Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crossview Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a large trust account balance had over $4,800 in clothing purchased in their name, documented with a perfectly formed "X" signature witnessed by the former administrator and receptionist, despite the resident’s usual mark being irregular. Staff reported being told not to inform the resident about the substantial funds in the account, and the resident later stated they were unaware of both the purchase and the extent of their funds. The former administrator admitted ordering a large wardrobe as a spend-down from the account, not disclosing the exact balance to the resident, and failing to return incorrectly sized clothing, resulting in misappropriation of the resident’s money without clear, informed consent.
A resident reported an unauthorized online clothing purchase charged to their funds, and the facility documented this as an allegation of exploitation/misappropriation of property. Facility policy required prompt reporting of such allegations to the Abuse Coordinator, state agency, and law enforcement. However, there was no evidence that the Sheriff’s Department was notified, and later contact with an investigator confirmed no report existed. Internal email communication also showed that police had not been to the facility, and staff did not perform a documented follow-up with law enforcement, resulting in a failure to report the alleged misappropriation as required.
The facility failed to ensure timely access to personal resident funds for multiple residents. A policy allowed petty cash withdrawals up to $99 and required larger requests to be processed through a check system within 3 business days, but residents reported they could only get money during office hours and had no access in the evenings, on weekends, or on holidays. Several cognitively intact residents with BIMS scores of 15/15 said they had requested money and still had not received it, and some needed others to cash checks because the facility had no transportation and no nearby bank.
A resident's DNR status was not entered in the EMR and no corresponding physician order was present, despite a POLST in the chart indicating allow natural death and do not attempt resuscitation. The face sheet, EMR profile, and orders section were blank for code status, and the resident also lacked a care plan entry for code status. An LPN confirmed code status should be documented in the EMR, care plan, POLST, and Red Book, and the administrator stated staff were to ensure a written MD order identified residents' end-of-life wishes upon admission.
Inaccurate MDS Diagnosis Coding: A resident’s quarterly MDS failed to include a cancer diagnosis even though the medical record documented colon cancer, prior hospitalization for an open hemicolectomy, and additional diagnoses including candidal sepsis, anemia, HTN, seizure disorder, anxiety, depression, schizophrenia, and anorexia. The DON acknowledged the resident had been hospitalized for colon cancer and stated a diagnosis should be on the MDS, and the MDSC confirmed the diagnosis section was inaccurately coded.
The facility failed to provide showers or baths according to the preferences and schedules of three residents, leading to a deficiency in promoting resident self-determination. One resident, with a history of aphasia and hemiplegia, received fewer showers than scheduled despite grievances. Another resident with COPD and diabetes also received showers less frequently than scheduled. A third resident, with cerebral infarction and schizophrenia, reported that showers were not given due to a lack of towels. Staff interviews revealed issues with linen availability, affecting the ability to provide showers as scheduled.
A resident with multiple diagnoses, including Alzheimer's and dementia, was found with a significant bruise around the left eye that was not reported to the State Agency within the required time frame. Staff interviews revealed uncertainty about the cause of the bruise, and the facility administrator confirmed that no report had been made until prompted by a surveyor's inquiry, violating the facility's policy and regulatory requirements.
A resident with multiple diagnoses, including dementia and intellectual disabilities, was found with a bruise on the left eye on two occasions, but the facility failed to investigate or report the injury as required by their abuse prevention policy. Interviews with staff, including an LPN and the administrator, revealed a lack of documentation and clarity regarding the incident, leading to a deficiency in the facility's handling of the situation.
The facility failed to accurately report direct care staffing data to CMS for Q1 2024, resulting in a one-star staffing rating. Discrepancies were found between the actual nursing hours worked on weekends and the hours reported. Current leadership was unable to explain the discrepancies, as they were not in their positions during the period in question.
The facility failed to maintain a clean and sanitary environment in the laundry department, leading to potential cross-contamination of dirty and clean laundry. Observations revealed spider webs, dust buildup, and grime on various surfaces, as well as a leaking handwashing sink. Staff interviews confirmed that daily cleaning was not adequately performed.
The facility failed to ensure that four residents did not have unsecured unauthorized medications stored at their bedside. The residents had various medications and antiseptic products in their rooms without being assessed for self-administration. Staff were unaware of these items, and the Director of Nursing confirmed that none of the residents were care planned or assessed to self-administer medications.
