Inspections
The latest standard inspection on Sep 19, 2024 cited 14 deficiencies.
View inspection evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
The latest standard inspection on Sep 19, 2024 cited 14 deficiencies.
View inspection evidenceCMS-published records list 0 ownership or control parties.
View ownership evidenceOwnership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
No matched current ownership party records were found in the loaded CMS sources.
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
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2025)
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS scope/severity H: Pattern; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2025)
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: Deficient, Provider has date of correction (Feb 5, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Oct 19, 2024)
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.
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 19, 2024)
PASARR screening for Mental disorders or Intellectual Disabilities
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 19, 2024)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 19, 2024)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 (Oct 19, 2024)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 19, 2024)
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 19, 2024)
Have a plan that describes the process for conducting QAPI and QAA activities.
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 (Oct 19, 2024)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 (Oct 19, 2024)
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 19, 2024)
Implement a program that monitors antibiotic use.
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 (Oct 19, 2024)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 (Oct 19, 2024)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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 (Oct 19, 2024)
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 19, 2024)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 24, 2024)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 24, 2024)
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 24, 2024)
No health-deficiency rows were deterministically linked to this inspection.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 31, 2023)
No health-deficiency rows were deterministically linked to this inspection.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 19, 2022)
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.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 19, 2022)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 19, 2022)
Provide and implement an infection prevention and control program.
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 (Aug 19, 2022)
Perform COVID19 testing on residents and staff.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 19, 2022)
Ensure staff are vaccinated for COVID-19
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 19, 2022)
Penalties & enforcement
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Facility history
6 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
2 deficiencies were recorded. That includes 2 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
1 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
14 deficiencies were recorded.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
No matched PBJ Daily Nurse Staffing quarter is currently loaded for this provider.
What we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.