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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D12 | E3 | F13 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jun 10, 2026 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Jun 10, 2026 | Health | Health Standard | 2 | Potential harm | — | Open → |
| Apr 29, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 23, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 1, 2025 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Apr 1, 2025 | Health | Health Standard | 1 | Potential harm | — | Open → |
| Nov 26, 2024 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Mar 21, 2024 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Mar 21, 2024 | Health | Health Standard | 7 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Nov 26, 2024 | Civil money penalty (fine) | $36,855 | — | 355052|Fine|99633 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D12 | E3 | F13 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 10, 2026 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 29, 2026 | |
| Jun 10, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 26, 2026 | |
| Jun 10, 2026 | K-0921 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Nelson County Health System | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 1, 2010 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Nelson County Health System | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 1, 2010 |
| Steven Forde | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 19, 2016 |
| Ivan Berg | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 6, 2011 |
| Brandon Jensen | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 7, 2013 |
| Brandon Lundeby | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 6, 2011 |
| Ranae Oxton |
Coordinates as published by CMS.
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 355052 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 355052 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected Jun 29, 2026 |
| Jun 10, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 15, 2026 |
| Jun 10, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 15, 2026 |
| Apr 29, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 1, 2026 | Complaint |
| Apr 29, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 1, 2026 | Complaint |
| Jun 23, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance Jun 23, 2025 | Complaint |
| Apr 1, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 1, 2025 |
| Apr 1, 2025 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 7, 2025 |
| Apr 1, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 1, 2025 |
| Apr 1, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 1, 2025 |
| Apr 1, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 6, 2025 |
| Nov 26, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | G · Actual harm Isolated | Corrected Jan 6, 2025 | Complaint |
| Nov 26, 2024 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 24, 2025 | Complaint |
| Mar 21, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2024 |
| Mar 21, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2024 |
| Mar 21, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 20, 2024 |
| Mar 21, 2024 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2024 |
| Mar 21, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2024 |
| Mar 21, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 20, 2024 |
| Mar 21, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2024 |
| Mar 21, 2024 | F-0657 | 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 · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2024 |
| Mar 21, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 29, 2024 |
| Mar 21, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 29, 2024 |
| Mar 21, 2024 | F-0690 | 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 · Clinical care | D · Potential harm Isolated | Corrected Apr 29, 2024 |
| Mar 21, 2024 | F-0761 | 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 · Medication management | D · Potential harm Isolated | Corrected Apr 29, 2024 |
| Mar 21, 2024 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Apr 29, 2024 |
| Mar 21, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 29, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 5.65 (case-mix index 1.07).
| Individual |
| Corporate officer / director |
| CORPORATE DIRECTOR |
| not provided |
| Nov 6, 2011 |
| Heather Stein | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 24, 2014 |
| Angela Twete | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 24, 2014 |
| Judith Twete | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 6, 2011 |
| Catherine Swenson | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Oct 14, 2015 |