2019 DCH Reports Involving Shepherd Hill Nursing Home

GEORGIA DEPARTMENT
OF COMIMUNfTY HEALTH
Brian P. Kemp, Governor

Frank W. Berry, Commissioner
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656- 4507 www. dch. georgia. gov
1
IMPORTANT NOTICE - PLEASE READ CAREFULLY
June 18, 2019
Mr. Dustin Hoang, Administrator

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728
Dear Mr. Hoang:
Revisit( s) were conducted at your facility to verify that your facility had achieved and maintained
substantial compliance. Our revisit( s) conducted June 13, 2019 and June 17, 2019 found that
your facility is in substantial compliance with the long- term care requirements. Your facility will
be certified as being in substantial compliance effective June 3, 2019.
If there are any questions concerning the above, or if we may be of assistance, please do not
hesitate to call or write us.
Sincerely,
6 D" aufacy R,72.
Jan Dunaway RN for Jean Levi

Regional Director, Northern
Long Term Care Section
Healthcare Facility Regulation Division
cc:
Georgia Department of Community Health/ Division of Medical Assistance
State Long Term Care Ombudsman
Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan I Health Planning
Equal Opportunity Employer
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH

2 Peachtree Street, NW I Atlanta, GA 30303- 3159 404- 656- 4507
1 1 www. dch. georgia. gov
May 28, 2019
Mr. Dustin Hoang, Administrator

800 Patterson Rd
Dear Mr. Hoang:
On April 19, 2019, a Recertification, Complaint Investigation and State Licensure survey was
conducted at your facility. In your plan of correction, you have alleged that the deficiencies
cited that survey have been or
on will be corrected. Your latest plan of correction date is
June 3, 2019.
We are accepting your plan of correction as your allegation of compliance.
If you have any questions concerning the instructions contained in this letter, or if we may be
of assistance, please do not hesitate to call or write to us.
Sincerely,
W Dcusaa" R,72.
Jan Dunaway RN
Regional Director, Central
cc: Facility File
Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan 1 Health Planning
GEGR+
GJA DEPARTMENT
COMMUNrrY HEALTH

2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656- 4507 1 www. dch. georgia. gov
AMENDED May 6, 2019

May 2, 2019
Mr. Marcus Oates, Administrator

800 Patterson Rd
Dear Mr. Oates:
On April 19, 2019 the Georgia survey agency conducted a Recertification, Complaint Investigation and ,
State Licensure survey to determine if your facility was incompliance with Federal program requirements
for nursing homes participating in Medicare and/ or Medicaid programs.
This survey found that your facility was not in substantial compliance with the program
requirements. Specific findings of the survey are included on the attached CMS form 2567, Statement
of Deficiencies.
All References to the regulatory requirements contained in this letter are found in Title 42, Code of
Federal Regulations.
Plan of Correction ( PoC)
A POC for the deficiencies cited on the CMS- 2567 must be submitted
by May 12, 2019. Submit an
electronic PoC to hfrd. poc( a-_)
dch. ga. gov and ianice. dunaway( a7dch. ga. gov and/ or submit your written PoC
to Healthcare Facility Regulation Division LTC, Suite 31. 447, 2 Peachtree St. N. W., Atlanta, GA.
30303- 3142, telephone ( 404) 657- 5850.
The date by which correction must be made, which is
reflected by the completion dates on the PoC, must be not later than June 3 2019.
Failure to submit an acceptable PoC by May 16, 2019 may result in the imposition of a civil money
penalty.
An acceptable PoC must:
Address how corrective action will be accomplished for those residents found to have been affected
by the deficient practice;
Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
Address what measures will be put into place or systemic changes made to ensure that the deficient
practice will not recur;
May 2, 2019
Page 2
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop a plan for ensuring that correction is achieved and sustained. This plan
must be implemented, and the corrective action evaluated for its effectiveness. The plan of
correction is integrated into the quality assurance system; and
Includes dates when corrective action will be completed.
The Plan of Correction will serve as the facility' s allegation of compliance. If a submitted plan of
correction does not adequately address all of these points it will not be acceptable
Remedies
Please note that this letter does not constitute formal notice of imposition of alternative
sanctions or termination of your provider agreement. Should the Centers for Medicare &
Medicaid Services determine that termination or any other sanction is warranted, they will
provide you with a separate formal notification of that determination.
Remedies will be recommended for imposition by CMS if your facility has failed to achieve substantial
compliance by the revisit.
Informal dispute resolution for the cited deficiencies will not delay the
imposition of the enforcement actions recommended. A change in the seriousness of the
noncompliance found may result in a change in the remedy recommended. When this occurs, you will
be advised of any change in remedy.
Civil Money Penalty, in an amount and duration to be determined by CMS.
A mandatory denial of payment for new admissions will be imposed July 19, 2019 if substantial
compliance is not achieved by that time.
Termination of Medicare Agreement. We are recommending to the CMS Regional Office and/ or
State Medicaid Agency that your provider agreement be terminated on October 19, 2019 if
substantial compliance is not achieved by that time.
If, upon the subsequent revisit, your facility has not achieved substantial compliance, the CMS Regional
Office or State Medicaid Agency will impose the other remedies indicated above, or a revised remedy, if
appropriate.
Informal Dispute Resolution ( IDR)
In accordance with 42 CFR §

488. 331, you have one opportunity to dispute cited deficiencies through an
informal dispute resolution progress.
To be -given such an opportgnity, you are required to send
our written request for IDR alona with the specific deficiencie ' being disputed, and an
explanation of why you are disputing those deficiencies includ ng any information or
documentation supporting your refutation.
This request and any supporting information must
be sent during the same 10 days you have for
submitting a PoClor the cited deficiencies. In
addition to submitting your refutation in writing, you will be given an opportunity for a face-to-face
meeting with the Director for the Long- Term Care Section in Atlanta. If you request an Informal Dispute
Resolution in writing, you will be contacted by the Regional Director to offer the opportunity for a
face-to-face meeting.
Please note that an incomplete informal dispute resolution process will not delay the effective
date of any enforcement action against the
facility.
May 2, 2019
Page 3
A copy of our informal dispute resolution process is available

upon request. At the completion of the
IDR process, you will receive a written response
outlining the results. If you are successful at
demonstrating that a deficiency should not have been cited, the deficiency citation will be marked deleted
on the original CMS-2567, and any enforcement action( s) imposed solely because of that deficiency
citation will be rescinded.
Disclosure of Survey Results
Public Lawto 92-

available the
603, Section 299 requires that all deficiencies found during surveys shall be made
public.
be
Consequently, the attached list of deficiencies will be on file in this office and will
available to any interested person upon request.
In addition, you are required to make the survey
results readily accessible to your residents.
If you have any questions concerning the instructions contained in this letter or if we may be of
assistance, please do not hesitate to call or write us.
Sincerely,
DWI"" R,
Jan Dunaway for Jean Levi

cc: Melanie Simon

CMS Regional Office
GEORGIA DEPARTMENT
OF COMMUNMY HF-ALT14

2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656- 4507 1 www. dch, georgia. gov
May 2, 2019

800 Patterson Rd
Dear Mr. Oates:
On April 19, 2019 the Georgia survey agency conducted a Recertification, Complaint Investigation and ,
State Licensure survey to determine if your facility was incompliance with Federal program requirements
for nursing homes participating in Medicare and/ or Medicaid programs.
This survey found that your facility was not in substantial compliance with the program
requirements.
Specific findings of the survey are included on the attached CMS form 2567, Statement
of Deficiencies.
All References to the regulatory requirements contained in this letter are found in Title 42, Code of
Federal Regulations.
Plan of Correction ( PoC)
A POC for the deficiencies cited on the CMS- 2567 must be submitted by May 12, 2019. Submit an
electronic PoC to hfrd. poc(a)-dch.ga. gov and ianice. dunawayp_dch ga gov and/ or submit your written PoC
to Healthcare Facility Regulation Division LTC, Suite 31. 447, 2 Peachtree St. N. W., Atlanta, GA.
30303- 3142, telephone ( 404) 657- 5850.
The date by which correction must be made which is
reflected by the completion dates on the PoC must be not later than June 3 2019.
Failure to submit an acceptable PoC by May 12, 2019 may result in the imposition of a civil money
penalty.
An acceptable PoC must:
Address how corrective action will be accomplished for those residents found to have been affected
by the deficient practice;
Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
Address what measures will be put into place or systemic changes made to ensure that the deficient
practice will not recur;
Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan 1 Health Planning
May 2, 2019
Page 2
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop a plan for ensuring that correction is achieved and sustained. This plan
must be implemented, and the corrective action evaluated for its effectiveness. The plan of
correction is integrated into the quality assurance system; and
Includes dates when corrective action will be completed.
The Plan of Correction facility' s allegation of compliance.

will serve as the
If a submitted plan of
correction does not adequately address all of these points it will not be acceptable
Remedies
Please note that this letter does not constitute formal notice of imposition of alternative
sanctions or termination of your provider agreement.
Should the Centers for Medicare &
Medicaid Services determine that termination or any other sanction is warranted, they will
provide you with a separate formal notification of that determination.
Remedies will be recommended for imposition by CMS if your facility has failed to achieve substantial
compliance by the revisit. Informal dispute resolution for the cited deficiencies will not delay the
imposition of the enforcement actions recommended. A change in the seriousness of the
noncompliance found may result in a change in the
remedy recommended. When this occurs, you will
be advised of any change in remedy.
Civil Money Penalty, in an amount and duration to be determined by CMS.
A mandatory denial of payment for new admissions will be imposed July 19, 2019 if substantial
compliance is not achieved by that time.
Termination of Medicare Agreement.

