Pinewood Manor Nursing Home & Rehabilitation Cntr

F-F812

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 115586 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28734 potential for actual harm Based on observation, staff interviews, record review, and review of facility's policies titled Hand Hygiene, Residents Affected - Some and Enhanced Barrier Precautions, the facility failed to perform hand hygiene between residents for six out of 21 residents observed during meal service, to prevent the spread of infection and communicable diseases. In addition, the facility failed to don gown prior to administering medications to one of three Residents (R) Resident R53 with a gastrostomy (G-tube).

Findings include:

Review of the facility policy titled, Hand Hygiene, dated 1/1/2025 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table: Condition: Between resident contacts. Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred).

A review of the facility policy titled, Enhanced Barrier Precautions dated 2025, stated, It is the policy of this facility to implement enhanced barrier precautions [EBP] for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities . 2. Initiation of Enhanced Barrier Precautions . b.

An order for enhanced barrier precautions will be obtained for residents with any of the following: i. indwelling medical devices (e.g. feeding tubes .) even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organism] . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident ' s room .4. High-contact resident care activities include .g. Device care or use .feeding tubes .

1. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 115586 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 3/5/2025 at 12:40 p.m., RN AA stated, I didn ' t wash my hands between helping each resident during lunch. I probably should have. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/5/2025 at 1:59 p.m., the Director of Nursing stated, I expect that when staff are helping a resident in the dining room, they wash their hands between each resident, and especially when Residents Affected - Some feeding them. [RN AA] does our in-services for infection prevention and hand hygiene. She also does our hand hygiene audits.

42991

2. A review of the document titled, Diagnosis Report revealed Resident R53 had the following diagnoses: acute respiratory failure with hypoxia, dysphagia, and encounter for attention to Gastrostomy (G-tube).

In a review of the Admission Minimum Data Set (MDS), dated [DATE REDACTED] revealed the facility admitted Resident R53 on 12/10/2024. Continued review of the MDS revealed Section C (Cognitive Patterns), the resident had both short-term and long-term memory loss, and Section K (Swallowing/Nutritional Status), the resident had a feeding tube.

In review of Resident R53's care plan, no date, stated, Focus - Prevent Spread of Multidrug resistant organism: G-tube. Goal - Staff will implement EBP daily to decrease the risk of spreading MDROs in facility. Interventions - Follow EBP as designed by the facility. Will be followed during .devices care or use .feeding tube. [sic]

Observation of Licensed Practical Nurse (LPN) BB, on 3/5/2025 at 2:00 p.m., during medication administration to Resident 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 Resident 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 Resident 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 Resident R53 had changed rooms recently; however, the signage and PPE cart had not been transferred along with the resident during the move.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 115586

F-F835

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 115586 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42991 potential for actual harm Based on staff interviews and record review, the facility Administration failed to ensure oversight of the Residents Affected - Many kitchen to ensure proper sanitation of pots, pans, dishes, utensils and countertop surfaces. This was evidenced by the Administration not being aware the dish machine and three-compartment sink did not have proper sanitation; and was not aware that the thermostat on the dish machine was inoperable. Also, the Dietary Manager did not have a Certified Dietary Manager (CDM) certification or equivalent. The deficient practice had the potential to affect 53 out of 56 residents that received an oral diet from the kitchen.

Findings include:

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