
- Ownership descriptor
- For profit - Limited Liability company
- 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
- 4177369332Verified public information · checked Aug 2026
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 Apr 21, 2025 cited 20 deficiencies.
View inspection evidenceOwnership
CMS-published records list 16 ownership or control parties.
View ownership evidenceChain context
CMS groups this facility with a chain covering 56 facilities across 2 states or territories.
View chain evidenceEnforcement record
CMS records show a 84-day payment denial 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 - Limited Liability companyCMS
- Chain
- JAMES & JUDY LINCOLNCMS identifies this facility as part of the JAMES & JUDY LINCOLN chain.
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 15 individual ownership interests
- a CMS chain / common-control group
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
- 16
- Organizations shown
- 1
- Individuals shown
- 15
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
LINCOLN, JAMES
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2001
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
LINCOLN, JUDY
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2001
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
BYSOR, BRANDON
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Apr 25, 2022
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
CRANE, GARY
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Oct 11, 2011
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
STUTTS, CHARLOTTE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Oct 11, 2011
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
DRAKE, TIMOTHY
Individual · CORPORATE OFFICER
Association date reported to CMS: Apr 25, 2022
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
STUTTS, CHARLOTTE
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 11, 2011
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
MANESS, BARBARA
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Mar 6, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
LINCOLN, JAMES
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2001
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
LINCOLN, JUDY
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Aug 1, 2001
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
BYSOR, BRANDON
Individual · CORPORATE DIRECTOR
Published ownership percentage: 50%
Association date reported to CMS: Apr 25, 2022
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
STUTTS, CHARLOTTE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Oct 11, 2011
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
DRAKE, TIMOTHY
Individual · CORPORATE OFFICER
Published ownership percentage: 50%
Association date reported to CMS: Apr 25, 2022
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
STUTTS, CHARLOTTE
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 11, 2011
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
MANESS, BARBARA
Individual · W-2 MANAGING EMPLOYEE
Published ownership percentage: 100%
Association date reported to CMS: Mar 6, 2013
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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
N & R OF STRAFFORD, INC.
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across MO.
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
- Jul 27, 2026
- Retrieved
- Aug 15, 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.
Chain context
CMS groups this facility with JAMES & JUDY LINCOLN
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 290 is a grouping identifier, not a legal organization.
- Facilities
- 56
- States and territories
- 2
- Average overall rating
- 2.4
- Average staffing rating
- 2.2
- Average total nurse HPRD
- 3.1
- Total fines
- 31
CMS-published history
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 56 | 2.4 | 2.2 |
| Mon Jun | 56 | 2.4 | 2.1 |
| Fri May | 56 | 2.4 | 2.1 |
| Wed Apr | 56 | 2.5 | 2.1 |
| Sun Mar | 58 | 2.5 | 2.1 |
| Sun Feb | 58 | 2.5 | 2.1 |
Questions to ask
- CMS groups facilities in 2 states or territories under this chain. Which operational policies are set at the chain level?
- CMS reports 31 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & 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 26, 2026
- Survey type
- Health Complaint
- Linked findings
- 8
- Highest linked CMS classification
- D — Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:72920:ccn:265656
Mar 26, 2026 — Health Complaint — 8 linked findings
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205029:ccn:265656
F0558 — Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each 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 (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205030:ccn:265656
F0559 — Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205031:ccn:265656
F0561 — Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205028:ccn:265656
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 (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205032:ccn:265656
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 (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205033:ccn:265656
F0804 — Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205027:ccn:265656
F0925 — Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 22, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205034:ccn:265656
Feb 25, 2026 — Health Complaint — 2 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 (Apr 10, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205035:ccn:265656
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 (Apr 10, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205036:ccn:265656
Jan 5, 2026 — Health Complaint — 2 linked findings
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 13, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205037:ccn:265656
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 13, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205038:ccn:265656
Dec 12, 2025 — Health Complaint — 1 linked finding
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity 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 (Jan 23, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205039:ccn:265656
Dec 11, 2025 — Health Complaint — 2 linked findings
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Past Non-Compliance (Sep 16, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205040:ccn:265656
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 (Jan 23, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205041:ccn:265656
Dec 10, 2025 — Health Complaint — 4 linked findings
F0583 — Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
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 23, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205042:ccn:265656
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 23, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205043:ccn:265656
F0805 — Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual 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 (Jan 23, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205044:ccn:265656
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 (Jan 23, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205045:ccn:265656
May 20, 2025 — Health Complaint — 1 linked finding
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity 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 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205066:ccn:265656
May 2, 2025 — Health Complaint — 3 linked findings
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 16, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205068:ccn:265656
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 (Jun 16, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205069:ccn:265656
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 16, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205067:ccn:265656
Apr 21, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 21, 2025 — Health Standard — 20 linked findings
F0607 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205052:ccn:265656
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 (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205053:ccn:265656
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205054:ccn:265656
F0623 — Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205055:ccn:265656
F0625 — Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205056:ccn:265656
F0644 — Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205061:ccn:265656
F0658 — Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205062:ccn:265656
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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205057:ccn:265656
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 (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205063:ccn:265656
F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management 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 (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205064:ccn:265656
F0700 — Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205058:ccn:265656
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205065:ccn:265656
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 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 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205046:ccn:265656
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 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 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205047:ccn:265656
