Pinewood Health and Rehabilitation at 433 N. McGriff St. in Whigham has faced years of serious federal violations, including three citations for “immediate jeopardy,” the most severe warning issued by federal regulators. According to the Centers for Medicare & Medicaid Services (CMS), an “immediate jeopardy” finding means a facility’s noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents. These findings, detailed in federal inspection reports, stem from incidents including resident-to-resident sexual abuse, a patient’s death following a fall, and a critical medical emergency related to a Foley catheter.
An August 2024 report describes a July 7, 2024, incident of resident-to-resident sexual abuse involving two residents, identified as R4 and R5. Federal surveyors found that the facility’s administrator was aware of the incident on the same day but did not begin a full investigation immediately, as required. The report also cited failures to notify a physician about a resident, R8, who had purple bruising extending from the right breast to the hip and around the back. Additionally, issues with medical records and infection control during wound care were noted. The “immediate jeopardy” status related to this incident was later removed after Pinewood Health and Rehabilitation submitted a removal plan to CMS. This plan included implementing 1-to-1 monitoring for residents, moving residents to different rooms, conducting head-to-toe skin checks on all 60 residents, monitoring resident behavior, and re-educating 98% of staff on abuse reporting procedures, according to the report.
Another “immediate jeopardy” citation arose from a March 10, 2026, complaint inspection concerning a Foley catheter case that led to a resident being sent to intensive care. Emergency Medical Services (EMS) were called at 8:26 p.m. and arrived at 8:45 p.m., finding the resident, identified as R1, responsive and on 15 liters of oxygen. During the transfer to the emergency room, R1 became unresponsive, experienced respiratory arrest, and began vomiting and bleeding profusely with clots, requiring suctioning and bag-valve-mask ventilation en route, the report states. Hospital records reviewed by surveyors indicated R1, who had a history of paraplegia, presented with respiratory distress after Foley catheter placement and removal on the same day. R1 was transferred to a second hospital in critical condition, admitted to the Intensive Care Unit, intubated, ventilated, and placed on multiple vasoactive drips. Surveyors cited the facility for failing to provide care according to physician orders and for failing to timely notify the physician of a significant change in the resident’s condition.
A separate 2025 survey by federal regulators cited Pinewood after a resident died following two falls. This resident, who had a history of multiple prior falls and was taking Plavix daily, received inaccurate and incomplete neurological checks after an initial fall. The resident then fell again, sustaining an acute bilateral tentorial subdural hemorrhage with midline shift. The report states the immediate cause of death was determined to be subdural hematoma. Surveyors cited failures to ensure accurate neurological checks for head injuries, failures to ensure nurses had the competency to assess head injuries, and failures in administration related to this incident. The facility’s census was 60 residents at the time of this survey.
Beyond these severe citations, federal inspection reports also cited Pinewood Health and Rehabilitation for lower-level deficiencies, including issues with pressure-ulcer care, infection control, food safety, resident rights, and maintaining a homelike environment. The current administration at Pinewood Health and Rehabilitation provided a statement, noting that the “event that was determined by CMS as deficient practice was prior to the hiring of the current Administration.” The administration also stated that a plan of correction was submitted and approved by CMS, and a revisit to the facility confirmed compliance with Federal and State Standards. The current administration emphasized its commitment, stating 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.”