GRACELEN CARE CENTER

PORTLAND, OR

CMS provider ID 38E188CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

1 of 5 CMS stars

Health inspection

1 of 5 CMS stars

Staffing

3 of 5 CMS stars

Quality-measure

4 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
80
Ownership descriptor
For profit - Corporation
Medicare participation
No
Medicaid participation
Yes

Facility information

Contact

CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.

Phone
5037601727Verified 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.

Staffing

CMS publishes a 3-star staffing rating for this facility.

RN staffing was 0.49 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership & operation

Ownership & Operation

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

Ownership type
For profit - CorporationCMS

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
0
Organizations shown
0
Individuals shown
0
Latest ownership source update
Not reported

CMS-published ownership and control parties

No matched current ownership party records were found in the loaded CMS sources.

What this means

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

Inspections & deficiencies

What CMS inspection records show

Scope and severity terms below are CMS classifications. They are not a TrustHub score.

Latest recorded inspection

Date
May 13, 2026
Survey type
Health Complaint
Linked findings
1
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
38E188
Source record locator
csv-row:104549:ccn:38E188
View official CMS source
May 13, 2026Health Complaint 1 linked finding
  • F0842Resident 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 (Jun 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291967:ccn:38E188
    View official CMS source
Mar 10, 2026Health Complaint 1 linked finding
  • 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291968:ccn:38E188
    View official CMS source
Oct 20, 2025Health Complaint 2 linked findings
  • 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 (Nov 25, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291969:ccn:38E188
    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 (Nov 25, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291970:ccn:38E188
    View official CMS source
Aug 28, 2025Health Complaint 1 linked finding
  • 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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Past Non-Compliance (Aug 18, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291971:ccn:38E188
    View official CMS source
Jul 25, 2025Fire Safety Standard 0 linked findings

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

Jul 25, 2025Health Standard 8 linked findings
  • 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 (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291973:ccn:38E188
    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 (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291974:ccn:38E188
    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 (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291975:ccn:38E188
    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 (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291976:ccn:38E188
    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 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 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291972:ccn:38E188
    View official CMS source
  • F0759Pharmacy 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 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291977:ccn:38E188
    View official CMS source
  • F0761Pharmacy 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 (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291978:ccn:38E188
    View official CMS source
  • F0880Infection 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 (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291979:ccn:38E188
    View official CMS source
Dec 19, 2024Health Complaint 2 linked findings
  • F0600Freedom 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 (Jan 28, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291980:ccn:38E188
    View official CMS source
  • F0622Resident Rights Deficiencies

    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

    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 28, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291981:ccn:38E188
    View official CMS source
Apr 8, 2024Fire Safety Standard 0 linked findings

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

Apr 8, 2024Health Complaint 2 linked findings
  • F0584Resident 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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291996:ccn:38E188
    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291997:ccn:38E188
    View official CMS source
Apr 8, 2024Health Standard 13 linked findings
  • F0550Resident 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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291987:ccn:38E188
    View official CMS source
  • F0552Resident Rights Deficiencies

    Ensure that residents are fully informed and understand their health status, care and treatments.

    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291988:ccn:38E188
    View official CMS source
  • 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 (May 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291989:ccn:38E188
    View official CMS source
  • 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 (May 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291991:ccn:38E188
    View official CMS source
  • F0657Resident 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 (May 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291992:ccn:38E188
    View official CMS source
  • F0661Resident 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 (May 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291993:ccn:38E188
    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291994:ccn:38E188
    View official CMS source
  • F0726Nursing 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 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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291983:ccn:38E188
    View official CMS source
  • F0730Nursing and Physician Services Deficiencies

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

    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291984:ccn:38E188
    View official CMS source
  • F0757Pharmacy Service Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (May 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291995:ccn:38E188
    View official CMS source
  • F0801Nutrition and Dietary Deficiencies

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291982:ccn:38E188
    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291985:ccn:38E188
    View official CMS source
  • F0947Nursing and Physician Services Deficiencies

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

    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 14, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291986:ccn:38E188
    View official CMS source
Sep 21, 2023Health Complaint 7 linked findings
  • F0580Resident 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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291998:ccn:38E188
    View official CMS source
  • 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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:291999:ccn:38E188
    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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292000:ccn:38E188
    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 (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292002:ccn:38E188
    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 (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292003:ccn:38E188
    View official CMS source
  • F0692Quality of Life and Care Deficiencies

    Provide enough food/fluids to maintain a resident's health.

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

    Correction status: Deficient, Provider has date of correction (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292001:ccn:38E188
    View official CMS source
  • F0777Administration Deficiencies

    Provide or obtain x-rays/tests 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 (Nov 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292004:ccn:38E188
    View official CMS source
Jan 19, 2023Fire Safety Standard 0 linked findings

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

Jan 19, 2023Health Standard 20 linked findings
  • F0550Resident 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292013:ccn:38E188
    View official CMS source
  • F0580Resident Rights Deficiencies

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292014:ccn:38E188
    View official CMS source
  • F0584Resident 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292015:ccn:38E188
    View official CMS source
  • 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292016:ccn:38E188
    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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292017:ccn:38E188
    View official CMS source
  • F0657Resident 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292018:ccn:38E188
    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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292019:ccn:38E188
    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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292020:ccn:38E188
    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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292007:ccn:38E188
    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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292008:ccn:38E188
    View official CMS source
  • F0690Quality 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292021:ccn:38E188
    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: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292012:ccn:38E188
    View official CMS source
  • F0757Pharmacy Service Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292022:ccn:38E188
    View official CMS source
  • F0759Pharmacy 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292023:ccn:38E188
    View official CMS source
  • F0801Nutrition and Dietary Deficiencies

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

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

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292010:ccn:38E188
    View official CMS source
  • F0825Quality of Life and Care Deficiencies

    Provide or get specialized rehabilitative services as required for a resident.

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

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292009:ccn:38E188
    View official CMS source
  • F0867Administration Deficiencies

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292006:ccn:38E188
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

    CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292005:ccn:38E188
    View official CMS source
  • F0882Infection 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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292011:ccn:38E188
    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 (Mar 10, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    38E188
    Source record locator
    csv-row:292024:ccn:38E188
    View official CMS source

Tags appearing across inspections

  • F0684 appears in 4 linked inspections.
  • F0689 appears in 4 linked inspections.
  • F0604 appears in 3 linked inspections.
  • F0609 appears in 3 linked inspections.
  • F0880 appears in 3 linked inspections.
  • F0550 appears in 2 linked inspections.
  • F0580 appears in 2 linked inspections.
  • F0584 appears in 2 linked inspections.
  • F0656 appears in 2 linked inspections.
  • F0657 appears in 2 linked inspections.
  • F0686 appears in 2 linked inspections.
  • F0727 appears in 2 linked inspections.
  • F0757 appears in 2 linked inspections.
  • F0759 appears in 2 linked inspections.
  • F0801 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 F0684 in 4 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0689 in 4 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0604 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0609 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0880 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0550 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0580 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0584 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0656 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 F0686 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0727 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0757 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0759 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0801 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

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

What changed recently?

  • Complaint inspection recorded1 deficiency was recorded.

2026

  1. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

2025

  1. Complaint inspection recorded

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    1 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  3. Health inspection completed

    8 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  3. Health inspection completed

    13 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2023

  1. Complaint inspection recorded

    7 deficiencies were recorded. That includes 4 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    20 deficiencies were recorded. That includes 5 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 3 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
4.517
reported hours per resident day
RN categories
0.492
reported hours per resident day
LPN/LVN categories
0.679
reported hours per resident day
CNA
2.845
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.6834.108
RN categories0.5130.439

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

Reported RN-category hours per resident day were 0.009 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
2025Q24.2280.4210.6522.697.2%91
2025Q34.2230.4190.7212.59511.2%92
2025Q44.3680.4830.62.7074%92
2026Q14.5170.4920.6792.8450.6%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 1-star overall rating.
  • CMS reports a 1-star health inspection rating.
  • CMS reports a 3-star staffing rating.
  • CMS reports a 4-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.

  • Chain / portfolio intelligence

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
Verified public facility information
Source organization
Public facility listing
Dataset identifier
commercial-corroboration:public-listing
Source updated
Aug 18, 2026
Retrieved
Aug 18, 2026
Supports
Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
How sources work

No paid placements. Facilities cannot pay to rank higher. We cite. You decide.