Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Pine Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that several residents receiving oxygen therapy did not have required cautionary signage posted, and in one instance, a resident had two conflicting active oxygen orders documented and administered. Additionally, an unsecured oxygen tank was observed in a resident's room without proper signage. Staff and leadership interviews confirmed expectations for signage and order management were not met, and audits failed to identify these ongoing issues.
A resident with a history of CHF, CAD, and hypertension received blood pressure medications despite physician orders to hold them for low blood pressure readings. Medication administration records and staff interviews confirmed that Amlodipine, Isosorbide Mononitrate ER, and Carvedilol were administered outside of the prescribed parameters, with staff acknowledging the oversight. The Medical Director and facility leadership confirmed that orders were not followed as written.
A nurse administered the wrong dosage of Lyrica to a resident with severe cognitive impairment, giving a 100 mg dose intended for another resident instead of the prescribed 25 mg. The error was discovered during a narcotic count, and the nurse admitted to not checking the medication label before administration. The affected resident was assessed and showed no adverse effects.
A resident with a chronic foot ulcer did not receive daily wound care as ordered by the physician over a weekend. Although the Treatment Administration Record indicated the treatment was completed, interviews with the resident and staff confirmed the dressing was not changed and the assigned nurse overlooked the treatment. The DON and wound nurse were notified after the lapse was discovered.
A resident with a history of wandering and severe cognitive impairment entered another resident's room and bed during a period of indirect supervision. The incident occurred when staff were assisting another resident, and the wandering resident was not directly observed. This led to a physical altercation, resulting in a nasal fracture for the other resident, who also had severe cognitive impairment and required assistance with ADLs.
The facility did not provide written notifications to residents or their responsible parties regarding hospital transfers, relying instead on phone calls and sending documentation only with the resident. Additionally, a resident discharged home did not receive a discharge summary, and staff were unclear about who was responsible for this documentation.
Two residents experienced deficiencies in medical record accuracy: one had conflicting active orders for oxygen therapy, with staff documenting administration for both rates despite only one being used, and another did not receive ordered wound care, yet the MAR was inaccurately completed by a nurse who did not perform the treatment.
The facility failed to properly manage and store medications on the 200 Hall Medication Cart and in the 100/200/300 Hall Medication Storeroom. Observations revealed expired medications, undated vials, and improper storage of single-use and refrigerated medications. Nurse #1 and the DON confirmed these findings and acknowledged the need for proper dating, discarding expired medications, and notifying the pharmacy for replacements.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in areas such as resident rights, care planning, and maintaining a clean environment. Specific incidents included a nurse speaking to a resident in a demeaning tone, residents not being invited to care plan meetings, and unclean conditions with overflowing garbage. The facility also failed to develop comprehensive care plans for residents' nutritional needs and discharge plans.
A nurse spoke to a resident in a loud and demeaning tone, telling her to get back in her room and stop stalking her. The resident felt embarrassed and humiliated, and the incident was confirmed by another nurse and a surveyor. The nurse received a final written warning for her unprofessional behavior.
The facility failed to offer two residents and one family member the opportunity to participate in care plan meetings. One resident had not been invited to or participated in any care plan meetings for over a year, while another had not attended any meetings since her admission. A third resident, who was severely cognitively impaired, had not had a formal care plan meeting since February 2023.
The facility failed to develop comprehensive nutrition care plans for two residents, leading to significant weight loss. Despite recommendations from the RD, the Dietary Manager did not update the care plans, resulting in a lack of nutritional interventions.
The facility failed to limit the duration of PRN psychotropic medications to 14 days and did not provide a rationale for extending the orders for two residents. Both residents had active PRN lorazepam orders without a stop date, and no doses were documented as administered. The consultant pharmacist and DON acknowledged the oversight.
The facility failed to provide consents with the benefits and risks of receiving the influenza vaccine for two residents. One resident did not receive the vaccine at the Responsible Party's request, and another was not offered the vaccine due to issues with obtaining consent from family members. Both residents were severely cognitively impaired.
The facility failed to maintain walls and a door in good repair in three rooms on the 100-hall. Observations revealed gouged drywall, a broken bathroom door, and separated baseboard molding. The Maintenance Director acknowledged the need for repairs and prioritized safety-related issues.
