Chestnut Hill Rehabilitation and Healthcare Center

WILKES BARRE, PA

CMS provider ID 395148CMS source updated July 29, 2026

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CMS overview

CMS overall

Health inspection

Staffing

Quality-measure

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: 180
Ownership descriptor: For profit - Corporation
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: 5708261011CMS 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 1-star staffing rating for this facility.

RN staffing was 0.45 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Inspections

The latest standard inspection on Feb 27, 2026 cited 8 deficiencies.

View inspection evidence

Ownership

CMS-published records list 24 ownership or control parties.

CMS records show an ownership change effective April 2021.

View ownership evidence

Chain context

CMS groups this facility with a chain covering 13 facilities across 1 states or territories.

View chain evidence

Enforcement record

CMS records show a 34-day payment denial in the loaded enforcement dataset.

View enforcement evidence →

Ownership & operation

Ownership & Operation

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

Ownership type: For profit - CorporationCMS
Chain: IMPERIAL HEALTHCARE GROUPCMS identifies this facility as part of the IMPERIAL HEALTHCARE GROUP chain.
Related facilities: 13Current CMS organization identity
Ownership changes: 1 recordedCMS enrollment records

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

14 CMS-reported ownership organizations
CMS reports 8 individual ownership interests
a CMS chain / common-control group
recorded ownership-change events

Related facilities

13 currently connected nursing homes share this CMS organization identity with ENS HOLDINGS, LLC.

Average CMS overall rating: 2.5 stars across 13 reporting facilities
CMS monetary penalties: 7 of 13 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties: 2 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement: 2 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections: 11 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines: $289,210

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: 24
Organizations shown: 16
Individuals shown: 8
Latest ownership source update: Jul 27, 2026

CMS-published ownership and control parties

TIMBER RIDGE SNF OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Apr 30, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
CH PA7 SNF HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Apr 30, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
CHRH EQUITIES LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
ENS HOLDINGS, LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
GOTTESMAN, DANIEL
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jun 20, 2021
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
IH PA OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Apr 30, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
THE ENS FAMILY TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
YMCS EQUITIES LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
HERZKA, YISROEL
Individual · CORPORATE OFFICER
Association date reported to CMS: Jun 20, 2021
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
SIMPSON, LOUANN
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Apr 30, 2021
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
TIMBER RIDGE SNF OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Apr 30, 2021
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 0 across PA.
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
CH PA7 SNF HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 40.01%
Association date reported to CMS: Apr 30, 2021
CMS classifications: Management services company
Other facilities connected through this exact CMS organization identity: 3 across PA.
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
CHRH EQUITIES LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 7.5%
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 10 across PA.
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
ENS HOLDINGS, LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 24.99%
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 12 across PA.
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
GOTTESMAN, DANIEL
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 24.99%
Association date reported to CMS: Jun 20, 2021
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
HERZKA, YISROEL
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 40.01%
Association date reported to CMS: Apr 30, 2021
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
IH PA OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Apr 30, 2021
CMS classifications: Management services company
Other facilities connected through this exact CMS organization identity: 1 across PA.
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
KOPELOWITZ, SHAUL
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 10%
Association date reported to CMS: Apr 30, 2021
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
THE ENS FAMILY TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 24.99%
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 12 across PA.
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
YMCS EQUITIES LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 7.5%
Association date reported to CMS: Jun 20, 2021
Other facilities connected through this exact CMS organization identity: 10 across PA.
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
HERZKA, YISROEL
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Jun 20, 2021
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
TIMBER RIDGE SNF REALTY LLC
Organization · OTHER
Association date reported to CMS: Apr 30, 2021
Other facilities connected through this exact CMS organization identity: 1 across PA.
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
SIMPSON, LOUANN
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Apr 30, 2021
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
TIMBER RIDGE SNF OPERATIONS LLC
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across PA.
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

Ownership changes reported in CMS enrollment records

Apr 30, 2021CHANGE OF OWNERSHIPVALLEY CREST NURSING, INC. to TIMBER RIDGE SNF OPERATIONS LLC
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Skilled Nursing Facility Change of Ownership
CMS dataset identifier
f557a6ed-95b3-4a22-8433-4175db2dec1c
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 enrollment records show a change of ownership effective Apr 30, 2021. What operational or leadership changes followed that event?
CMS records connect CH PA7 SNF HOLDINGS LLC to 4 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with IMPERIAL HEALTHCARE GROUP

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 282 is a grouping identifier, not a legal organization.

Facilities: 13
States and territories: 1
Average overall rating: 2.5
Average staffing rating: 1.5
Average total nurse HPRD: 3.2
Total fines: 11

Review CMS chain evidence

CMS-published history

Monthly chain measures
Month	Facilities	Overall rating	Staffing rating
Wed Jul	13	2.5	1.5
Mon Jun	13	2.8	1.8
Fri May	13	2.8	1.8
Wed Apr	13	2.8	1.8
Sun Mar	13	2.4	1.9
Sun Feb	13	2.5	1.9

Questions to ask

CMS groups facilities in 1 states or territories under this chain. Which operational policies are set at the chain level?
CMS reports 11 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: Feb 27, 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: 395148
Source record locator: csv-row:105157:ccn:395148

View official CMS source

Feb 27, 2026 — Fire Safety Standard — 0 linked findings

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

Feb 27, 2026 — Health Complaint — 0 linked findings

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

Feb 27, 2026 — Health Standard — 8 linked findings

F0578 — Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293765:ccn:395148
View official CMS source
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity 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 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293766:ccn:395148
View official CMS source
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293768:ccn:395148
View official CMS source
F0690 — Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293769:ccn:395148
View official CMS source
F0694 — Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids 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 (Apr 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293770:ccn:395148
View official CMS source
F0744 — Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293771:ccn:395148
View official CMS source
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293772:ccn:395148
View official CMS source
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293773:ccn:395148
View official CMS source

Sep 23, 2025 — Health Complaint — 1 linked finding

F0810 — Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
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 21, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293774:ccn:395148
View official CMS source

Jun 18, 2025 — Health Complaint — 2 linked findings

F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293775:ccn:395148
View official CMS source
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293776:ccn:395148
View official CMS source

Apr 25, 2025 — Fire Safety Standard — 0 linked findings

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

Apr 25, 2025 — Health Standard — 10 linked findings

F0578 — Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293780:ccn:395148
View official CMS source
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293778:ccn:395148
View official CMS source
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293781:ccn:395148
View official CMS source
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293782:ccn:395148
View official CMS source
F0658 — Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293783:ccn:395148
View official CMS source
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293779:ccn:395148
View official CMS source
F0699 — Quality 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 (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293784:ccn:395148
View official CMS source
F0757 — Pharmacy 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 (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293785:ccn:395148
View official CMS source
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293786:ccn:395148
View official CMS source
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 18, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293777:ccn:395148
View official CMS source

Jun 14, 2024 — Fire Safety Standard — 0 linked findings

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

Jun 14, 2024 — Health Complaint — 0 linked findings

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

Jun 14, 2024 — Health Standard — 16 linked findings

F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293788:ccn:395148
View official CMS source
F0554 — Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
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 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293794:ccn:395148
View official CMS source
F0583 — Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293795:ccn:395148
View official CMS source
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 18, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293789:ccn:395148
View official CMS source
F0622 — Resident 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 (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293796:ccn:395148
View official CMS source
F0623 — Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293803:ccn:395148
View official CMS source
F0625 — Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293790:ccn:395148
View official CMS source
F0640 — Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293797:ccn:395148
View official CMS source
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity 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 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293798:ccn:395148
View official CMS source
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293791:ccn:395148
View official CMS source
F0690 — Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293799:ccn:395148
View official CMS source
F0692 — Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293800:ccn:395148
View official CMS source
F0694 — Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293792:ccn:395148
View official CMS source
F0698 — Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293801:ccn:395148
View official CMS source
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293802:ccn:395148
View official CMS source
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293793:ccn:395148
View official CMS source

