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
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 Mar 5, 2025 cited 20 deficiencies.
View inspection evidenceCMS-published records list 68 ownership or control parties.
CMS records show an ownership change effective May 2021.
View ownership evidenceCMS records show a 10-day payment denial 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:
4 currently connected nursing homes share this CMS organization identity with FOUNDATION HEALTHCARE SERVICES 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.
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 1, 2019
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 24, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 24, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 8, 2025
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 24, 2023
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2024
Individual · ADP OF THE SNF
Association date reported to CMS: Mar 18, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: May 5, 2021
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 1, 2024
Organization · DIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Feb 1, 2019
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Feb 24, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 24, 2024
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 15, 2018
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 24, 2023
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2024
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Mar 18, 2024
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 2024
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 1, 2019
Individual · ADP OF THE SNF
Association date reported to CMS: Feb 24, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 24, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 8, 2025
Other facilities connected through this exact CMS organization identity: 3 across WA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 24, 2023
Organization · ADP OF THE SNF
Association date reported to CMS: Sep 10, 2025
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · ADP OF THE SNF
Association date reported to CMS: Sep 10, 2025
Other facilities connected through this exact CMS organization identity: 0 across WA.
Organization · ADP OF THE SNF
Association date reported to CMS: Sep 10, 2025
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2024
Individual · ADP OF THE SNF
Association date reported to CMS: Mar 18, 2024
Organization · ADP OF THE SNF
Association date reported to CMS: May 5, 2021
Other facilities connected through this exact CMS organization identity: 0 across WA.
Individual · ADP OF THE SNF
Association date reported to CMS: Jan 1, 2024
Organization · DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2021
CMS classifications: Parent company
Other facilities connected through this exact CMS organization identity: 3 across WA.
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 25%
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 25%
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 25%
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 25%
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Feb 1, 2019
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Feb 24, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 24, 2024
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 15, 2018
Other facilities connected through this exact CMS organization identity: 3 across WA.
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 24, 2023
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2024
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Mar 18, 2024
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jan 1, 2024
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.
Inspections & 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.
No health-deficiency rows were deterministically linked to this inspection.
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 (Apr 21, 2025)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 2025)
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 (Apr 18, 2025)
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 (Apr 18, 2025)
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 (Apr 18, 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 (Apr 18, 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 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 (Apr 18, 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 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 (Apr 18, 2025)
Plan the resident's discharge to meet the resident's goals and 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 (Apr 18, 2025)
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 (Apr 18, 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 (Apr 18, 2025)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 2025)
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 F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 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 (Apr 18, 2025)
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 (Apr 18, 2025)
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 (Apr 18, 2025)
Implement a program that monitors antibiotic use.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 2025)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 18, 2025)
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 5, 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 (Jan 15, 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 (Jan 15, 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 F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 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 F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 2024)
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 date of correction (Jan 15, 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 (Jan 15, 2024)
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 (Jan 15, 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 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 15, 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 (Jan 15, 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 (Jan 15, 2024)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 2024)
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 (Jan 15, 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 (Jan 15, 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 (Jan 15, 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 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 15, 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 (Jan 15, 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 (Jan 15, 2024)
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 15, 2024)
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 (Jan 15, 2024)
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate 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 (Jan 15, 2024)
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 (Jan 15, 2024)
Post nurse staffing information every day.
CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Jan 15, 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 (Jan 15, 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 (Jan 15, 2024)
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 2024)
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 2024)
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 (Jan 15, 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 (Jan 15, 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 (Jan 15, 2024)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 15, 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 (Jan 15, 2024)
Implement a program that monitors antibiotic use.
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 15, 2024)
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 date of correction (Nov 17, 2023)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
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 (Nov 17, 2023)
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 (Nov 17, 2023)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Provide care or services that was trauma informed and/or culturally competent.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
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 F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Post nurse staffing information every day.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
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 (Nov 17, 2023)
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
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 (Nov 17, 2023)
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 (Nov 17, 2023)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 2023)
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 17, 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 (Nov 17, 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 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 10, 2022)
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
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 (Oct 10, 2022)
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 10, 2022)
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 10, 2022)
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 (Oct 10, 2022)
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 (Oct 10, 2022)
Plan the resident's discharge to meet the resident's goals and needs.
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 10, 2022)
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 (Oct 10, 2022)
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 (Oct 10, 2022)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
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 10, 2022)
Provide enough food/fluids to maintain a resident's health.
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 10, 2022)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 10, 2022)
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 (Oct 10, 2022)
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 10, 2022)
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 10, 2022)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
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 10, 2022)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
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 (Oct 10, 2022)
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 (Oct 10, 2022)
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
Implement a program that monitors antibiotic use.
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 10, 2022)
Report COVID19 data to residents and families.
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 10, 2022)
Perform COVID19 testing on residents and staff.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 10, 2022)
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 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 10, 2022)
Penalties & enforcement
Payment denial length: 10 days
Published fine amount: $143,754.00
Published fine amount: $62,318.00
Questions to ask
Facility history
15 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
RN staffing increased from 0.24 to 0.38 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
0.24 → 0.38
CMS · Reported in a source release · View related evidence
Total nurse staffing increased from 3.37 to 3.58 hours per resident day between 2025Q4 and 2026Q1. Staffing improved across those reported periods.
3.37 → 3.58
CMS · Reported in a source release · View related evidence
Total nurse staffing decreased from 3.71 to 3.37 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
3.71 → 3.37
CMS · Reported in a source release · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
20 deficiencies were 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
32 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
CMS recorded a Medicare payment denial lasting 10 days.
CMS · Recorded event date · View related evidence
CMS recorded a $143,754 civil monetary penalty.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
CMS recorded a $62,318 civil monetary penalty.
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 | 3.72 | 3.238 |
| RN categories | 0.439 | 0.222 |
Contract staff accounted for 1.4% of reported nursing hours included in this quarter calculation.
PBJ reports zero combined RN-category hours on 4 days with a positive MDS census in this quarter.
Reported RN-category hours per resident day were 0.136 higher 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 | 3.719 | 0.195 | 1.274 | 2.138 | 1% | 91 |
| 2025Q3 | 3.708 | 0.236 | 1.114 | 2.335 | 0.1% | 92 |
| 2025Q4 | 3.373 | 0.24 | 1.052 | 2.081 | 0% | 92 |
| 2026Q1 | 3.58 | 0.376 | 0.955 | 2.249 | 1.4% | 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.