REGENCY REDMOND REHABILITATION AND NURSING CENTER

REDMOND, OR

CMS provider ID 385230CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

5 of 5 CMS stars

Health inspection

4 of 5 CMS stars

Staffing

5 of 5 CMS stars

Quality-measure

5 of 5 CMS stars

No proprietary TrustHub score. These ratings are published separately by CMS.

How CMS describes these ratings
CMS overall rating
The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
Health inspection rating
The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
Staffing rating
The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
Quality-measure rating
The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
CMS certified beds
50
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
5415485066CMS Provider Information

Decision guide

What to review

Factual evidence to examine before you decide. These summaries are not a score or recommendation.

Staffing

CMS publishes a 5-star staffing rating for this facility.

RN staffing was 1.48 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Chain context

CMS groups this facility with a chain covering 27 facilities across 3 states or territories.

View chain 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
REGENCY PACIFIC MANAGEMENTCMS identifies this facility as part of the REGENCY PACIFIC MANAGEMENT chain.
Related facilities
9Current CMS organization identity

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • 2 CMS-reported ownership organizations
  • CMS reports 19 individual ownership interests
  • a CMS chain / common-control group

Related facilities

9 currently connected nursing homes share this CMS organization identity with BD FACILITIES LLC.

Average CMS overall rating
4.1 stars across 9 reporting facilities
CMS monetary penalties
4 of 9 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
0 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
0 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
6 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$297,273

These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.

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
32
Organizations shown
13
Individuals shown
19
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • BD FACILITIES LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Mar 1, 2019

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • BD FACILITIES LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jul 5, 2025

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • BEDDOE, MARVIN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 1, 2016

    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
    View official CMS source
  • BEDDOE, SANDRA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 1, 2016

    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
    View official CMS source
  • OMNICARE LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Sep 1, 2013

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • RAPP, ANDREW

    Individual · ADP OF THE SNF

    Association date reported to CMS: Mar 8, 2016

    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
    View official CMS source
  • REGENCY PACIFIC MANAGEMENT LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Aug 26, 2025

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • STAUFFER, GRETCHEN

    Individual · ADP OF THE SNF

    Association date reported to CMS: May 16, 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
    View official CMS source
  • SUAREZ, YOLANDA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 1, 2026

    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
    View official CMS source
  • BEDDOE, MARVIN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jun 1, 2016

    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
    View official CMS source
  • RAPP, ANDREW

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Mar 8, 2016

    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
    View official CMS source
  • REGENCY PACIFIC MANAGEMENT LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2010

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • STAUFFER, GRETCHEN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: May 16, 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
    View official CMS source
  • SUAREZ, YOLANDA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 1, 2026

    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
    View official CMS source
  • BD FACILITIES LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 100%

    Association date reported to CMS: Mar 1, 2019

    Other facilities connected through this exact CMS organization identity: 8 across OR, WA.

    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
    View official CMS source
  • BEDDOE, MARVIN

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Published ownership percentage: 98.5%

    Association date reported to CMS: Mar 1, 2009

    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
    View official CMS source
  • BD FACILITIES LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jul 5, 2025

    Other facilities connected through this exact CMS organization identity: 8 across OR, WA.

    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
    View official CMS source
  • BEDDOE, MARVIN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 1, 2016

    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
    View official CMS source
  • BEDDOE, SANDRA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 1, 2016

    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
    View official CMS source
  • Individual name not published by CMS

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jul 8, 2025

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • Individual name not published by CMS

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jul 8, 2025

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source
  • OMNICARE LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Sep 1, 2013

    Other facilities connected through this exact CMS organization identity: 32 across IN, KY, MI, MS, ND, NY, OH, OR, PA, WA.

    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
    View official CMS source
  • RAPP, ANDREW

    Individual · ADP OF THE SNF

    Association date reported to CMS: Mar 8, 2016

    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
    View official CMS source
  • REGENCY PACIFIC MANAGEMENT LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Aug 26, 2025

    CMS classifications: Chain / home office, Management services company

    Other facilities connected through this exact CMS organization identity: 18 across HI, OR, WA.

