Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pinewood Healthcare Center during CMS and state inspections, most recent first.
Improper Food Date Marking and Spoiled Items in Kitchen Storage: Surveyors found spoiled produce in the refrigerator and multiple food items in the refrigerator, freezers, and pantry without required expiration or discard-by dates. The DKM confirmed the food storage concerns and stated staff should discard food with signs of spoilage or expiration dates, but she was unaware the perishable items were not labeled or dated.
A resident had prescription medications left unsecured at the bedside without a physician order or completed self-administration assessment. The resident, who had visual loss but little to no cognitive impairment, stated she took the medications daily without nurse supervision and that staff allowed it. An LPN confirmed the medications were present and that the resident had not been assessed, and the DON and ADON confirmed the resident had a history of unauthorized medications being brought into the facility.
Failure to timely report a resident fall with major injury: The facility did not submit a state reportable within the required 2-hour timeframe after an unwitnessed fall. The resident had intact cognition, required extensive assistance with transfers, and later complained of back and stump pain; ER x-ray showed a T12 compression/burst fracture. The DON confirmed the report was not filed because she was unaware of the fracture, and an LPN knew of the injury but did not notify her.
Improper Storage of Aerosol and Cleaning Products in Resident Rooms: Surveyors observed aerosol cans in two residents' rooms and bleach disinfectant wipes in another resident's room. CNA GG confirmed the items were present and stated they should not be in resident rooms, especially with wandering residents, and the DON also confirmed the items were in the rooms and should not have been there.
The governing body did not ensure timely payment to vendors, leading to the removal of linens by the linen supplier and threats of service disruption from the pharmacy vendor due to unpaid balances. Staff assumed the hospital would handle vendor communications, resulting in missed notifications and unresolved payment issues. Observations also revealed a shortage of essential adult briefs in storage, impacting residents who required these supplies.
The facility failed to properly sanitize kitchen equipment, affecting 53 residents. Staff used expired test strips, resulting in incorrect sanitizer concentration readings. The facility had not been serviced by a vendor for sanitizing solutions for two years, and the dish machine was not reaching required temperatures. Staff were unaware of proper procedures, and the Dietary Manager did not address known issues.
The facility administration failed to oversee kitchen sanitation, resulting in improper sanitation of equipment and surfaces. The Dietary Manager lacked certification and did not monitor sanitation logs, affecting 53 residents. The Administrator was unaware of equipment issues and did not ensure proper oversight.
The facility failed to follow hand hygiene protocols during meal service, as an RN did not wash hands between assisting residents. Additionally, EBP was not implemented for a resident with a G-tube, as an LPN administered medication without donning a gown. The LPN had not received EBP training, and necessary signage and PPE were not provided after the resident's room change.
A resident with severe cognitive impairment and multiple health conditions had a swollen foot with a bruise, which was not reported as an injury of unknown origin according to the facility's policy. Despite the facility's protocol requiring immediate reporting and investigation of such injuries, the incident was not reported to the DON or Administrator, and no investigation was initiated promptly.
A facility failed to refer a resident with paranoid schizophrenia for a Level II PASARR evaluation, despite the requirement to coordinate assessments with the PASARR program. The resident had a PASARR Level I completed, but the facility did not follow its policy to ensure appropriate care for individuals with mental disorders. Interviews revealed confusion among staff about who was responsible for completing the PASARR Level II.
A facility failed to implement a comprehensive care plan for a resident with a G-tube, specifically regarding Enhanced Barrier Precautions (EBP). The resident's care plan required EBP to prevent the spread of multidrug-resistant organisms. However, an LPN was observed administering medication via the G-tube without wearing a gown, contrary to the care plan. Interviews with the DON and an LPN highlighted the expectation for staff to follow care plans to ensure proper resident care.