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205048:ccn:265656
F0865 — Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205049:ccn:265656
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 (Jul 10, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205050:ccn:265656
F0881 — Infection Control Deficiencies
Implement a program that monitors antibiotic use.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205059:ccn:265656
F0882 — Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205051:ccn:265656
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 (Jun 4, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205060:ccn:265656
Feb 6, 2025 — Health Complaint — 3 linked findings
F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205070:ccn:265656
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205071:ccn:265656
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205072:ccn:265656
Dec 11, 2024 — Health Complaint — 1 linked finding
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 3, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205073:ccn:265656
Oct 31, 2024 — Health Complaint — 2 linked findings
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Dec 13, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205074:ccn:265656
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 13, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205075:ccn:265656
Oct 18, 2024 — Health Complaint — 7 linked findings
F0602 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205077:ccn:265656
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 (Dec 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205081:ccn:265656
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 (Dec 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205082:ccn:265656
F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205078:ccn:265656
F0726 — Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 2, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205076:ccn:265656
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205079:ccn:265656
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
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 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205080:ccn:265656
Jun 4, 2024 — 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 (Jul 5, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205089:ccn:265656
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 (Jul 5, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205090:ccn:265656
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 (Jul 5, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205091:ccn:265656
Apr 7, 2024 — Health Complaint — 4 linked findings
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 20, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205092:ccn:265656
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 (Jul 5, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205093:ccn:265656
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 (Jul 5, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205094:ccn:265656
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 (Jul 5, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205095:ccn:265656
Jul 12, 2023 — Health Complaint — 4 linked findings
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205096:ccn:265656
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 (Aug 25, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205097:ccn:265656
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 (Aug 25, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205098:ccn:265656
F0697 — Quality of Life and Care Deficiencies
Provide safe, appropriate pain management 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 (Aug 25, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205099:ccn:265656
Jun 29, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jun 29, 2023 — Health Standard — 6 linked findings
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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 20, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205084:ccn:265656
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity 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 20, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205085:ccn:265656
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 (Aug 20, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205087:ccn:265656
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205088:ccn:265656
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 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 20, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205086:ccn:265656
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 (Aug 20, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:205083:ccn:265656
Feb 13, 2020 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Tags appearing across inspections
- F0609 appears in 6 linked inspections.
- F0684 appears in 6 linked inspections.
- F0610 appears in 4 linked inspections.
- F0697 appears in 4 linked inspections.
- F0550 appears in 3 linked inspections.
- F0580 appears in 3 linked inspections.
- F0686 appears in 3 linked inspections.
- F0760 appears in 3 linked inspections.
- F0842 appears in 3 linked inspections.
- F0600 appears in 2 linked inspections.
- F0688 appears in 2 linked inspections.
- F0755 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Payment Denial — Oct 18, 2024
Payment denial length: 84 days
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:7983:ccn:265656
Fine — Oct 18, 2024
Published fine amount: $52,456.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 265656
- Source record locator
- csv-row:7982:ccn:265656
Questions to ask
Questions generated from the evidence above
- CMS records show F0609 in 6 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0684 in 6 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0610 in 4 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0697 in 4 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0550 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0580 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0686 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0760 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0842 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0600 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0688 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0755 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Oct 18, 2024. What changes were made after that enforcement action?
Facility history
Facility History
23 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded8 deficiencies were recorded.
- Total nurse staffing decreasedTotal nurse staffing decreased from 3.38 to 3.15 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
2026
- Complaint inspection recorded
8 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- Total nurse staffing decreased
Total nurse staffing decreased from 3.38 to 3.15 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
3.38 → 3.15
CMS · Reported in a source release · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Total nurse staffing decreased
Total nurse staffing decreased from 3.86 to 3.38 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
3.86 → 3.38
CMS · Reported in a source release · View related evidence
- RN staffing decreased
RN staffing decreased from 0.56 to 0.38 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
0.56 → 0.38
CMS · Reported in a source release · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Health inspection completed
20 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 1 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
- 3.155 reported hours per resident day
- RN categories
- 0.297 reported hours per resident day
- LPN/LVN categories
- 0.606 reported hours per resident day
- CNA
- 1.872 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.284 | 2.839 |
| RN categories | 0.332 | 0.21 |
Contract staff accounted for 32.3% of reported nursing hours included in this quarter calculation.
PBJ reports zero combined RN-category hours on 1 day with a positive MDS census in this quarter.
Reported RN-category hours per resident day were 0.025 lower 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 | 3.857 | 0.555 | 0.585 | 2.197 | 58.9% | 91 |
| 2025Q3 | 3.379 | 0.379 | 0.605 | 1.943 | 32.9% | 92 |
| 2025Q4 | 3.147 | 0.322 | 0.553 | 1.806 | 31.7% | 92 |
| 2026Q1 | 3.155 | 0.297 | 0.606 | 1.872 | 32.3% | 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 1-star health inspection rating.
- CMS reports a 1-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.
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Source register
See where this record came from
Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Health deficiencies and facility history
Penalties
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- g6vv-u9sr
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 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
- Jul 1, 2026
- Retrieved
- Aug 15, 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
- Jul 27, 2026
- Retrieved
- Aug 15, 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
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Nursing Home Chain Performance Measures
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 97ecfad1-d3f1-4d42-b774-d74661d830bc
- Coverage
- Wed Jul
- Source updated
- Aug 12, 2026
- Retrieved
- Aug 16, 2026
- Supports
- CMS chain context, performance, and monthly history
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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