Pinewood Healthcare Center
Pinewood Healthcare Center in HAWKINSVILLE, GA — inspection on March 14, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
sources were reported to the Administrator immediately and an investigation was started
time.
When asked if an investigation had started, the nurse said that she had started an investigation;
An interview with CNA FF on 3/6/2025 at 5:45 p.m. revealed that on the morning of Monday, 3/3/2025, he notified the charge nurse, LPN EE, and the wound nurse, LPN GG about R5's bruise on top of his foot.
In an interview with the wound nurse, LPN GG on 3/7/2025 at 9:18 a.m., LPN GG said that CNA FF reported that he discovered a bruise on top of R5's foot and wanted her to look at it. LPN GG said that the bruise was about the size of a quarter on 3/3/2025, and when she saw it again on the morning of 3/4/2025, the resident's foot was swollen, and the bruise had spread and become much larger.
She notified the physician, and an x-ray of the foot was ordered.
She reported the injury of unknown origin to the charge nurse and to the DON.
In an interview on 3/7/2025 at 9:46 a.m., the facility's Administrator said that the protocol in addressing injuries of unknown origin was to ensure an incident report was completed, and if the origin of the injury was unknown, then follow-up was required, and it was a reportable event to the state.
The Administrator said that the chain of command for reporting injuries of unknown origin was for the aide to report to the charge nurse; the charge nurse reported to the DON; and then the DON reported to the Administrator. If it was not determined how an injury happened, then an investigation was initiated, and an investigation report was completed.
The Administrator confirmed R5's injury of unknown origin was not reported to her on 3/4/2025, as it should have been, and confirmed that an investigation was not initiated regarding the resident's injury of unknown origin.
115586 03/14/2025
Pinewood Healthcare Center 277 Commerce Street Hawkinsville, GA 31036
the lead role on whether or not a PASARR should be completed on a resident.
She stated it was
115586 03/14/2025
Pinewood Healthcare Center 277 Commerce Street Hawkinsville, GA 31036
Observation of Licensed Practical Nurse (LPN) BB, on 3/5/2025 at 2:00 p.m., during medication administration to R53 revealed the LPN administered quetiapine fumarate 150 milligrams (mg) and valproic acid oral solution 250 mg via the resident's G-tube.
Continued observation revealed the LPN had donned gloves but had failed to don a gown.
In an interview with the Director of Nursing (DON) on 3/7/2025 at 9:30 a.m., it was revealed it was her expectation that staff follow each resident's care plan, mostly, in order to protect and care for each resident.
An interview with LPN CC, on 3/7/2025 at 9:36 a.m., revealed care plans were developed by the MDS Nurse, but any nurse could update the care plans as needed.
She revealed the purpose of a care plan was so staff would be aware of how to care for each resident. He/She continued to state if staff did not follow the care plan, the residents would not be properly cared for.
An interview with the Administrator on 3/7/2025 at 9:41 a.m., revealed it was his/her expectation that staff follow all the facility's policies and procedures related to EHB.
plates and plasticware over the weekend.
The Administrator stated that they had supplies and
the plumber will return 3/11/2025 to add a new thermostat and install a recirculation line.
The
Administrator stated that all of kitchen staff had received a written warning on 3/10/2025 for falsifying temperature lot information.
Cross Reference F-F835
115586 03/14/2025
Pinewood Healthcare Center 277 Commerce Street Hawkinsville, GA 31036
Review of Administrator's job description, Copyright 2023 from The [Name], LLC, revealed, Major Duties and Responsibilities - Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with the current state and federal laws and regulations .
Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revisions related facility's outcomes, regulatory compliance and/or customer satisfaction.
Review of Dietary Manager's job description, Copyright 2023 from The [Name], LLC, revealed, Required Qualifications .Certification as a dietary manger.
Certification as a food service manager .Major Duties and Responsibilities - Oversees the budget and purchasing of food and supplies, and food preparation, services, and storage .Dietary Manager Assigned Tasks .
Ensures proper sanitation and safety practices of staff.
During an interview on 3/6/2025 at 3:01 p.m., the Dietary Manager stated she did not have her Certified Dietary Manager certification (or equivalent) and did not enroll in an online class until January 25.
The Dietary Manager stated they did not review the sanitation or temperature logs.
She also stated she did not appoint anyone to review or monitor the logs.
During an interview on 3/6/2025 at 4:45 p.m. with the Administrator, she stated she did not make sure sanitation test strips and sanitizing chemicals were ordered right away once she was informed the sanitation test strips and did not know the hot water to the dish machine was not working properly.
The administrator stated that she did not monitor the Dietary Manager nor ensure oversight of the kitchen.
The Administrator stated she started working at the facility 11/2024.
