Staffing
CMS publishes a 5-star staffing rating for this facility.
RN staffing was 2.30 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceFacility record
Hebron Oaks has 70 certified beds in Madison, Wisconsin. The CMS overall rating is 4 of 5, compared with the Wisconsin average of 3.0. The CMS health inspection rating is 3 of 5, compared with the Wisconsin average of 2.8. The CMS staffing rating is 5 of 5. The latest standard health survey on Jul 17, 2025 lists 2 deficiencies, compared with the Wisconsin average of 5.8. CMS records a fine of $14,901 dated Feb 18, 2025. Total nurse staffing is 5.91 hours per resident day in 2026Q1, compared with the Wisconsin average of 4.20.
Nearby facilities
- CAPITOL LAKES HEALTH CENTER MADISON
- Complete Care at Maple Grove LLC Madison
- Madison Health and Rehabilitation Center Madison
- OAK PARK NURSING AND REHAB CENTER MADISON
- Oak Park Place of Nakoma Madison
- OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER MADISON
- Avina of Sun Prairie Sun Prairie
- BADGER PRAIRIE HCC VERONA
- Complete Care at Nazareth LLC Stoughton
- FOUR WINDS MANOR VERONA
Independent research from official CMS public records. No paid ranking. No Trust Hub quality score.
Research this nursing home using CMS and federal public records. CMS Certification Number 525375.
At a glance
CMS research snapshot
CMS overall rating
4 of 5
CMS health inspection rating
3 of 5
CMS staffing rating
5 of 5
CMS quality-measure rating
4 of 5
CMS ownership-change history
No attached CMS ownership-change event.
These are CMS star ratings, not Trust Hub ratings. Missing evidence is shown as not reported, not as zero.
Quality & care evidence
What CMS reports about quality
- MDS quality observations are in the CMS extract.
- PBJ staffing records are in the CMS extract.
- Inspection evidence is in the CMS extract.
- Fire-safety evidence is in the CMS extract.
Staffing, inspections, and fire safety are separate CMS evidence families below.
Ownership & management
Who CMS/PECOS connects to this nursing home
Current ownership uses CURRENT OWNED_BY evidence only. UNKNOWN is not a former owner.
Current owners
- OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
- OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
Operators
- BARROS, MARYIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- BARROS, MARYIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- DONOVAN, AMBERIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- DONOVAN, AMBERIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- HAMILTON-CRAWFORD, JANICEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- HAMILTON-CRAWFORD, JANICEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- HUSOM, SUSANIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- HUSOM, SUSANIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- JACOBSON, ERICIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- JACOBSON, ERICIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- LEFEL, KRISTINIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- LEFEL, KRISTINIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- O'DONNELL, CHRISTINEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- O'DONNELL, CHRISTINEIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- RAFFERTY, SUSANIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- RAFFERTY, SUSANIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- SACHTJEN, LAURAIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- SACHTJEN, LAURAIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- SIDHU, SARFRAZIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- SIDHU, SARFRAZIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- TURNER, MARCIAIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- TURNER, MARCIAIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- WILLIAMS-RACETTE, SARAHIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- WILLIAMS-RACETTE, SARAHIndividual owner · CURRENTOPERATIONAL/MANAGERIAL CONTROL
- BARROS, MARYIndividual owner · UNKNOWNOPERATIONAL/MANAGERIAL CONTROL
Showing 25 of 48 relationships from CMS/PECOS evidence.
Enrollment organizations
- OAKWOOD VILLAGE UNIVERSITY WOODS HOMES INCOrganization · CURRENTMedicare-enrolled legal organization
- OAKWOOD VILLAGE UNIVERSITY WOODS HOMES INCOrganization · UNKNOWNMedicare-enrolled legal organization
Ownership observations with UNKNOWN status
These relationships were observed in an older snapshot. UNKNOWN does not mean former owner, previous owner, or that ownership ended.
UNKNOWN
- OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.Organization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
- OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.Organization · UNKNOWN5% OR GREATER DIRECT OWNERSHIP INTEREST100% ownership interest
Ownership change history
CMS ownership-change records
No CMS ownership-change event is currently attached to this profile in the Trust Hub research graph. That is not proof that ownership never changed.
Source freshness
How current each evidence family is
- nursing-home-mds-quality-measures
- STALE · source as of 2026-08-01
- nursing-home-provider-information
- STALE · source as of 2026-08-01
- skilled-nursing-facility-all-owners
- AGING · source as of 2026-08-17
- skilled-nursing-facility-change-of-ownership
- CURRENT · source as of 2026-08-24
Profile generated 2026-11-03. That timestamp is not CMS evidence freshness.
Methodology
How Trust Hub researches this provider
- CMS is the source for national nursing-home evidence.
- Trust Hub does not create the CMS star ratings.
- Ownership evidence does not measure care quality.
- CMS CHOW records document reported ownership-change events.
- Missing evidence is not interpreted as zero.
- UNKNOWN ownership history is not interpreted as divestiture.
- Ownership evidence is not a quality measure.
- Missing evidence is not a zero score.
- CMS ratings are CMS ratings, not Trust Hub ratings.
- UNKNOWN ownership does not prove an owner left.
- CHOW records are CMS transaction records, not Trust Hub judgments or sales.
CMS overview
CMS rating overview
No proprietary TrustHub score. These ratings are published separately by CMS. How CMS ratings and facility records are read
- CMS certified beds
- 70
- Ownership descriptor
- Non profit - Corporation
- Medicare participation
- Yes
- Medicaid participation
- Yes
Facility information
Contact
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
- Phone
- 6082304000CMS Provider Information
CMS designations
Special Focus and abuse-icon status
This CMS Certification Number appears in the latest CMS Nursing Home Provider Information extract of currently listed nursing homes.
Not currently SFF or candidate
CMS does not currently identify this nursing home as a Special Focus Facility or candidate in the loaded Provider Information extract.
CMS field value: (blank). Observed Aug 1, 2026.
CMS abuse-icon designation
CMS does not currently apply its abuse-icon designation to this facility in the loaded Provider Information extract.
CMS field value: N. Observed Aug 1, 2026.
Enrollment identity
Medicare enrollment organization NPI associated with this CMS Certification Number
These identifiers come from CMS SNF enrollment records linked to this CCN. They are not a substitute for the CMS Certification Number.
- NPI 1174510010 · enrollment O20080123000809
- NPI 1174510010 · enrollment O20080123000809
MDS quality measures
Individual CMS quality measures
These MDS quality measures are individual CMS-published scores. They are not the CMS quality-measure star rating.
MDS source release 2026-08-01.
View individual MDS measures
- Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (Long Stay): 97.297297
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (Long Stay): 86.363636
- Percentage of long-stay residents experiencing one or more falls with major injury (Long Stay): 0.000000 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who have depressive symptoms (Long Stay): 7.042254
- Percentage of long-stay residents who lose too much weight (Long Stay): 3.703704
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (Long Stay): 11.111111
- Percentage of long-stay residents who received an antipsychotic medication (Long Stay): 0.000000 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents who were physically restrained (Long Stay): 0.000000
- Percentage of long-stay residents whose ability to walk independently worsened (Long Stay): 9 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents whose need for help with daily activities has increased (Long Stay): 7.407407 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a catheter inserted and left in their bladder (Long Stay): 1.804462 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with a urinary tract infection (Long Stay): 2.702703 · CMS uses this measure in the quality-measure star rating
- Percentage of long-stay residents with new or worsened bowel or bladder incontinence (Long Stay): 41.950613
- Percentage of long-stay residents with pressure ulcers (Long Stay): 2.875545 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (Short Stay): 93.506494
- Percentage of short-stay residents who newly received an antipsychotic medication (Short Stay): 0.313480 · CMS uses this measure in the quality-measure star rating
- Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (Short Stay): 85.204082
Fire-safety citations
CMS fire-safety citations
These are fire-safety citations, not health deficiencies and not a count of fires.
- 2025-07-17 · tag 0293 · scope/severity F — Have properly located and lighted "Exit" signs.
- 2025-07-17 · tag 0324 · scope/severity F — Provide properly protected cooking facilities.
- 2025-07-17 · tag 0346 · scope/severity F — Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 2025-07-17 · tag 0353 · scope/severity F — Inspect, test, and maintain automatic sprinkler systems.
- 2025-07-17 · tag 0345 · scope/severity F — Have approved installation, maintenance and testing program for fire alarm systems.
- 2025-07-17 · tag 0712 · scope/severity F — Have simulated fire drills held at unexpected times.
- 2025-07-17 · tag 0918 · scope/severity F — Have generator or other power source capable of supplying service within 10 seconds.
- 2025-07-17 · tag 0531 · scope/severity E — Have elevators that firefighters can control in the event of a fire.
- 2025-07-17 · tag 0912 · scope/severity E — Have power receptacles that are properly grounded.
- 2025-07-17 · tag 0541 · scope/severity D — Install properly constructed and protected linen or trash chutes.
- 2025-07-17 · tag 0355 · scope/severity F — Properly select, install, inspect, or maintain portable fire extinguishes.
- 2024-05-23 · tag 0293 · scope/severity F — Have properly located and lighted "Exit" signs.
Decision guide
What to review
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
Inspections
The latest standard inspection on Jul 17, 2025 cited 2 deficiencies.
View inspection evidenceOwnership
CMS-published records list 71 ownership or control parties.
View ownership evidenceEnforcement record
CMS records show a $14,901 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Ownership & Operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
- Ownership type
- Non profit - CorporationCMS
- Related facilities
- 113Current CMS organization identity
Who is behind this facility?
SeniorTrustHub found evidence connecting this facility to:
- 2 CMS-reported ownership organizations
- CMS reports 66 individual ownership interests
Related facilities
113 currently connected nursing homes share this CMS organization identity with CLIFTONLARSONALLEN LLP.
- Average CMS overall rating
- 3 stars across 113 reporting facilities
- CMS monetary penalties
- 51 of 113 facilities had a recorded monetary penalty in the available CMS period.
- Recent CMS penalties
- 26 facilities had a CMS penalty in the last 18 months.
- Recent high-value CMS enforcement
- 26 facilities had a high-value CMS fine or payment denial in the last 18 months.
- Recent CMS complaint inspections
- 82 facilities had a CMS complaint inspection in the last 18 months.
- Total recorded CMS fines
- $3,994,793
Ownership
Who CMS records show is connected to this facility
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
- Reported party records
- 71
- Organizations shown
- 5
- Individuals shown
- 66
- Latest ownership source update
- Aug 17, 2026
CMS-published ownership and control parties
OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 1966
Other facilities connected through this exact CMS organization identity: 0 across WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
CLIFTONLARSONALLEN LLP
Organization · ADP OF THE SNF
Association date reported to CMS: Dec 31, 2020
Other facilities connected through this exact CMS organization identity: 0 across WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
DONOVAN, AMBER
Individual · ADP OF THE SNF
Association date reported to CMS: Dec 17, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HAYDEN, KEVIN
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HUSOM, SUSAN
Individual · ADP OF THE SNF
Association date reported to CMS: Dec 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
JACOBSON, ERIC
Individual · ADP OF THE SNF
Association date reported to CMS: Mar 31, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
METZ, MARY
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
O'DONNELL, CHRISTINE
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 9, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
ROSSMILLER, RICHARD
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
SIDHU, SARFRAZ
Individual · ADP OF THE SNF
Association date reported to CMS: Mar 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
VERCAUTEREN, THOMAS
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HAYDEN, KEVIN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
METZ, MARY
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
ROSSMILLER, RICHARD
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
VERCAUTEREN, THOMAS
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
BARROS, MARY
Individual · CORPORATE OFFICER
Association date reported to CMS: Jul 30, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HAMILTON-CRAWFORD, JANICE
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 31, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HUSOM, SUSAN
Individual · CORPORATE OFFICER
Association date reported to CMS: Dec 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
O'DONNELL, CHRISTINE
Individual · CORPORATE OFFICER
Association date reported to CMS: Apr 9, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
RAFFERTY, SUSAN
Individual · CORPORATE OFFICER
Association date reported to CMS: Jun 12, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HAYDEN, KEVIN
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
ROSSMILLER, RICHARD
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
VERCAUTEREN, THOMAS
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
BARROS, MARY
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 30, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
DONOVAN, AMBER
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 17, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HAMILTON-CRAWFORD, JANICE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 31, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
HUSOM, SUSAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
JACOBSON, ERIC
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Mar 31, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
LEFEL, KRISTIN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 31, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
O'DONNELL, CHRISTINE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 9, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
RAFFERTY, SUSAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 12, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
SACHTJEN, LAURA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 29, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
SIDHU, SARFRAZ
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Mar 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
TURNER, MARCIA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 4, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
WILLIAMS-RACETTE, SARAH
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 2, 2014
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Ownership
- CMS dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 1, 1966
CMS classifications: Parent company
Other facilities connected through this exact CMS organization identity: 1 across WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
CLIFTONLARSONALLEN LLP
Organization · ADP OF THE SNF
Association date reported to CMS: Dec 31, 2020
Other facilities connected through this exact CMS organization identity: 114 across CA, CT, FL, IA, IL, KY, MA, MI, MN, NM, OH, PA, RI, TX, WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
DONOVAN, AMBER
Individual · ADP OF THE SNF
Association date reported to CMS: Dec 17, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HAYDEN, KEVIN
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HUSOM, SUSAN
Individual · ADP OF THE SNF
Association date reported to CMS: Dec 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
JACOBSON, ERIC
Individual · ADP OF THE SNF
Association date reported to CMS: Mar 31, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
METZ, MARY
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
O'DONNELL, CHRISTINE
Individual · ADP OF THE SNF
Association date reported to CMS: Apr 9, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
ROSSMILLER, RICHARD
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
SIDHU, SARFRAZ
Individual · ADP OF THE SNF
Association date reported to CMS: Mar 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
VERCAUTEREN, THOMAS
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HAYDEN, KEVIN
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
METZ, MARY
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
ROSSMILLER, RICHARD
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
VERCAUTEREN, THOMAS
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
BARROS, MARY
Individual · CORPORATE OFFICER
Association date reported to CMS: Jul 30, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HAMILTON-CRAWFORD, JANICE
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 31, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HUSOM, SUSAN
Individual · CORPORATE OFFICER
Association date reported to CMS: Dec 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
O'DONNELL, CHRISTINE
Individual · CORPORATE OFFICER
Association date reported to CMS: Apr 9, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
RAFFERTY, SUSAN
Individual · CORPORATE OFFICER
Association date reported to CMS: Jun 12, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HAYDEN, KEVIN
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
ROSSMILLER, RICHARD
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2019
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
VERCAUTEREN, THOMAS
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
BARROS, MARY
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 30, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
DONOVAN, AMBER
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 17, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HAMILTON-CRAWFORD, JANICE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 31, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
HUSOM, SUSAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 1, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
JACOBSON, ERIC
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Mar 31, 2025
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
LEFEL, KRISTIN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Dec 31, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
O'DONNELL, CHRISTINE
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Apr 9, 2023
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
RAFFERTY, SUSAN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 12, 2013
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
SACHTJEN, LAURA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 29, 2024
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
SIDHU, SARFRAZ
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Mar 1, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
TURNER, MARCIA
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 4, 2021
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
WILLIAMS-RACETTE, SARAH
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 2, 2014
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility All Owners
- CMS dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
OAKWOOD VILLAGE UNIVERSITY WOODS HOMES INC
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 1 across WI.
View ownership source details
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Skilled Nursing Facility Enrollments
- CMS dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
What this means
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Questions to ask
- CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
- CMS records connect OAKWOOD LUTHERAN SENIOR MINISTRIES, INC. to 2 facilities. Which policies and staffing decisions are managed centrally versus locally?
Inspections & deficiencies
What CMS inspection records show
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Latest recorded inspection
- Date
- Jan 8, 2026
- Survey type
- Health Complaint
- Linked findings
- 3
- Highest linked CMS classification
- D — Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy
View source details
- Dataset
- Inspection Dates
- CMS dataset ID
- svdt-c123
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:128362:ccn:525375
Jan 8, 2026 — Health Complaint — 3 linked findings
F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 2, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363793:ccn:525375
F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 2, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363794:ccn:525375
F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 2, 2026)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363795:ccn:525375
Jul 17, 2025 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Jul 17, 2025 — Health Standard — 2 linked findings
F0607 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 6, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363797:ccn:525375
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 30, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363796:ccn:525375
Feb 18, 2025 — Health Complaint — 2 linked findings
F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Apr 1, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363798:ccn:525375
F0730 — Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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 (Mar 11, 2025)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363799:ccn:525375
May 23, 2024 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
May 23, 2024 — Health Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Mar 9, 2023 — Fire Safety Standard — 0 linked findings
No health-deficiency rows were deterministically linked to this inspection.
Mar 9, 2023 — Health Standard — 3 linked findings
F0686 — Quality of Life and Care Deficiencies
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 (Apr 4, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363801:ccn:525375
F0694 — Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids 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 (Apr 4, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363802:ccn:525375
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 4, 2023)
View source details
- Dataset
- Health Deficiencies
- CMS dataset ID
- r5ix-sfxw
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:363800:ccn:525375
Tags appearing across inspections
- F0686 appears in 2 linked inspections.
- F0812 appears in 2 linked inspections.
