Pinewood Healthcare Center: Injury Unreported for Days - GA
The resident is identified in inspection records only as R5. On the morning of March 3, 2025, CNA FF spotted the bruise on top of R5's foot and reported it to two nurses: the charge nurse, LPN EE, and the wound nurse, LPN GG.
LPN GG told inspectors she saw the bruise that Monday and described it as roughly the size of a quarter. When she checked again the following morning, March 4, the foot had swollen and the bruise had grown significantly. She contacted the physician, who ordered a mobile x-ray. She then reported the injury to the charge nurse and to the Director of Nursing.
That should have triggered a chain of events. It didn't.
The administrator told inspectors on March 7 that the facility's protocol for injuries of unknown origin required an incident report, a reportable event to the state, and a full investigation if the cause couldn't be determined. She laid out the chain of command precisely: aide to charge nurse, charge nurse to Director of Nursing, Director of Nursing to administrator. If the origin remained unknown, an investigation report was completed.
Then she confirmed that none of that happened. R5's injury was not reported to her on March 4, as it should have been. No investigation had been initiated.
The Director of Nursing confirmed the same gap. She told inspectors the injury should have been reported the morning the x-ray was ordered, and acknowledged it wasn't. When asked whether an investigation had started, she said she had begun one, but nothing had been documented yet.
Nothing documented. No report filed. No administrator notified. A resident's foot swollen enough to require emergency imaging, and the facility's own required response had not happened by the time inspectors were already in the building asking questions.
The inspection report classifies the harm level as minimal, with few residents affected. That classification reflects what inspectors could measure. What it doesn't capture is the purpose the reporting requirement exists to serve in the first place. When a nursing home resident develops a bruise of unknown origin that worsens overnight, the question of how it happened matters. Falls go undocumented. Rough handling goes unwitnessed. Injuries appear and, without investigation, disappear into the record as simply unknown.
The administrator described the protocol in careful detail to inspectors, which means the expectation was not ambiguous. The charge nurse who received CNA FF's report on Monday morning knew what an injury of unknown origin required. LPN GG, who watched the bruise grow and ordered the x-ray, knew. The Director of Nursing knew. The administrator knew. The process existed. It just didn't happen.
CNA FF did what he was supposed to do. He found the bruise, and he told the nurses above him before the start of his shift on March 3. What happened after that, at every level above him, is what inspectors documented.
By March 7, when inspectors were conducting interviews, R5's foot had already been x-rayed three days earlier. Whether the x-ray showed a fracture, a soft tissue injury, or something else is not recorded in the inspection narrative. What the record does show is that a resident was hurt in a way nobody could explain, and the people responsible for finding out what happened had not yet written a single word about it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinewood Healthcare Center from 2025-03-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 5, 2026 · Our methodology
Pinewood Healthcare Center in HAWKINSVILLE, GA was cited for violations during a health inspection on March 14, 2025.
The resident is identified in inspection records only as R5.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.