Failure to Ensure Safe and Appropriate Oxygen Therapy Practices
Penalty
Summary
Surveyors identified multiple deficiencies related to the provision of safe and appropriate respiratory care for residents requiring supplemental oxygen. Several residents with physician orders for oxygen therapy were observed receiving oxygen via nasal cannula, but there were no cautionary oxygen signs posted either outside or inside their rooms. Staff interviews confirmed that signage was expected but not present, and both the DON and Administrator were unaware of the missing signs despite recent audits intended to ensure compliance. In one case, a resident had two active physician orders for different oxygen flow rates (2 L/min and 3 L/min) simultaneously, and both orders were being documented as administered on the MAR. The nurse responsible for entering the new order acknowledged that the previous order should have been discontinued but was not, resulting in conflicting active orders. The Medical Director, DON, and Administrator all confirmed that the previous order should have been discontinued when the new order was received. Additionally, a resident's oxygen tank was found unsecured in the room, not placed in a holster or rack, and there was no oxygen signage present. Staff interviews revealed a lack of awareness regarding the unsecured tank and missing signage, despite expectations that all oxygen users have appropriate signs posted and equipment properly secured. These findings were based on direct observations, record reviews, and staff interviews.
Failure to Hold Blood Pressure Medications per Physician Orders
Penalty
Summary
Nursing staff failed to follow physician orders regarding blood pressure medication administration for a resident with diagnoses including congestive heart failure, coronary artery disease, and hypertension. The resident had specific physician orders for Amlodipine, Isosorbide Mononitrate Extended Release, and Carvedilol, each with parameters to hold the medication if the resident's systolic or diastolic blood pressure fell below certain thresholds. Despite these orders, medication administration records showed that the resident received these medications on multiple occasions when their blood pressure readings were below the specified parameters. Interviews with medication aides and review of the medication administration record confirmed that the medications were given outside of the ordered parameters, with one aide acknowledging the administration as an oversight. The Medical Director stated that while a few doses outside parameters may not have caused serious harm, he expected staff to follow the written orders. The facility's Administrator and Director of Nursing also confirmed their expectation that staff adhere to medication hold parameters as ordered by the physician.
Medication Administration Error: Incorrect Lyrica Dosage Given
Penalty
Summary
A medication administration error occurred when a nurse failed to ensure the correct dosage of Lyrica was given to the correct resident. One resident with severely impaired cognition, who was prescribed Lyrica 25 mg twice daily, was instead given a 100 mg dose intended for another resident. The error was discovered during a narcotic count, which revealed that the 25 mg dose had not been removed from the correct resident's blister pack, while two 100 mg pills had been removed from the other resident's pack. The nurse involved could not recall if the correct medication was administered and admitted to not checking the medication label before giving the dose. The medication administration record indicated that the medication was provided, but did not note the error. The nurse self-reported the discrepancy after discovering it during the narcotic count and assessed the affected resident, who showed no adverse effects and maintained stable vital signs throughout the monitoring period. Interviews with facility staff, including the DON and Medical Director, confirmed the sequence of events and the nurse's failure to verify the medication label before administration. The incident involved two residents with different cognitive statuses and medication regimens, and the error was identified through routine medication count procedures rather than at the time of administration.
Failure to Provide Physician-Ordered Wound Care Treatment
Penalty
Summary
A deficiency occurred when a resident with a non-pressure chronic ulcer on the left foot did not receive wound care treatment as ordered by the physician. The resident's care plan identified multiple risk factors for skin breakdown, including peripheral vascular disease, diabetes, and mobility issues, and required daily cleansing and dressing of the affected toe. Despite these orders, the resident did not receive the prescribed wound care over a weekend, as confirmed by both the resident and the wound nurse. The Treatment Administration Record indicated that the treatment was documented as completed, but interviews revealed that the bandage had not been changed since the previous dressing by the wound nurse. The nurse assigned to the resident during the missed days acknowledged that the treatment was accidentally overlooked and not performed. The wound nurse and the DON were made aware of the missed treatments after discovering the unchanged bandage. The resident remained alert and oriented and was able to report the lapse in care. The facility's documentation and staff interviews confirmed that the physician's orders for wound care were not followed as required.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of wandering and severely impaired cognition entered another resident's room in the memory care unit. The wandering resident, who had previously been documented as entering other residents' beds, was not being directly supervised at the time. Staff had checked both residents approximately 15 minutes prior to the incident and found them asleep in their respective beds. During a period when staff were assisting another resident, the wandering resident entered the other resident's room, lay down in the bed, and was subsequently startled, resulting in physical contact that caused a nasal fracture to the other resident. The resident who sustained the injury had diagnoses including dementia, osteoporosis, and osteoarthritis, and was noted to be severely cognitively impaired, requiring limited assistance with most activities of daily living. This resident was not coded for behaviors or wandering on the Minimum Data Set (MDS) and had care plan interventions related to impaired memory and communication, but not for wandering or aggressive behaviors. The resident who wandered had a care plan that included interventions for wandering, such as documenting episodes, orienting the resident, and providing familiar objects, but was also not coded for wandering or behaviors on the MDS. The incident was discovered when the injured resident was found in the doorway, bleeding from the nose and mouth, and reported being hit by another resident. The staff member assigned to both residents responded immediately upon hearing the call for help. The investigation revealed that the wandering resident had a pattern of entering other residents' rooms and beds, and that staff did not witness the incident as it occurred during a lapse in direct supervision. The event resulted in a closed fracture of the nasal bone for the injured resident, who required hospital evaluation.
Failure to Provide Written Transfer Notices and Discharge Summaries
Penalty
Summary
The facility failed to provide written notification to residents or their responsible representatives regarding the reason for hospital transfers for multiple residents. In several documented cases, residents were transferred to the hospital for changes in condition such as stroke, feeding tube complications, vomiting, respiratory distress, and altered mental status. Although staff reported that a copy of the face sheet, medication administration record, DNR information, change in condition form, transfer form, and bed hold policy were sent with the resident to the hospital, there was no evidence in the medical records that written notices of transfer were provided to the residents or their responsible parties. Interviews with responsible parties confirmed that they were notified by phone but did not receive any written documentation regarding the transfers. Additionally, the facility did not provide a discharge summary or a recapitulation of the resident's stay to a resident who was discharged home. The responsible party for this resident reported not receiving a discharge summary, and staff interviews revealed a lack of clarity regarding who was responsible for completing this documentation. The social worker and DON were unaware of the requirement to complete and provide a discharge summary upon discharge. Staff interviews, including those with the unit manager, DON, administrator, and social worker, consistently indicated a lack of awareness of the regulatory requirement to provide written notices of transfer and discharge summaries to residents and their responsible parties. The documentation reviewed did not include any written notifications or summaries, and staff confirmed that their practice was to notify by phone only and send documentation with the resident to the hospital, but not to the responsible party.
Failure to Maintain Accurate Medical Records for Oxygen Therapy and Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, there were two active physician orders for oxygen therapy at different flow rates (2 liters and 3 liters per minute via nasal cannula), both of which remained active in the medical record. Medication administration records (MARs) reflected both orders, and staff documented administration for both, despite the resident only receiving oxygen at 2 liters per minute. The nurse responsible for entering the new order did not discontinue the previous order, and staff did not seek clarification about the conflicting orders. For another resident, wound care was not provided as ordered over a weekend, but the MAR was inaccurately documented to indicate that the treatment had been completed. The unit manager checked off the treatment as completed based on verbal confirmation from the assigned nurse, who later admitted to having overlooked the treatment. The resident confirmed that the wound dressing had not been changed as required, and the wound nurse verified that the same bandage was in place from a previous date. Documentation was completed by a nurse who did not perform the treatment, resulting in inaccurate medical records.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications on the 200 Hall Medication Cart and in the 100/200/300 Hall Medication Storeroom. Observations revealed multiple instances of expired medications, including Lantus insulin, Novolog insulin, Humalog insulin, and lidocaine solution, which were not discarded after their expiration dates. Additionally, some medications were not dated when opened, making it impossible to determine their shortened expiration dates. A single-dose vial of sterile water for injection was also found stored on the med cart after being opened, contrary to guidelines that it should be discarded after a single use. Furthermore, an unopened bottle of latanoprost eye drops was improperly stored at room temperature instead of being refrigerated as required by the manufacturer’s instructions. Nurse #1 confirmed these findings and acknowledged the need to contact the pharmacy for replacements and discard the improperly stored medications. The Director of Nursing (DON) expressed surprise at these findings, noting that the med carts had been inspected the previous week to ensure proper storage of medications. The DON also confirmed that nursing staff should have dated the vials of insulin, removed expired medications, and notified the pharmacy for replacements. Additionally, the DON stated that the single-use vial of sterile water should have been discarded immediately after its first use and that the unopened bottle of latanoprost eye drops should have been refrigerated until needed. In the 100/200/300 Hall Medication Storeroom, expired medications were also found, including acetaminophen suppositories, simethicone chew tablets, and Kaopectate medication. An opened multi-dose vial of Tuberculin PPD injectable solution was also found stored in the med room refrigerator beyond its 30-day use period. The DON confirmed that nursing staff should have dated everything as to when it was opened and discarded expired medications in accordance with the manufacturer's instructions. The hall nurses were responsible for checking the facility's stock medications in the Med Storeroom to ensure they were not expired.