Pinewood Health And Rehabilitation
Pinewood Health and Rehabilitation in WHIGHAM, GA — inspection on August 20, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
investigation revealed that there was no evidence that R1 had refused to go to the ER.
The physician was informed that there was no documentation of R1 refusal.
The only refusal identified was R4, who declined a surgical repair for a fractured hip.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pinewood Health and Rehabilitation
433 North McGriff Street Whigham, GA 39897
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
previous fall on 5/15/2025.
She noticed that the resident had a knot on his head that was getting larger, and his head looked warped.
She stated that the Director of Nursing (DON) was aware of the knot.
She further stated that R1 was more confused. He had a fall in his room and was placed in his bed.
She stated she left the room to call the physician, returned to R1's room, saw him unresponsive, and sent him to the hospital via EMS services.In an interview on 8/5/2025 at 2:02 pm, Registered Nurse (RN) BB revealed the R1 fell on 5/15/2025.
She stated that the resident stood and tumbled while going into his room and fell backward.
His head hit the door as he was falling. In an interview on 8/6/2025 at 9:52 am, Certified Nurse Aide (CNA) DD revealed that before his fall with injury, R1 was able to go to the shower, dress, and feed himself. He was ambulatory with a walker and would place his clothes over the walker. He had a walker with wheels (rollator).
She stated that he was still his usual self and was not a bed person. CNA DD further stated that R1 changed after the fall and before he had the last fall.
She stated he started urinating on himself, had to be encouraged to come to the dining room, started taking off his clothes, and would sleep a lot, which were not his usual behaviors.
She stated that after the last fall, when he came back from the hospital, he was not talking, could not open his eyes, and was not eating. He was pretty much a vegetable. In an interview on 8/7/2025 at 1:24 pm, LPN II revealed that after a fall on 5/15/2025, R1 started needing some assistance with dressing and had some confusion. LPN II stated she was unable to recall if she conducted the neuro checks for R1 after the fall. In an interview on 8/11/2025 at 9:27 am. RN BB revealed that she witnessed the fall on 5/15/2025.
She stated she was in the hallway close to the resident's room.
She stated she called the physician about the fall and told him the resident seemed fine. In an interview on 8/11/2025 at 10:19 am, the physician revealed that he recalled RN BB calling him and telling him the R1 had fallen and that R1 refused to go to the emergency room (ER). He gave instructions to watch closely and was concerned about the resident not going to the ER.
The physician stated RN BB told him that neuro checks were started, but she did not tell him the resident was on Plavix. He stated he was not called about the resident showing signs of confusion. He stated his expectation was that residents are to go to the ER for a visible head injury, and if on an anticoagulant. He further stated that residents were to be monitored closely and that documentation was to be completed. In an interview on 8/11/2025 at 2:01 pm, RN WW, Interim DON, and RN XX, newly hired DON, confirmed R1 was on Plavix and sustained a head injury.
The nurse should have informed the physician that the resident received Plavix, neurological checks should have been assessed for differences, and R1 monitored for changes.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pinewood Health and Rehabilitation
433 North McGriff Street Whigham, GA 39897
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
not called about the R1 showing signs of confusion.
The Physician further revealed that he read the nurse's note for [DATE], and his expectation that residents on an anticoagulant with a visible head injury should be monitored and taken to the ER for evaluation.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pinewood Health and Rehabilitation
433 North McGriff Street Whigham, GA 39897
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review, staff and resident interviews, and review of the facility policy titled Documentation in Medical Record, the facility failed to ensure the medical record documentation was complete and accurate for one of 10 sampled residents (R) (R5).
Specifically, staff documented the presence of maggots between the left great toe and the second toe for R5.Findings include:
Review of the facility policy titled Documentation in Medical Record, dated 1/13/2025, revealed: Policy Explanation and Compliance Guidelines: 4.
Principles of documentation include, but are not limited to: a.
Documentation shall be factual, objective, and resident-centered.
Review of the admission record revealed that R5 was admitted to the facility with diagnoses including, but not limited to, type 2 diabetes mellitus, unspecified dementia, peripheral vascular disease, and severe morbid obesity.
Review of the 6/30/2025 Wound Care Physician note indicated the resident had a wound to the left medial leg that was being treated with medical-grade honey and a two-layer compression wrap every Monday, Wednesday, and Thursday.
Review of the 7/2/2025 Wound Care Physician note indicated the order was changed to cleanse with wound cleanser, pat dry, apply collagen, and cover with ABD [abdominal] pad every Monday, Wednesday, and Thursday.Review of the 7/17/2025 progress notes documented the Wound Care Nurse and the Wound Care Nurse Practitioner (NP) were in the resident's room for weekly rounds. It was noted the left foot was noted to have non-skin abnormalities.
There was no redness or open areas noted.
The Physician and the Director of Nursing were notified.
Review of the Physician's Order for R5 revealed an order dated 7/17/2025 to cleanse the left foot with normal saline, pat dry, soak in Dakin's solution for five to ten minutes, pat dry, apply calcium alginate to left foot digits, and apply nystatin powder.
Remove calcium alginate in the am.
One-time, only for one day order.
During an interview with Registered Nurse (RN) EE on 7/23/2025 at 3:37 pm, she stated that she had seen maggots between the resident's left foot toes.
She stated that there was no open area between her toes.
She stated there were about 10 maggots for about two to three days.
She also stated she did not document the maggots on the resident's foot because she was instructed not to write maggots in her documentation.
During an interview with the NP Wound Consultant on 8/5/2025 at 10:55 am, she stated the resident had maggots between the toes, and she did not document the maggots in her report because the maggots were not in the wounds.
She stated she was seeing the resident for wounds.
During an interview with RN BB on 8/5/2025 at 11:08 am, she stated that the Wound Care NP told her that the resident had maggots between her toes and feet.
The Wound Care NP asked her if she had seen the maggots.
She stated that if she had seen the maggots, she would have documented that in the resident's chart.During an interview with Licensed Practical Nurse (LPN) GG on 8/5/2025 at 12:39 pm, she stated the maggots were in the resident's left toes and that she was standing near RN BB and RN EE and overheard the conversation about the resident having maggots.
Facility ID: