Avina of Milwaukee

MILWAUKEE, WI

CMS provider ID 525523CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

1 of 5 CMS stars

Health inspection

1 of 5 CMS stars

Staffing

2 of 5 CMS stars

Quality-measure

3 of 5 CMS stars

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
108
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
4143559300Verified public information · checked Aug 2026

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 0.78 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence
Enforcement record

CMS records show a $74,120 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
Related facilities
12Current CMS organization identity

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • CMS reports 9 individual ownership interests

Related facilities

12 currently connected nursing homes share this CMS organization identity with ASCENSION HEALTH SENIOR CARE.

Average CMS overall rating
2.8 stars across 12 reporting facilities
CMS monetary penalties
9 of 12 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
6 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
6 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
10 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$717,079

These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.

Ownership

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
11
Organizations shown
2
Individuals shown
9
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • BACHLEITNER, JOAN

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Apr 19, 2018

    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
  • BORDO, DAVID

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Apr 19, 2018

    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
  • FOLEY, BRAD

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Apr 19, 2018

    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
  • OHMAN, ANDREA

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Apr 26, 2016

    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
  • GORDON, MICHAEL

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jan 1, 2018

    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
  • STRICKER, DANIEL

    Individual · CORPORATE OFFICER

    Association date reported to CMS: May 1, 2011

    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
  • ASCENSION HEALTH SENIOR CARE

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jul 1, 2014

    Other facilities connected through this exact CMS organization identity: 11 across IL, KS, NY, OK, TN, 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
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • STRICKER, DANIEL

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jul 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
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • GORDON, MICHAEL

    Individual · W-2 MANAGING EMPLOYEE

    Association date reported to CMS: Jan 1, 2018

    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
  • OHMAN, ANDREA

    Individual · W-2 MANAGING EMPLOYEE

    Association date reported to CMS: Apr 26, 2016

    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
  • ALEXIAN VILLAGE OF MILWAUKEE

    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

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 ASCENSION HEALTH SENIOR CARE to 12 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
Apr 14, 2026
Survey type
Health Complaint
Linked findings
6
Highest linked CMS classification
G — Isolated; Actual 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
525523
Source record locator
csv-row:129071:ccn:525523
View official CMS source
Apr 14, 2026Health Complaint 6 linked findings
  • F0554Resident 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 (May 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365438:ccn:525523
    View official CMS source
  • F0585Resident Rights Deficiencies

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365439:ccn:525523
    View official CMS source
  • F0600Freedom 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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365437:ccn:525523
    View official CMS source
  • F0609Freedom 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 (May 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365440:ccn:525523
    View official CMS source
  • F0610Freedom 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 (May 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365441:ccn:525523
    View official CMS source
  • F0804Nutrition and Dietary Deficiencies

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 2, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365442:ccn:525523
    View official CMS source
Mar 12, 2026Fire Safety Standard 0 linked findings

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

Mar 12, 2026Health Complaint 0 linked findings

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

Mar 12, 2026Health Standard 12 linked findings
  • F0578Resident 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 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 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365445:ccn:525523
    View official CMS source
  • F0679Quality of Life and Care Deficiencies

    Provide activities to meet all resident's needs.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365447:ccn:525523
    View official CMS source
  • F0684Quality 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365448:ccn:525523
    View official CMS source
  • F0692Quality 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365449:ccn:525523
    View official CMS source
  • F0698Quality 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365450:ccn:525523
    View official CMS source
  • F0759Pharmacy 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365451:ccn:525523
    View official CMS source
  • F0761Pharmacy 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365452:ccn:525523
    View official CMS source
  • F0809Nutrition and Dietary Deficiencies

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    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 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365446:ccn:525523
    View official CMS source
  • F0812Nutrition 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 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365444:ccn:525523
    View official CMS source
  • F0825Quality 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365453:ccn:525523
    View official CMS source
  • F0849Administration Deficiencies

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365454:ccn:525523
    View official CMS source
  • F0880Infection 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 (Apr 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365455:ccn:525523
    View official CMS source
Feb 3, 2026Health Complaint 6 linked findings
  • F0553Resident Rights Deficiencies

    Allow resident to participate in the development and implementation of his or her person-centered plan of care.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 3, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365456:ccn:525523
    View official CMS source
  • F0609Freedom 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 (Mar 3, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365457:ccn:525523
    View official CMS source
  • F0610Freedom 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 (Mar 3, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365458:ccn:525523
    View official CMS source
  • F0655Resident 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 3, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365459:ccn:525523
    View official CMS source
  • F0684Quality 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 (Mar 3, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365460:ccn:525523
    View official CMS source
  • F0689Quality 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 3, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365461:ccn:525523
    View official CMS source
Jan 8, 2026Health Complaint 4 linked findings
  • F0677Quality 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 (Feb 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365464:ccn:525523
    View official CMS source
  • F0755Pharmacy 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 (Feb 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365465:ccn:525523
    View official CMS source
  • F0812Nutrition 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 (Feb 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365463:ccn:525523
    View official CMS source
  • F0909Environmental Deficiencies

