Amethyst Health of Brown Deer

MILWAUKEE, WI

CMS provider ID 525498CMS source updated July 29, 2026

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CMS overview

CMS overall

Health inspection

Staffing

Quality-measure

No proprietary TrustHub score. These ratings are published separately by CMS.

How CMS describes these ratings

CMS overall rating: The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
Health inspection rating: The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
Staffing rating: The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
Quality-measure rating: The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.

CMS certified beds: 87
Ownership descriptor: For 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: 4143717500CMS Provider Information

Decision guide

What to review

Factual evidence to examine before you decide. These summaries are not a score or recommendation.

Staffing

CMS publishes a 2-star staffing rating for this facility.

RN staffing was 0.56 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Inspections

The latest standard inspection on Feb 26, 2026 cited 22 deficiencies.

View inspection evidence

Ownership

CMS-published records list 19 ownership or control parties.

CMS records show an ownership change effective July 2025.

View ownership evidence

Enforcement record

CMS records show a $176,345 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: For profit - CorporationCMS
Ownership changes: 1 recordedCMS enrollment records

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

2 CMS-reported ownership organizations
CMS reports 12 individual ownership interests
recorded ownership-change events

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: 19
Organizations shown: 7
Individuals shown: 12
Latest ownership source update: Jul 27, 2026

CMS-published ownership and control parties

PATRICK, JENSEN
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2025
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
SIDHU, SARFRAZ
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2015
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
VELORAH HEALTH MANAGEMENT LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2025
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
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
AMETHYST HEALTH OF BROWN DEER LLC
Organization · DIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2025
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
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
BERNATH, HERSHEY
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Jul 1, 2025
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
BERNATH, HERSHEY
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2025
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
PATRICK, JENSEN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2025
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
SIDHU, SARFRAZ
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 2025
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Ownership
CMS dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
View official CMS source
Individual name not published by CMS
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 23, 2025
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
Skilled Nursing Facility All Owners
CMS dataset identifier
afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
Individual name not published by CMS
Organization · ADP OF THE SNF
Association date reported to CMS: Oct 28, 2025
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
Skilled Nursing Facility All Owners
CMS dataset identifier
afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
PATRICK, JENSEN
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 1, 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
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
SIDHU, SARFRAZ
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2015
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Skilled Nursing Facility All Owners
CMS dataset identifier
afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
VELORAH HEALTH MANAGEMENT LLC
Organization · ADP OF THE SNF
Association date reported to CMS: Jul 1, 2025
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
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
AMETHYST HEALTH OF BROWN DEER LLC
Organization · DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 1, 2025
CMS classifications: Parent company
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
Skilled Nursing Facility All Owners
CMS dataset identifier
afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
BERNATH, HERSHEY
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 1, 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
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
BERNATH, HERSHEY
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 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
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
PATRICK, JENSEN
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 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
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
SIDHU, SARFRAZ
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 1, 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
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source
BROWN DEER HEALTH OPCO LLC
Organization · Medicare-enrolled legal organization
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
Skilled Nursing Facility Enrollments
CMS dataset identifier
5f2c306f-3b1c-42cd-b037-187b2ce22126
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source

Ownership changes reported in CMS enrollment records

Jul 1, 2025CHANGE OF OWNERSHIPWATERFALL HEALTH OF BROWN DEER LLC to BROWN DEER HEALTH OPCO LLC
View ownership source details
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset
Skilled Nursing Facility Change of Ownership
CMS dataset identifier
f557a6ed-95b3-4a22-8433-4175db2dec1c
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
View official CMS source

What this means

Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.

