HAWKINSVILLE, GA - Federal inspectors documented multiple infection control violations at Pinewood Manor Nursing Home & Rehabilitation Center during a March 2025 survey, finding staff failed to follow basic hand hygiene protocols and safety procedures for vulnerable residents.
Hand Hygiene Violations During Meal Service
The most significant finding involved a registered nurse who failed to wash hands between assisting six different residents during lunch service on March 4, 2025. Federal surveyors observed RN AA moving from resident to resident in the main dining room, cutting food, feeding multiple residents, and handling meal items without performing hand hygiene between each contact.
The detailed observation showed RN AA walking to a resident's table and cutting food without washing hands, then moving to another table to assist a different resident with cutting pork chops. The nurse retrieved a wrapped sandwich from kitchen staff and delivered it to another resident, then sat beside a fourth resident to feed them with a spoon until the meal was finished.
After completing the feeding, RN AA moved to another table and fed a fifth resident using the resident's own spoon. The nurse then collected another wrapped sandwich from the kitchen and brought it to a sixth resident, unwrapping the food and placing it on the resident's plate - all without performing hand hygiene between any of these resident contacts.
When interviewed the following day, RN AA acknowledged the violation, stating "I didn't wash my hands between helping each resident during lunch. I probably should have."
Facility Hand Hygiene Policy Requirements
Pinewood Manor's own Hand Hygiene policy, effective January 1, 2025, clearly states that "all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors." The policy specifically requires hand hygiene "between resident contacts" using either soap and water or alcohol-based hand rub.
Hand hygiene represents the single most important measure for preventing healthcare-associated infections. In nursing homes, where residents often have compromised immune systems and multiple chronic conditions, proper hand hygiene becomes even more critical. Failure to wash hands between resident contacts can facilitate the transmission of harmful bacteria, viruses, and antibiotic-resistant organisms throughout the facility.
The Director of Nursing confirmed expectations during an interview, stating "I expect that when staff are helping a resident in the dining room, they wash their hands between each resident, and especially when feeding them." Notably, RN AA was responsible for conducting infection prevention training and hand hygiene audits at the facility.
Enhanced Barrier Precaution Violations
Inspectors also discovered violations of enhanced barrier precautions (EBP) protocols designed to prevent transmission of multidrug-resistant organisms. A licensed practical nurse failed to don required protective gowning while administering medications through a feeding tube to a resident with specific infection control requirements.
On March 5, 2025, surveyors observed LPN BB administering quetiapine fumarate and valproic acid through Resident 53's gastrostomy tube while wearing gloves but without the required protective gown. Resident 53 had diagnoses including acute respiratory failure with hypoxia, dysphagia, and required attention to the G-tube.
Missing Training and Safety Infrastructure
The facility's EBP policy, implemented in 2025, requires enhanced barrier precautions for residents with indwelling medical devices like feeding tubes, even when residents are not known to be infected with multidrug-resistant organisms. The policy mandates making gowns and gloves available near or outside residents' rooms during "high-contact resident care activities" including device care and feeding tube use.
However, training records revealed LPN BB had not received required EBP training. During a phone interview, the nurse stated they could not recall receiving EBP training and were unaware the resident required enhanced precautions. The LPN explained that typically, nursing leadership would post signage on residents' doors and provide personal protective equipment carts.
Investigation revealed Resident 53 had recently changed rooms, but the required signage and PPE cart were not transferred during the move. The Assistant Director of Nursing confirmed this oversight during interviews.
Medical Device Safety Standards
Gastrostomy tubes create direct access to residents' digestive systems, bypassing natural protective barriers. Proper infection control during G-tube care prevents introduction of harmful microorganisms that could cause serious infections including pneumonia, sepsis, or localized infections at the insertion site.
Enhanced barrier precautions serve as an additional layer of protection for residents at higher risk of infection transmission. The protocols become particularly important in congregate care settings where resistant organisms can spread rapidly between residents through inadequate infection control practices.
Regulatory Context and Consequences
The violations fall under federal regulation F880, which requires nursing homes to "provide and implement an infection prevention and control program." While inspectors classified these violations as causing "minimal harm or potential for actual harm," the findings highlight systemic gaps in infection control implementation.
Federal regulations require nursing homes to maintain comprehensive infection prevention programs that include staff training, proper implementation of precautions, and ongoing monitoring of compliance. These requirements became more stringent following lessons learned during the COVID-19 pandemic about infection transmission in long-term care facilities.
Facility Response Requirements
Pinewood Manor must submit a plan of correction addressing how they will ensure consistent hand hygiene compliance and proper implementation of enhanced barrier precautions. This typically includes retraining all staff, implementing monitoring systems, and establishing protocols to ensure infection control measures transfer with residents during room changes.
The facility must demonstrate sustained compliance through ongoing auditing and staff education programs. Federal oversight will continue until inspectors verify the nursing home has corrected the identified deficiencies and implemented systems to prevent recurrence.
Infection control violations in nursing homes can have serious consequences for vulnerable residents who may have weakened immune systems or multiple chronic conditions. Proper adherence to established protocols helps protect residents from preventable infections and ensures safe care delivery in these critical healthcare settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinewood Manor Nursing Home & Rehabilitation Cntr from 2025-03-14 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.