    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

    CMS scope/severity 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 (Feb 8, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365462:ccn:525523
    View official CMS source
Dec 4, 2025Health Complaint 4 linked findings
  • F0585Resident Rights Deficiencies

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Jan 4, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365466:ccn:525523
    View official CMS source
  • F0645Resident 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 (Jan 4, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365467:ccn:525523
    View official CMS source
  • F0689Quality 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 (Jan 4, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365468:ccn:525523
    View official CMS source
  • F0692Quality 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 (Jan 4, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365469:ccn:525523
    View official CMS source
Jul 28, 2025Health Complaint 2 linked findings
  • F0609Freedom 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 (Aug 28, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365470:ccn:525523
    View official CMS source
  • F0740Quality of Life and Care Deficiencies

    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 (Sep 18, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365471:ccn:525523
    View official CMS source
Mar 20, 2025Health Complaint 5 linked findings
  • F0580Resident 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 (Apr 20, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365473:ccn:525523
    View official CMS source
  • F0600Freedom 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 (Apr 20, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365474:ccn:525523
    View official CMS source
  • F0602Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Protect each resident from the wrongful use of the resident's belongings or money.

    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 20, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365472:ccn:525523
    View official CMS source
  • F0609Freedom 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 (Apr 20, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365475:ccn:525523
    View official CMS source
  • F0610Freedom 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 (Apr 20, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365476:ccn:525523
    View official CMS source
Dec 3, 2024Health Complaint 2 linked findings
  • F0609Freedom 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 (Dec 20, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365478:ccn:525523
    View official CMS source
  • F0689Quality 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 20, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365477:ccn:525523
    View official CMS source
Oct 7, 2024Fire Safety Standard 0 linked findings

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

Oct 7, 2024Health Complaint 0 linked findings

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

Oct 7, 2024Health Standard 9 linked findings
  • F0645Resident 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365485:ccn:525523
    View official CMS source
  • F0656Resident 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365486:ccn:525523
    View official CMS source
  • F0684Quality 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365487:ccn:525523
    View official CMS source
  • F0686Quality 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365479:ccn:525523
    View official CMS source
  • F0690Quality 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365488:ccn:525523
    View official CMS source
  • F0692Quality 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365489:ccn:525523
    View official CMS source
  • F0695Quality 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365490:ccn:525523
    View official CMS source
  • F0812Nutrition 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365481:ccn:525523
    View official CMS source
  • F0880Infection 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 (Nov 5, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365482:ccn:525523
    View official CMS source
Jul 1, 2024Health Complaint 19 linked findings
  • F0583Resident Rights Deficiencies

    Keep residents' personal and medical records private and confidential.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365498:ccn:525523
    View official CMS source
  • F0609Freedom 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365503:ccn:525523
    View official CMS source
  • F0610Freedom 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365504:ccn:525523
    View official CMS source
  • F0684Quality of Life and Care Deficiencies

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Aug 21, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365491:ccn:525523
    View official CMS source
  • F0687Quality of Life and Care Deficiencies

    Provide appropriate foot care.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365505:ccn:525523
    View official CMS source
  • F0689Quality 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365506:ccn:525523
    View official CMS source
  • F0730Nursing 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365492:ccn:525523
    View official CMS source
  • F0745Quality of Life and Care Deficiencies

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365507:ccn:525523
    View official CMS source
  • F0842Resident Assessment and Care Planning Deficiencies

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365508:ccn:525523
    View official CMS source
  • F0887Infection Control Deficiencies

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

    CMS scope/severity 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, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365509:ccn:525523
    View official CMS source
  • F0940Administration Deficiencies

    Develop, implement, and/or maintain an effective training program for all new and existing staff members.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365499:ccn:525523
    View official CMS source
  • F0941Administration Deficiencies

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365500:ccn:525523
    View official CMS source
  • F0942Resident Rights Deficiencies

    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

    CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365493:ccn:525523
    View official CMS source
  • F0943Freedom 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365501:ccn:525523
    View official CMS source
  • F0944Administration 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365494:ccn:525523
    View official CMS source
  • F0945Infection 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365495:ccn:525523
    View official CMS source
  • F0946Administration 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 (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365496:ccn:525523
    View official CMS source
  • F0947Nursing 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 E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365502:ccn:525523
    View official CMS source
  • F0949Administration Deficiencies