Questions to ask

CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
CMS enrollment records show a change of ownership effective Jul 1, 2025. What operational or leadership changes followed that event?
CMS records connect VELORAH HEALTH MANAGEMENT LLC 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: May 20, 2026
Survey type: Health Complaint
Linked findings: 4
Highest linked CMS classification: E — Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy

View source details

Dataset: Inspection Dates
CMS dataset ID: svdt-c123
CMS source updated: Jul 1, 2026
CMS provider ID: 525498
Source record locator: csv-row:128928:ccn:525498

View official CMS source

May 20, 2026 — Health Complaint — 4 linked findings

F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 12, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365028:ccn:525498
View official CMS source
F0757 — Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 12, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365029:ccn:525498
View official CMS source
F0760 — Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 12, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365030:ccn:525498
View official CMS source
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 12, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365031:ccn:525498
View official CMS source

Apr 14, 2026 — Health Complaint — 4 linked findings

F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365033:ccn:525498
View official CMS source
F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365032:ccn:525498
View official CMS source
F0692 — Quality of Life and Care Deficiencies
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 (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365034:ccn:525498
View official CMS source
F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365035:ccn:525498
View official CMS source

Feb 26, 2026 — Fire Safety Standard — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Feb 26, 2026 — Health Complaint — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Feb 26, 2026 — Health Standard — 22 linked findings

F0554 — Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365046:ccn:525498
View official CMS source
F0578 — Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365047:ccn:525498
View official CMS source
F0582 — Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365048:ccn:525498
View official CMS source
F0605 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365049:ccn:525498
View official CMS source
F0628 — Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365041:ccn:525498
View official CMS source
F0640 — Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365042:ccn:525498
View official CMS source
F0641 — Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365052:ccn:525498
View official CMS source
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365054:ccn:525498
View official CMS source
F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365036:ccn:525498
View official CMS source
F0690 — Quality of Life and Care Deficiencies
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 (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365055:ccn:525498
View official CMS source
F0692 — Quality of Life and Care Deficiencies
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 (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365056:ccn:525498
View official CMS source
F0699 — Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365057:ccn:525498
View official CMS source
F0742 — Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365058:ccn:525498
View official CMS source
F0756 — Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365059:ccn:525498
View official CMS source
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365044:ccn:525498
View official CMS source
F0812 — Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365045:ccn:525498
View official CMS source
F0814 — Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
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 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365037:ccn:525498
View official CMS source
F0868 — Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365038:ccn:525498
View official CMS source
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365039:ccn:525498
View official CMS source
F0882 — Infection Control Deficiencies
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 (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365040:ccn:525498
View official CMS source
F0883 — Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365060:ccn:525498
View official CMS source
F0919 — Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365061:ccn:525498
View official CMS source

Feb 17, 2026 — Health Complaint — 13 linked findings

F0655 — Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365069:ccn:525498
View official CMS source
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365065:ccn:525498
View official CMS source
F0684 — Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365070:ccn:525498
View official CMS source
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 (May 1, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365062:ccn:525498
View official CMS source
F0690 — Quality of Life and Care Deficiencies
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 J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365063:ccn:525498
View official CMS source
F0693 — Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365071:ccn:525498
View official CMS source
F0725 — Nursing and Physician Services Deficiencies
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 (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365066:ccn:525498
View official CMS source
F0726 — Nursing and Physician Services Deficiencies
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 (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365067:ccn:525498
View official CMS source
F0727 — Nursing and Physician Services Deficiencies
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 (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365064:ccn:525498
View official CMS source
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365074:ccn:525498
View official CMS source
F0755 — Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365072:ccn:525498
View official CMS source
F0825 — Quality of Life and Care Deficiencies
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 (Mar 18, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365073:ccn:525498
View official CMS source
F0880 — Infection Control Deficiencies
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 (Mar 19, 2026)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365068:ccn:525498
View official CMS source

Dec 5, 2025 — Health Complaint — 1 linked finding

F0684 — Quality of Life and Care Deficiencies
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 (Dec 16, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365075:ccn:525498
View official CMS source

Apr 29, 2025 — Health Complaint — 1 linked finding

F0695 — Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 2, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365076:ccn:525498
View official CMS source

