Afton Oaks Nursing And Rehabilitation Center

Penalties

• Jan 14, 2026 — Fine ($14,722)
• Oct 27, 2025 — Fine ($45,760)
• Jul 11, 2025 — Fine ($10,529)
• Sep 13, 2023 — Fine ($19,861)

Inspection findings

1. Jan 14, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

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

     CMS health inspection

2. Nov 21, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Nov 22, 2025 · CMS health inspection

3. Oct 27, 2025 Health · 10 findings
   • Not serious Scope/severity D Complaint

     F0551 Resident Rights Deficiencies

     Give the resident's representative the ability to exercise the resident's rights.

     Corrected Oct 28, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0580 Resident Rights Deficiencies

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

     Corrected Oct 28, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Oct 28, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Oct 28, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Oct 28, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Oct 28, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Oct 28, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Oct 28, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Oct 28, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Oct 28, 2025 · CMS health inspection

4. Jul 11, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     CMS health inspection

5. Apr 9, 2025 Health · 9 findings
   • Not serious Scope/severity D

     F0637 Resident Assessment and Care Planning Deficiencies

     Assess the resident when there is a significant change in condition

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 30, 2025 · CMS fire safety

6. Apr 1, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Apr 7, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 7, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Apr 7, 2025 · CMS health inspection

7. Mar 13, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 7, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 7, 2025 · CMS health inspection

8. Nov 27, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 6, 2024 · CMS health inspection

9. Nov 14, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Dec 4, 2024 · CMS health inspection

10. Feb 7, 2024 Fire Safety · 2 findings
    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Feb 23, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Feb 23, 2024 · CMS fire safety

11. Sep 13, 2023 Health · 6 findings
    • Serious Scope/severity J Complaint

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Develop and implement policies and procedures to prevent abuse, neglect, and theft.

      Corrected Oct 5, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Oct 5, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Oct 5, 2023 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Oct 5, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0689 Quality of Life and Care Deficiencies

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

      Corrected Oct 5, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0835 Administration Deficiencies

      Administer the facility in a manner that enables it to use its resources effectively and efficiently.

      Corrected Oct 5, 2023 · CMS health inspection

12. Nov 10, 2022 Health · 6 findings
    • Not serious Scope/severity D

      F0636 Resident Assessment and Care Planning Deficiencies

      Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

      Corrected Dec 9, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Dec 9, 2022 · CMS health inspection

    • Not serious Scope/severity D

      K0222 Egress Deficiencies

      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 Dec 6, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Dec 27, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Dec 9, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0374 Smoke Deficiencies

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

      Corrected Dec 6, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• BODIE, REBECCA — operational/managerial control, NOT APPLICABLE, since 09/01/2024
• GARRETT, CHANDRA — adp of the snf, NOT APPLICABLE, since 07/29/2025
• GARRETT, CHANDRA — operational/managerial control, NOT APPLICABLE, since 09/01/2024
• JIAN, PETER — operational/managerial control, NOT APPLICABLE, since 01/20/2025
• JIAN, PETER — adp of the snf, NOT APPLICABLE, since 07/29/2025
• MURRELL, EDWARD — corporate director, NOT APPLICABLE, since 09/01/2024
• NEE, STEPHEN — operational/managerial control, NOT APPLICABLE, since 09/01/2024
• ROLLO, JEFFERY — corporate director, NOT APPLICABLE, since 09/01/2024
• STRAMECKI, ANTHONY — corporate director, NOT APPLICABLE, since 09/01/2024
• VRATIS, KACEY — corporate director, NOT APPLICABLE, since 09/01/2024
• WAY, GEORGE — corporate director, NOT APPLICABLE, since 09/01/2024
• WEISHAAR, MATTHEW — operational/managerial control, NOT APPLICABLE, since 09/01/2024
• DIVERSICARE AFTON OAKS, LLC — operational/managerial control, NOT APPLICABLE, since 09/01/2024
• JOURNEY MEDICAL PLLC — operational/managerial control, NOT APPLICABLE, since 01/20/2025
• WINNIE-STOWELL HOSPITAL DISTRICT — operational/managerial control, NOT APPLICABLE, since 09/01/2024