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

    CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 6, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365497:ccn:525523
    View official CMS source
Apr 8, 2024Health Complaint 1 linked finding
  • F0678Quality of Life and Care Deficiencies

    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 7, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365510:ccn:525523
    View official CMS source
Aug 9, 2023Fire Safety Standard 0 linked findings

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

Aug 9, 2023Health Standard 6 linked findings
  • F0580Resident 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 (Sep 9, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365512:ccn:525523
    View official CMS source
  • F0623Resident Rights Deficiencies

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Sep 9, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365513:ccn:525523
    View official CMS source
  • F0625Resident Rights Deficiencies

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Sep 9, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365514:ccn:525523
    View official CMS source
  • F0758Pharmacy 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 (Sep 9, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365515:ccn:525523
    View official CMS source
  • F0761Pharmacy 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 (Sep 9, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365511:ccn:525523
    View official CMS source
  • F0880Infection 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 (Sep 9, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:365516:ccn:525523
    View official CMS source

Tags appearing across inspections

  • F0609 appears in 6 linked inspections.
  • F0610 appears in 4 linked inspections.
  • F0684 appears in 4 linked inspections.
  • F0689 appears in 4 linked inspections.
  • F0692 appears in 3 linked inspections.
  • F0812 appears in 3 linked inspections.
  • F0880 appears in 3 linked inspections.
  • F0580 appears in 2 linked inspections.
  • F0585 appears in 2 linked inspections.
  • F0600 appears in 2 linked inspections.
  • F0645 appears in 2 linked inspections.
  • F0761 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • FineOct 7, 2024

    Published fine amount: $74,120.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:13836:ccn:525523
    View official CMS source
  • Payment DenialOct 7, 2024

    Payment denial length: 51 days

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:13837:ccn:525523
    View official CMS source
  • FineJul 1, 2024

    Published fine amount: $16,801.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:13835:ccn:525523
    View official CMS source
  • Payment DenialJul 1, 2024

    Payment denial length: 22 days

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    525523
    Source record locator
    csv-row:13838:ccn:525523
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show F0609 in 6 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0610 in 4 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0684 in 4 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0689 in 4 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 F0812 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0880 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0580 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0585 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0600 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0645 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 Oct 7, 2024. What changes were made after that enforcement action?

Facility history

Facility History

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

What changed recently?

  • Complaint inspection recorded6 deficiencies were recorded. That includes 1 higher-severity deficiency.
  • Total nurse staffing decreasedTotal nurse staffing decreased from 4.19 to 3.97 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.

2026

  1. Complaint inspection recorded

    6 deficiencies were recorded. That includes 1 higher-severity deficiency.

    CMS · Recorded event date · View related evidence

  2. Total nurse staffing decreased

    Total nurse staffing decreased from 4.19 to 3.97 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.

    4.193.97

    CMS · Reported in a source release · View related evidence

  3. RN staffing decreased

    RN staffing decreased from 0.88 to 0.78 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.

    0.880.78

    CMS · Reported in a source release · View related evidence

  4. Health inspection completed

    12 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  5. Complaint inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    CMS · Recorded event date · View related evidence

  6. Complaint inspection recorded

    6 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  7. Complaint inspection recorded

    4 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2025

  1. Total nurse staffing increased

    Total nurse staffing increased from 2.87 to 4.19 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.

    2.874.19

    CMS · Reported in a source release · View related evidence

  2. RN staffing increased

    RN staffing increased from 0.61 to 0.88 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.

    0.610.88

    CMS · Reported in a source release · View related evidence

  3. Complaint inspection recorded

    4 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  4. RN staffing decreased

    RN staffing decreased from 1.01 to 0.61 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

    1.010.61

    CMS · Reported in a source release · View related evidence

  5. Total nurse staffing decreased

    Total nurse staffing decreased from 3.85 to 2.87 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

    3.852.87

    CMS · Reported in a source release · 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
3.966
reported hours per resident day
RN categories
0.776
reported hours per resident day
LPN/LVN categories
0.859
reported hours per resident day
CNA
2.054
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.2373.298
RN categories0.8330.635

Contract staff accounted for 5.1% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.107 lower 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
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q23.8461.010.7762.0625.4%91
2025Q32.8690.6130.5321.69326.5%92
2025Q44.1880.8830.782.30813%92
2026Q13.9660.7760.8592.0545.1%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, 2026Mar 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.

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
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
Verified public facility information
Source organization
Public facility listing
Dataset identifier
commercial-corroboration:public-listing
Source updated
Aug 18, 2026
Retrieved
Aug 18, 2026
Supports
Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
How sources work

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