Inspection Report

Pinewood Health and Rehab: Immediate Jeopardy Fall Failure - GA

July 3, 2026

Whigham, GA

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The nurse who called his doctor after his fall never mentioned he was on Plavix.

The resident, identified in inspection records only as R1, fell on May 15, 2025, at Pinewood Health and Rehabilitation, a nursing facility on North McGriff Street in this small southwest Georgia town. A registered nurse named BB was in the hallway when it happened. She watched him stand, tumble, and fall backward, his head striking the door on the way down.

She called the physician. She told him the resident seemed fine. She told him neuro checks had been started. She did not tell him the resident was on Plavix, a blood-thinning medication that dramatically raises the risk of internal bleeding after a head injury.

The physician, interviewed by inspectors on August 11, remembered the call clearly. He said he was already concerned that R1 was refusing to go to the emergency room. He gave instructions to watch the resident closely. His expectation, he told inspectors, was that any resident with a visible head injury goes to the ER, and any resident on an anticoagulant goes to the ER. He was never called about the confusion that followed.

The confusion came quickly. A certified nurse aide named DD, who had known R1 well enough to describe his habits in detail, watched him change in the weeks after the fall. He started urinating on himself. He had to be coaxed to come to the dining room. He began taking his clothes off. He slept constantly. None of that, DD told inspectors, was like him.

An LPN identified as LPN II told inspectors she noticed R1 needed help dressing after the fall and showed some confusion. When asked whether she had conducted neurological checks on him after the May 15 incident, she said she could not recall.

Then came another fall. A nurse, not further identified in the inspection records, found him in his room with a knot on his head that was growing larger. His head, she said, looked warped. She told inspectors the Director of Nursing was aware of the knot. R1 was more confused. He fell again in his room and was put to bed. She left to call the physician. When she came back, he was unresponsive. EMS took him to the hospital.

He came back, DD told inspectors, as someone unrecognizable. "He was not talking, could not open his eyes, and was not eating," she said. "He was pretty much a vegetable."

The interim Director of Nursing and the newly hired Director of Nursing both confirmed to inspectors on August 11 what the physician had already said: the nurse should have told the doctor about the Plavix. Neurological checks should have tracked changes over time. R1 should have been monitored and the findings documented.

Federal inspectors who reviewed the case rated the violation at Immediate Jeopardy, the most serious classification available, meaning the failure created a situation likely to cause serious injury or death.

Before May 15, R1 was, by every account in the inspection record, a man who took care of himself. He went to the shower. He dressed. He fed himself. He walked the hallways with his rollator, clothes folded over the frame.

What the inspection record does not say is what he is now.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Pinewood Health and Rehabilitation from 2025-08-20 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: July 3, 2026 · Our methodology

Quick Answer

Pinewood Health and Rehabilitation in WHIGHAM, GA was cited for immediate jeopardy violations during a health inspection on August 20, 2025.

The nurse who called his doctor after his fall never mentioned he was on Plavix.

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.

Frequently Asked Questions

What happened at Pinewood Health and Rehabilitation?

The nurse who called his doctor after his fall never mentioned he was on Plavix.

How serious are these violations?

These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WHIGHAM, GA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Pinewood Health and Rehabilitation or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 115607.

Has this facility had violations before?

To check Pinewood Health and Rehabilitation's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.