Data from CMS, updated September 1, 2026. How we rate · Report a correction
CMS file
CCN 265539
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: 2.73. Adjusted RN hours: 0.32. Case-mix total: 4.79. Case-mix index: 1.752.
Total nursing staff turnover: 41.7%. RN turnover: 50.0%. Administrators who left: 0.
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
CMS reports 1 fine totaling $275,739, and 2 payment denials.
| Date | Type | Amount or days |
|---|---|---|
| April 9, 2024 | Payment Denial | 4 days |
| December 11, 2023 | Fine | $275,739 |
| December 11, 2023 | Payment Denial | 17 days |
Cycle 1 standard survey: May 30, 2025. Health deficiencies counted in cycle 1: 8. Cycle 1 total health score: 56.
Cycle 2 standard survey: April 9, 2024. Cycle 2/3 health deficiencies: 35. Total weighted health survey score: 279.75.
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 66 citations for this home, including 3 at immediate jeopardy and 2 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 |
|---|---|---|---|
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 18, 2025 |
7 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2025 |
| F699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2025 |
| F741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2025 |
| 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 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 17, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2025 |
| F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2025 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2025 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 6, 2024 |
18 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| 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 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 6, 2024 |
| F730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| 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 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Complaint survey · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 6, 2024 |
| 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 · June 6, 2024 |
| F800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies · Complaint survey · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 6, 2024 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F554 | Allow residents to self-administer drugs if determined clinically appropriate. 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 9, 2024 |
| F641 | Ensure each resident receives an accurate assessment. 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 9, 2024 |
| 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 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| 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 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F776 | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
| F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 9, 2024 |
16 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 3 | L: widespread, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · January 12, 2024 |
| F678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | K: pattern, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · January 12, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · January 12, 2024 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | H: pattern, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · January 12, 2024 |
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · January 12, 2024 |
| F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F584 | 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. Resident Rights Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F585 | 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. Resident Rights Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 29, 2024 |
| F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| 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 · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 12, 2024 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 29, 2024 |
23 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
| F554 | Allow residents to self-administer drugs if determined clinically appropriate. 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 · September 12, 2022 |
| F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 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 · September 12, 2022 |
| 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 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 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 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
| 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 · September 12, 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 · September 12, 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 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 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 · September 12, 2022 |
| F567 | Honor the resident's right to manage his or her financial affairs. 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 · September 12, 2022 |
| F584 | 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. 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 · September 12, 2022 |
| F585 | 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. 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 · September 12, 2022 |
| F622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. 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 · September 12, 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 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
| F658 | Ensure services provided by the nursing facility meet professional standards of quality. 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 · September 12, 2022 |
| F660 | Plan the resident's discharge to meet the resident's goals and needs. 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 · September 12, 2022 |
| F661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. 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 · September 12, 2022 |
| F692 | Provide enough food/fluids to maintain a resident's health. 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 · September 12, 2022 |
| 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 · September 12, 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 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
| F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
| F575 | Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Resident Rights Deficiencies · Standard survey · Cycle 3 | C: widespread, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
| F582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Standard survey · Cycle 3 | C: widespread, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · September 12, 2022 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Aegis Health and Rehabilitation has an overall rating of 1 out of 5. The health inspection rating is 1, staffing is 1, and the quality measure rating is 3.
The Health Deficiencies file lists 66 health citations for this home. 3 are coded immediate jeopardy (J, K, or L) and 2 are coded actual harm that is not immediate jeopardy (G, H, or I).
CMS reports 3.41 total nurse hours per resident per day, including 0.40 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.