The Legacy Living and Rehabilitation Center

Gillette, WY

CMS provider ID 535022CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

Not reported in this CMS release

Health inspection

Not reported in this CMS release

Staffing

Not reported in this CMS release

Quality-measure

Not reported in this CMS release

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
160
Ownership descriptor
Government - Hospital district
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
3076887000Verified 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 staffing rating that is not reported for this facility.

RN staffing was 0.90 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence
Enforcement record

CMS records show a $14,505 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
Government - Hospital districtCMS

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • CMS reports 30 individual ownership interests

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
31
Organizations shown
1
Individuals shown
30
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • ALEXANDER, HOLLIE

    Individual · ADP OF THE SNF

    Association date reported to CMS: Apr 1, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PATEL, KIRTIKUMAR

    Individual · ADP OF THE SNF

    Association date reported to CMS: Oct 13, 2020

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • POPP, DOUGLAS

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Mar 20, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • SHAHAN, MATTHEW

    Individual · CORPORATE OFFICER

    Association date reported to CMS: May 16, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • BIGGS, ANGELA

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Nov 22, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • HARTSAW, SARA

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Dec 9, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • HITE, RANDAL

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Oct 26, 2020

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MANSELL, JOHN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Oct 29, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MURPHY, TOM

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Nov 1, 2020

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • RICE, JOHN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Oct 29, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • STUBER, ALAN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Nov 1, 2018

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • ALEXANDER, HOLLIE

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PATEL, KIRTIKUMAR

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Oct 13, 2020

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • POPP, DOUGLAS

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Mar 20, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • SHAHAN, MATTHEW

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: May 16, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • ALEXANDER, HOLLIE

    Individual · ADP OF THE SNF

    Association date reported to CMS: Apr 1, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PATEL, KIRTIKUMAR

    Individual · ADP OF THE SNF

    Association date reported to CMS: Oct 13, 2020

    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
  • POPP, DOUGLAS

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Mar 20, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • SHAHAN, MATTHEW

    Individual · CORPORATE OFFICER

    Association date reported to CMS: May 16, 2022

    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
  • BIGGS, ANGELA

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Nov 22, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • HARTSAW, SARA

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Dec 9, 2022

    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
  • HITE, RANDAL

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Oct 26, 2020

    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
  • MANSELL, JOHN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Oct 29, 2022

    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
  • MURPHY, TOM

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Nov 1, 2020

    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
  • RICE, JOHN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Oct 29, 2022

    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
  • STUBER, ALAN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Nov 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
  • ALEXANDER, HOLLIE

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PATEL, KIRTIKUMAR

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Oct 13, 2020

    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
  • POPP, DOUGLAS

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Mar 20, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility All Owners
    CMS dataset identifier
    afe44b85-cc6d-40d7-b5df-00ae8910d1d2
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • SHAHAN, MATTHEW

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: May 16, 2022

    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
  • CAMPBELL COUNTY HOSPITAL DISTRICT

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 0 across WY.

    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.

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
Mar 13, 2026
Survey type
Fire Safety Standard
Linked findings
0
Highest linked CMS classification
No linked health-deficiency finding in the loaded record
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Jul 1, 2026
CMS provider ID
535022
Source record locator
csv-row:130483:ccn:535022
View official CMS source
Mar 13, 2026Fire Safety Standard 0 linked findings

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

Mar 13, 2026Health Complaint 0 linked findings

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

Mar 13, 2026Health Standard 4 linked findings
  • F0644Resident Assessment and Care Planning Deficiencies

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

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

    Correction status: Deficient, Provider has date of correction (Apr 13, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368949:ccn:535022
    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 13, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368950:ccn:535022
    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 (Apr 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368951:ccn:535022
    View official CMS source
  • F0744Quality of Life and Care Deficiencies

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    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 30, 2026)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368947:ccn:535022
    View official CMS source
Sep 11, 2025Fire Safety Standard 0 linked findings

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

Sep 11, 2025Health Complaint 0 linked findings

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

Sep 11, 2025Health Standard 3 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 (Oct 2, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368953:ccn:535022
    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 (Oct 16, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368954:ccn:535022
    View official CMS source
  • F0744Quality of Life and Care Deficiencies

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

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

    Correction status: Deficient, Provider has date of correction (Oct 1, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368955:ccn:535022
    View official CMS source
Apr 15, 2025Health Complaint 2 linked findings
  • 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: Past Non-Compliance (Apr 8, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368956:ccn:535022
    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: Past Non-Compliance (Apr 8, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368957:ccn:535022
    View official CMS source
Feb 21, 2025Health Complaint 1 linked finding
  • 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 (Feb 21, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368958:ccn:535022
    View official CMS source
Jan 17, 2025Health Complaint 3 linked findings
  • 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 J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Past Non-Compliance (Jan 13, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368959:ccn:535022
    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 G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Feb 13, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368961:ccn:535022
    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 J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Past Non-Compliance (Jan 13, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368960:ccn:535022
    View official CMS source
Jun 19, 2024Health Complaint 1 linked finding
  • 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: Past Non-Compliance (Jun 18, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368962:ccn:535022
    View official CMS source
May 23, 2024Fire Safety Standard 0 linked findings

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

May 23, 2024Health Complaint 0 linked findings

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

May 23, 2024Health Standard 0 linked findings

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

Feb 27, 2024Health Complaint 1 linked finding
  • 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: Past Non-Compliance (Feb 15, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368978:ccn:535022
    View official CMS source
Sep 22, 2023Health Complaint 5 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 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 6, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368980:ccn:535022
    View official CMS source
  • F0800Nutrition and Dietary Deficiencies

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

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

    Correction status: Deficient, Provider has date of correction (Nov 6, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368981:ccn:535022
    View official CMS source
  • F0802Nutrition and Dietary Deficiencies

    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

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

    Correction status: Deficient, Provider has date of correction (Nov 6, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368979:ccn:535022
    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 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 6, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368982:ccn:535022
    View official CMS source
  • F0806Nutrition and Dietary Deficiencies

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

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

    Correction status: Deficient, Provider has date of correction (Nov 6, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:368983:ccn:535022
    View official CMS source
Sep 22, 2023Infection Control 0 linked findings

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

Tags appearing across inspections

  • F0600 appears in 4 linked inspections.
  • F0689 appears in 3 linked inspections.
  • F0609 appears in 2 linked inspections.
  • F0744 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • FineApr 15, 2025

    Published fine amount: $14,505.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:13990:ccn:535022
    View official CMS source
  • FineJan 17, 2025

    Published fine amount: $14,508.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:13991:ccn:535022
    View official CMS source
  • FineMay 23, 2024

    Published fine amount: $78,566.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:13992:ccn:535022
    View official CMS source
  • FineFeb 27, 2024

    Published fine amount: $8,018.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    535022
    Source record locator
    csv-row:13989:ccn:535022
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show F0600 in 4 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0689 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0609 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0744 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show a monetary penalty dated Apr 15, 2025. What changes were made after that enforcement action?

Facility history

Facility History

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

What changed recently?

  • Health inspection completed4 deficiencies were recorded.
  • Total nurse staffing increasedTotal nurse staffing increased from 4.15 to 4.63 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.
  • Civil monetary penalty recordedCMS recorded a $14,505 civil monetary penalty.

2026

  1. Health inspection completed

    4 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

2025

  1. Total nurse staffing increased

    Total nurse staffing increased from 4.15 to 4.63 hours per resident day between 2025Q3 and 2025Q4. Staffing improved across those reported periods.

    4.154.63

    CMS · Reported in a source release · View related evidence

  2. RN staffing increased

    RN staffing increased from 0.82 to 0.97 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.

    0.820.97

    CMS · Reported in a source release · View related evidence

  3. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

  4. Health inspection completed

    3 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  5. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

  6. Civil monetary penalty recorded

    CMS recorded a $14,505 civil monetary penalty.

    CMS · Recorded event date · View related evidence

  7. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  8. Complaint inspection recorded

    3 deficiencies were recorded. That includes 3 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

  9. Civil monetary penalty recorded

    CMS recorded a $14,508 civil monetary penalty.

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

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

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: not reported. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter
Total nursing
4.586
reported hours per resident day
RN categories
0.902
reported hours per resident day
LPN/LVN categories
0.92
reported hours per resident day
CNA
2.646
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing4.8553.92
RN categories1.0750.476

Contract staff accounted for 26.4% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.035 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
2025Q24.1170.8170.5582.54623.7%91
2025Q34.1480.9680.3382.66722.4%92
2025Q44.6330.9370.7742.80127.5%92
2026Q14.5860.9020.922.64626.4%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 did not publish an overall star rating for this provider in this release.
  • CMS did not publish a health inspection star rating for this provider in this release.
  • CMS did not publish a staffing star rating for this provider in this release.
  • CMS did not publish a quality-measure star rating for this provider in this release.

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
Ownership
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
y2hd-n93e
Source updated
Jul 1, 2026
Retrieved
Aug 15, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Skilled Nursing Facility All Owners
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
afe44b85-cc6d-40d7-b5df-00ae8910d1d2
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
Skilled Nursing Facility Enrollments
Source organization
Centers for Medicare & Medicaid Services (CMS)
Dataset identifier
5f2c306f-3b1c-42cd-b037-187b2ce22126
Source updated
Jul 27, 2026
Retrieved
Aug 15, 2026
Supports
Ownership parties, organization connections, and ownership history
View official CMS source
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.