    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
    View official CMS source
  • STAUFFER, GRETCHEN

    Individual · ADP OF THE SNF

    Association date reported to CMS: May 16, 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
    View official CMS source
  • SUAREZ, YOLANDA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 1, 2026

    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
    View official CMS source
  • BEDDOE, MARVIN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Published ownership percentage: 100%

    Association date reported to CMS: Jun 1, 2016

    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
    View official CMS source
  • RAPP, ANDREW

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Mar 8, 2016

    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
    View official CMS source
  • REGENCY PACIFIC MANAGEMENT LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Published ownership percentage: 100%

    Association date reported to CMS: Apr 1, 2010

    CMS classifications: Chain / home office, Management services company

    Other facilities connected through this exact CMS organization identity: 18 across HI, OR, WA.

    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
    View official CMS source
  • STAUFFER, GRETCHEN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: May 16, 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
    View official CMS source
  • SUAREZ, YOLANDA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 1, 2026

    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
    View official CMS source
  • BD REDMOND IV LLC

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 0 across OR.

    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
    View official CMS source

What this means

Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.

Questions to ask

  • CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
  • CMS records connect BD FACILITIES LLC to 9 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with REGENCY PACIFIC MANAGEMENT

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 442 is a grouping identifier, not a legal organization.

Facilities
27
States and territories
3
Average overall rating
4
Average staffing rating
4
Average total nurse HPRD
4.8
Total fines
20
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul2744
Mon Jun2743.9
Fri May273.83.9
Wed Apr263.83.8
Sun Mar273.64
Sun Feb273.74

Questions to ask

  • CMS groups facilities in 3 states or territories under this chain. Which operational policies are set at the chain level?
  • CMS reports 20 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 source

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
Jan 16, 2026
Survey type
Fire Safety Standard
Linked findings
0
Highest linked CMS classification
No linked health-deficiency finding in the loaded record
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Jul 1, 2026
CMS provider ID
385230
Source record locator
csv-row:104151:ccn:385230
View official CMS source
Jan 16, 2026Fire Safety Standard 0 linked findings

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

Jan 16, 2026Health Standard 6 linked findings
  • F0604Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

    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 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290700:ccn:385230
    View official CMS source
  • F0677Quality 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 (Jan 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290701:ccn:385230
    View official CMS source
  • F0679Quality of Life and Care Deficiencies

    Provide activities to meet all resident's 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 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290702:ccn:385230
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

    Correction status: Deficient, Provider has date of correction (Jan 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290703:ccn:385230
    View official CMS source
  • F0695Quality 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 (Jan 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290704:ccn:385230
    View official CMS source
  • F0699Quality of Life and Care Deficiencies

    Provide care or services that was trauma informed and/or culturally competent.

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

    Correction status: Deficient, Provider has date of correction (Jan 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290705:ccn:385230
    View official CMS source
Aug 16, 2024Fire Safety Standard 0 linked findings

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

Aug 16, 2024Health Complaint 0 linked findings

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

Aug 16, 2024Health Standard 9 linked findings
  • F0558Resident 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 (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290708:ccn:385230
    View official CMS source
  • F0585Resident Rights Deficiencies

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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

    Correction status: Deficient, Provider has date of correction (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290709:ccn:385230
    View official CMS source
  • F0656Resident 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 D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290711:ccn:385230
    View official CMS source
  • F0686Quality 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 (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290713:ccn:385230
    View official CMS source
  • F0699Quality of Life and Care Deficiencies

    Provide care or services that was trauma informed and/or culturally competent.

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

    Correction status: Deficient, Provider has date of correction (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290715:ccn:385230
    View official CMS source
  • F0727Nursing 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Past Non-Compliance (Apr 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290706:ccn:385230
    View official CMS source
  • F0758Pharmacy 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 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290716:ccn:385230
    View official CMS source
  • F0803Nutrition 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 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 (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290707:ccn:385230
    View official CMS source
  • F0883Infection Control Deficiencies

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

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

    Correction status: Deficient, Provider has date of correction (Oct 1, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290717:ccn:385230
    View official CMS source
Apr 7, 2023Fire Safety Standard 0 linked findings

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

Apr 7, 2023Health Standard 12 linked findings
  • F0553Resident Rights Deficiencies

    Allow resident to participate in the development and implementation of his or her person-centered plan of care.

    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 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290722:ccn:385230
    View official CMS source
  • F0609Freedom 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 (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290723:ccn:385230
    View official CMS source
  • F0610Freedom 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 (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290724:ccn:385230
    View official CMS source
  • F0658Resident Assessment and Care Planning Deficiencies

    Ensure services provided by the nursing facility meet professional standards of quality.

    CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290718:ccn:385230
    View official CMS source
  • F0677Quality 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 (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290725:ccn:385230
    View official CMS source
  • F0684Quality 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 (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290726:ccn:385230
    View official CMS source
  • F0686Quality 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 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290727:ccn:385230
    View official CMS source
  • F0730Nursing and Physician Services Deficiencies

    Observe each nurse aide's job performance and give regular training.

    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 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290728:ccn:385230
    View official CMS source
  • F0756Pharmacy Service Deficiencies

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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

    Correction status: Deficient, Provider has date of correction (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290729:ccn:385230
    View official CMS source
  • F0760Pharmacy Service Deficiencies

    Ensure that residents are free from significant medication errors.

    CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290719:ccn:385230
    View official CMS source
  • F0812Nutrition and Dietary Deficiencies

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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

    Correction status: Deficient, Provider has date of correction (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290720:ccn:385230
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

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

    Correction status: Deficient, Provider has date of correction (May 19, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    385230
    Source record locator
    csv-row:290721:ccn:385230
    View official CMS source

Tags appearing across inspections

  • F0677 appears in 2 linked inspections.
  • F0686 appears in 2 linked inspections.
  • F0699 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 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 F0699 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

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

What changed recently?

  • Total nurse staffing increasedTotal nurse staffing increased from 5.45 to 5.72 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
  • Health inspection completed6 deficiencies were recorded.

2026

  1. Total nurse staffing increased

    Total nurse staffing increased from 5.45 to 5.72 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.

    5.455.72

    CMS · Reported in a source release · View related evidence

  2. RN staffing increased

    RN staffing increased from 1.19 to 1.48 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.

    1.191.48

    CMS · Reported in a source release · View related evidence

  3. Health inspection completed

    6 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2025

  1. RN staffing increased

    RN staffing increased from 0.81 to 1.19 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.

    0.811.19

    CMS · Reported in a source release · View related evidence

  2. Total nurse staffing decreased

    Total nurse staffing decreased from 5.71 to 5.45 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.

    5.715.45

    CMS · Reported in a source release · View related evidence

  3. Total nurse staffing increased

    Total nurse staffing increased from 5.23 to 5.71 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.

    5.235.71

    CMS · Reported in a source release · View related evidence

2024

  1. Health inspection completed

    9 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    CMS · Recorded event date · View related evidence

2023

  1. Health inspection completed

    12 deficiencies were recorded. That includes 2 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 5 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter
Total nursing
5.724
reported hours per resident day
RN categories
1.48
reported hours per resident day
LPN/LVN categories
0.561
reported hours per resident day
CNA
3.29
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing6.1474.685
RN categories1.7050.93

Contract staff accounted for 0.6% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.292 higher than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q25.2260.7291.0743.2293.2%91
2025Q35.7130.8111.0873.1997.1%92
2025Q45.4451.1880.8282.9113.9%92
2026Q15.7241.480.5613.290.6%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, 2026Mar 31, 2026
Days represented
90 (90 with positive MDS census)
CMS source updated
Jul 29, 2026
Calculation version
pbj-quarter-ratio-of-sums-v1

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

View official CMS PBJ source

What we can verify today

Current Provider Information facts

These measures come from the current successfully ingested CMS Nursing Home Provider Information release.

  • CMS reports a 5-star overall rating.
  • CMS reports a 4-star health inspection rating.
  • CMS reports a 5-star staffing rating.
  • CMS reports a 5-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.

    Trust participation

    See something that needs correction?

    Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.

    How corrections work

    Source register

    See where this record came from

    Provider Information
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    4pq5-n9py
    Source updated
    Jul 29, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Overview, facility facts, and CMS ratings
    View official CMS source
    Inspection Dates
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    svdt-c123
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Inspections and facility history
    View official CMS source
    Health Deficiencies
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    r5ix-sfxw
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Health deficiencies and facility history
    View official CMS source
    Payroll Based Journal Daily Nurse Staffing
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    7e0d53ba-8f02-4c66-98a5-14a1c997c50d
    Coverage
    Apr 1, 2025–Mar 31, 2026
    Source updated
    Jul 29, 2026
    Retrieved
    Aug 15, 2026
    Supports
    PBJ staffing cards, history, and transparent calculations
    View official CMS source
    Ownership
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    Supports
    Ownership parties, organization connections, and ownership history
    View official CMS source
    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
    View official CMS source
    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
    View official CMS source
    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
    View official CMS source

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