Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 1.19 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceCMS overview
CMS rating overview
No proprietary TrustHub score. These ratings are published separately by CMS.
How CMS describes these ratings
- CMS overall rating
- The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
- Health inspection rating
- The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
- Staffing rating
- The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
- Quality-measure rating
- The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
- CMS certified beds
- 41
- 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
- 4353105800CMS Provider Information
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on Dec 15, 2025 cited 13 deficiencies.
View inspection evidenceOwnership
CMS-published records list 23 ownership or control parties.
View ownership evidenceChain context
CMS groups this facility with a chain covering 7 facilities across 2 states or territories.
View chain evidenceEnforcement record
CMS records show a $41,340 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
- MISSION HEALTH SERVICESCMS identifies this facility as part of the MISSION HEALTH SERVICES chain.
- Related facilities
- 15Current CMS organization identity
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- CMS reports 19 individual ownership interests
- a CMS chain / common-control group
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
- 23
- Organizations shown
- 4
- Individuals shown
- 19
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
DUNN, MARC
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 1, 2019
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
LARSEN, NICHOLAS
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 1, 2019
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
LARSEN, RYAN
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 1, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
MSM BRIGHAM CITY
Organization · ADP OF THE SNF
Association date reported to CMS: Feb 27, 2026
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
PATH ACCOUNTING LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 1, 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
RAWLS, DANIELLE
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 1, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
ANDERSEN, JEANETTE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2016
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
ANDERSON, STEVE
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2015
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
BARTHOLOMEW, LAMAR
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jul 1, 2014
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
BLACKHAM, BRADY
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jul 1, 2020
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
DYRENG, CASEY
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 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
PICKETT, KIM
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jan 1, 2015
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
SORENSON, MERRI LYNN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: May 31, 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
BARTHOLOMEW, BRENDA
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
MURRAY, BRIAN
Individual · CORPORATE OFFICER
Association date reported to CMS: May 1, 2014
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
LARSEN, RYAN
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Apr 1, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
RAWLS, DANIELLE
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Apr 1, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
DUNN, MARC
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2023
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
LARSEN, NICHOLAS
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2023
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
LARSEN, RYAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 1, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
MSM BRIGHAM CITY
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2023
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
RAWLS, DANIELLE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 1, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
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
What this means
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Questions to ask
- CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
- CMS records connect GUNNISON VALLEY HOSPITAL to 15 facilities. Which policies and staffing decisions are managed centrally versus locally?
Chain context
CMS groups this facility with MISSION HEALTH SERVICES
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 355 is a grouping identifier, not a legal organization.
- Facilities
- 7
- States and territories
- 2
- Average overall rating
- 3.4
- Average staffing rating
- 2.9
- Average total nurse HPRD
- 3.5
- Total fines
- 6
CMS-published history
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 7 | 3.4 | 2.9 |
| Mon Jun | 7 | 3.6 | 2.7 |
| Fri May | 7 | 3.6 | 2.7 |
| Wed Apr | 7 | 3.6 | 2.7 |
| Sun Mar | 4 | 3.3 | 3.3 |
| Sun Feb | 4 | 3 | 3.3 |
Questions to ask
- CMS groups facilities in 2 states or territories under this chain. Which operational policies are set at the chain level?
- CMS reports 6 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- Dec 15, 2025
- Survey type
- Fire Safety Standard
- Linked findings
- 0
- Highest linked CMS classification
- No linked health-deficiency finding in the loaded record
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:120759:ccn:465165
Dec 15, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 15, 2025 — Health Standard — 13 linked findings
F0580 — Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 16, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332709:ccn:465165
F0628 — Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332710:ccn:465165
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 13, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332711:ccn:465165
F0690 — Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332702:ccn:465165
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 16, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332712:ccn:465165
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332704:ccn:465165
F0773 — Administration Deficiencies
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 (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332713:ccn:465165
F0775 — Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332705:ccn:465165
F0779 — Administration Deficiencies
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 (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332714:ccn:465165
F0801 — Nutrition and Dietary Deficiencies
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332706:ccn:465165
F0804 — Nutrition 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 (Jan 16, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332707:ccn:465165
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 12, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332703:ccn:465165
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 31, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332708:ccn:465165
Dec 18, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 18, 2023 — Health Complaint — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Dec 18, 2023 — Health Standard — 10 linked findings
F0554 — Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332720:ccn:465165
F0609 — Freedom 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 (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332716:ccn:465165
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332721:ccn:465165
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332723:ccn:465165
F0756 — Pharmacy Service Deficiencies
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 (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332724:ccn:465165
F0757 — Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332725:ccn:465165
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332717:ccn:465165
F0770 — Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332726:ccn:465165
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332718:ccn:465165
F0881 — Infection Control Deficiencies
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 (Jan 18, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332727:ccn:465165
Mar 2, 2022 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Mar 2, 2022 — Health Standard — 21 linked findings
F0554 — Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332738:ccn:465165
F0561 — Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332739:ccn:465165
F0580 — Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332740:ccn:465165
F0583 — Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332741:ccn:465165
F0585 — Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332732:ccn:465165
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332729:ccn:465165
F0603 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332730:ccn:465165
F0607 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and 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 (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332733:ccn:465165
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332742:ccn:465165
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332743:ccn:465165
F0622 — Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332744:ccn:465165
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332745:ccn:465165
F0729 — Nursing and Physician Services Deficiencies
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332746:ccn:465165
F0745 — Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332747:ccn:465165
F0759 — Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332734:ccn:465165
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332731:ccn:465165
F0825 — Quality of Life and Care Deficiencies
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 (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332748:ccn:465165
F0835 — Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332735:ccn:465165
F0867 — Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332736:ccn:465165
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity L: Widespread; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332728:ccn:465165
F0888 — Infection Control Deficiencies
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 (Apr 15, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:332737:ccn:465165
Tags appearing across inspections
- F0812 appears in 3 linked inspections.
