Pinewood Health and Rehabilitation

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 142 beds and averages 68.2 residents a day — about 48% occupied, or roughly 74 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.79 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.29 hrs/resident/day on weekends vs 2.99 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 21 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the record review, staff interviews, and review of the facility's policies titled Abuse, Neglect and Exploitation, and Notification of Changes, and review of procedures titled Foley Irrigation Procedure, the facility failed to ensure two of three Residents (R) (R1 and R2) received the necessary care and services in accordance with physician orders. In addition, the facility also failed to ensure the physician was notified in a timely manner of significant changes in the resident conditions.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:23 pm. The noncompliance related to the IJ was identified to have existed on [DATE].An acceptable IJ Removal Plan was received on [DATE]. Based…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2026-03-10 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interviews and review of the facility's policy titled Comprehensive Care Plan, the facility failed to implement care plan interventions for two of three Residents (R ) (R1 and R2). Specifically, R1 was prescribed antiplatelet medication and had care plan interventions that included monitoring and documenting adverse outcome. In addition, R2 had a care plan for obstructive uropathy and an indwelling Foley catheter with care plan interventions to provide catheter care.On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on November 22, 2025.An acceptable IJ Removal Plan was received on March 5, 2026. Based on observation, record reviews, and review…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2026-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interviews, and review of the facility's policy titled Incidents and Accidents, the facility failed to ensure one of one Hoyer lifts to transfer 13 residents was functional and free of defective parts. Specifically, the facility failed to remove a malfunctioned Hoyer lift and to ensure that it was properly repaired prior to the residents' use and the purchase of a new Hoyer lift. On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on October 4, 2025.An acceptable IJ Removal Plan was received on March 5, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2026-03-10 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and the facility job description for the former Administrator and Director of Nursing, the facility failed to provide administrative oversight to ensure physician orders were obtained and implemented as written and failed to ensure adequate supervision of the quality of care was provided for two of three Residents (R) R1 and R2.On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on October 4, 2025.An acceptable IJ Removal Plan was received on March 5, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records review, staff interviews, and the facility policy titled Fall Prevention Policy, the facility failed to ensure that one Resident (R1) with a history of multiple falls and receiving Plavix daily had accurate and complete neurological checks for a head injury on [DATE] and a second fall on [DATE] resulting in an acute bilateral tentorial subdural hemorrhage to the left side of the head with a right-to-left midline shift. The resident expired on [DATE] with an immediate cause of death determined to be a subdural hematoma. The facility census was 60. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on [DATE], at 4:07 p.m. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-08-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, the facility failed to ensure that staff nurses assessed and completed neurological checks for one of 10 Residents (R1) who had a fall (5/15/2025) with a head injury and sustained a hematoma. The census was 60. On August 12, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on August 12, 2025, at 4:07 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on May 15, 2025. An Acceptable IJ Removal Plan was received on 8/14/2025. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-08-20 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and a review of the facility-provided Administrator and Director of Nursing (DON) Job Description, the Administration failed to provide oversight and supervision related to assessments of post fall monitoring and neurological checks by licensed nurses and failed to ensure safety measures implemented were effective for R1, who suffered head trauma after a fall, resulting in death.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Interim Director of Nursing (DON), Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on [DATE], at 4:07 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-08-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews, and a review of the facility's policies titled Abuse Prevention Policy & Procedure and Identifying Sexual Abuse and Capacity to Consent policy, the facility failed to protect Resident (R) 4's right to be free from sexual abuse by R5. The facility sample size was 21. On 8/8/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-08-19 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews, and review of the policy titled Abuse Prevention Policy & Procedure, the facility failed to ensure that allegations of abuse or injury of unknown origin were reported to the State Survey Agency in a timely manner for four Residents (R) (R4, R5, R3, and R8), failed to ensure that an allegation of sexual abuse involving two residents (R4 and R5) was reported to law enforcement in a timely manner, and failed to ensure that the initial and follow up reports to the State Survey Agency, for an allegation of sexual abuse involving two residents (R4 and R5), contained complete and accurate information, from a total sample of 21 residents. On 8/8/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-08-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the Abuse Prevention Policy & Procedure, the facility failed to conduct an investigation and implement protective measures in a timely manner following an allegation of resident-to-resident sexual abuse involving two Residents (R) (R4 and R5) from a total sample of 21 residents. On 8/8/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-08-19 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record reviews, and review of the job descriptions for Nursing Home Administrator and Director of Nursing (DON), facility Administration failed to ensure that all components of the facility's abuse prevention system were implemented in a thorough and timely manner to address allegations of abuse or injury of unknown origin for four Residents (R) (R4, R5, R3, and R8), from a total sample of 21 residents. On 8/8/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-06-03 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain the outdoor garbage and refuse area in a sanitary condition. One of two dumpsters was observed with the lid left open, creating the potential to attract and harbor pests and insects. The facility census was 63.Findings include:A review of the facility policy titled, Infection Prevention and Control Program, last revised on 04/09/2026, documented under Waste Management: 21. The facility shall ensure that all dumpster lids and/or covers are kept closed at all times to maintain a safe, sanitary environment and to prevent attraction of pests and the potential spread of infection. Staff are responsible for ensuring lids and covers are securely closed after each use and are to report any damages or missing lids to the appropriate department for immediate repair or replacement.Observations on 05/31/2026 at 11:47 AM, 06/01/2026 at 1:44 PM, and 06/02/2026 at 11:44 AM revealed that one of the two dumpsters had it's lid open.Interview on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff and resident interviews, and review of the facility policy titled Documentation in Medical Record, the facility failed to ensure the medical record documentation