Winchester, IN

Pineknoll Rehabilitation Centre

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

160 N Middle School Rd, Winchester, IN

(765) 584-5084

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

58

Certified beds

Average residents

55

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Hcf Management Indiana

Operator or chain grouping

Approved since

1994-06-30

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

6 facilities

Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.69

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.87

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.88

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.91

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.27

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.64

CMS adjusted RN staffing hours

Adjusted total hours

3.59

CMS adjusted total nurse staffing hours

Case-mix index

1.48

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

29%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,720

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.22

Composite VBP score used to determine payment impact.

Payment multiplier

0.9889

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.60% · Performance 22.30% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.88

Baseline 7.26% · Performance 6.08% · Measure score 5.88 · Achievement 5.88 · Improvement 4.72

Total nurse turnover

6.52

Baseline 25.00% · Performance 37.04% · Measure score 6.52 · Achievement 6.52 · Improvement 0

Adjusted total nurse staffing

1.69

Baseline 2.69 hours · Performance 3.37 hours · Measure score 1.69 · Achievement 1.01 · Improvement 1.69

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.54%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 110 · Observed rate 13.64% · Lower 95% interval 8.91%
Discharge to community	56.71%	50.57% 6.1 pts better	No Different than the National Rate · Eligible stays 100 · Observed rate 53% · Lower 95% interval 44.68%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 89 · Denominator 89
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 89
Discharge self-care score	53.03%	53.69% 0.7 pts worse	Numerator 35 · Denominator 66
Discharge mobility score	66.67%	50.94% 15.7 pts better	Numerator 44 · Denominator 66
Pressure ulcers or injuries, new or worsened	3.37%	2.29% 1.1 pts worse	Numerator 3 · Denominator 89 · Adjusted rate 2.8%
Healthcare-associated infections requiring hospitalization	6.08%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 64 · Observed rate 3.13% · Lower 95% interval 3.04%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 93
Staff flu vaccination coverage	25.77%	42% 16.2 pts worse	Numerator 25 · Denominator 97
Discharge function score	62.12%	56.45% 5.7 pts better	Numerator 41 · Denominator 66
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 57 · Denominator 57
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	41.82%	25.2% 16.6 pts better	Numerator 23 · Denominator 55

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	1.6 0.3 pts worse	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.5 0.2 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	93.6% 6.4 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.4% 4.6 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.8% 3.8 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	14.5%	24.6% 10.1 pts better	11.4% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 14.3% · Q3 18.4% · Q4 12.5% · 4Q avg 14.5%
Percentage of long-stay residents who lose too much weight	11.0%	5.6% 5.4 pts worse	5.4% 5.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 19.4% · Q3 12.8% · Q4 2.6% · 4Q avg 11.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.3%	23.5% 3.2 pts better	19.6% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.4% · Q3 20.5% · Q4 19.5% · 4Q avg 20.3%
Percentage of long-stay residents who received an antipsychotic medication	0.8%	14.8% 14 pts better	16.7% 15.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	29.0%	13.3% 15.7 pts worse	16.3% 12.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 29.3% · 4Q avg 29.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.3%	11.7% 15.6 pts worse	14.9% 12.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 47.2% · Q3 17.9% · Q4 23.1% · 4Q avg 27.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.4% 0.1 pts worse	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	5.1%	1.2% 3.9 pts worse	1.7% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 11.6% · Q3 4.7% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	31.9%	24.2% 7.7 pts worse	19.8% 12.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 38.7% · Q3 36.8% · Q4 30.1% · 4Q avg 31.9%
Percentage of long-stay residents with pressure ulcers	3.2%	4.1% 0.9 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.7% · Q3 2.9% · Q4 1.9% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	81.6% 18.4 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	3.0%	10.5% 7.5 pts better	12.0% 9 pts better	Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 2.7% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.5%	1.3% 0.2 pts worse	1.6% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 2.7% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.3%	79.0% 19.3 pts better	79.7% 18.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.0%	22.4% 10.6 pts worse	23.9% 9.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 31.5% · Expected 22.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-27 · Fire 2025-05-27

2 health deficiencies

Top issue: Administration (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-04-19 · Fire 2024-04-19

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-02-20 · Fire 2023-02-20

5 health deficiencies

Top issue: Infection Control (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-05-27

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-05-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-05-27

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-07-18

E · Potential for more than minimal harm 2024-04-19

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-05-20

C · Minimal harm 2024-04-19

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-20

F · Potential for more than minimal harm 2023-02-20

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-03-21

E · Potential for more than minimal harm 2023-02-20

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-03-21

E · Potential for more than minimal harm 2023-02-20

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2023-03-21

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-27

F839 · Administration Deficiencies

Health

Employ staff that are licensed, certified, or registered in accordance with state laws.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-05-27

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-06-20

F · Potential for more than minimal harm 2024-04-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-04

E · Potential for more than minimal harm 2023-02-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-13

E · Potential for more than minimal harm 2023-02-20

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-20

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-20

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-03-13

Penalties and ownership

What sits behind the stars

Ownership

Witham Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 29 facilities 2011-12-01

Bayston, Brett