Apr 12, 2024 — Health Complaint — 2 linked findings

F0585 — Resident 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 26, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293804:ccn:395148
View official CMS source
F0655 — Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 26, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293805:ccn:395148
View official CMS source

Feb 7, 2024 — Health Complaint — 1 linked finding

F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 12, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293806:ccn:395148
View official CMS source

Nov 7, 2023 — Health Complaint — 6 linked findings

F0558 — Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each 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 (Dec 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293807:ccn:395148
View official CMS source
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 19, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293808:ccn:395148
View official CMS source
F0745 — Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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 (Dec 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293809:ccn:395148
View official CMS source
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 19, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293810:ccn:395148
View official CMS source
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293812:ccn:395148
View official CMS source
F0867 — Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity 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 (Dec 19, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293811:ccn:395148
View official CMS source

Sep 28, 2023 — Health Complaint — 12 linked findings

F0580 — Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293820:ccn:395148
View official CMS source
F0584 — Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity 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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293813:ccn:395148
View official CMS source
F0661 — Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293821:ccn:395148
View official CMS source
F0677 — Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293814:ccn:395148
View official CMS source
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293822:ccn:395148
View official CMS source
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293823:ccn:395148
View official CMS source
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293815:ccn:395148
View official CMS source
F0693 — Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293824:ccn:395148
View official CMS source
F0726 — Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS scope/severity 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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293816:ccn:395148
View official CMS source
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 19, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293817:ccn:395148
View official CMS source
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity 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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293818:ccn:395148
View official CMS source
F0919 — Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293819:ccn:395148
View official CMS source

Aug 18, 2023 — Health Complaint — 4 linked findings

F0584 — Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity 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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293825:ccn:395148
View official CMS source
F0585 — Resident 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 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 (Sep 28, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293826:ccn:395148
View official CMS source
F0677 — Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293827:ccn:395148
View official CMS source
F0744 — Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 (Sep 28, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293828:ccn:395148
View official CMS source

Jul 11, 2023 — Health Complaint — 2 linked findings

F0584 — Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity 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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293829:ccn:395148
View official CMS source
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity 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 (Nov 7, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:293830:ccn:395148
View official CMS source

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

Payment Denial — Jun 14, 2024
Payment denial length: 34 days
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
395148
Source record locator
csv-row:11143:ccn:395148
View official CMS source

Questions to ask

Questions generated from the evidence above

CMS records show F0755 in 4 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0584 in 3 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0600 in 3 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0684 in 3 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0578 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0585 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 F0677 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0688 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0690 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0694 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0744 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0812 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0868 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

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

What changed recently?

Health inspection completed8 deficiencies were recorded.
Total nurse staffing decreasedTotal nurse staffing decreased from 4.04 to 3.68 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.

2026

Feb 27
Health inspection completed
8 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Feb 27
Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence

2025

Dec 2025
Total nurse staffing decreased
Total nurse staffing decreased from 4.04 to 3.68 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
4.04 → 3.68
CMS · Reported in a source release · View related evidence
Sep 23
Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
Jun 18
Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Apr 25
Health inspection completed
10 deficiencies were recorded.
CMS · Recorded event date · View related evidence

2024

Jun 14
Medicare payment denial recorded
CMS recorded a Medicare payment denial lasting 34 days.
CMS · Recorded event date · View related evidence
Jun 14
Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
Jun 14
Health inspection completed
16 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Apr 12
Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Feb 7
Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence

2023

Nov 7
Complaint inspection recorded
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 1 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter

Total nursing: 3.503
RN categories: 0.446
LPN/LVN categories: 0.947
CNA: 2.11

Weekday and weekend calculations

2026Q1 reported hours per resident day
Measure	Monday–Friday	Saturday–Sunday
Total nursing	3.666	3.102
RN categories	0.536	0.225

Contract staff accounted for 14.3% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.021 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
Quarter	Total nursing	RN categories	LPN/LVN	CNA	Contract share	Days
2025Q2	3.994	0.492	0.988	2.514	31.9%	91
2025Q3	4.035	0.398	1.004	2.633	28.5%	92
2025Q4	3.68	0.425	1.013	2.242	18.6%	92
2026Q1	3.503	0.446	0.947	2.11	14.3%	90

Questions to ask

PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?