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeated deficiencies. These deficiencies were observed in areas such as Resident Rights/Exercise of Rights, Right to Participate in Planning Care, Develop/Implement Comprehensive Care Plan, and Safe/Clean/Comfortable/Homelike Environment. Specific incidents included a nurse speaking to a resident in a loud and demeaning tone, residents not being invited to care plan meetings, and the facility failing to maintain a clean environment with garbage observed in hallways and rooms. Additionally, the facility did not develop comprehensive care plans for residents' nutritional needs and discharge plans, as evidenced by record reviews and staff interviews. During the recertification and complaint surveys, it was found that the facility failed to treat residents with dignity, as seen in the case where a nurse's behavior made a resident feel embarrassed and humiliated. Other instances included residents not receiving timely incontinent care, leading to feelings of neglect and abandonment. The facility also failed to maintain a clean and homelike environment, with observations of overflowing garbage and unclean conditions. Furthermore, the facility did not involve residents in care planning meetings and failed to develop comprehensive care plans addressing specific needs such as nutrition and discharge planning. These repeated failures indicate the facility's inability to sustain an effective QAA program, as noted during interviews with the Administrator and other staff members.
Resident Dignity Violation
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by an incident involving a nurse and a resident. Nurse #2 spoke to Resident #17 in a loud and demeaning tone, telling her to get back in her room and stop stalking her. This interaction was overheard by a surveyor and another nurse, who confirmed the unprofessional and harsh manner in which Nurse #2 addressed the resident. Resident #17, who was cognitively intact and required substantial assistance with her activities of daily living, felt embarrassed and humiliated by the nurse's comments. She was waiting in the hallway for her pain medication and had not made any prior requests to the nurse before being spoken to in this manner. During interviews, Resident #17 expressed that she felt demeaned and treated like a child. Nurse #2 defended her actions by stating that she and the resident always spoke to each other in that manner and that the resident was waiting for her medications before a smoke break. The Director of Nursing confirmed that Nurse #2 received a final written warning due to her unprofessional language, and the Administrator documented the incident as a grievance. The facility emphasized that such behavior was not tolerated and that staff were expected to treat residents with dignity and respect.
Failure to Involve Residents and Family in Care Plan Meetings
Penalty
Summary
The facility failed to offer two residents and one family member the opportunity to participate in care plan meetings. Resident #47, who was cognitively intact and diagnosed with hemiplegia, had not been invited to or participated in any care plan meetings for over a year. The Social Worker (SW) responsible for scheduling these meetings could not provide documentation of Resident #47's participation since September 2022, despite the resident's most recent Minimum Data Set (MDS) being in January 2024. Similarly, Resident #49, who was also cognitively intact and diagnosed with secondary Parkinsonism, had not been invited to or attended any care plan meetings since her admission in June 2023. The SW confirmed that there was no documentation indicating Resident #49's participation in any care plan meetings since her admission. Resident #80, who was severely cognitively impaired and diagnosed with respiratory disease and dementia, had not had a formal care plan meeting since February 2023. Although the SW met informally with Resident #80's family member, no formal care plan meetings involving the interdisciplinary team were scheduled. The Administrator confirmed that Resident #80 should have had a scheduled care plan meeting every three months and that both the resident and the resident's representatives should have been invited. The SW acknowledged the oversight and the lack of formal documentation for these meetings.
