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On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 72 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare Special Focus status indicates a history of serious quality problems and heightened oversight. Review the latest inspection records, ask what corrective actions remain open, and visit in person before deciding.
Families considering Afton Oaks will find a significant divide in experiences, with many recent reviews praising a recent management turnaround and a warm, welcoming admissions process. However, there are serious, recurring allegations of medical neglect, bedsores, and poor hygiene that must be addressed directly with the administration during your visit.
Quality Themes
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Concerns
Rating Trends
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Distribution · 73 analyzed
The owner provides personalized responses that frequently use the reviewer's name and acknowledge specific staff members mentioned in the text. For negative reviews, they maintain a professional tone, expressing a desire to improve and providing specific contact information for resolution.
Personalized based on this facility's data
Key Review Excerpts
“The facility staff have been so helpful and caring. The administrator and the interim DON went out of their way to ensure all my questions were answered. The treatment nurse and ADON ensured I was comfortable and checked on me regularly.”
“My dad was released from here and we had to have him rushed to the hospital. He had bed sores, declined in so many ways, and we thought we were going to lose him.”
“Te'lorr has been extremely kind and supportive. You can tell that she truly cares about the residents and their families which speaks volumes about her character.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
8
measures
8
measures
1
measures
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families filed numerous complaints at this facility, triggering 30 of 45 total deficiencies across multiple surveys, with serious concerns about accident prevention recurring five times and remaining unresolved as of November 2025. The most problematic areas include resident safety and accident prevention, care planning and assessments, medication management, and protection from abuse and neglect, with issues persisting rather than being effectively corrected over time.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
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.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
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
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.
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.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Federal Penalties
Fine
Jan 14, 2026
$14,722
Fine
Oct 27, 2025
$70,400
Fine
Jul 11, 2025
$10,529
Fine
Sep 13, 2023
$19,861
Winniestowell Hospital District
for profit
DIVERSICARE AFTON OAKS LLC
CHANDRA WILTZ-GARRETT
Creative Solutions in Healthcare
149 facilities nationwide
Chain avg rating: 2.7/5 · Rank 118 of 148 (Lowest rating)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
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Google Reviews
72 reviews from families & visitors
Medicare data downloads
Original nursing home datasets
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