The facility failed to maintain a safe, clean, and homelike environment in the 100 Hall, with issues such as a loose handrail, jagged door frames, rusty heaters, and damaged flooring. Specific rooms and bathrooms had peeling paint, stained tiles, and jagged edges, which were confirmed by the Administrator, Maintenance Director, and Housekeeping Supervisor.
The facility failed to follow the care plan for a resident with COPD, resulting in the resident receiving an incorrect oxygen level. Observations and staff interviews confirmed that the oxygen was set at 4.5 L/M, contrary to the physician's order.
A resident with COPD was observed receiving oxygen at 4.5 L/M instead of the physician-ordered 2 L/M. Staff were unaware of the correct setting, and the resident confirmed she did not alter the oxygen levels. The DON and MDS Coordinator acknowledged the failure to follow the physician's orders, putting the resident at risk.
Misappropriation of Resident Trust Funds for Unauthorized Clothing Purchase
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of resident trust account funds, contrary to its policy on Freedom of Abuse and Abuse Prevention. The policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without consent. The resident involved had mild intellectual disabilities, a brief psychotic disorder, paranoid personality disorder, and seizures, and an MDS BIMS score of 09 indicating moderately impaired cognition. The resident had a transferring resident fund account set up with the facility for automatic transfer of care-cost payments. An invoice dated 11/25/2025 from a vendor showed that 63 articles of clothing, ranging from medium to 3X sizes, were purchased in the resident’s name for a total of $4,899.05. The invoice bore a perfectly formed “X” mark, purported to be the resident’s authorization, witnessed by the previous Administrator and the previous receptionist. However, other facility documents, including a Check Cashing Authorization form and a Resident Shopping List/Spending Report, showed that the resident’s usual “X” mark had very irregular lines. Staff, including an LPN, reported concerns that the resident could not make a perfect “X” and that they had heard the previous Administrator and receptionist instructed staff not to tell the resident he had a substantial amount of money in his account. The resident later reported to the corporate President of Operations that he was unaware of the clothing purchase and did not authorize it, and also that he did not know about the funds in his Resident Funds Management System. In a written statement, the previous Administrator acknowledged ordering a large amount of clothing for the resident because she believed he needed a spend-down from his account and stated she did not tell him the exact amount of money in his account, citing concerns about his decision-making and susceptibility to manipulation by other residents. She also stated she ordered clothing in different sizes after asking if she could get him a new wardrobe, but the resident did not like the outfits and she had accidentally ordered the wrong sizes and had not returned them. These actions and omissions resulted in the use of the resident’s trust account funds for a large clothing purchase without clear, informed authorization from the resident, constituting misappropriation of resident property as defined by facility policy.
Failure to Report Alleged Misappropriation of Resident Funds to Law Enforcement
Penalty
Summary
The facility failed to protect a resident from misappropriation of funds by not ensuring timely and complete reporting of an allegation of exploitation to the state agency and law enforcement, as required by its own abuse prevention policy. The facility’s policy, titled Freedom of Abuse, Abuse Prevention: Fast Alerts, required that any complaint, allegation, observation, or suspicion of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property be communicated to the Abuse Coordinator and reported immediately, but no later than two hours if involving abuse or serious bodily injury, and within 24 hours if not. An incident report dated 02/06/2026 documented an allegation of exploitation/misappropriation of resident property/funds for one resident, indicating the resident had not authorized an online clothing purchase made on 11/25/2025. Record review of the facility’s investigation showed no evidence that the Sheriff’s Department was notified of this allegation. During an interview, the Interim Administrator reported that when he later contacted an investigator with the Sheriff’s Department, he was told there was no report on file for the 02/06/2026 allegation. An email dated 02/10/2026 from the previous President of Operations asked whether the police had been by and was answered in the negative, with no documentation that staff followed up with the Sheriff’s Department. In a subsequent interview, the Interim Administrator acknowledged that staff should have made a follow-up call to the Sheriff’s Department, confirming that the required law enforcement notification and follow-up did not occur as outlined in the facility’s policy.
Delayed Access to Resident Funds
Penalty
Summary
The facility failed to ensure timely availability of personal resident funds for four of four residents reviewed for access to personal funds. Review of the facility policy titled RFMS stated that residents could withdraw no more than $99 from petty cash, requests for $99 or lower were to be provided the same day, and requests over $100 were to be provided within 3 business days through a check process. However, the facility’s banking hours were limited to times when business office staff were present, and residents did not have access to their money after office hours, on weekends, or on holidays. The facility also had no bank in town and no transportation to take residents to a bank. Resident interviews confirmed delays in receiving requested funds. One cognitively intact resident with a BIMS score of 15 out of 15 reported requesting $200 and not receiving it by the time of interview, and stated money was only available from the office during the day. Another resident reported requesting money for Thanksgiving and still not having received it. Two additional cognitively intact residents, both with BIMS scores of 15 out of 15, also stated they had requested money in November and had not received it; one said she had previously needed her pastor to cash checks because she was wheelchair-bound and the facility had no transportation, and another said the Administrator had previously taken her checks to the bank for cashing. The Administrator and corporate staff confirmed the cashier’s office was only open during office hours and that there was no access to money in the evenings, on weekends, or on holidays.
Missing DNR Documentation and Physician Order
Penalty
Summary
The facility failed to enter a DNR status in the EMR and failed to obtain a corresponding physician order for one of two residents reviewed for advance directives, Resident 30. Review of the record showed the resident was admitted on 9/15/2025, but the face sheet and EMR profile both had the code status left blank. The EMR orders section also did not contain a code status order on or around the admission date. A POLST dated 9/24/2025 in the EMR documents section indicated allow natural death and do not attempt resuscitation. Facility policy titled Advanced Directives stated the facility must inform residents of the right to accept or refuse treatment and upload a copy of the resident's decision to the chart on admission or readmission. Facility policy titled Physician Service stated no medications, treatments, diet orders, or therapy procedures are to be administered without a physician's order and that the nurse who notes the order will transcribe it to the appropriate record. An LPN verified code status should be documented in the EMR, care plan, POLST, and Red Book, and stated a doctor's order should have been written the day of or shortly after admission. The Red Book contained the resident's face sheet, POLST, and a purple sticker indicating DNR, but the resident did not have a care plan indicating code status. The administrator stated staff were to ensure there was a written doctor's order identifying residents' end-of-life wishes upon admission.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for one resident, whose quarterly MDS with an ARD of 11/3/2025 did not include a cancer diagnosis even though the resident’s medical record documented multiple diagnoses, including malignant neoplasm of overlapping colon and a history of breast cancer and bronchus cancer. Review of the RAI Manual 3.0 dated 10/2019 showed that if an MDS assessment contains errors that incorrectly reflect the resident’s status, the assessment must be corrected. Record review showed the resident had been hospitalized for an open hemicolectomy to remove part of the colon due to cancer and remained in the hospital until 10/22/2025. The resident’s EMR face sheet also listed candidal sepsis, anemia, hypertension, seizure disorder, anxiety disorder, depression, schizophrenia, and anorexia. During interviews, the DON stated the resident had been in the hospital for colon cancer and that a diagnosis should be on the MDS, and the MDSC confirmed she completed the diagnosis section and that the quarterly MDS was inaccurately coded for cancer.
Failure to Provide Scheduled Showers/Baths
Penalty
Summary
The facility failed to ensure that three residents received showers or baths according to their preferences and scheduled days, leading to a deficiency in promoting resident self-determination and choice. Resident 1, who had a history of aphasia, dysphagia, and hemiplegia, was scheduled for showers on Mondays, Wednesdays, and Fridays but received fewer showers than scheduled. Despite grievances filed by the resident and their family, the facility did not consistently provide showers as per the resident's preference. Resident 2, diagnosed with COPD, diabetes, and hemiplegia, was scheduled for showers on Tuesdays, Thursdays, and Saturdays. However, the resident received showers less frequently than scheduled, and a grievance was filed when the resident did not receive a shower for a week. Similarly, Resident 3, with a history of cerebral infarction and schizophrenia, was scheduled for showers on Mondays, Wednesdays, and Fridays but did not receive them consistently. The resident reported that staff documented refusals when, in fact, showers could not be given due to a lack of towels. Interviews with staff revealed that the facility faced issues with linen availability, which affected the ability to provide showers as scheduled. Certified Nursing Assistants reported that baths could not be given at times due to a lack of clean linens, and the Director of Nursing confirmed that there had been issues with linen availability. Despite these challenges, the facility did not adequately address the residents' preferences and needs for personal hygiene, leading to the deficiency.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency within the required time frame. According to the facility's policy, any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be reported immediately, but not later than 2 hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not. The resident in question, who had diagnoses including intellectual disabilities, Alzheimer's disease, and dementia, was observed with a significant bruise around the left eye that had not been evaluated or reported in a timely manner. Interviews with staff revealed uncertainty about the cause of the bruise, with a CNA noting the injury was present after returning from days off, and an LPN suggesting a possible fall but finding no documentation to confirm this. The facility administrator admitted to completing a report to the state only after being prompted by the surveyor's inquiry, confirming that no prior report of the injury had been made. This delay in reporting violated the facility's policy and regulatory requirements for timely notification of injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as R6, who was admitted with multiple diagnoses including intellectual disabilities, Alzheimer's disease, dementia with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and a need for assistance with personal care. The deficiency was identified through a review of the facility's policy on abuse prevention, which mandates immediate reporting and investigation of any suspected abuse, mistreatment, or neglect. Despite this policy, the facility did not evaluate or report a bruise found on R6's left eye on two separate occasions. Interviews with staff revealed a lack of clarity and documentation regarding the incident. An LPN suggested that R6 might have fallen but could not find any documentation to support this claim. The facility's administrator confirmed that no incident report had been completed for the bruising and acknowledged that the staff did not follow the expected procedures for reporting and documenting such incidents. This lack of action and documentation led to the deficiency noted in the report.
Inaccurate Reporting of Direct Care Staffing Data
Penalty
Summary
The facility failed to accurately report direct care staffing data to CMS for the first quarter of Fiscal Year 2024. A review of the PBJ Report for Q1 2024 revealed that the facility triggered a one-star staffing rating due to excessively low weekend staffing, failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. Discrepancies were found between the total number of hours nursing staff worked on weekends and the total number of nursing hours reported to CMS. Interviews with the Director of Nursing (DON), the Administrator, and the Regional President revealed that the current leadership was unable to explain the discrepancies, as they were not in their positions during the period in question. The DON reported working weekends and weekdays to ensure coverage, and the Regional President acknowledged the one-star staffing rating and stated that the facility was currently in compliance with RN coverage and staffing. The former leadership, including the previous Administrator and DON, were no longer working at the facility, making it difficult to determine the baseline and the cause of the staffing shortages and inaccuracies in the PBJ reports submitted.
Infection Control Deficiency in Laundry Department
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry department, leading to potential cross-contamination of dirty and clean laundry. Observations during a tour revealed spider webs and a buildup of dust on walls, ceiling tiles, pipes, and behind washing machines and dryers. Additionally, there was a heavy accumulation of dust, dirt, and grime on pipes, electrical cords, and the floor behind the machines. Heavily soiled and dusty cloths were used as fillers around the air conditioning unit in the clean sorting and folding area. A pink bath pan under the handwashing sink was filled with dark-colored liquid, indicating a leak that had been present long enough for the liquid to overflow onto the floor, with unidentifiable black spots on the rim of the pan. Interviews with staff revealed that the facility was using agency staff for housekeeping and laundry. The Housekeeping Manager confirmed that staff were supposed to clean the laundry area daily, but acknowledged the presence of dust and other cleanliness issues. The Maintenance Director and Corporate Maintenance were unaware of the cleaning and maintenance issues in the laundry department until they reviewed pictures and confirmed the unsanitary conditions. The Administrator stated that her expectations were for the laundry department to be clean and sanitary, and mentioned that a new AC/heat unit was needed in the folding/sorting room, which required a capital expenditure request to corporate due to the cost exceeding $500.
Unsecured Unauthorized Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that four residents did not have unsecured unauthorized medications stored at their bedside. Resident 3, who had diagnoses including Type 2 diabetes, schizophrenia, Alzheimer’s, and hypertension, was observed with medicated creams on her bedside table. She reported using the cream daily, although she had not been assessed to self-administer medications. Similarly, Resident 10, with diagnoses including gastro-esophageal reflux disease and mild cognitive impairment, had peroxide and mupirocin ointment in her bathroom. She stated that her wound nurse gave her the ointment to self-apply, but she had not been assessed for self-administration either. Resident 22, with chronic obstructive pulmonary disease and mild cognitive impairment, had oral tooth gel on his nightstand, which he reported using for mouth pain. He also had not been assessed for self-administration. Resident 27, with heart disease, Type 2 diabetes, and hypertension, had mouthwash and rubbing alcohol in her bathroom and artificial tears on her bedside table. She reported using these items without supervision, but she had not been assessed for self-administration either. During rounds with the Director of Nursing (DON) and an LPN, all medications and antiseptic products were confirmed in the residents' rooms. Both staff members were unaware of the medications and products. The DON reported that none of the residents were care planned or assessed to self-administer medications or antiseptic products. The DON removed the medications from the residents' rooms and noted that some items, like the artificial tears, should be kept at the nurse station. The DON also mentioned that the facility has a monitoring system called Angels Guardian Rounds to inspect rooms for unauthorized items, but she had not been in the residents' rooms lately. An LPN confirmed that the eyedrops were in Resident 27's room and denied leaving them there. She also stated that zinc ointment or any incontinent cream items should be placed in a secure place and not left at the bedside. The LPN reported being unaware of Resident 27 using the vaginal cream independently and mentioned that nurses would typically apply such creams for infection control. She also stated that nurses and certified nursing assistants were educated to place these items in a secure place after use.
