Pinewood Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pinewood Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 10, 2026

  Based on the record review, staff interviews, and review of the facility's policies titled Abuse, Neglect and Exploitation, and Notification of Changes, and review of procedures titled Foley Irrigation Procedure, the facility failed to ensure two of three Residents (R) (R1 and R2) received the necessary care and services in accordance with physician orders. In addition, the facility also failed to ensure the physician was notified in a timely manner of significant changes in the resident conditions.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant… […]

• Immediate jeopardy, isolatedF656Mar 10, 2026

  Based on record review, staff interviews and review of the facility's policy titled Comprehensive Care Plan, the facility failed to implement care plan interventions for two of three Residents (R ) (R1 and R2). Specifically, R1 was prescribed antiplatelet medication and had care plan interventions that included monitoring and documenting adverse outcome. In addition, R2 had a care plan for obstructive uropathy and an indwelling Foley catheter with care plan interventions to provide catheter care.On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant… […]

• Immediate jeopardy, isolatedF689Mar 10, 2026

  Based on record review, staff interviews, and review of the facility's policy titled Incidents and Accidents, the facility failed to ensure one of one Hoyer lifts to transfer 13 residents was functional and free of defective parts. Specifically, the facility failed to remove a malfunctioned Hoyer lift and to ensure that it was properly repaired prior to the residents' use and the purchase of a new Hoyer lift. On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026,… […]

• Immediate jeopardy, isolatedF835Mar 10, 2026

  Based on record review, staff interview, and the facility job description for the former Administrator and Director of Nursing, the facility failed to provide administrative oversight to ensure physician orders were obtained and implemented as written and failed to ensure adequate supervision of the quality of care was provided for two of three Residents (R) R1 and R2.On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. […]

• Immediate jeopardy, isolatedF689Aug 20, 2025

  Based on records review, staff interviews, and the facility policy titled Fall Prevention Policy, the facility failed to ensure that one Resident (R1) with a history of multiple falls and receiving Plavix daily had accurate and complete neurological checks for a head injury on [DATE] and a second fall on [DATE] resulting in an acute bilateral tentorial subdural hemorrhage to the left side of the head with a right-to-left midline shift. The resident expired on [DATE] with an immediate cause of death determined to be a subdural hematoma. The facility census was 60. […]