Staffing source and calculation details

Source: Centers for Medicare & Medicaid Services (CMS)
Dataset: Payroll Based Journal Daily Nurse Staffing
CMS dataset ID: 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter: 2026Q1
Coverage: Jan 1, 2026–Mar 31, 2026
Days represented: 90 (90 with positive MDS census)
CMS source updated: Jul 29, 2026
Calculation version: pbj-quarter-ratio-of-sums-v1

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

View official CMS PBJ 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 2-star health inspection rating.
CMS reports a 1-star staffing rating.
CMS reports a 2-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.

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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

Penalties

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: g6vv-u9sr
Source updated: Jul 1, 2026
Retrieved: Aug 14, 2026
Supports: Penalties, enforcement, and facility history

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

Skilled Nursing Facility Change of Ownership

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: f557a6ed-95b3-4a22-8433-4175db2dec1c
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

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

CMS rating overview

CMS overall

Health inspection

Staffing

Quality-measure

Contact

What to review

Staffing

Inspections

Ownership

Chain context

Ownership & Operation

Who is behind this facility?

Related facilities

Facilities currently connected to this organization

Who CMS records show is connected to this facility

CMS-published ownership and control parties

TIMBER RIDGE SNF OPERATIONS HOLDINGS LLC

CH PA7 SNF HOLDINGS LLC

CHRH EQUITIES LLC

ENS HOLDINGS, LLC

GOTTESMAN, DANIEL

IH PA OPERATIONS HOLDINGS LLC

THE ENS FAMILY TRUST

YMCS EQUITIES LLC

HERZKA, YISROEL

SIMPSON, LOUANN

TIMBER RIDGE SNF OPERATIONS HOLDINGS LLC

CH PA7 SNF HOLDINGS LLC

CHRH EQUITIES LLC

ENS HOLDINGS, LLC

GOTTESMAN, DANIEL

HERZKA, YISROEL

IH PA OPERATIONS HOLDINGS LLC

KOPELOWITZ, SHAUL

THE ENS FAMILY TRUST

YMCS EQUITIES LLC

HERZKA, YISROEL

TIMBER RIDGE SNF REALTY LLC

SIMPSON, LOUANN

TIMBER RIDGE SNF OPERATIONS LLC

Ownership changes reported in CMS enrollment records

What this means

Questions to ask

CMS groups this facility with IMPERIAL HEALTHCARE GROUP

CMS-published history

Questions to ask

What CMS inspection records show

Latest recorded inspection

F0578 — Resident Rights Deficiencies

F0656 — Resident Assessment and Care Planning Deficiencies

F0684 — Quality of Life and Care Deficiencies

F0690 — Quality of Life and Care Deficiencies

F0694 — Quality of Life and Care Deficiencies

F0744 — Quality of Life and Care Deficiencies

F0755 — Pharmacy Service Deficiencies

F0868 — Administration Deficiencies

F0810 — Nutrition and Dietary Deficiencies

F0684 — Quality of Life and Care Deficiencies

F0755 — Pharmacy Service Deficiencies

F0578 — Resident Rights Deficiencies

F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

F0641 — Resident Assessment and Care Planning Deficiencies

F0658 — Resident Assessment and Care Planning Deficiencies

F0695 — Quality of Life and Care Deficiencies

F0699 — Quality of Life and Care Deficiencies

F0757 — Pharmacy Service Deficiencies

F0758 — Pharmacy Service Deficiencies

F0880 — Infection Control Deficiencies

F0550 — Resident Rights Deficiencies

F0554 — Resident Rights Deficiencies

F0583 — Resident Rights Deficiencies

F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

F0622 — Resident Rights Deficiencies

F0623 — Resident Rights Deficiencies

F0625 — Resident Rights Deficiencies

F0640 — Resident Assessment and Care Planning Deficiencies

F0656 — Resident Assessment and Care Planning Deficiencies

F0688 — Quality of Life and Care Deficiencies