Monument Healthcare Murray Creek

Also known publicly as Monument Health Murray Creek

Millcreek, UT

CMS provider ID 465094CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

2 of 5 CMS stars

Health inspection

1 of 5 CMS stars

Staffing

3 of 5 CMS stars

Quality-measure

5 of 5 CMS stars

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

How CMS describes these ratings
CMS overall rating
The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
Health inspection rating
The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
Staffing rating
The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
Quality-measure rating
The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
CMS certified beds
184
Ownership descriptor
For profit - Limited Liability company
Medicare participation
Yes
Medicaid participation
Yes

Facility information

Contact

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

Phone
8012684766Verified public information · checked Aug 2026
Also known publicly as
Monument Health Murray CreekVerified public information · checked Aug 2026

Decision guide

What to review

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

Staffing

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

RN staffing was 1.02 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership

CMS-published records list 30 ownership or control parties.

CMS records show an ownership change effective July 2018.

View ownership evidence

Chain context

CMS groups this facility with a chain covering 11 facilities across 1 states or territories.

View chain evidence
Enforcement record

CMS records show a $112,800 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
For profit - Limited Liability companyCMS
Chain
MONUMENT HEALTH GROUPCMS identifies this facility as part of the MONUMENT HEALTH GROUP chain.
Related facilities
15Current CMS organization identity
Ownership changes
1 recordedCMS enrollment records

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • CMS reports 23 individual ownership interests
  • a CMS chain / common-control group
  • recorded ownership-change events

Related facilities

15 currently connected nursing homes share this CMS organization identity with GUNNISON VALLEY HOSPITAL.

Average CMS overall rating
2.9 stars across 15 reporting facilities
CMS monetary penalties
12 of 15 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
6 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
5 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
10 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$482,600

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
30
Organizations shown
7
Individuals shown
23
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • CLAWSON, TRAVIS

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • ESPINOSA, STEPHANIE

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • FRAGOSO, LINDSAY

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • GANGOTENA-BERNARD, FATIMA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • HEALTH GROUP MANAGEMENT LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: May 28, 2025

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

    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
  • MARRIOTT, STEPHEN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • MONUMENT HEALTH GROUP LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Mar 26, 2025

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

    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
  • MONUMENT HEALTH PROPERTIES LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 2025

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

    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
  • MONUMENT REAL ESTATE MURRAY CREEK LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 2025

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

    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
  • ROBERTSON, BRETT

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • SAMUELIAN, SPENCER

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • SEASTRAND, JASON

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • THAP, RENUKA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • WEST, CHRISTIAN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • WILSON, BRENT

    Individual · ADP OF THE SNF

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • MURRAY, BRIAN

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jul 1, 2018

    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
  • CLAWSON, TRAVIS

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • ESPINOSA, STEPHANIE

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • FRAGOSO, LINDSAY

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • GANGOTENA-BERNARD, FATIMA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • HEALTH GROUP MANAGEMENT LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 2025

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

    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
  • MARRIOTT, STEPHEN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • MONUMENT HEALTH GROUP LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 2025

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

    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
  • ROBERTSON, BRETT

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • SAMUELIAN, SPENCER

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • SEASTRAND, JASON

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • THAP, RENUKA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • WEST, CHRISTIAN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • WILSON, BRENT

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 7, 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
    View official CMS source
  • GUNNISON VALLEY HOSPITAL

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 14 across UT.

    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

  1. CHANGE OF OWNERSHIPWOODLAND CARE CENTER, LLC to GUNNISON VALLEY HOSPITAL
    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 Jul 1, 2018. What operational or leadership changes followed that event?
  • CMS records connect GUNNISON VALLEY HOSPITAL to 15 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with MONUMENT HEALTH GROUP

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 770 is a grouping identifier, not a legal organization.

Facilities
11
States and territories
1
Average overall rating
2.8
Average staffing rating
2.8
Average total nurse HPRD
3.9
Total fines
14
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul112.82.8
Mon Jun113.22.7
Fri May113.22.7
Wed Apr113.22.7
Sun Mar143.32.6
Sun Feb143.22.6

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 14 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
Mar 31, 2026
Survey type
Health Complaint
Linked findings
2
Highest linked CMS classification
G — Isolated; Actual harm that is not immediate jeopardy
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Jul 1, 2026
CMS provider ID
465094
Source record locator
csv-row:120459:ccn:465094
View official CMS source
Mar 31, 2026Health Complaint 2 linked findings
  • F0684Quality of Life and Care Deficiencies

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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

    Correction status: Past Non-Compliance (Aug 13, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331503:ccn:465094
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

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

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

    Correction status: Past Non-Compliance (Aug 26, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331502:ccn:465094
    View official CMS source
Jun 28, 2025Fire Safety Standard 0 linked findings

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

Jun 28, 2025Health Complaint 0 linked findings

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

Jun 28, 2025Health Standard 13 linked findings
  • F0554Resident 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 (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331511:ccn:465094
    View official CMS source
  • F0609Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    CMS scope/severity 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 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331509:ccn:465094
    View official CMS source
  • F0610Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Respond appropriately to all alleged violations.