Mar 17, 2025 — Health Complaint — 13 linked findings

F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365086:ccn:525498
View official CMS source
F0688 — Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365087:ccn:525498
View official CMS source
F0689 — Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365088:ccn:525498
View official CMS source
F0692 — Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365077:ccn:525498
View official CMS source
F0693 — Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365089:ccn:525498
View official CMS source
F0940 — Administration Deficiencies
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 (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365078:ccn:525498
View official CMS source
F0941 — Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care 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 (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365079:ccn:525498
View official CMS source
F0943 — Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
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 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365080:ccn:525498
View official CMS source
F0944 — Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement 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 (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365081:ccn:525498
View official CMS source
F0945 — Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the 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 (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365082:ccn:525498
View official CMS source
F0946 — Administration Deficiencies
Provide training in compliance and ethics.
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 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365083:ccn:525498
View official CMS source
F0947 — Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS scope/severity 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 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365084:ccn:525498
View official CMS source
F0949 — Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility 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 (Mar 26, 2025)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365085:ccn:525498
View official CMS source

Oct 30, 2024 — Fire Safety Standard — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Oct 30, 2024 — Health Complaint — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Oct 30, 2024 — Health Standard — 8 linked findings

F0644 — Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365092:ccn:525498
View official CMS source
F0645 — Resident Assessment and Care Planning Deficiencies
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 (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365093:ccn:525498
View official CMS source
F0656 — Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365094:ccn:525498
View official CMS source
F0732 — Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365099:ccn:525498
View official CMS source
F0756 — Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365096:ccn:525498
View official CMS source
F0758 — Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365097:ccn:525498
View official CMS source
F0759 — Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365098:ccn:525498
View official CMS source
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 17, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365091:ccn:525498
View official CMS source

May 30, 2024 — Health Complaint — 1 linked finding

F0837 — Administration Deficiencies
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 (Jun 30, 2024)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365100:ccn:525498
View official CMS source

Sep 13, 2023 — Fire Safety Standard — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Sep 13, 2023 — Health Complaint — 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Sep 13, 2023 — Health Standard — 10 linked findings

F0580 — Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365103:ccn:525498
View official CMS source
F0661 — Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365104:ccn:525498
View official CMS source
F0677 — Quality of Life and Care Deficiencies
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 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365105:ccn:525498
View official CMS source
F0684 — Quality of Life and Care Deficiencies
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 (Oct 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365101:ccn:525498
View official CMS source
F0686 — Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365106:ccn:525498
View official CMS source
F0698 — Quality of Life and Care Deficiencies
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 (Oct 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365109:ccn:525498
View official CMS source
F0757 — Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365110:ccn:525498
View official CMS source
F0761 — Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS scope/severity 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 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365112:ccn:525498
View official CMS source
F0791 — Quality of Life and Care Deficiencies
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 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365113:ccn:525498
View official CMS source
F0880 — Infection Control Deficiencies
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 12, 2023)
View source details
Dataset
Health Deficiencies
CMS dataset ID
r5ix-sfxw
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:365102:ccn:525498
View official CMS source

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

Fine — Mar 17, 2025
Published fine amount: $176,345.00
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:13823:ccn:525498
View official CMS source
Payment Denial — Oct 30, 2024
Payment denial length: 10 days
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:13824:ccn:525498
View official CMS source
Fine — Oct 30, 2024
Published fine amount: $16,346.00
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:13821:ccn:525498
View official CMS source
Payment Denial — Sep 13, 2023
Payment denial length: 27 days
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:13825:ccn:525498
View official CMS source
Fine — Sep 13, 2023
Published fine amount: $84,065.00
View source details
Dataset
Penalties
CMS dataset ID
g6vv-u9sr
CMS source updated
Jul 1, 2026
CMS provider ID
525498
Source record locator
csv-row:13822:ccn:525498
View official CMS source

Questions to ask

Questions generated from the evidence above

CMS records show F0684 in 5 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0686 in 5 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0880 in 5 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0692 in 3 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0656 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0690 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0693 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0695 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0732 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0755 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0756 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0757 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show F0761 in 2 inspections in the available record. What changes has the facility made to address this issue?
CMS records show a monetary penalty dated Mar 17, 2025. What changes were made after that enforcement action?

Facility history

Facility History

20 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.

What changed recently?

Complaint inspection recorded4 deficiencies were recorded.
Total nurse staffing increasedTotal nurse staffing increased from 3.98 to 4.56 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
Ownership change recordedAn ownership change was recorded. New organization: BROWN DEER HEALTH OPCO LLC.

