Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.81 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceEVERGREEN HEALTH AND REHABILITATION CENTER
Also known publicly as Evergreen Health & Rehab Center
WINCHESTER, VA
CMS 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
- 176
- 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
- 5406677010Verified public information · checked Aug 2026
- Also known publicly as
- Evergreen Health & Rehab CenterVerified public information · checked Aug 2026
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on Jan 10, 2024 cited 22 deficiencies.
View inspection evidenceOwnership
CMS-published records list 23 ownership or control parties.
CMS records show an ownership change effective July 2021.
View ownership evidenceChain context
CMS groups this facility with a chain covering 43 facilities across 6 states or territories.
View chain evidenceOwnership & 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
- HILL VALLEY HEALTHCARECMS identifies this facility as part of the HILL VALLEY HEALTHCARE chain.
- Related facilities
- 47Current CMS organization identity
- Ownership changes
- 1 recordedCMS enrollment records
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 16 CMS-reported ownership organizations
- CMS reports 6 individual ownership interests
- a CMS chain / common-control group
- recorded ownership-change events
Related facilities
47 currently connected nursing homes share this CMS organization identity with SABRINA 1818 HOLDINGS LLC.
- Average CMS overall rating
- 1.7 stars across 47 reporting facilities
- CMS monetary penalties
- 27 of 47 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 15 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 14 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 36 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $1,451,986
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
- 17
- Individuals shown
- 6
- Latest ownership source update
- Jul 27, 2026
CMS-published ownership and control parties
EVERGREEN SNF OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
COPPER VA TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
EVERGREEN NOBLE PARENTCO LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
GOLD VA TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
HVH EVERGREEN OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
MEISNER, ROBERT
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 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
SILVER VA TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
IDELS, SHIMON
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 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
RINGSTAFF, RAMONA
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jul 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
EVERGREEN SNF OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
COPPER VA TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 10%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 1 across VA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
EVERGREEN NOBLE PARENTCO LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
GOLD VA TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 17.5%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 1 across VA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
HVH EVERGREEN OPERATIONS HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across VA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
LION 26 HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 23.75%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 45 across IN, KY, MD, NV, OR, TN, VA, WA, WV.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
MEISNER, ROBERT
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5%
Association date reported to CMS: Jul 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
SABRINA 1818 HOLDINGS LLC
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 23.75%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 46 across IN, KY, MD, NV, OR, TN, VA, WA, WV.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
SAESSY IRREVOCABLE TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 22.59%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 46 across IN, KY, MD, NV, OR, TN, VA, WA, WV.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
SILVER VA TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 17.5%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 1 across VA.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
TATIRIQ IRREVOCABLE TRUST
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 22.59%
Association date reported to CMS: Jul 1, 2021
Other facilities connected through this exact CMS organization identity: 46 across IN, KY, MD, NV, OR, TN, VA, WA, WV.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
IDELS, SHIMON
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
RINGSTAFF, RAMONA
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jul 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
EVERGREEN SNF OPERATIONS LLC
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across VA.
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
Ownership changes reported in CMS enrollment records
- CHANGE OF OWNERSHIPPINNACLE SERVICES WINCHESTER, INC. to EVERGREEN SNF OPERATIONS LLC
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility Change of Ownership
- CMS dataset identifier
- f557a6ed-95b3-4a22-8433-4175db2dec1c
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
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, 2021. What operational or leadership changes followed that event?
- CMS records connect COPPER VA TRUST to 2 facilities. Which policies and staffing decisions are managed centrally versus locally?
Chain context
CMS groups this facility with HILL VALLEY HEALTHCARE
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 270 is a grouping identifier, not a legal organization.
- Facilities
- 43
- States and territories
- 6
- Average overall rating
- 1.7
- Average staffing rating
- 2
- Average total nurse HPRD
- 3.4
- Total fines
- 36
CMS-published history
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 43 | 1.7 | 2 |
| Mon Jun | 44 | 1.9 | 1.8 |
| Fri May | 44 | 2 | 1.8 |
| Wed Apr | 43 | 2 | 1.8 |
| Sun Mar | 40 | 2.2 | 2 |
| Sun Feb | 39 | 2.2 | 1.9 |
Questions to ask
- CMS groups facilities in 6 states or territories under this chain. Which operational policies are set at the chain level?
- CMS reports 36 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- May 6, 2026
- Survey type
- Health Complaint
- Linked findings
- 6
- Highest linked CMS classification
- D — Isolated; No actual harm with potential for more than minimal 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
- 495142
- Source record locator
- csv-row:121691:ccn:495142
May 6, 2026 — Health Complaint — 6 linked findings
F0607 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 1, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336105:ccn:495142
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 (Jun 1, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336106:ccn:495142
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 1, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336107:ccn:495142
F0740 — Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 1, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336108:ccn:495142
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 (Jun 1, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336109:ccn:495142
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 1, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336110:ccn:495142
Jan 10, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jan 10, 2024 — Health Standard — 22 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 (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336118:ccn:495142
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 (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336119:ccn:495142
F0582 — Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336120:ccn:495142
F0623 — Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity 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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336113:ccn:495142
F0625 — Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS scope/severity 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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336121:ccn:495142
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336122:ccn:495142
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 (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336123:ccn:495142
F0658 — Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336124:ccn:495142
F0687 — Quality of Life and Care Deficiencies
Provide appropriate foot care.
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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336125:ccn:495142
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336126:ccn:495142
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336127:ccn:495142
F0698 — Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336114:ccn:495142
F0730 — Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336128:ccn:495142
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336132:ccn:495142
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 (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336129:ccn:495142
F0759 — Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336130:ccn:495142
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 (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336115:ccn:495142
F0840 — Administration Deficiencies
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336116:ccn:495142
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336131:ccn:495142
F0865 — Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336111:ccn:495142
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336112:ccn:495142
F0887 — Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 19, 2024)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336117:ccn:495142
Apr 14, 2022 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 14, 2022 — Health Standard — 17 linked findings
F0578 — Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS scope/severity 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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336134:ccn:495142
F0582 — Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336140:ccn:495142
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 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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336135:ccn:495142
F0623 — Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity 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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336136:ccn:495142
F0625 — Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336137:ccn:495142
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336141:ccn:495142
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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336142:ccn:495142
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336138:ccn:495142
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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336143:ccn:495142
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336144:ccn:495142
F0700 — Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336145:ccn:495142
F0730 — Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336139:ccn:495142
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336149:ccn:495142
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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336133:ccn:495142
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336146:ccn:495142
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336147:ccn:495142
F0947 — Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS scope/severity 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 (May 16, 2022)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336148:ccn:495142
Apr 25, 2019 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Apr 25, 2019 — Health Standard — 16 linked findings
F0550 — Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity 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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336154:ccn:495142
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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336155:ccn:495142
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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336156:ccn:495142
F0623 — Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity 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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336157:ccn:495142
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336158:ccn:495142
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 (Jun 21, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336159:ccn:495142
F0657 — Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336160:ccn:495142
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 21, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336150:ccn:495142
F0697 — Quality 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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336161:ccn:495142
F0730 — Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336151:ccn:495142
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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336162:ccn:495142
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336163:ccn:495142
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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336152:ccn:495142
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 (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336153:ccn:495142
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 28, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336164:ccn:495142
F0842 — Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 21, 2019)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Jul 1, 2026
- CMS provider ID
- 495142
- Source record locator
- csv-row:336165:ccn:495142
Tags appearing across inspections
- F0842 appears in 4 linked inspections.
- F0623 appears in 3 linked inspections.
- F0641 appears in 3 linked inspections.
- F0656 appears in 3 linked inspections.
- F0657 appears in 3 linked inspections.
- F0695 appears in 3 linked inspections.
- F0730 appears in 3 linked inspections.
- F0812 appears in 3 linked inspections.
- F0580 appears in 2 linked inspections.
- F0582 appears in 2 linked inspections.
- F0622 appears in 2 linked inspections.
- F0625 appears in 2 linked inspections.
- F0732 appears in 2 linked inspections.
- F0755 appears in 2 linked inspections.
- F0759 appears in 2 linked inspections.
- F0880 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Questions generated from the evidence above
- CMS records show F0842 in 4 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0623 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0641 in 3 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 F0657 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0695 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0730 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0812 in 3 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0580 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0582 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0622 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0625 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0732 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 F0759 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?
Facility history
Facility History
6 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded6 deficiencies were recorded.
- RN staffing increasedRN staffing increased from 0.66 to 0.77 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
2026
- Complaint inspection recorded
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- RN staffing increased
RN staffing increased from 0.66 to 0.77 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
0.66 → 0.77
CMS · Reported in a source release · View related evidence
2024
- Health inspection completed
22 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2022
- Health inspection completed
17 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2021
- Ownership change recorded
An ownership change was recorded. New organization: EVERGREEN SNF OPERATIONS LLC.
PINNACLE SERVICES WINCHESTER, INC. → EVERGREEN SNF OPERATIONS LLC
CMS · Recorded event date · View related evidence
2019
- Health inspection completed
16 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 2 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
- Total nursing
- 3.157 reported hours per resident day
- RN categories
- 0.811 reported hours per resident day
- LPN/LVN categories
- 0.635 reported hours per resident day
- CNA
- 1.711 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.249 | 2.93 |
| RN categories | 0.884 | 0.628 |
Contract staff accounted for 15.6% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.044 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 | 3.103 | 0.657 | 0.763 | 1.683 | 19.4% | 91 |
| 2025Q3 | 3.288 | 0.767 | 0.749 | 1.749 | 15.7% | 92 |
| 2025Q4 | 3.203 | 0.767 | 0.699 | 1.732 | 17.8% | 92 |
| 2026Q1 | 3.157 | 0.811 | 0.635 | 1.711 | 15.6% | 90 |
Questions to ask
- PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
- PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 2-star overall rating.
- CMS reports a 2-star health inspection rating.
- CMS reports a 2-star staffing rating.
- CMS reports a 4-star quality-measure rating.
Planned evidence layers
Additional public-source research
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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
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
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Jul 1, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility All Owners
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility Enrollments
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Jul 27, 2026
- Retrieved
- Aug 15, 2026
- Supports
- Ownership parties, organization connections, and ownership history
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
Nursing Home Chain Performance Measures
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 97ecfad1-d3f1-4d42-b774-d74661d830bc
- Coverage
- Wed Jul
- Source updated
- Aug 12, 2026
- Retrieved
- Aug 16, 2026
- Supports
- CMS chain context, performance, and monthly history
Verified public facility information
- Source organization
- Public facility listing
- Dataset identifier
- commercial-corroboration:public-listing
- Source updated
- Aug 18, 2026
- Retrieved
- Aug 18, 2026
- Supports
- Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
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