Penalties & enforcement
CMS penalty records in the loaded three-year dataset
Fine — Feb 18, 2025
Published fine amount: $14,901.00
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:13364:ccn:525375
Payment Denial — Feb 18, 2025
Payment denial length: 17 days
View source details
- Dataset
- Penalties
- CMS dataset ID
- g6vv-u9sr
- CMS source updated
- Aug 1, 2026
- CMS provider ID
- 525375
- Source record locator
- csv-row:13365:ccn:525375
Questions to ask
Questions generated from the evidence above
- CMS records show F0686 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show F0812 in 2 inspections in the available record. What changes has the facility made to address this issue?
- CMS records show a monetary penalty dated Feb 18, 2025. What changes were made after that enforcement action?
Facility history
Facility History
10 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
What changed recently?
- Complaint inspection recorded3 deficiencies were recorded.
- Total nurse staffing decreasedTotal nurse staffing decreased from 6.02 to 5.72 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
2026
- Complaint inspection recorded
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
2025
- Total nurse staffing decreased
Total nurse staffing decreased from 6.02 to 5.72 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
6.02 → 5.72
CMS · Reported in a source release · View related evidence
- Total nurse staffing decreased
Total nurse staffing decreased from 6.57 to 6.02 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
6.57 → 6.02
CMS · Reported in a source release · View related evidence
- RN staffing decreased
RN staffing decreased from 2.48 to 2.19 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
2.48 → 2.19
CMS · Reported in a source release · View related evidence
- Health inspection completed
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
- Civil monetary penalty recorded
CMS recorded a $22,925 civil monetary penalty.
CMS · Recorded event date · View related evidence
- Medicare payment denial recorded
CMS recorded a Medicare payment denial lasting 17 days.
CMS · Recorded event date · View related evidence
- Complaint inspection recorded
2 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
2024
- Health inspection completed
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
2023
- Health inspection completed
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
Reported nursing staffing at a glance
CMS staffing rating: 5 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
- Total nursing
- 5.907 reported hours per resident day
- RN categories
- 2.295 reported hours per resident day
- LPN/LVN categories
- 0.545 reported hours per resident day
- CNA
- 2.765 reported hours per resident day
Weekday and weekend calculations
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 6.091 | 5.443 |
| RN categories | 2.435 | 1.941 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.053 higher than the prior loaded quarter.
Staffing over time
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 6.567 | 2.478 | 0.882 | 2.921 | 0.9% | 91 |
| 2025Q3 | 6.019 | 2.192 | 0.783 | 2.99 | 0% | 92 |
| 2025Q4 | 5.719 | 2.242 | 0.681 | 2.746 | 0% | 92 |
| 2026Q1 | 5.907 | 2.295 | 0.545 | 2.765 | 0% | 90 |
Questions to ask
- PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
Staffing source and calculation details
- Source
- Centers for Medicare & Medicaid Services (CMS)
- Dataset
- Payroll Based Journal Daily Nurse Staffing
- CMS dataset ID
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Quarter
- 2026Q1
- Coverage
- Jan 1, 2026–Mar 31, 2026
- Days represented
- 90 (90 with positive MDS census)
- CMS source updated
- Jul 29, 2026
- Calculation version
- pbj-quarter-ratio-of-sums-v1
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
Current Provider Information facts
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
- CMS reports a 4-star overall rating.
- CMS reports a 3-star health inspection rating.
- CMS reports a 5-star staffing rating.
- CMS reports a 4-star quality-measure rating.
Trust participation
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Representation claims are reviewed manually. Live profile-management tools are not yet enabled for this facility.
How corrections workSource register
See where this record came from
Provider Information
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 4pq5-n9py
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Overview, facility facts, and CMS ratings
Inspection Dates
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- svdt-c123
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Inspections and facility history
Health Deficiencies
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- r5ix-sfxw
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Health deficiencies and facility history
Penalties
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- g6vv-u9sr
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Penalties, enforcement, and facility history
Payroll Based Journal Daily Nurse Staffing
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
- Coverage
- Apr 1, 2025–Mar 31, 2026
- Source updated
- Jul 29, 2026
- Retrieved
- Aug 15, 2026
- Supports
- PBJ staffing cards, history, and transparent calculations
Ownership
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- y2hd-n93e
- Source updated
- Aug 1, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility All Owners
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- afe44b85-cc6d-40d7-b5df-00ae8910d1d2
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Ownership parties, organization connections, and ownership history
Skilled Nursing Facility Enrollments
- Source organization
- Centers for Medicare & Medicaid Services (CMS)
- Dataset identifier
- 5f2c306f-3b1c-42cd-b037-187b2ce22126
- Source updated
- Aug 17, 2026
- Retrieved
- Aug 26, 2026
- Supports
- Ownership parties, organization connections, and ownership history
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.