2026

May 20
Complaint inspection recorded
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Apr 14
Complaint inspection recorded
4 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Feb 26
Health inspection completed
22 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Feb 26
Complaint inspection recorded
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
Feb 17
Complaint inspection recorded
13 deficiencies were recorded. That includes 2 higher-severity deficiencies.
CMS · Recorded event date · View related evidence

2025

Dec 2025
Total nurse staffing increased
Total nurse staffing increased from 3.98 to 4.56 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
3.98 → 4.56
CMS · Reported in a source release · View related evidence
Dec 5
Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
Jul 1
Ownership change recorded
An ownership change was recorded. New organization: BROWN DEER HEALTH OPCO LLC.
WATERFALL HEALTH OF BROWN DEER LLC → BROWN DEER HEALTH OPCO LLC
CMS · Recorded event date · View related evidence
Apr 29
Complaint inspection recorded
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
Mar 17
Civil monetary penalty recorded
CMS recorded a $176,345 civil monetary penalty.
CMS · Recorded event date · View related evidence
Mar 17
Complaint inspection recorded
13 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence

2024

Oct 30
Civil monetary penalty recorded
CMS recorded a $16,346 civil monetary penalty.
CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 2 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter

Total nursing: 4.51
RN categories: 0.557
LPN/LVN categories: 1.146
CNA: 2.806

Weekday and weekend calculations

2026Q1 reported hours per resident day
Measure	Monday–Friday	Saturday–Sunday
Total nursing	4.678	4.097
RN categories	0.657	0.313

Contract staff accounted for 9.5% of reported nursing hours included in this quarter calculation.

PBJ reports zero combined RN-category hours on 1 day with a positive MDS census in this quarter.

Reported RN-category hours per resident day were 0.021 higher than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
Quarter	Total nursing	RN categories	LPN/LVN	CNA	Contract share	Days
2025Q2	3.824	0.55	1.174	2.1	3.7%	91
2025Q3	3.982	0.477	1.181	2.325	6.4%	92
2025Q4	4.559	0.536	1.177	2.827	5%	92
2026Q1	4.51	0.557	1.146	2.806	9.5%	90

Questions to ask

PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?

Staffing source and calculation details

Source: Centers for Medicare & Medicaid Services (CMS)
Dataset: Payroll Based Journal Daily Nurse Staffing
CMS dataset ID: 7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter: 2026Q1
Coverage: Jan 1, 2026–Mar 31, 2026
Days represented: 90 (90 with positive MDS census)
CMS source updated: Jul 29, 2026
Calculation version: pbj-quarter-ratio-of-sums-v1

Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.

View official CMS PBJ source

What 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 1-star overall rating.
CMS reports a 1-star health inspection rating.
CMS reports a 2-star staffing rating.
CMS reports a 3-star quality-measure rating.

Planned evidence layers

Additional public-source research

These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.

Chain / portfolio intelligence

Trust participation

See something that needs correction?

Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.

Suggest a correction Report a source-data concern Represent this facility? Submit a profile claim

How corrections work

Source register

See where this record came from

Provider Information

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: 4pq5-n9py
Source updated: Jul 29, 2026
Retrieved: Aug 14, 2026
Supports: Overview, facility facts, and CMS ratings

View official CMS source

Inspection Dates

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: svdt-c123
Source updated: Jul 1, 2026
Retrieved: Aug 14, 2026
Supports: Inspections and facility history

View official CMS source

Health Deficiencies

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: r5ix-sfxw
Source updated: Jul 1, 2026
Retrieved: Aug 14, 2026
Supports: Health deficiencies and facility history

View official CMS source

Penalties

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: g6vv-u9sr
Source updated: Jul 1, 2026
Retrieved: Aug 14, 2026
Supports: Penalties, enforcement, and facility history

View official CMS source

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

View official CMS source

Ownership

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: y2hd-n93e
Source updated: Jul 1, 2026
Retrieved: Aug 15, 2026
Supports: Ownership parties, organization connections, and ownership history