- F0554 appears in 2 linked inspections.
- F0580 appears in 2 linked inspections.
- F0609 appears in 2 linked inspections.
- F0610 appears in 2 linked inspections.
- F0755 appears in 2 linked inspections.
- F0761 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Dec 15, 2025
Published fine amount: $41,340.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:12966:ccn:465165
Fine — Dec 18, 2023
Published fine amount: $40,565.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:12965:ccn:465165
Payment Denial — Dec 18, 2023
Payment denial length: 32 days
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 465165
- Source record locator
- csv-row:12967:ccn:465165
Questions to ask
Questions generated from the evidence above
- CMS records show F0812 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 F0580 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 F0755 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0761 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Dec 15, 2025. What changes were made after that enforcement action?
Facility history
Facility History
11 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Total nurse staffing increasedTotal nurse staffing increased from 3.80 to 4.16 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
- Civil monetary penalty recordedCMS recorded a $41,340 civil monetary penalty.
- Health inspection completed13 deficiencies were recorded. That includes 1 higher-severity deficiency.
2026
- Total nurse staffing increased
Total nurse staffing increased from 3.80 to 4.16 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
3.80 → 4.16
CMS · Reported in a source release · View related evidence
- RN staffing increased
RN staffing increased from 1.07 to 1.19 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
1.07 → 1.19
CMS · Reported in a source release · View related evidence
2025
- Total nurse staffing decreased
Total nurse staffing decreased from 4.06 to 3.80 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
4.06 → 3.80
CMS · Reported in a source release · View related evidence
- Civil monetary penalty recorded
CMS recorded a $41,340 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Health inspection completed
13 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
- Total nurse staffing increased
Total nurse staffing increased from 3.56 to 4.06 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
3.56 → 4.06
CMS · Reported in a source release · View related evidence
2023
- Civil monetary penalty recorded
CMS recorded a $40,565 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Medicare payment denial recorded
CMS recorded a Medicare payment denial lasting 32 days.
CMS · Recorded event date · View related evidence
- Health inspection completed
10 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
2022
- Health inspection completed
21 deficiencies were recorded. That includes 3 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 4 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
- Total nursing
- 4.164 reported hours per resident day
- RN categories
- 1.193 reported hours per resident day
- LPN/LVN categories
- 0.039 reported hours per resident day
- CNA
- 2.564 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 4.168 | 4.155 |
| RN categories | 1.311 | 0.904 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.120 higher than the prior loaded quarter.
Staffing over time
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.556 | 1.114 | 0.016 | 2.082 | 0% | 91 |
| 2025Q3 | 4.058 | 1.171 | 0.058 | 2.52 | 0% | 92 |
| 2025Q4 | 3.8 | 1.073 | 0.011 | 2.355 | 0% | 92 |
| 2026Q1 | 4.164 | 1.193 | 0.039 | 2.564 | 0% | 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?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 3-star overall rating.
- CMS reports a 2-star health inspection rating.
- CMS reports a 4-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.
Trust participation
See something that needs correction?
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
See where this record came from
Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Health deficiencies and facility history
Penalties
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- g6vv-u9sr
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 14, 2026
- Supports
- Penalties, enforcement, and facility history
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility Enrollments
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Nursing Home Chain Performance Measures
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 97ecfad1-d3f1-4d42-b774-d74661d830bc
- Coverage
- Wed Jul
- Source updated
- Aug 12, 2026
- Retrieved
- Aug 16, 2026
- Supports
- CMS chain context, performance, and monthly history
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.