Data from CMS, updated September 1, 2026. How we rate · Report a correction
CMS file
CCN 225382
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
Adjusted total nurse hours: 3.30. Adjusted RN hours: 0.80. Case-mix total: 3.82. Case-mix index: 1.398.
Total nursing staff turnover: 41.1%. RN turnover: 48.1%. Administrators who left: —.
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
CMS reports 0 fines totaling $0, and 0 payment denials.
The Penalties file has no individual penalty rows for this CCN.
Cycle 1 standard survey: April 30, 2025. Health deficiencies counted in cycle 1: 10. Cycle 1 total health score: 72.
Cycle 2 standard survey: April 23, 2024. Cycle 2/3 health deficiencies: 7. Total weighted health survey score: 61.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
The Health Deficiencies file lists 62 citations for this home, including 0 at immediate jeopardy and 3 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 16, 2026 |
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2026 |
| F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2026 |
7 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
| F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
| F658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
| F551 | Give the resident's representative the ability to exercise the resident's rights. Resident Rights Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 3, 2025 |
7 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F761 | 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. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
| F558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
| F658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
| F758 | 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. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
| F848 | Provide a neutral and fair arbitration process and agree to arbitrator and venue. Administration Deficiencies · Standard survey · Cycle 2 | B: pattern, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
45 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F675 | Honor each resident's preferences, choices, values and beliefs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | H: pattern, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · December 21, 2022 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · December 21, 2022 |
| F740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · December 21, 2022 |
| F838 | 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. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F888 | Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F946 | Provide training in compliance and ethics. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F761 | 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. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F551 | Give the resident's representative the ability to exercise the resident's rights. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F578 | 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. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 23, 2023 |
| F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F625 | 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. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F711 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F758 | 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. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F825 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 21, 2023 |
| F849 | 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. Administration Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F886 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
| F582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Standard survey · Cycle 3 | B: pattern, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · December 21, 2022 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
The Guardian Center has an overall rating of 1 out of 5. The health inspection rating is 2, staffing is 3, and the quality measure rating is 1.
The Health Deficiencies file lists 62 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 3 are coded actual harm that is not immediate jeopardy (G, H, or I).
CMS reports 3.29 total nurse hours per resident per day, including 0.80 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.