Staffing
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.38 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
Also known publicly as Glenburnie Rehabilitation and Nursing Center
RICHMOND, VA
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.38 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Jan 25, 2024 cited 16 deficiencies.
View inspection evidenceCMS-published records list 26 ownership or control parties.
CMS records show an ownership change effective January 2020.
View ownership evidenceCMS groups this facility with a chain covering 69 facilities across 5 states or territories.
View chain evidenceCMS records show a $54,211 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
40 currently connected nursing homes share this CMS organization identity with CHARLES 1994 FAMILY GRANTOR TRUST.
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 17, 2020
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 17, 2020
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Aug 18, 2022
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jan 17, 2020
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 4 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 27.7%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 39 across MD, NC, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 24.85%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 36 across MD, NC, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 29.16%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 6 across MD, NC, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 29.16%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 6 across MD, NC, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 29.16%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 6 across MD, NC, VA.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 17, 2020
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 27.7%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 37 across MD, NC, VA.
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Jan 17, 2020
Organization · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Dec 1, 2019
Other facilities connected through this exact CMS organization identity: 3 across VA.
Individual · OTHER
Published ownership percentage: 0%
Association date reported to CMS: Aug 18, 2022
Individual · W-2 MANAGING EMPLOYEE
Published ownership percentage: 100%
Association date reported to CMS: Aug 18, 2022
Individual · W-2 MANAGING EMPLOYEE
Published ownership percentage: 100%
Association date reported to CMS: Jan 17, 2020
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across VA.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 768 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 69 | 2 | 1.6 |
| Mon Jun | 66 | 2.1 | 1.4 |
| Fri May | 66 | 2.1 | 1.5 |
| Wed Apr | 62 | 2.1 | 1.5 |
| Sun Mar | 59 | 2.1 | 1.5 |
| Sun Feb | 59 | 2.1 | 1.5 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
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 (Dec 1, 2025)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 2, 2026)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity 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 2, 2026)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 2, 2026)
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 (Jan 2, 2026)
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 (Dec 1, 2025)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 1, 2025)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 1, 2025)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 1, 2025)
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 (Jan 2, 2026)
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 (Dec 1, 2025)
Provide or arrange emergency care by a doctor 24 hours a day.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 1, 2025)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 2, 2026)
Provide and implement an infection prevention and control program.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 2, 2026)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity L: Widespread; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (May 6, 2025)
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
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 6, 2025)
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 6, 2025)
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 (May 6, 2025)
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 (May 6, 2025)
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 31, 2025)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity 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 31, 2025)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity 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 31, 2025)
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 31, 2025)
Ensure services provided by the nursing facility meet professional standards of quality.
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 31, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 31, 2025)
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 31, 2025)
Ensure each resident’s drug regimen must be free from unnecessary 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 31, 2025)
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 31, 2025)
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 (Mar 1, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 1, 2025)
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 (Mar 1, 2025)
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 (Mar 1, 2025)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 31, 2025)
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 (Mar 1, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 1, 2025)
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 (Mar 1, 2025)
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 (Mar 1, 2025)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 31, 2025)
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 26, 2024)
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 26, 2024)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 26, 2024)
No health-deficiency rows were deterministically linked to this inspection.
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 (Mar 8, 2024)
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 (Mar 8, 2024)
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 (Mar 8, 2024)
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 (Mar 8, 2024)
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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
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 (Mar 8, 2024)
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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Provide care or services that was trauma informed and/or culturally competent.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
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 (Mar 8, 2024)
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 (Mar 8, 2024)
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 (Mar 8, 2024)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
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 (Mar 8, 2024)
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
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 (Mar 21, 2023)
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 (Mar 21, 2023)
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Provide for the safe, appropriate administration of IV fluids 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 (Mar 21, 2023)
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 (Mar 21, 2023)
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 (Mar 21, 2023)
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's 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 (Mar 21, 2023)
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
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 (Mar 21, 2023)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
Ensure that residents are free from significant medication errors.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
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 (Mar 21, 2023)
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 (Mar 21, 2023)
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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 21, 2023)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
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 (Aug 20, 2021)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
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 (Aug 20, 2021)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
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 (Aug 20, 2021)
Dispose of garbage and refuse properly.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Aug 20, 2021)
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 (Aug 20, 2021)
Penalties & enforcement
Published fine amount: $54,211.00
Questions to ask
Facility history
15 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
Total nurse staffing decreased from 3.60 to 3.20 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.
3.60 → 3.20
CMS · Reported in a source release · View related evidence
Total nurse staffing decreased from 3.90 to 3.60 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
3.90 → 3.60
CMS · Reported in a source release · View related evidence
RN staffing decreased from 0.54 to 0.43 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
0.54 → 0.43
CMS · Reported in a source release · View related evidence
14 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Total nurse staffing increased from 3.64 to 3.90 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
3.64 → 3.90
CMS · Reported in a source release · View related evidence
5 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
9 deficiencies were recorded.
CMS · Recorded event date · View related evidence
CMS recorded a $54,211 civil monetary penalty.
CMS · Recorded event date · View related evidence
10 deficiencies were recorded.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
16 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 1 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.482 | 2.503 |
| RN categories | 0.461 | 0.177 |
Contract staff accounted for 13.5% of reported nursing hours included in this quarter calculation.
PBJ reports zero combined RN-category hours on 1 day with a positive MDS census in this quarter.
Reported RN-category hours per resident day were 0.050 lower than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.641 | 0.614 | 0.966 | 2.061 | 6.3% | 91 |
| 2025Q3 | 3.901 | 0.54 | 1.22 | 2.14 | 24.5% | 92 |
| 2025Q4 | 3.595 | 0.43 | 1.184 | 1.982 | 21.2% | 92 |
| 2026Q1 | 3.2 | 0.379 | 1.055 | 1.765 | 13.5% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.