was complete and accurate for one of 10 sampled residents (R) (R5). Specifically, staff documented the presence of maggots between the left great toe and the second toe for R5.Findings include:Review of the facility policy titled Documentation in Medical Record, dated 1/13/2025, revealed: Policy Explanation and Compliance Guidelines: 4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident-centered.Review of the admission record revealed that R5 was admitted to the facility with diagnoses including, but not limited to, type 2 diabetes mellitus, unspecified dementia, peripheral vascular disease, and severe morbid obesity.Review of the 6/30/2025 Wound Care Physician note indicated the resident had a wound to the left medial leg that was being treated with medical-grade honey and a two-layer compression wrap every Monday, Wednesday,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-02-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food in refrigeration and freezer storage, failed to discard food in refrigeration storage with expired use by dates or signs of spoilage, and ensure scoops were not stored in containers of sugar, flour, and corn meal. The facility also failed to keep the kitchen's oven, large manual can opener, and metal exhaust hood vents clean. This failure had the potential to create an environment for food-borne illnesses which could affect 57 of 57 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Food Receiving and Storage, with a revision date of 07/2014, indicated, . Food shall be received and stored in a manner that complies with safe food handling practices . 7. All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . Review of the facility's undated policy titled, Leftover Food, indicated, . 3. Leftover foods will be stored in approved containers and labeled with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to implement interventions to aid in the healing of pressure ulcers for two of two residents (Resident (R) 45 and R48) reviewed for pressure ulcers out of a total sample of 21. This had the potential to cause delay in the healing of the residents' pressure ulcers. Findings include: Review of the facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, revealed, . The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example immobility, recent weight loss, and a history of pressure ulcer(s) . The nurse should describe, document, and report: a full assessment of the pressure ulcer, including stage, length, width, depth, presence of exudate (drainage) or necrotic (dead) tissue; pain assessment; resident's mobility status; current treatments, including support surfaces, and all active diagnoses. The physician would…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-19 · tag F0578 — failed to honor advance directives / code status — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure a resident's wish for a Do Not Resuscitate (DNR) code status as specified in the resident's Physician Orders For Life-Sustaining Treatment (POLST, this is a Physician's Order guided by the patient's medical condition and based upon personal preferences verbalized to the physician or expressed in an Advanced Directive) was ordered and accurately documented in the resident's medical record for one of two residents (Resident (R) 54) reviewed for advanced directives in a total sample of 21 residents. This failure created the potential for residents not to have their wishes followed should they suffer a health emergency. Findings include: Review of the facility policy titled, Advanced Directives, revised on 12/2016, indicated, Policy Statement Advanced directives will be respected in accordance with state law and facility policy. 1. Upon Admission, the resident will be provided with written information concerning the right…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-19 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for two of three residents (Resident (R) R7 and R41) reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the resident's appeal rights. Findings include: Review of the facility's policy titled Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed The resident and representative are notified in writing of the following information: .d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; f. The name, address, and telephone number of the Office of the State…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-19 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to implement the comprehensive plan of care for one resident ((R) 29) of three residents reviewed for nutrition out of 21 sampled residents. The facility's failure to assist R29 with meals as indicated in the resident's plan of care placed R29 at risk for weight loss and nutritional complications. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised on 03/2022, indicated, Policy Statement A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and nutritional needs is developed and implemented for each resident. Policy interpretation and Implementation 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family of legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of R29's admission Record, located…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-19 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to review and revise the care plan for one of two residents reviewed for care plans (Resident (R) 48). R48's care plan was not revised to reflect repositioning and/or limiting the resident's time in her wheelchair per the physician's order. This failure placed the resident at risk for unmet care needs and worsening of a pressure ulcer. Findings include: Review of R48's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/13/24, located in the EMR under the MDS tab revealed an admission date of 12/19/22. R48 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R48 was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have impairment on both sides of the lower extremities, required supervision or touching assistance to roll left and right, required substantial/maximal assistance for chair/bed-to-chair transfer, always…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide eating assistance for one of three residents (Resident (R) 29) reviewed for nutrition out of 21 sampled residents. This failure had the potential to cause weight loss and/or nutritional complications for this resident. Findings include: Review of the facility's policy titled, Assistance with Meals, revised on 03/2022, indicated, Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . Dining Room Residents: . 2. Facility staff will serve resident trays and will help residents who require assistance with eating . Review of R29's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with diagnoses which included psychosis, Alzheimer's Disease, other specified eating disorder, and anxiety disorder. Review of R29's quarterly Minimum Data Set (MDS), with an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-19 · tag F0773 — isolated
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to report abnormal blood sugar levels to the physician for one of two residents reviewed for laboratory services (Resident (R)32). This deficient practice could lead to serious health complications for R32 such as nerve damage, kidney disease, vision problems, heart disease, and even diabetic coma. Findings include: Review of the facility policy titled Obtaining a Fingerstick Glucose Level, dated 10/11, provided by the facility, revealed 1. Report results promptly to the supervisor and the Attending Physician. Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised 11/18, provided by the facility revealed 3. A nurse will identify the urgency of communicating with the Attending Physician based on the physician request, the seriousness of any abnormality, and the individual's current condition. 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the physician has…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$210,094 in federal fines across 2 penalties.

• $205,861 — penalty dated 2024-08-19
• $4,233 — penalty dated 2023-10-30

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BRIGHTON HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $432K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA