Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.97 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.97 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Feb 3, 2025 cited 12 deficiencies.
View inspection evidenceCMS-published records list 22 ownership or control parties.
View ownership evidenceCMS groups this facility with a chain covering 20 facilities across 4 states or territories.
View chain evidenceCMS records show a 17-day payment denial in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
41 currently connected nursing homes share this CMS organization identity with BEAVER VALLEY HOSPITAL.
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
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.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 1, 2023
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 15, 2025
Other facilities connected through this exact CMS organization identity: 0 across UT.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 1, 2023
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 1, 2023
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 29, 2024
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Sep 18, 2018
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Sep 18, 2018
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Sep 18, 2018
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Sep 18, 2018
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Sep 18, 2018
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Sep 18, 2018
Individual · CORPORATE OFFICER
Association date reported to CMS: Sep 18, 2018
Organization · DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Sep 18, 2018
Other facilities connected through this exact CMS organization identity: 0 across UT.
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Sep 18, 2018
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jan 1, 2023
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 2023
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 18, 2018
Other facilities connected through this exact CMS organization identity: 0 across UT.
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 2023
Other facilities connected through this exact CMS organization identity: 0 across UT.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 18, 2018
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 18, 2018
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Feb 29, 2024
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 40 across UT.
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.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 117 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 20 | 1.9 | 2 |
| Mon Jun | 20 | 2 | 2.2 |
| Fri May | 20 | 2 | 2.2 |
| Wed Apr | 20 | 2 | 2.2 |
| Sun Mar | 20 | 2 | 2.1 |
| Sun Feb | 20 | 1.9 | 2.1 |
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
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
No health-deficiency rows were deterministically linked to this inspection.
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 (Mar 27, 2025)
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 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 27, 2025)
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 (Mar 27, 2025)
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 (Mar 27, 2025)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 27, 2025)
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 (Mar 27, 2025)
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 (Mar 27, 2025)
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 (Mar 27, 2025)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 27, 2025)
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 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 27, 2025)
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 (Mar 27, 2025)
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 (Mar 27, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 12, 2024)
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 (Feb 12, 2024)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 12, 2024)
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 (Feb 12, 2024)
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 12, 2024)
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS scope/severity 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 (Feb 12, 2024)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 (Feb 12, 2024)
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 12, 2024)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 12, 2024)
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 12, 2024)
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 (Feb 12, 2024)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 (Feb 12, 2024)
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 (Feb 12, 2024)
Implement a program that monitors antibiotic use.
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 (Feb 12, 2024)
No health-deficiency rows were deterministically linked to this inspection.
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 (Jun 23, 2022)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 (Jun 23, 2022)
Honor the resident's right to organize and participate in resident/family groups in the facility.
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 23, 2022)
Honor the resident's right to manage his or her financial affairs.
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 23, 2022)
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 23, 2022)
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 23, 2022)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 23, 2022)
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 (Jun 23, 2022)
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 (Jun 23, 2022)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
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 23, 2022)
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
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 23, 2022)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Respond appropriately to all alleged violations.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 (Jun 23, 2022)
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
PASARR screening for Mental disorders or Intellectual Disabilities
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 23, 2022)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 23, 2022)
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 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 23, 2022)
Plan the resident's discharge to meet the resident's goals and needs.
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 23, 2022)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Assist a resident in gaining access to vision and hearing 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 (Jun 23, 2022)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 (Jun 23, 2022)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide safe, appropriate pain management for a resident who requires such services.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 (Jun 23, 2022)
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 (Jun 23, 2022)
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 (Jun 23, 2022)
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 23, 2022)
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 (Jun 23, 2022)
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 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 23, 2022)
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Keep complete, dated laboratory records in the resident's record.
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 23, 2022)
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
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 23, 2022)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 23, 2022)
Provide or get specialized rehabilitative services as required for a resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 23, 2022)
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 (Jun 23, 2022)
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
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 23, 2022)
Implement a program that monitors antibiotic use.
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 23, 2022)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 23, 2022)
Perform COVID19 testing on residents and staff.
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 23, 2022)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 23, 2022)
Ensure staff are vaccinated for COVID-19
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 23, 2022)
Keep all essential equipment working safely.
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 23, 2022)
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 (Jun 23, 2022)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 23, 2022)
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
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 23, 2022)
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS scope/severity 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 23, 2022)
Penalties & enforcement
Payment denial length: 17 days
Published fine amount: $53,472.00
Questions to ask
Facility history
6 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
No major recent changes were identified in the available history.
12 deficiencies were recorded.
CMS · Recorded event date · View related evidence
CMS recorded a $53,472 civil monetary penalty.
CMS · Recorded event date · View related evidence
CMS recorded a Medicare payment denial lasting 17 days.
CMS · Recorded event date · View related evidence
13 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
71 deficiencies were recorded. That includes 25 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
Staffing
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).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.638 | 3.127 |
| RN categories | 1.032 | 0.805 |
Contract staff accounted for 0.3% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.029 lower than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.221 | 0.909 | 0.313 | 1.65 | 1.8% | 91 |
| 2025Q3 | 3.419 | 0.907 | 0.268 | 2.079 | 2.1% | 92 |
| 2025Q4 | 3.439 | 0.996 | 0.301 | 2.002 | 1% | 92 |
| 2026Q1 | 3.491 | 0.967 | 0.32 | 2.036 | 0.3% | 90 |
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
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.