The Administrator stated that she knew the Dietary Manager was not certified and did not hire her for the position.
The Administrator stated her expectations was the Dietary Manager was monitoring sanitizing logs.
During an interview on 3/11/2025 at 11:21 a.m., the Administrator stated they had arranged for a Dietitian to work every day with the Dietary Manager until she was certified.
The Administrator stated they also will have the Dietary Manager enroll in an education program to help with the education of the dietary staff.
Cross Reference F-F812
115586 03/14/2025
Pinewood Healthcare Center 277 Commerce Street Hawkinsville, GA 31036
Observation of Licensed Practical Nurse (LPN) BB, on 3/5/2025 at 2:00 p.m., during medication administration to R53 revealed the LPN administered quetiapine fumarate 150 milligrams (mg) and valproic acid oral solution 250 mg via the resident's G-tube.
Continued observation revealed the LPN had donned gloves but had failed to don a gown.
An interview with DON on 3/7/2025 at 9:30 a.m., revealed R53 should have been on EBP because the resident had received medications through a GT and the staff should have donned a gown.
The DON stated some staff may not have been trained on EBP.
A review of the document titled, Inservice Sign-In Sheet, Enhanced Barrier Precautions dated 4/2/2024 revealed LPN BB had not received training on EBP.
A telephonic interview with LPN BB on 3/72025 at 9:38 a.m., revealed he/she could not recall if he/she had or had not received training on EBP and he/she had not been aware R53 was on EBP.
The LPN stated in the past, the DON, or the ADON would post signage on the resident's door, as well as provide a (Personal Protective Equipment) PPE cart.
Interview with the Assistant Director of Nursing (ADON) on 3/7/2025 at 10:14 a.m., revealed R53 had changed rooms recently; however, the signage and PPE cart had not been transferred along with the resident during the move.
115586 03/14/2025
Pinewood Healthcare Center 277 Commerce Street Hawkinsville, GA 31036
During a meal service observation in the main dining room on 3/4/2025 at 11:33 a.m., Registered Nurse (RN) AA, without performing hand hygiene, walked over to a resident seated at the dining room table, and started cutting up their food on their plate for them.
Without performing hand hygiene, RN AA went to another table and assisted a resident with cutting up her pork chops.
Then RN AA went over to the kitchen door and retrieved a sandwich, wrapped in a clear bag, from the kitchen staff and delivered the sandwich to the resident, seated at another table. RN AA went to another table, sat down beside a resident and, without performing hand hygiene, started feeding the resident with a spoonful of food.
The RN continued to feed the resident until the resident finished eating. RN AA got up from the chair after feeding the resident and went over to another table and sat down across from another resident. RN AA picked up the resident ' s spoon and fed the resident a bite of her food.
After the RN finished feeding the resident, RN AA got up and walked to the doorway of the kitchen.
The RN was handed another sandwich wrapped in clear plastic wrap. RN AA, without performing hand hygiene, brought the sandwich over to another resident seated in the dining room, removed the sandwich from the package and set it on the resident ' s plate in front of her.
115586
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115586 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pinewood Manor Nursing Home & Rehabilitation Cntr 277 Commerce Street Hawkinsville, GA 31036
Review of Dietary Manager's job description, Copyright 2023 from The [Name], LLC, revealed, Required Qualifications .Certification as a dietary manger.
Certification as a food service manager .Major Duties and Responsibilities - Oversees the budget and purchasing of food and supplies, and food preparation, services, and storage .Dietary Manager Assigned Tasks .
Ensures proper sanitation and safety practices of staff.
During an interview on 3/6/2025 at 3:01 p.m., the Dietary Manager stated she did not have her Certified Dietary Manager certification (or equivalent) and did not enroll in an online class until January 25.
The Dietary Manager stated they did not review the sanitation or temperature logs.
She also stated she did not appoint anyone to review or monitor the logs.
During an interview on 3/6/2025 at 4:45 p.m. with the Administrator, she stated she did not make sure sanitation test strips and sanitizing chemicals were ordered right away once she was informed the sanitation test strips and did not know the hot water to the dish machine was not working properly.
The administrator stated that she did not monitor the Dietary Manager nor ensure oversight of the kitchen.
The Administrator stated she started working at the facility 11/2024.
The Administrator stated that she knew the Dietary Manager was not certified and did not hire her for the position.
The Administrator stated her expectations was the Dietary Manager was monitoring sanitizing logs.
During an interview on 3/11/2025 at 11:21 a.m., the Administrator stated they had arranged for a Dietitian to work every day with the Dietary Manager until she was certified.
The Administrator stated they also will have the Dietary Manager enroll in an education program to help with the education of the dietary staff.
Cross Reference
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.