Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.66 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceFacility record
MENNONITE MEMORIAL HOME has 60 certified beds in BLUFFTON, Ohio. The CMS overall rating is 3 of 5, compared with the Ohio average of 3.2. The CMS health inspection rating is 3 of 5, compared with the Ohio average of 2.8. The CMS staffing rating is 4 of 5. The latest standard health survey on Nov 18, 2024 lists 11 deficiencies, compared with the Ohio average of 6.6. Total nurse staffing is 4.02 hours per resident day in 2026Q1, compared with the Ohio average of 3.69.
Nearby facilities
- WILLOW RIDGE OF MENNONITE HOME COMMUNITIES OF OHIO BLUFFTON
- CARECORE AT LIMA LIMA
- LIBERTY RETIREMENT COMMUNITY OF LIMA INC LIMA
- LIMA CONVALESCENT HOME LIMA
- LOST CREEK REHABILITATION AND NURSING CENTER LIMA
- ROSELAWN MANOR SPENCERVILLE
- SHAWNEE MANOR LIMA
- SPRINGS OF LIMA THE LIMA
- SPRINGVIEW MANOR LIMA
- VANCREST OF DELPHOS DELPHOS
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 366144.
At a glance
CMS research snapshot
CMS overall rating
3 of 5
CMS health inspection rating
3 of 5
CMS staffing rating
4 of 5
CMS quality-measure rating
4 of 5
CMS ownership-change history
No attached CMS ownership-change event.
These are CMS star ratings, not Trust Hub ratings. Missing evidence is shown as not reported, not as zero.
Quality & care evidence
What CMS reports about quality
- MDS quality observations are in the CMS extract.
- PBJ staffing records are in the CMS extract.
- Inspection evidence is in the CMS extract.
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
- BRETHREN RETIREMENT COMMUNITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
Operators
- NICKLES, LANCEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- WOODRUFF, DAVIDIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- NICKLES, LANCEIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
- WOODRUFF, DAVIDIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
Enrollment organizations
- MENNONITE MEMORIAL HOMEOrganization · CURRENTMedicare-enrolled legal organization
- MENNONITE MEMORIAL HOMEOrganization · UNKNOWNMedicare-enrolled legal organization
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
- BRETHREN RETIREMENT COMMUNITYOrganization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST100% 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
- STALE · source as of 2026-08-01
- nursing-home-provider-information
- STALE · 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 2026-11-04. 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 ratings and facility records are read
- CMS certified beds
- 60
- Ownership descriptor
- Non profit - Church related
- 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
- 4193581015Verified 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 1831907005 · enrollment O20120521000433
- NPI 1831907005 · enrollment O20120521000433
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): 93.814433
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 96.226415
- Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 8.762887 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who have depressive symptoms (Long Stay): 0.000000
- Percentage of long-stay residents who lose too much weight (Long Stay): 2.597403
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 17.419355
- Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 7.079646 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who were physically restrained (Long Stay): 2.061856
- Percentage of long-stay residents whose ability to walk independently worsened (Long Stay): 10.563650 · 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): 12.751678 · 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): 1.313739 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a urinary tract infection (Long Stay): 2.590674 · 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): 22.990420
- Percentage of long-stay residents with pressure ulcers (Long Stay): 2.995386 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 83.435583
- Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 3.191489 · 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): 47.222222
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 Nov 18, 2024 cited 11 deficiencies.
View inspection evidenceOwnership
CMS-published records list 18 ownership or control parties.
View ownership evidenceOwnership & operation
Ownership & Operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
- Ownership type
- Non profit - Church relatedCMS
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 1 CMS-reported ownership organization
- CMS reports 15 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
- 18
- Organizations shown
- 3
- Individuals shown
- 15
- Latest ownership source update
- Aug 17, 2026
CMS-published ownership and control parties
BRETHREN RETIREMENT COMMUNITY
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Dec 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across OH.
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
BRETHREN RETIREMENT COMMUNITY
Organization · ADP OF THE SNF
Association date reported to CMS: Dec 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across OH.
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
NICKLES, LANCE
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 15, 2024
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
WOODRUFF, DAVID
Individual · ADP OF THE SNF
Association date reported to CMS: Dec 31, 2024
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
ALLREAD, KARA
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
ARNOLD, MATTHEW
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
KELLER, LORI
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
KEPLER, DAVID
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
MAURER, REBECCA
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
NORTH, STEVEN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
POLHAMUS, MARJORIE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
SHETLER, DAVID
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
SUBLER, JEFF
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
WARNER, JOHN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Dec 31, 2024
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
WARNER, JOHN
Individual · CORPORATE OFFICER
Association date reported to CMS: Dec 31, 2024
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
NICKLES, LANCE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 15, 2024
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
WOODRUFF, DAVID
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 31, 2024
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
MENNONITE MEMORIAL HOME
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 1 across OH.
