WHIGHAM, Ga. (WALB) — Federal inspection reports obtained by WALB Investigates describe years of serious violations at Pinewood Health and Rehabilitation, including three separate findings of “immediate jeopardy”, which is the most severe citation federal regulators can issue.

Immediate jeopardy means the facility’s noncompliance caused or was likely to cause serious injury, harm, impairment or death to residents, according to the Centers for Medicare & Medicaid Services (CMS).

WALB reviewed CMS Statements of Deficiencies for Pinewood Health and Rehabilitation at 433 N. McGriff St. in Whigham:

• Aug. 19, 2024 survey: Immediate jeopardy for failure to protect residents from abuse, failure to timely report abuse, failure to investigate, and failure of administration (F600, F609, F610, F835)
• March 10, 2026 complaint inspection: Immediate jeopardy for failure to provide physician-ordered care, notify physicians of change, and keep residents free from accident hazards (F600, F656, F689, F835)
• 2025 survey: Immediate jeopardy for failure to prevent accidents/supervision after falls resulting in death, nurse competency and administration failures (F689, F726, F835)

The facility was fined $205,861.

Lower-level deficiencies were also cited for pressure-ulcer care, infection control, food safety, resident rights and a homelike environment.

2024: Resident-to-resident sexual abuse, delayed reporting

The August 2024 report centers on a July 7, 2024, incident of resident-to-resident sexual abuse involving two residents identified as R4 and R5.

Surveyors found the facility:

• Failed to conduct a timely investigation and implement protective measures
• Failed to report the allegation to the state survey agency within the required 2-hour window
• Submitted an initial state report with inaccurate information
• Failed to timely report extensive bruising on another resident, R8, found July 14, 2024. The report was not made to the state until July 15. R8 was sent to the hospital July 15 and later transferred to another facility.

The report also cites failures to notify a physician of R8’s bruising which is described as purple bruising from the right breast to the hip and around the back and failures in medical records and infection control during wound care.

Surveyors wrote that the administrator knew of the July 7 incident that day but a full investigation did not begin immediately as required.

The immediacy was later removed after the facility submitted a removal plan, including 1-to-1 monitoring, room moves, head-to-toe skin checks on all 60 residents, behavior monitoring, and re-education of 98% of staff on abuse reporting, according to the report.

2026 complaint: Foley catheter emergency, blood clots, ICU

The March 10, 2026, complaint inspection describes a Foley catheter case that sent a resident to intensive care.

According to surveyors:

• An LPN inserted a Foley catheter for R1 at end of day shift and noted bleeding in the tubing, then irrigated the catheter with sterile water without a physician order.
• Evening staff reported no urine output and blood in the drainage bag. The nurse did not notify the physician.
• The Foley was removed without a physician order. Upon removal, R1 began bleeding from the penis and rectum, with altered mental status and loss of consciousness.

EMS was called at 8:26 p.m. and arrived at 8:45 p.m. to find R1 on 15 liters of oxygen, responsive. During transfer, R1 became unresponsive and went into respiratory arrest, vomiting, bleeding profusely with clots, requiring suctioning and bag-valve-mask ventilation en route to the ER, the report states.

Hospital records show R1, with a history of paraplegia, presented with respiratory distress after the Foley placement and removal the same day, was transferred to a second hospital in critical condition, admitted to ICU, intubated and ventilated on multiple vasoactive drips.

Surveyors cited the facility for failing to provide care per physician orders and failing to timely notify the physician of a significant change — an immediate jeopardy.

2025: Fall death on blood thinner, missed neuro checks

A separate 2025 survey cites Pinewood after a resident with multiple prior falls who was taking Plavix daily had inaccurate and incomplete neurological checks after a fall, then fell again, sustaining an acute bilateral tentorial subdural hemorrhage with midline shift.

The resident died. Immediate cause of death was determined to be subdural hematoma, according to the report.

Surveyors cited failure to ensure accurate neuro checks for head injury, failure to ensure nurses had competency to assess head injury, and administration failure. Census was 60.

