Pinewood Healthcare Center: Care Plan Failures - GA
The resident, identified in inspection records only as Resident 53, was admitted to Pinewood on December 10, 2024. The resident carried diagnoses of acute respiratory failure with hypoxia, dysphagia, and a gastrostomy tube, and had both short-term and long-term memory loss. Because of the feeding tube, the care plan required staff to follow Enhanced Barrier Precautions every day, specifically to reduce the risk of spreading multi-drug-resistant organisms to other residents in the facility.
On March 5, 2025, at 2:00 in the afternoon, an inspector watched a licensed practical nurse administer quetiapine fumarate and valproic acid through the resident's G-tube. The nurse had put on gloves. The nurse had not put on a gown.
That was the entire violation. One piece of protective equipment, missing, during a procedure the care plan explicitly covered.
The Director of Nursing, interviewed two days later, told inspectors it was her expectation that staff follow each resident's care plan, "mostly," to protect and care for each resident. That word, "mostly," appeared in the inspection report without elaboration.
Another nurse, LPN CC, explained that care plans existed so staff would know how to care for each resident. If staff didn't follow them, she said, residents wouldn't be properly cared for. The administrator told inspectors the expectation was that staff follow all policies and procedures related to Enhanced Barrier Precautions.
Everyone agreed, in other words, on what should have happened. Nobody had made sure it did.
Enhanced Barrier Precautions exist specifically for residents who carry organisms that don't respond to standard antibiotics. The precautions are designed not just to protect the individual resident but to prevent those organisms from moving through a facility on the hands, arms, and clothing of staff who move from room to room. A gown is part of that barrier. Without it, whatever is on the resident's environment can transfer to the nurse's clothing and travel.
Resident 53 had memory loss, both short-term and long-term. The resident could not have monitored whether the nurse approaching with a syringe was wearing the right protective equipment. The care plan was the mechanism that was supposed to do that work instead.
Pinewood's own policy, dated 2025, states that staff responsible for carrying out care plan interventions must be notified of their roles and responsibilities, both at the start and when changes are made. The care plan for Resident 53 had been in place since the day of admission.
Inspectors rated the violation as causing minimal harm or potential for actual harm and found it affected only one of the 21 residents in their sample. It was a single observation of a single nurse on a single afternoon. The inspection report does not say how many times the gown requirement had been skipped before an inspector happened to be watching.
Resident 53 was dependent on a feeding tube, had difficulty swallowing, and had been admitted following acute respiratory failure. The care plan's infection precautions were not incidental. They were written in because the risk of spreading a drug-resistant organism through a device that goes directly into the body was real enough to document and assign to every nurse who walked through that door.
On March 5, one of them walked through without a gown.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 7, 2026 · Our methodology
Pinewood Healthcare Center in HAWKINSVILLE, GA was cited for violations during a health inspection on March 14, 2025.
The resident, identified in inspection records only as Resident 53, was admitted to Pinewood on December 10, 2024.
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.