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

Staffing

Hours and turnover

RN hours / resident day

0.69

Registered nurse staffing

LPN hours / resident day

0.87

Licensed practical nurse staffing

Aide hours / resident day

2.32

Nurse aide staffing

Weekend hours

2.91

Weekend nurse staffing

RN turnover

29%

Annual RN turnover

Total nurse turnover

29%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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