    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 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331510:ccn:465094
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

    Correction status: Deficient, Provider has date of correction (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331512:ccn:465094
    View official CMS source
  • F0677Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

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

    Correction status: Deficient, Provider has date of correction (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331513:ccn:465094
    View official CMS source
  • F0679Quality of Life and Care Deficiencies

    Provide activities to meet all resident's needs.

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

    Correction status: Deficient, Provider has date of correction (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331514:ccn:465094
    View official CMS source
  • F0688Quality 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 (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331515:ccn:465094
    View official CMS source
  • F0842Resident Assessment and Care Planning Deficiencies

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

    Correction status: Deficient, Provider has date of correction (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331516:ccn:465094
    View official CMS source
  • F0847Administration Deficiencies

    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

    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 (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331505:ccn:465094
    View official CMS source
  • F0848Administration Deficiencies

    Provide a neutral and fair arbitration process and agree to arbitrator and venue.

    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 (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331506:ccn:465094
    View official CMS source
  • F0868Administration Deficiencies

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    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 (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331507:ccn:465094
    View official CMS source
  • F0880Infection 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 (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331508:ccn:465094
    View official CMS source
  • F0910Environmental Deficiencies

    Ensure resident rooms meet each resident's needs.

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

    Correction status: Deficient, Provider has date of correction (Jul 23, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331517:ccn:465094
    View official CMS source
Jan 31, 2024Health Complaint 1 linked finding
  • F0689Quality of Life and Care Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Mar 11, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331529:ccn:465094
    View official CMS source
Aug 31, 2023Fire Safety Standard 0 linked findings

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

Aug 31, 2023Health Complaint 1 linked finding
  • F0610Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Respond appropriately to all alleged violations.

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

    Correction status: Deficient, Provider has date of correction (Nov 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331530:ccn:465094
    View official CMS source
Aug 31, 2023Health Standard 11 linked findings
  • F0554Resident Rights Deficiencies

    Allow residents to self-administer drugs if determined clinically appropriate.

    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 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331519:ccn:465094
    View official CMS source
  • F0609Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

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

    Correction status: Deficient, Provider has date of correction (Nov 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331524:ccn:465094
    View official CMS source
  • F0636Resident Assessment and Care Planning Deficiencies

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    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 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331525:ccn:465094
    View official CMS source
  • F0638Resident Assessment and Care Planning Deficiencies

    Assure that each resident’s assessment is updated at least once every 3 months.

    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 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331526:ccn:465094
    View official CMS source
  • F0641Resident 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 (Nov 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331527:ccn:465094
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    CMS scope/severity 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 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331520:ccn:465094
    View official CMS source
  • F0677Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    CMS scope/severity 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 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331521:ccn:465094
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

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

    CMS scope/severity 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 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331522:ccn:465094
    View official CMS source
  • F0695Quality 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 (Nov 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331523:ccn:465094
    View official CMS source
  • F0755Pharmacy 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 (Nov 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331528:ccn:465094
    View official CMS source
  • F0812Nutrition and Dietary Deficiencies

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

    CMS scope/severity 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 (Nov 3, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331518:ccn:465094
    View official CMS source
Dec 6, 2021Fire Safety Standard 0 linked findings

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

Dec 6, 2021Health Standard 21 linked findings
  • F0558Resident Rights Deficiencies

    Reasonably accommodate the needs and preferences of each resident.

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331540:ccn:465094
    View official CMS source
  • F0578Resident 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 (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331541:ccn:465094
    View official CMS source
  • F0584Resident Rights Deficiencies

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    CMS scope/severity 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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331532:ccn:465094
    View official CMS source
  • F0585Resident Rights Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331542:ccn:465094
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    CMS scope/severity 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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331533:ccn:465094
    View official CMS source
  • F0676Quality of Life and Care Deficiencies

    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331543:ccn:465094
    View official CMS source
  • F0677Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    CMS scope/severity 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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331534:ccn:465094
    View official CMS source
  • F0684Quality of Life and Care Deficiencies

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331544:ccn:465094
    View official CMS source
  • F0686Quality of Life and Care Deficiencies

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331545:ccn:465094
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

