Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 0.70 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
Also known publicly as Orchard Park Health and Rehabilitation Center
TACOMA, WA
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 4-star staffing rating for this facility.
RN staffing was 0.70 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Jun 1, 2026 cited 28 deficiencies.
View inspection evidenceCMS-published records list 47 ownership or control parties.
View ownership evidenceCMS groups this facility with a chain covering 185 facilities across 18 states or territories.
View chain evidenceCMS records show a $34,671 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:
142 currently connected nursing homes share this CMS organization identity with ZAC PROPERTIES XI LLC.
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
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 0 across WA.
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 WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
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 WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Dec 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
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 WA.
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 WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jan 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · CONTRACTED MANAGING EMPLOYEE
Association date reported to CMS: Jan 1, 2020
Individual · CORPORATE OFFICER
Association date reported to CMS: Dec 1, 2015
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 1, 2020
Individual · CORPORATE OFFICER
Association date reported to CMS: Dec 1, 2015
Individual · CORPORATE OFFICER
Association date reported to CMS: Jan 1, 2020
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 1, 2015
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 1, 2015
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Sep 30, 2021
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 7 across CA, NV, WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 8 across CA, NV, WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 135 across MA, MD, ME, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 2 across WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Dec 6, 2015
Other facilities connected through this exact CMS organization identity: 139 across MA, MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 140 across MA, MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 136 across MA, MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 138 across MA, MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 127 across MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 4 across MD, WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 14%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 140 across MA, MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2019
Other facilities connected through this exact CMS organization identity: 11 across CA, NV, WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 13 across CA, MA, NM, PA, WA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 52.24%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 136 across MA, MD, ME, NH, NJ, NM, PA, RI, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.81%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 131 across MA, MD, ME, NC, NH, NJ, NM, NV, PA, RI, TN, VA, VT, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5.9%
Association date reported to CMS: Jan 1, 2020
Other facilities connected through this exact CMS organization identity: 89 across IL, IN, MD, MI, NJ, NM, OH, PA, TX, VA, WA, WV.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 8.1%
Association date reported to CMS: Jul 6, 2015
Other facilities connected through this exact CMS organization identity: 141 across MA, MD, ME, NC, NH, NJ, NM, NV, PA, RI, TN, VA, VT, WA, WV.
Individual · CONTRACTED MANAGING EMPLOYEE
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Dec 1, 2015
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Dec 1, 2015
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 2020
Individual · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Dec 1, 2015
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 1, 2015
Other facilities connected through this exact CMS organization identity: 138 across MA, MD, ME, NC, NH, NJ, NM, PA, RI, TN, VA, VT, WA, WV.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Sep 30, 2021
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across WA.
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 237 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 185 | 2.4 | 2.5 |
| Mon Jun | 187 | 2.4 | 2.5 |
| Fri May | 187 | 2.4 | 2.5 |
| Wed Apr | 191 | 2.4 | 2.6 |
| Sun Mar | 193 | 2.4 | 2.5 |
| Sun Feb | 197 | 2.4 | 2.5 |
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.
No health-deficiency rows were deterministically linked to this inspection.
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 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 plan of correction (Jun 19, 2026)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 19, 2026)
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 plan of correction (Jun 19, 2026)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 19, 2026)
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
Assess the resident when there is a significant change in condition
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 plan of correction (Jun 19, 2026)
Assure that each resident’s assessment is updated at least once every 3 months.
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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
PASARR screening for Mental disorders or Intellectual Disabilities
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 19, 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 plan of correction (Jun 19, 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 plan of correction (Jun 19, 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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
Provide routine and 24-hour emergency dental care for 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 plan of correction (Jun 19, 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 plan of correction (Jun 19, 2026)
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 plan of correction (Jun 19, 2026)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has plan of correction (Jun 1, 2026)
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 plan of correction (May 22, 2026)
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 plan of correction (May 22, 2026)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2026)
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: Past Non-Compliance (Mar 8, 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 30, 2026)
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 (Jan 30, 2026)
Provide or get specialized rehabilitative services as required for a resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 30, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 (Aug 9, 2025)
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 (Jul 31, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Respond appropriately to all alleged violations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Ensure each resident receives an accurate assessment.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
PASARR screening for Mental disorders or Intellectual Disabilities
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 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 (Jul 3, 2025)
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Provide activities to meet all resident's needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 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 (Jul 3, 2025)
Assist a resident in gaining access to vision and hearing services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 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 (Jul 3, 2025)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Provide routine and 24-hour emergency dental care for 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 (Jul 3, 2025)
Provide or obtain dental services for 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 (Jul 3, 2025)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
Provide and implement an infection prevention and control program.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 3, 2025)
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 (Jul 3, 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 (May 7, 2025)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Ensure that residents are fully informed and understand their health status, care and treatments.
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
Ensure each resident receives an accurate assessment.
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 (Oct 14, 2024)
PASARR screening for Mental disorders or Intellectual Disabilities
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 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 G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 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 (Oct 14, 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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Oct 14, 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 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 (Oct 14, 2024)
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 (Oct 14, 2024)
Provide routine and 24-hour emergency dental care for 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 (Oct 14, 2024)
Provide or obtain dental services for 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 (Oct 14, 2024)
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 (Oct 14, 2024)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2024)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 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 (Oct 14, 2024)
Provide or get specialized rehabilitative services as required for a resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 14, 2024)
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
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 (Oct 14, 2024)
Hire a qualified full-time social worker in a facility with more than 120 beds.
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 (Oct 14, 2024)
Have a plan that describes the process for conducting QAPI and QAA activities.
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 (Oct 14, 2024)
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 (Oct 14, 2024)
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 (Aug 8, 2024)
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 (Aug 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 (Aug 8, 2024)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 28, 2024)
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 (Jun 24, 2024)
Penalties & enforcement
Published fine amount: $34,671.00
Published fine amount: $101,384.00
Questions to ask
Facility history
24 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
28 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
1 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
CMS recorded a $34,671 civil monetary penalty.
CMS · Recorded event date · View related evidence
18 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 4 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.829 | 3.255 |
| RN categories | 0.8 | 0.465 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.018 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 | 3.794 | 0.752 | 1.042 | 2.001 | 0% | 91 |
| 2025Q3 | 3.783 | 0.76 | 1.039 | 1.984 | 0% | 92 |
| 2025Q4 | 3.81 | 0.721 | 1.126 | 1.963 | 0% | 92 |
| 2026Q1 | 3.664 | 0.704 | 1.14 | 1.821 | 0% | 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.