Pinewood Healthcare: Infection Control Failures Cited - GA
The resident, identified in inspection records as Resident 53, was admitted to the facility in December 2024 with acute respiratory failure, hypoxia, and a swallowing disorder severe enough to require a gastrostomy tube for all nutrition and medication. The resident also had both short-term and long-term memory loss. Because of the feeding tube, the resident had been placed on Enhanced Barrier Precautions, a protocol designed to prevent the spread of multidrug-resistant organisms inside the facility.
The nurse, Licensed Practical Nurse BB, administered two medications through the G-tube that afternoon: quetiapine fumarate, an antipsychotic, and valproic acid, an anticonvulsant. She wore gloves. She did not wear a gown. The inspection report does not describe what she wore instead.
Two days later, inspectors interviewed the facility's Director of Nursing. The DON confirmed that a gown was required any time staff administered medication through the resident's feeding tube, and acknowledged that some staff may not have been trained on Enhanced Barrier Precautions.
The training records made that concrete. A sign-in sheet for an Enhanced Barrier Precautions in-service held on April 2, 2024 did not include LPN BB's name. The nurse had never received the training.
When inspectors reached LPN BB by phone, she said she could not recall whether she had or hadn't been trained on the precaution. She also said she had not known Resident 53 was on Enhanced Barrier Precautions at all. In the past, she explained, the DON or the Assistant Director of Nursing would post a sign on the resident's door and place a cart of personal protective equipment nearby. There had been no sign on this door. There had been no cart.
The Assistant Director of Nursing explained why. Resident 53 had recently been moved to a different room. When the resident was transferred, the signage and the PPE cart did not come along. Nobody had moved them. Nobody had noticed they were missing.
The care plan for Resident 53 had documented the Enhanced Barrier Precautions requirement, though without a date. It directed staff to follow evidence-based practices during all device care, including feeding tube use, to reduce the risk of spreading multidrug-resistant organisms within the facility. The plan existed. The training did not reach the nurse who needed it. The supplies did not follow the resident to her new room.
Multidrug-resistant organisms are bacteria that have developed resistance to the antibiotics most commonly used to treat them. They spread through contact, including contact during routine care procedures like feeding tube medication administration. Protective gowns exist specifically to reduce that transfer between a healthcare worker's clothing and a patient's environment.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that some residents were affected. The inspection was completed March 14, 2025.
Resident 53 spent her days in a facility where staff were expected to follow a precaution protocol that at least one nurse had never been taught, posted on a door the resident no longer lived behind.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinewood Healthcare Center from 2025-03-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 5, 2026 · Our methodology
Pinewood Healthcare Center in HAWKINSVILLE, GA was cited for violations during a health inspection on March 14, 2025.
The resident also had both short-term and long-term memory loss.
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.