Improper Food Date Marking and Spoiled Items in Kitchen Storage
Penalty
Summary
The facility failed to ensure that food items were properly dated, labeled, and discarded in the refrigerator, freezers, and dry storage, as required by its policy titled Date Marking for Food Safety. Review of the policy showed that ready-to-eat, time/temperature control for safety foods were to be clearly marked with the date or day by which they were to be consumed or discarded, and that the person opening or preparing the food was responsible for date marking it at that time. The policy also stated that the Head Cook or designee was to check the refrigerator daily for expiring food items and discard them accordingly, and that the Dietary Kitchen Manager or designee was to spot-check refrigerators weekly for compliance. During the kitchen inspection, surveyors observed spoiled produce in the residential refrigerator, including two bags of cucumbers with black discoloration and a head of lettuce with black discoloration. The refrigerator also contained bags of bacon, sandwich meat, ground beef, cheese, lettuce, cucumbers, eggs, and tomatoes without expiration or discard-by dates. In two two-door reach-in freezers in the dining room area, multiple food items were found without expiration or discard-by dates, including ground beef, barbecue meat, pepperoni, beef patties, chicken patties, chicken nuggets, sweet corn nuggets, breaded vegetables, hash browns, tater tots, rutabagas, and chopped rutabagas; additional frozen vegetables had sell-by dates of 11/24/2025 and 12/27/2025. In the pantry, tortilla chips and cornmeal had use-by dates of 01/27/2026, and five jars of maraschino cherries had no expiration date and were marked with 05/16/2024 in black marker on the lids. The Dietary Kitchen Manager confirmed the food storage concerns and stated that staff should discard food with signs of spoilage or expiration dates, and that she was unaware the perishable food items were not labeled or dated.
Unsecured medications found at resident bedside without self-administration assessment
Penalty
Summary
The facility failed to ensure that one resident did not have unauthorized, unsecured medications at bedside. The resident had diagnoses including bilateral nonexudative age-related macular degeneration with visual loss, hypertension, and unspecified atrial fibrillation. The resident’s MDS assessment showed a BIMS score of 15, indicating little to no cognitive impairment, but the clinical record contained no physician order or completed assessment to determine whether the resident was capable of self-administering medications. An observation of the resident’s room revealed prescription medications, including a bottle of nasal spray, muscle cramp spray, eye drops, and an anti-inflammatory pain lotion, lying on the bedside stand. The resident stated the medications were her own personal medications and that she took them daily without nurse supervision, and said the nurses allowed her to take medications. An LPN later confirmed the medications were at the bedside and that the resident had not been assessed to self-administer medications independently. The LPN was unsure how the medications were left in the resident’s possession and reported that the resident’s friend had previously brought medications into the facility. The DON and ADON also confirmed the resident had not been assessed to self-administer medications and stated the resident had a history of unauthorized medications being brought into the facility.
Failure to Timely Report Resident Fall With Major Injury
Penalty
Summary
The facility failed to report to the State Survey Agency within the required two-hour time frame a resident’s fall with major injury. The facility’s policy titled Abuse, Neglect, and Exploitation stated that alleged violations involving abuse or serious bodily injury must be reported immediately, but not later than 2 hours after the allegation is made. Record review showed the resident had a diagnosis of T12 fracture, and an EHR progress note documented an unwitnessed fall on 6/25/2025 at 11:31 AM when the resident was found on the floor. The incident report described the event as an unwitnessed fall from bed, with the resident turning on the light and a CNA finding the resident on the floor; the resident was assessed at that time with no injuries and no pain documented. Further record review showed that on 6/27/2025 the resident complained of back and stump pain and was sent to the ER for evaluation, where x-ray findings documented a compression fracture at T12 with a clinical impression of stable T12 burst fracture. Review of the facility’s Self Reportable records for the past year showed no report was submitted for the resident. During interview, the DON confirmed the facility failed to submit the state reportable within the two-hour time frame because she was unaware the resident had a T12 fracture, and stated she learned of the injury during the survey. She also reported that an LPN knew of the fracture but did not inform her.
Improper Storage of Aerosol and Cleaning Products in Resident Rooms
Penalty
Summary
The facility failed to ensure that aerosol containers and cleaning chemicals were not stored in three of 47 resident rooms, including room [ROOM NUMBER], room 40, and room 42. Surveyors observed an aerosol can of deodorant spray sitting on the bedside table in room [ROOM NUMBER] on 3/9/2026, 3/10/2026, and 3/11/2026, and observed an aerosol can on the bedside table in room [ROOM NUMBER] on 3/9/2026, 3/10/2026, and 3/11/2026. Surveyors also observed a container of bleach disinfectant wipes stored on a portable cubby in room [ROOM NUMBER] on 3/9/2026, 3/10/2026, and 3/11/2026. During interviews, CNA GG verified that the aerosol containers and disinfectant wipes were present in the identified rooms and stated these items should not be in residents' rooms, particularly because of residents who wander, and noted the facility had a policy restricting aerosol and disinfectant products from resident care areas. The DON also confirmed the items were present in the identified rooms and stated they should not be in resident rooms.
Failure to Ensure Timely Vendor Payments Resulting in Disruption of Resident Care Supplies
Penalty
Summary
The facility's governing body failed to ensure timely payment to supply vendors, resulting in disruptions to essential supplies for resident care. Specifically, the linen supply company de-installed linens from the facility due to an outstanding unpaid balance, after repeated attempts to collect payment and multiple service suspensions over the past year and a half. The hospital, which manages the nursing home and is responsible for vendor payments, was unresponsive to vendor communications, and staff within the nursing home assumed the hospital would handle such issues without direct follow-up. Additionally, the facility's pharmacy vendor reported a significant outstanding balance, with the last payment received several months prior and no further payments made for the current year. The pharmacy vendor indicated that continued nonpayment would result in the facility being placed on a Cash on Delivery (COD) status, and previous COD notices had only been resolved after direct intervention from hospital leadership. This pattern of delayed or missed payments extended to other critical supplies as well. During facility observations, it was noted that the storage area for adult briefs was depleted, with no 3XL briefs and only one pack of XL briefs available, despite residents requiring these sizes. The Housekeeping Supervisor confirmed the shortage and indicated that there may be some supplies in residents' rooms, but the central storage was insufficient. These events collectively demonstrate a failure by the governing body to maintain adequate supplies for resident care due to lapses in financial management and vendor relations.
Improper Sanitization of Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper sanitization of dishes, pots, pans, and cooking utensils, which could potentially affect 53 out of 56 residents receiving an oral diet from the kitchen. The deficiency was identified through observations, staff interviews, and record reviews, revealing that the facility staff did not have the proper method to check the sanitizer solution concentration levels for the dish machine and three-compartment sink. The facility's policies required testing of sanitizing solutions using a test kit or device that accurately measures concentration levels, but the test strips used were expired and did not provide accurate readings. Observations showed that the Dietary Manager and Dietary Aides repeatedly tested the sanitizer solution using expired test strips, resulting in incorrect concentration readings. The test strips used for the dish machine and three-compartment sink showed lower than required concentration levels, indicating improper sanitization. Interviews with the Dietary Manager and aides revealed a lack of awareness and understanding of the proper procedures for checking and maintaining sanitization levels, as well as uncertainty about who was responsible for maintaining the sanitization logs. Further investigation revealed that the facility had not been serviced by a vendor for sanitizing solutions since a contract ended two years ago, and the facility was using leftover chemicals. The dish machine's sanitizing chemical solution was found to be empty, and the machine itself was not reaching the required temperatures for proper sanitization. The Dietary Manager admitted to being aware of these issues but had not taken steps to address them, such as ordering new test strips or servicing the dish machine. The Administrator was also unaware of the lack of vendor service and the issues with the sanitizing solutions.
