Staffing
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.58 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
Also known publicly as Greendale Park Nursing & Rehab (Formerly Heritage Square)
Greendale, WI
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.58 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Jan 27, 2026 cited 13 deficiencies.
View inspection evidenceCMS-published records list 32 ownership or control parties.
CMS records show an ownership change effective October 2019.
View ownership evidenceCMS groups this facility with a chain covering 9 facilities across 3 states or territories.
View chain evidenceCMS records show a $14,950 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
7 currently connected nursing homes share this CMS organization identity with BEDROCK HC WI LLC.
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across WI.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across WI.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · CONTRACTED MANAGING EMPLOYEE
Association date reported to CMS: Oct 1, 2019
Individual · CORPORATE OFFICER
Association date reported to CMS: Oct 1, 2019
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 1, 2019
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across WI.
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across WI.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 6 across WI.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 0 across WI.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 6 across WI.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 18%
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 18%
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 7%
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 5%
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 10%
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 12.5%
Association date reported to CMS: Oct 1, 2019
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 12.5%
Association date reported to CMS: Oct 1, 2019
Individual · CONTRACTED MANAGING EMPLOYEE
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Individual · CORPORATE OFFICER
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Individual · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Organization · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 3 across WI.
Organization · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2019
Other facilities connected through this exact CMS organization identity: 4 across WI.
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across WI.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 73 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 9 | 1.4 | 2.1 |
| Mon Jun | 9 | 1.4 | 2 |
| Fri May | 9 | 1.4 | 2 |
| Wed Apr | 9 | 1.4 | 2 |
| Sun Mar | 9 | 1.3 | 1.6 |
| Sun Feb | 8 | 1.1 | 1.6 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
No health-deficiency rows were deterministically linked to this inspection.
Allow residents to 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 2, 2026)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 2, 2026)
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 2, 2026)
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 2, 2026)
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 (Mar 2, 2026)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 2, 2026)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 2, 2026)
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 2, 2026)
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 (Mar 2, 2026)
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 2, 2026)
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 2, 2026)
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 2, 2026)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 2, 2026)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 4, 2025)
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 (Dec 4, 2025)
Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 (Dec 4, 2025)
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 (Dec 4, 2025)
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 (Sep 10, 2025)
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/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 (Sep 10, 2025)
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 10, 2025)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 10, 2025)
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 (Sep 10, 2025)
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 (Sep 10, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 11, 2025)
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 (Apr 11, 2025)
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 (Apr 11, 2025)
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 (Feb 13, 2025)
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 (Feb 13, 2025)
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 13, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2024)
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 (Nov 7, 2024)
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 7, 2024)
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 7, 2024)
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 (Aug 6, 2024)
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 (Aug 30, 2024)
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 30, 2024)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 30, 2024)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Aug 30, 2024)
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 30, 2024)
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 30, 2024)
Ensure residents do not lose the ability to perform activities of daily living unless there is 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 (Aug 30, 2024)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 30, 2024)
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 (Aug 30, 2024)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 30, 2024)
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 30, 2024)
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 (Aug 30, 2024)
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 30, 2024)
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 30, 2024)
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 3, 2024)
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 (May 3, 2024)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2024)
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 (Jan 31, 2024)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2024)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2024)
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 (Jan 31, 2024)
No health-deficiency rows were deterministically linked to this inspection.
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 (Jul 20, 2023)
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 (Jul 20, 2023)
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 (Jul 20, 2023)
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 (Jul 20, 2023)
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 (Jul 20, 2023)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 20, 2023)
Plan the resident's discharge to meet the resident's goals and needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 20, 2023)
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 (Jul 20, 2023)
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 (Jul 20, 2023)
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 (Jul 20, 2023)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 29, 2023)
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 (Jul 20, 2023)
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 (Jul 20, 2023)
Provide safe, appropriate pain management for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 20, 2023)
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 (Jul 20, 2023)
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 20, 2023)
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 20, 2023)
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 (Jul 20, 2023)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 20, 2023)
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 (Jul 20, 2023)
Penalties & enforcement
Published fine amount: $14,950.00
Published fine amount: $169,527.00
Payment denial length: 13 days
Questions to ask
Facility history
20 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
13 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Total nurse staffing increased from 3.64 to 4.21 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
3.64 → 4.21
CMS · Reported in a source release · View related evidence
RN staffing decreased from 0.66 to 0.50 hours per resident day between 2025Q3 and 2025Q4. Staffing declined across those reported periods.
0.66 → 0.50
CMS · Reported in a source release · View related evidence
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Total nurse staffing increased from 3.34 to 3.64 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
3.34 → 3.64
CMS · Reported in a source release · View related evidence
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
CMS recorded a $14,950 civil monetary penalty.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 1 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 4.295 | 3.756 |
| RN categories | 0.609 | 0.492 |
Contract staff accounted for 21.2% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.078 higher than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.337 | 0.63 | 1.018 | 1.677 | 0% | 91 |
| 2025Q3 | 3.644 | 0.659 | 1.129 | 1.838 | 0.6% | 92 |
| 2025Q4 | 4.207 | 0.498 | 1.487 | 2.167 | 5.7% | 92 |
| 2026Q1 | 4.14 | 0.576 | 1.215 | 2.288 | 21.2% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.