Environmental Deficiencies in 100 Hall
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in the 100 Hall. Observations revealed a loose handrail along the interior corridor, jagged and rough edges on the exit door frame, an old rusty inoperable heater attached to the wall, and chipped and scratched flooring near the dining area. These issues were confirmed by the Administrator and the Maintenance Director during walking rounds. Additionally, the Maintenance Director acknowledged that the handrail and flooring needed repairs, but approval from the corporate office was required for the flooring fix. Further observations identified environmental concerns in specific rooms and bathrooms. Room 13 had peeling paint exposing dirty tiles and scraped closet and bathroom doors. Room 10's bathroom floor tiles were stained with a dark brown sticky substance, and the bathroom door was damaged, preventing closure. Room 4 had scraped closet doors with protruding sharp jagged edges. The exit door frame had missing parts causing jagged sharp edges, and a wall-mounted heater near the exit door was covered with rust. Room 8's bathroom had two uncovered basins on the floor with dirt and debris, and dark wet coffee-colored stains coating the tiles near the commode. These issues were confirmed by the Maintenance Director, Administrator, and Housekeeping Supervisor, who acknowledged the environmental deficiencies and the need for repairs.
Failure to Implement Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement the care plan for a resident (R17) related to oxygen administration. The resident was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and shortness of breath. The care plan indicated that the resident required supplemental oxygen, with specific oxygen settings as ordered by the physician. However, during observations on two separate occasions, the surveyor noted that the resident's oxygen level was set at 4.5 L/M, which was not in accordance with the physician's order. This discrepancy was confirmed through interviews with the Director of Nursing (DON) and the MDS Coordinator, who both stated that the expectation was for nurses to monitor and ensure the oxygen is set at the correct level per the physician's order and to follow the resident's care plan. The facility's policy titled RAI/Care Planning Management emphasized the importance of conducting a comprehensive and accurate assessment of each resident's functional capacity and ensuring that care plans are accessible for clinical staff to facilitate care plan interventions. Despite this policy, the facility did not adhere to the care plan for R17, leading to the deficiency. The DON and MDS Coordinator acknowledged that the care plan was not followed, which resulted in the resident receiving an incorrect oxygen level.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident with chronic obstructive pulmonary disease (COPD) and shortness of breath. The physician's order specified that the resident should receive oxygen at 2 liters per minute (L/M) continuously via nasal cannula. However, during an initial screening, the surveyor observed that the oxygen was set at 4.5 L/M. This discrepancy was confirmed by two Licensed Practical Nurses (LPNs) who were unaware of the correct oxygen setting as per the physician's order. The resident confirmed that she did not alter the oxygen settings herself, indicating that the staff failed to monitor and adjust the oxygen levels as required. Further interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the facility's policy and the resident's care plan both required the oxygen to be administered as ordered by the physician. The DON acknowledged that failing to adhere to the prescribed oxygen levels could put the resident at risk of adverse reactions, especially given her COPD diagnosis. The MDS Coordinator also emphasized that nurses are expected to follow the physician's orders and the resident's care plan, which was not done in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pineview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinewood Healthcare Center | 12.1 mi | ★★★★★ | 15 | 0 |
| Abbeville Crossing Of Journey Llc | 13.8 mi | ★★★★★ | 0 | 0 |
| Crisp Regional Nsg & Rehab Ctr | 18.6 mi | ★★★★★ | 14 | 0 |
| Cordele Health And Rehabilitation | 18.9 mi | ★★★★★ | 0 | 0 |
| Heart Of Georgia Nursing Home | 19.3 mi | ★★★★★ | 7 | 0 |
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