Deficiency in Kitchen Sanitation Oversight
Penalty
Summary
The facility administration failed to ensure proper oversight of the kitchen, leading to deficiencies in sanitation practices. The administration was unaware that the dish machine and three-compartment sink were not properly sanitized, and the dish machine's thermostat was inoperable. Additionally, the Dietary Manager lacked the required Certified Dietary Manager (CDM) certification or equivalent. This oversight had the potential to affect 53 out of 56 residents who received an oral diet from the kitchen. Interviews revealed that the Dietary Manager did not review sanitation or temperature logs and had not appointed anyone to monitor these logs. The Administrator, who started working at the facility in November 2024, admitted to not ensuring that sanitation test strips and sanitizing chemicals were ordered promptly and was unaware of the dish machine's hot water issue. The Administrator also acknowledged knowing that the Dietary Manager was not certified and did not monitor the Dietary Manager's activities or the kitchen's oversight.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during meal service, as observed with a registered nurse (RN) who did not perform hand hygiene between assisting multiple residents. The RN was seen cutting food, feeding residents, and handling food items without washing hands or using an alcohol-based hand rub between each resident interaction. This was confirmed by the RN during an interview, who acknowledged the oversight and the expectation to perform hand hygiene between resident interactions, especially during feeding. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (G-tube), as required by the facility's policy. A licensed practical nurse (LPN) administered medication via the G-tube without donning a gown, which is part of the EBP protocol for residents with indwelling medical devices. The Director of Nursing (DON) confirmed that the resident should have been on EBP and that the staff should have donned a gown during such procedures. The deficiency was further compounded by a lack of training and communication regarding EBP. The LPN involved had not received training on EBP, and there was no signage or personal protective equipment (PPE) cart available for the resident after a room change. The Assistant Director of Nursing (ADON) acknowledged that the necessary signage and PPE cart were not transferred with the resident, contributing to the oversight in implementing EBP for the resident with a G-tube.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown source for a resident, identified as R5, who was severely cognitively impaired and required substantial assistance with activities of daily living. The resident had a swollen right foot with a circular red bruise, which was first noticed by a Certified Nursing Aide (CNA) and reported to a Licensed Practical Nurse (LPN) and the wound nurse. Despite the facility's policy requiring immediate reporting of such injuries to the Director of Nursing (DON) and the Administrator, the injury was not reported as required, and an investigation was not initiated promptly. The facility's policy mandates that injuries of unknown origin be reported immediately to the Administrator and other relevant authorities, but this protocol was not followed. The DON confirmed that the injury should have been reported and investigated immediately, but this did not occur. The Administrator also confirmed that the injury was not reported to her, and an investigation was not initiated as required by the facility's protocol. The failure to report and investigate the injury of unknown origin represents a deficiency in the facility's adherence to its abuse prohibition plan.
Failure to Complete PASARR Level II for Resident with Schizophrenia
Penalty
Summary
The facility failed to refer a resident with a serious mental disorder for a Level II PASARR evaluation. The resident, who was admitted with diagnoses including paranoid schizophrenia, osteoarthritis, and dementia, had a PASARR Level I completed prior to admission. However, despite the diagnosis of schizophrenia, the facility did not refer the resident for a Level II PASARR screening. The facility's policy requires coordination with the PASARR program to ensure appropriate care for individuals with mental disorders, but this was not followed in the case of the resident. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASARR Level II evaluations. The Social Worker was unaware that a PASARR II had not been completed and believed it was the responsibility of the Admissions Department. The Medical Records staff also did not know who was responsible for completing a PASARR II. The Administrator expected that a psychiatrist would lead the decision on PASARR completion, but the facility's policies and procedures were not adhered to, resulting in the deficiency.
Failure to Implement Enhanced Barrier Precautions for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as R53, specifically regarding Enhanced Barrier Precautions (EBP). R53 had diagnoses including acute respiratory failure with hypoxia, dysphagia, and required attention to a gastrostomy tube (G-tube). The care plan for R53, dated 12/10/2024, included a focus on preventing the spread of multidrug-resistant organisms through the implementation of EBP during G-tube care. However, during an observation on 3/5/2025, an LPN administered medication via R53's G-tube while only wearing gloves and failing to don a gown, which was a requirement of the EBP outlined in the care plan. Interviews with facility staff, including the Director of Nursing (DON) and an LPN, revealed that care plans were developed by the MDS Nurse and could be updated by any nurse as needed. The DON expressed the expectation that staff follow each resident's care plan to ensure proper care and protection. The Administrator also expected staff to adhere to all facility policies and procedures related to EBP. The failure to follow the care plan as designed led to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hawkinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bryant Health And Rehabilitation Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Crossview Care Center | 12.1 mi | ★★★★★ | 7 | 0 |
| Eastman Trails Of Journey Llc | 18.5 mi | ★★★★★ | 11 | 0 |
| Heart Of Georgia Nursing Home | 19.2 mi | ★★★★★ | 7 | 0 |
| Summerhill Elderliving Home & Care | 19.3 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.