Failure to Develop Comprehensive Nutrition Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan that included a focus on nutrition for two residents, leading to significant weight loss. Resident #90, who had diagnoses including cancer, dementia, and Type 2 diabetes, experienced a significant weight loss of 5.37% in one month. Despite recommendations from the Registered Dietitian (RD) to liberalize the diet and initiate a high-calorie supplement, the resident's care plan did not include any nutritional interventions. Interviews with staff revealed that the Dietary Manager was responsible for updating the care plans but had not done so for Resident #90. Similarly, Resident #75, who had a progressive neurological disease, seizure disorder, and dementia, also experienced significant weight loss. The resident required extensive assistance with eating and had increased nutritional needs. Despite these needs being documented by the RD, there was no care plan for nutrition in place. Staff interviews indicated that the Dietary Manager was again responsible for this oversight. Interviews with various staff members, including the MDS Nurse, the facility's Regional Dietary Consultant, and the Director of Nursing (DON), confirmed that the Dietary Manager was expected to complete the nutrition care plans. However, it was apparent that the Dietary Manager may not have been aware of this responsibility, leading to the deficiencies in the care plans for both residents.
Failure to Limit Duration of PRN Psychotropic Medications
Penalty
Summary
The facility failed to limit the duration of psychotropic medications ordered on an as-needed (PRN) basis to 14 days and did not indicate the duration and rationale for extending the PRN order beyond 14 days. This deficiency was identified for two residents. Resident #71 had a physician's order for 0.5 mg lorazepam to be given three times daily for anxiousness and another order for 1 mg lorazepam intramuscularly every 12 hours as needed for agitation. Both orders continued as active without a stop date, and no doses of the PRN lorazepam were documented as administered. The facility's consultant pharmacist and Director of Nursing (DON) acknowledged the oversight, with the DON stating the PRN order was inadvertently left on the resident's current orders. Resident #73 had a physician's order for 1 mg lorazepam to be given sublingually every 4 hours as needed for end-of-life care, anxiety, and agitation, with an indefinite end date. The resident's medication administration records showed no doses of the PRN lorazepam were administered, and the controlled substance inventory confirmed that none of the tablets were removed. The consultant pharmacist and DON confirmed the issue, with the DON noting that PRN psychotropic medications should have a stop date, typically limited to 14 days or extended up to 90 days with a designated stop date.
Failure to Obtain Consent for Influenza Vaccine
Penalty
Summary
The facility failed to provide consents with the benefits and risks of receiving the influenza vaccine for two residents. Resident #64, who was admitted with diagnoses of dementia with anxiety and stroke, did not have a consent form for the influenza vaccine in their medical record for the last year. The Director of Nursing confirmed that the consent form, which should have been reviewed with the Responsible Party, was missing. Resident #64 did not receive the influenza vaccine at the Responsible Party's request. The Director of Nursing stated that the nursing staff should obtain a signed consent form or a verbal consent witnessed by two nurses if the resident is cognitively impaired and unable to give consent themselves. Similarly, Resident #80, who was admitted with diagnoses of respiratory disease and dementia with agitation, also did not have a consent form for the influenza vaccine in their medical record for the last year. The Director of Nursing acknowledged the absence of the consent form and mentioned issues with obtaining consent from family members of cognitively impaired residents. As a result, Resident #80 was not offered the influenza vaccine. The Administrator confirmed that both residents should have been provided with the benefits and risks of receiving the influenza vaccine and that family members should have been contacted for consent if the residents were not cognitively intact.
Facility Failed to Maintain Walls and Door in Good Repair
Penalty
Summary
The facility failed to maintain walls and a door in good repair in three of the fifteen rooms reviewed on the 100-hall. Specifically, room 111 B had gouged drywall to the left of the bathroom door and a broken section of the bathroom door. Room 114 B's bathroom had a vinyl baseboard molding that had separated from the wall. Room 115 A had a section of gouged drywall behind the head of the bed. These deficiencies were observed on multiple occasions over several days. During an interview, the Maintenance Director acknowledged the need for repairs and stated that he prioritized repairs impacting resident safety first. He used a web-based software to manage building tasks and work orders. The Administrator confirmed that the Maintenance Director was expected to prioritize safety-related repairs before attending to cosmetic issues.
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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 Thomasville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Gardens Center For Nursing And Rehabilita | 2.2 mi | ★★★★★ | 3 | 0 |
| Piedmont Crossing | 3.6 mi | ★★★★★ | 0 | 0 |
| Westchester Manor At Providence Place | 5.1 mi | ★★★★★ | 3 | 0 |
| Meridian Center | 6.9 mi | ★★★★★ | 9 | 2 |
| Abbotts Creek Center | 7.6 mi | ★★★★★ | 5 | 0 |
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