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

    CMS scope/severity 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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331535:ccn:465094
    View official CMS source
  • F0692Quality 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 (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331546:ccn:465094
    View official CMS source
  • F0697Quality of Life and Care Deficiencies

    Provide safe, appropriate pain management 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 (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331547:ccn:465094
    View official CMS source
  • F0725Nursing and Physician Services Deficiencies

    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 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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331536:ccn:465094
    View official CMS source
  • F0757Pharmacy Service Deficiencies

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

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331548:ccn:465094
    View official CMS source
  • F0761Pharmacy Service Deficiencies

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331549:ccn:465094
    View official CMS source
  • F0804Nutrition and Dietary Deficiencies

    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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331537:ccn:465094
    View official CMS source
  • F0807Nutrition and Dietary Deficiencies

    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

    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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331550:ccn:465094
    View official CMS source
  • F0812Nutrition and Dietary Deficiencies

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

    CMS scope/severity 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 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331531:ccn:465094
    View official CMS source
  • F0842Resident Assessment and Care Planning Deficiencies

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331551:ccn:465094
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

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

    Correction status: Deficient, Provider has date of correction (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331538:ccn:465094
    View official CMS source
  • F0886Infection Control Deficiencies

    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 (Feb 1, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:331539:ccn:465094
    View official CMS source

Tags appearing across inspections

  • F0689 appears in 4 linked inspections.
  • F0656 appears in 3 linked inspections.
  • F0677 appears in 3 linked inspections.
  • F0554 appears in 2 linked inspections.
  • F0609 appears in 2 linked inspections.
  • F0610 appears in 2 linked inspections.
  • F0684 appears in 2 linked inspections.
  • F0812 appears in 2 linked inspections.
  • F0842 appears in 2 linked inspections.
  • F0880 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • FineJun 28, 2025

    Published fine amount: $112,800.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:12924:ccn:465094
    View official CMS source
  • FineJan 31, 2024

    Published fine amount: $8,148.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    465094
    Source record locator
    csv-row:12923:ccn:465094
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show F0689 in 4 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0656 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0677 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0554 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0609 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0610 in 2 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 F0812 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0842 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 Jun 28, 2025. What changes were made after that enforcement action?

Facility history

Facility History

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

What changed recently?

  • Complaint inspection recorded2 deficiencies were recorded. That includes 1 higher-severity deficiency.
  • RN staffing decreasedRN staffing decreased from 1.14 to 1.02 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.
  • Civil monetary penalty recordedCMS recorded a $112,800 civil monetary penalty.

2026

  1. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

  2. RN staffing decreased

    RN staffing decreased from 1.14 to 1.02 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.

    1.141.02

    CMS · Reported in a source release · View related evidence

2025

  1. RN staffing increased

    RN staffing increased from 1.01 to 1.14 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.

    1.011.14

    CMS · Reported in a source release · View related evidence

  2. Civil monetary penalty recorded

    CMS recorded a $112,800 civil monetary penalty.

    CMS · Recorded event date · View related evidence

  3. Health inspection completed

    13 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  4. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

  2. Civil monetary penalty recorded

    CMS recorded a $8,148 civil monetary penalty.

    CMS · Recorded event date · View related evidence

2023

  1. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    11 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2021

  1. Health inspection completed

    21 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2018

  1. Ownership change recorded

    An ownership change was recorded. New organization: GUNNISON VALLEY HOSPITAL.

    WOODLAND CARE CENTER, LLCGUNNISON VALLEY HOSPITAL

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 3 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter
Total nursing
3.824
reported hours per resident day
RN categories
1.018
reported hours per resident day
LPN/LVN categories
0.542
reported hours per resident day
CNA
2.199
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.0093.37
RN categories1.1330.737

Contract staff accounted for 1.8% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.119 lower than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q23.931.0470.6312.2523.7%91
2025Q33.8971.0080.6192.1616.2%92
2025Q43.9491.1370.5422.1634%92
2026Q13.8241.0180.5422.1991.8%90

Questions to ask

  • PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
  • PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
Source
Centers for Medicare & Medicaid Services (CMS)
Dataset
Payroll Based Journal Daily Nurse Staffing
CMS dataset ID
7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter
2026Q1
Coverage
Jan 1, 2026Mar 31, 2026
Days represented
90 (90 with positive MDS census)
CMS source updated
Jul 29, 2026
Calculation version
pbj-quarter-ratio-of-sums-v1

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

View official CMS PBJ source

What we can verify today

Current Provider Information facts

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

  • CMS reports a 2-star overall rating.
  • CMS reports a 1-star health inspection rating.
  • CMS reports a 3-star staffing rating.
  • CMS reports a 5-star quality-measure rating.

Planned evidence layers

Additional public-source research

These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.

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

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

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