Other violations: Wounds, food, bathrooms, trash

• Pressure ulcers: Both the 2024 and February 2025 reports cite failure to provide wound-physician-ordered pressure ulcer treatments, including a heel deep-tissue injury that declined to Stage 4 and a skin-substitute graft case where secondary dressing instructions were not followed.
• December 2023: Surveyors cited dirty, odorous bathrooms on 300 Hall — brown buildup around toilets, missing tiles, lifting flooring, holes in walls, rust, missing caulk-affecting “some” of 64 residents. Minimal harm.
• February 2025: Minimal-harm citations for food procurement/kitchen, ADL care, care plans, lab services, arbitration and medical records.
• June 3, 2026, health inspection: Minimal-harm citation for leaving a dumpster lid open on three separate days, creating pest risk.

Facility response

WALB provided Pinewood’s current administration a detailed summary of the findings and the former worker’s allegations and requested an interview.

The facility provided this statement:

“The event that was determined by CMS as deficient practice was prior to the hiring of the current Administration, however a plan of correction was submitted and approved by CMS along with a revisit to the facility in which the facility was placed back into compliance with Federal and State Standards. It is in the utmost interest of the employees to ensure we maintain compliance & meet or exceed the standards of care for those we serve.”

The statements provided by a former employee describe her personal opinions and alleged experiences during a brief period of employment. While we respect the right of current and former employees to raise concerns, we cannot comment on specific residents or potential resident situations due to federal privacy laws and our obligation to protect resident confidentiality. However, we would like to state that there are programs and policies in place for any staff member to anonymously file complaints/grievances they have, and we have not received any related to the allegations brought forth from any employee.

Whenever concerns are identified through surveys, inspections, employee reports, resident grievances, or quality assurance reviews, they are thoroughly investigated and addressed through established corrective action processes. We encourage staff, residents, families, and visitors to report concerns so they can be promptly reviewed and resolved.

Pinewood Health and Rehabilitation is committed to providing safe, compassionate, and high-quality care to every resident we serve as well as providing a homelike environment. Our facility is subject to ongoing oversight by state and federal regulatory agencies, and we continuously evaluate our operations to ensure compliance with all applicable healthcare regulations and standards. Pinewood Health and Rehab utilizes a multidisciplinary approach to resident care. The residents are supported by an interdisciplinary team, including medical providers who round routinely throughout the week. This collaborative approach helps ensure residents’ physical, emotional, clinical, and psychosocial needs are continually assessed and addressed.

We are proud of the work our caregivers, nurses, therapists, support staff, and leadership team perform every day to care for our residents. While no healthcare organization is perfect, we remain committed to continuous improvement and to maintaining an environment that supports the health, dignity, and well-being of those entrusted to our care.

We understand that Pinewood has had its past challenges, under previous administration and ownership. The current company, administration, and leadership team are committed to changing that narrative through accountability, transparency, and a relentless focus on resident care. While we acknowledge there is always room for improvement, we are proud of the progress that has been made and remain dedicated to building a facility that our residents, families, employees, and community can be proud of.

Pinewood Health and Rehabilitation holds all employees accountable to established standards of care, professionalism, and regulatory compliance. We are committed to fostering a culture of accountability and do not tolerate conduct, performance deficiencies, or practices that place residents, visitors, or fellow staff members at risk. When concerns regarding employee performance are identified, they are thoroughly investigated and addressed through appropriate corrective action processes, including disciplinary action when warranted. Pinewood Health and Rehab provides ongoing education, supervision, performance monitoring, and accountability measures. We strive to ensure that every employee upholds the high standards expected of those entrusted with the care of our residents

This commitment helps ensure that residents receive safe, respectful, and quality care from every member of our team. The forementioned employee was terminated in August 2026. The facility had a regulatory compliance survey in September 2026, in which they were founded to be in compliance.

To provide context for your reporting, we are also furnishing our most recent survey information and compliance documentation for review.

Thank you for the opportunity to respond.

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