Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.48 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceCMS overview
CMS rating overview
No proprietary TrustHub score. These ratings are published separately by CMS.
How CMS describes these ratings
- CMS overall rating
- The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
- Health inspection rating
- The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
- Staffing rating
- The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
- Quality-measure rating
- The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
- CMS certified beds
- 100
- Ownership descriptor
- Non 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
- 8149276670Verified public information · checked Aug 2026
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on May 29, 2026 cited 6 deficiencies.
View inspection evidenceOwnership
CMS-published records list 25 ownership or control parties.
View ownership evidenceChain context
CMS groups this facility with a chain covering 6 facilities across 1 states or territories.
View chain evidenceEnforcement record
CMS records show a $25,853 fine 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
- Non profit - CorporationCMS
- Chain
- LECOM SENIOR LIVINGCMS identifies this facility as part of the LECOM SENIOR LIVING chain.
- Related facilities
- 5Current CMS organization identity
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 22 individual ownership interests
- a CMS chain / common-control group
Related facilities
5 currently connected nursing homes share this CMS organization identity with MILLCREEK MANOR.
- Average CMS overall rating
- 4 stars across 5 reporting facilities
- CMS monetary penalties
- 3 of 5 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 0 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 0 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 2 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $141,064
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
- 25
- Organizations shown
- 3
- Individuals shown
- 22
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
BABIAK, JAIME
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
BEERBOWER, JOSHUA
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
EBERLIN, RICHARD
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
LIN, JAMES
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
MILLCREEK MANOR
Organization · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
ROSCOE, BRANDON
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
SHUTTLEWORTH, JONATHAN
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
BABIAK, JAIME
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
BEERBOWER, JOSHUA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
EBERLIN, RICHARD
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
LIN, JAMES
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
SHUTTLEWORTH, JONATHAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
BABIAK, JAIME
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
BEERBOWER, JOSHUA
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
EBERLIN, RICHARD
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
LIN, JAMES
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
MILLCREEK MANOR
Organization · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
Other facilities connected through this exact CMS organization identity: 4 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
ROSCOE, BRANDON
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
SHUTTLEWORTH, JONATHAN
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
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
BABIAK, JAIME
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
BEERBOWER, JOSHUA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
EBERLIN, RICHARD
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
LIN, JAMES
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
SHUTTLEWORTH, JONATHAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
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
LECOM AT SNYDER MEMORIAL
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
What this means
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Questions to ask
- CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
- CMS records connect MILLCREEK MANOR to 5 facilities. Which policies and staffing decisions are managed centrally versus locally?
Chain context
CMS groups this facility with LECOM SENIOR LIVING
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 876 is a grouping identifier, not a legal organization.
- Facilities
- 6
- States and territories
- 1
- Average overall rating
- 3.8
- Average staffing rating
- 3.3
- Average total nurse HPRD
- 3.9
- Total fines
- 5
CMS-published history
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 6 | 3.8 | 3.3 |
| Mon Jun | 6 | 3.8 | 3.7 |
| Fri May | 5 | 3.6 | 3.6 |
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 5 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- May 29, 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
- 395728
- Source record locator
- csv-row:109366:ccn:395728
May 29, 2026 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
May 29, 2026 — Health Standard — 6 linked findings
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 no plan of correction
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305940:ccn:395728
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has no plan of correction
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305941:ccn:395728
F0711 — Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 no plan of correction
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305939:ccn:395728
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has no plan of correction
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305942:ccn:395728
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 D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has no plan of correction
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305943:ccn:395728
F0814 — Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
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 no plan of correction
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305944:ccn:395728
May 8, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
May 8, 2025 — Health Standard — 5 linked findings
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 7, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305945:ccn:395728
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 7, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305948:ccn:395728
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 7, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305946:ccn:395728
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 (Jun 7, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305949:ccn:395728
F0880 — Infection 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 (Jun 7, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305947:ccn:395728
Jan 8, 2025 — Fire Safety Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Oct 2, 2024 — Health Complaint — 1 linked finding
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 12, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305950:ccn:395728
Jun 18, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jun 18, 2024 — Health Standard — 5 linked findings
F0565 — Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
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 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305953:ccn:395728
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 (Aug 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305951:ccn:395728
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305954:ccn:395728
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 (Aug 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305955:ccn:395728
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 (Aug 15, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305952:ccn:395728
Mar 6, 2024 — Health Complaint — 3 linked findings
F0678 — Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Mar 26, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305956:ccn:395728
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 (Mar 26, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305958:ccn:395728
F0835 — Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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 26, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305957:ccn:395728
Nov 22, 2023 — Health Complaint — 2 linked findings
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305959:ccn:395728
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 10, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305960:ccn:395728
Sep 22, 2023 — Health Complaint — 1 linked finding
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305961:ccn:395728
Sep 5, 2023 — Health Complaint — 3 linked findings
F0561 — Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305963:ccn:395728
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305964:ccn:395728
F0880 — Infection 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 (Oct 11, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305962:ccn:395728
Jul 25, 2023 — Health Complaint — 2 linked findings
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 (Sep 13, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305965:ccn:395728
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 13, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:305966:ccn:395728
Tags appearing across inspections
- F0657 appears in 3 linked inspections.
- F0761 appears in 3 linked inspections.
- F0812 appears in 3 linked inspections.
- F0684 appears in 2 linked inspections.
- F0880 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Mar 6, 2024
Published fine amount: $25,853.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 395728
- Source record locator
- csv-row:11486:ccn:395728
Questions to ask
Questions generated from the evidence above
- CMS records show F0657 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0761 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0812 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0684 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0880 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Mar 6, 2024. What changes were made after that enforcement action?
Facility history
Facility History
13 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Health inspection completed6 deficiencies were recorded.
- Total nurse staffing decreasedTotal nurse staffing decreased from 4.16 to 3.63 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
2026
- Health inspection completed
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- Total nurse staffing decreased
Total nurse staffing decreased from 4.16 to 3.63 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
4.16 → 3.63
CMS · Reported in a source release · View related evidence
- RN staffing decreased
RN staffing decreased from 0.69 to 0.47 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
0.69 → 0.47
CMS · Reported in a source release · View related evidence
- Health inspection completed
5 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Fire-safety complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
2024
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Health inspection completed
5 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $25,853 civil monetary penalty.
CMS · Recorded event date · View related evidence
2023
- Complaint inspection recorded
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 2 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
- Total nursing
- 3.758 reported hours per resident day
- RN categories
- 0.482 reported hours per resident day
- LPN/LVN categories
- 1.094 reported hours per resident day
- CNA
- 2.182 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.96 | 3.259 |
| RN categories | 0.554 | 0.303 |
Contract staff accounted for 23.1% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.018 lower than the prior loaded quarter.
Staffing over time
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 4.156 | 0.693 | 0.947 | 2.517 | 14.4% | 91 |
| 2025Q3 | 3.635 | 0.471 | 1.052 | 2.111 | 30% | 92 |
| 2025Q4 | 3.789 | 0.499 | 1.158 | 2.131 | 23.7% | 92 |
| 2026Q1 | 3.758 | 0.482 | 1.094 | 2.182 | 23.1% | 90 |
Questions to ask
- PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
- PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 2-star overall rating.
- CMS reports a 2-star health inspection rating.
- CMS reports a 2-star staffing rating.
- CMS reports a 3-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
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Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
See where this record came from
Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Health deficiencies and facility history
Penalties
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- g6vv-u9sr
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Penalties, enforcement, and facility history
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility All Owners
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility Enrollments
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Nursing Home Chain Performance Measures
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 97ecfad1-d3f1-4d42-b774-d74661d830bc
- Coverage
- Wed Jul
- Source updated
- Aug 12, 2026
- Retrieved
- Aug 16, 2026
- Supports
- CMS chain context, performance, and monthly history
Verified public facility information
- Source organization
- Public facility listing
- Dataset identifier
- commercial-corroboration:public-listing
- Source updated
- Aug 18, 2026
- Retrieved
- Aug 18, 2026
- Supports
- Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
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