View official CMS source

Skilled Nursing Facility All Owners

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated: Jul 27, 2026
Retrieved: Aug 15, 2026
Supports: Ownership parties, organization connections, and ownership history

View official CMS source

Skilled Nursing Facility Enrollments

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: 5f2c306f-3b1c-42cd-b037-187b2ce22126
Source updated: Jul 27, 2026
Retrieved: Aug 15, 2026
Supports: Ownership parties, organization connections, and ownership history

View official CMS source

Skilled Nursing Facility Change of Ownership

Source organization: Centers for Medicare & Medicaid Services (CMS)
Dataset identifier: f557a6ed-95b3-4a22-8433-4175db2dec1c
Source updated: Jul 27, 2026
Retrieved: Aug 15, 2026
Supports: Ownership parties, organization connections, and ownership history

View official CMS source

No paid placements. Facilities cannot pay to rank higher. We cite. You decide.

CMS rating overview

CMS overall

Health inspection

Staffing

Quality-measure

Contact

What to review

Staffing

Inspections

Ownership

Ownership & Operation

Who is behind this facility?

Who CMS records show is connected to this facility

CMS-published ownership and control parties

PATRICK, JENSEN

SIDHU, SARFRAZ

VELORAH HEALTH MANAGEMENT LLC

AMETHYST HEALTH OF BROWN DEER LLC

BERNATH, HERSHEY

BERNATH, HERSHEY

PATRICK, JENSEN

SIDHU, SARFRAZ

Individual name not published by CMS

Individual name not published by CMS

PATRICK, JENSEN

SIDHU, SARFRAZ

VELORAH HEALTH MANAGEMENT LLC

AMETHYST HEALTH OF BROWN DEER LLC

BERNATH, HERSHEY

BERNATH, HERSHEY

PATRICK, JENSEN

SIDHU, SARFRAZ

BROWN DEER HEALTH OPCO LLC

Ownership changes reported in CMS enrollment records

What this means

Questions to ask

What CMS inspection records show

Latest recorded inspection

F0755 — Pharmacy Service Deficiencies

F0757 — Pharmacy Service Deficiencies

F0760 — Pharmacy Service Deficiencies

F0880 — Infection Control Deficiencies

F0684 — Quality of Life and Care Deficiencies

F0686 — Quality of Life and Care Deficiencies

F0692 — Quality of Life and Care Deficiencies

F0695 — Quality of Life and Care Deficiencies

F0554 — Resident Rights Deficiencies

F0578 — Resident Rights Deficiencies

F0582 — Resident Rights Deficiencies

F0605 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

F0628 — Resident Rights Deficiencies

F0640 — Resident Assessment and Care Planning Deficiencies

F0641 — Resident Assessment and Care Planning Deficiencies

F0684 — Quality of Life and Care Deficiencies

F0686 — Quality of Life and Care Deficiencies

F0690 — Quality of Life and Care Deficiencies

F0692 — Quality of Life and Care Deficiencies

F0699 — Quality of Life and Care Deficiencies

F0742 — Quality of Life and Care Deficiencies

F0756 — Pharmacy Service Deficiencies

F0761 — Pharmacy Service Deficiencies

F0812 — Nutrition and Dietary Deficiencies

F0814 — Nutrition and Dietary Deficiencies

F0868 — Administration Deficiencies

F0880 — Infection Control Deficiencies

F0882 — Infection Control Deficiencies

F0883 — Infection Control Deficiencies

F0919 — Environmental Deficiencies

F0655 — Resident Assessment and Care Planning Deficiencies

F0656 — Resident Assessment and Care Planning Deficiencies

F0684 — Quality of Life and Care Deficiencies

F0686 — Quality of Life and Care Deficiencies

F0690 — Quality of Life and Care Deficiencies

F0693 — Quality of Life and Care Deficiencies

F0725 — Nursing and Physician Services Deficiencies

F0726 — Nursing and Physician Services Deficiencies

F0727 — Nursing and Physician Services Deficiencies

F0732 — Nursing and Physician Services Deficiencies

F0755 — Pharmacy Service Deficiencies

F0825 — Quality of Life and Care Deficiencies