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.
Questions to ask
- CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
- CMS records connect MENNONITE MEMORIAL HOME to 2 facilities. Which policies and staffing decisions are managed centrally versus locally?
Inspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- Jun 3, 2025
- Survey type
- Health Complaint
- Linked findings
- 2
- 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
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:98226:ccn:366144
Jun 3, 2025 — 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 (Jun 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274249:ccn:366144
F0677 — Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity 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 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274248:ccn:366144
Nov 18, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Nov 18, 2024 — Health Standard — 11 linked findings
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274238:ccn:366144
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 C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has plan of correction (Dec 16, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274247:ccn:366144
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 (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274239:ccn:366144
F0661 — Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274240:ccn:366144
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 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274241:ccn:366144
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 (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274242:ccn:366144
F0693 — Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274243:ccn:366144
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274244:ccn:366144
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 (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274245:ccn:366144
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 (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274237:ccn:366144
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 18, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274246:ccn:366144
Apr 15, 2024 — Health Complaint — 3 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 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 6, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274256:ccn:366144
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 (May 6, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274257:ccn:366144
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 (May 6, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274258:ccn:366144
Nov 14, 2023 — Health Complaint — 1 linked finding
F0727 — Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 (Nov 17, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274259:ccn:366144
Sep 21, 2023 — 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: Past Non-Compliance (Sep 8, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274260:ccn:366144
Aug 8, 2022 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Aug 8, 2022 — Health Standard — 6 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 (Aug 25, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274250:ccn:366144
F0677 — Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274251:ccn:366144
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 25, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274252:ccn:366144
F0759 — Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274253:ccn:366144
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 (Aug 25, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274254:ccn:366144
F0773 — Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274255:ccn:366144
Aug 29, 2019 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Aug 29, 2019 — Health Standard — 5 linked findings
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 D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 18, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274261:ccn:366144
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 (Oct 18, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274262:ccn:366144
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 (Oct 18, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274263:ccn:366144
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 18, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274264:ccn:366144
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 18, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 366144
- Source record locator
- csv-row:274265:ccn:366144
Tags appearing across inspections
- F0550 appears in 2 linked inspections.
- F0600 appears in 2 linked inspections.
- F0657 appears in 2 linked inspections.
- F0677 appears in 2 linked inspections.
- F0686 appears in 2 linked inspections.
- F0758 appears in 2 linked inspections.
- F0760 appears in 2 linked inspections.
- F0761 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Questions generated from the evidence above
- CMS records show F0550 in 2 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 F0657 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0677 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0686 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0758 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0760 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0761 in 2 inspections in the available record. What changes has the facility made to address this issue?
Facility history
Facility History
7 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded2 deficiencies were recorded.
2025
- Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2024
- Health inspection completed
11 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2023
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
2022
- Health inspection completed
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2019
- Health inspection completed
5 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
- 4.021 reported hours per resident day
- RN categories
- 0.663 reported hours per resident day
- LPN/LVN categories
- 0.978 reported hours per resident day
- CNA
- 2.36 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 4.199 | 3.583 |
| RN categories | 0.766 | 0.409 |
Contract staff accounted for 13.9% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.087 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 | 3.878 | 0.558 | 1.014 | 2.278 | 16.2% | 91 |
| 2025Q3 | 3.998 | 0.602 | 1.034 | 2.349 | 20.3% | 92 |
| 2025Q4 | 4.042 | 0.576 | 1.092 | 2.354 | 14.5% | 92 |
| 2026Q1 | 4.021 | 0.663 | 0.978 | 2.36 | 13.9% | 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 3-star overall rating.
- CMS reports a 3-star health inspection rating.
- CMS reports a 4-star staffing rating.
- CMS reports a 4-star quality-measure rating.
Trust participation
See something that needs correction?
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Suggest a correctionReport a source-data concernRepresent this facility? Submit a representation claim
Representation claims are reviewed manually. Live profile-management tools are not yet enabled for this facility.
How corrections workSource register
See where this record came from
Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Overview, facility facts, and CMS ratings
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
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 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.
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.