We are recommending to the CMS Regional Office and/ or
State Medicaid Agency that your provider agreement be terminated on October 19, 2019 if
substantial compliance is not achieved by that time.
If, upon the subsequent revisit, your facility has not achieved substantial compliance, the CMS Regional
Office or State Medicaid Agency will impose the other remedies indicated above, or a revised remedy, if
appropriate.
Informal Dispute Resolution ( IDR)
In accordance with 42 CFR §

488. 331, you have one opportunity to dispute cited deficiencies through an
informal dispute resolution progress.
To be -given such an opportunity, you are required to send
our written request for IDR along with the specific deficiencies being disputed, and an
explanation of why you are dist) utina those deficiencies includ na any information or
documentation supporting your refutation
This request and a v supporting information must
be sent during the same 10 days you have for a PoC for the
submitting cited deficiencies. In
addition to submitting your refutation in writing, you will be given an opportunity for a face- to- face
i
meeting with the Director for the Long- Term Care Section in Atlanta. If you request an Informal Dispute
Resolution in writing, you will be contacted by the Regional Director to offer the opportunity for a
face- to-face meeting.
Please note that an incomplete informal dispute resolution process will not delay the effective
date of any enforcement action against the
facility.
Pruitthealth - Shepherd Hilts
May 2, 2019
Page 3
A copy of our informal dispute resolution process is available upon request.

At the completion of the
IDR process, you will receive a written response
outlining the results. If you are successful at
demonstrating that a deficiency should not have been cited, the deficiency citation will be marked deleted
on the original CMS- 2567, and any enforcement action( s) imposed solely because of that deficiency
citation will be rescinded.
Disclosure of Survey Results
Public Law 92- 603, Section 299 requires that all deficiencies found during surveys shall be made
available to the public.
Consequently, the attached list of deficiencies will be on file in this office and will
be available to any interested person request.
upon
In addition, you are required to make the survey
results readily accessible to your residents.
If you have any questions concerning the instructions contained in this letter or if we may be of
assistance, please do not hesitate to call or write us.
Sincerely,
D"" R,72,

cc: Melanie Simon

CMS Regional Office
h
G DEPARTMENT
OF COMMuwry

2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656- 4507 1 www. dch. georgia. gov
May 2, 2019

800 Patterson Rd
Dear Mr. Oates:
Federal regulations require this office to conduct periodic compliance reviews for Title VI of
the Civil Rights Act of 1964. On April 19, 2019, this office completed its review of your
facility for compliance with this Act.
As a result of this review, we have notified appropriate agencies that your facility meets (or
continues to meet) the requirements of Title VI.
Thank you for your cooperation. If this office can assist you in any way, do not hesitate to
write or call us.
Sincerely,
Daa" R,-l.

Regional Director Northern
cc: Facility File
Healthcare Facility Regulation 1 Medical Assistance Plans I State Health Benefit Plan 1 Health Planning
Approved 5128119 LPOC: 613119
JLtkL DLUULN
PRINTED: 05106/ 2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391

cSTATEMENT OF DEFICIENCIES xi) PROVIDERISUPPLIERICLIA X3) DATE SURVEY
ANU PLAN OF CORRECTION IDENTIFICATION NUMBER: x2) MULTIPLE CONSTRUCTION
COMPLETED
A, BUILDING
B. WING
115452 1812419
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS LA FAYETTE, GA 38728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION 05)

COMPLETION
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
ATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROMREFERENCED TO THE APPROPRIATE
DEFICIENCY)
F 000 F 000
INITIAL_ COMMENTS E
AMENDED 5/ 6/ 19
A standard survey was conducted at Pruittheafth

Shephard Hills from 04/ 15/ 2019 through
04/ 19/ 2019. In addition, Complaint Intake
Number ( CA00195764) were investigated in
conjunction with this standard surrey. The
standard survey revealed that the facility was not
in substantial compliance with Medicare/ Medicaid
E regulations at 42 Code of Federal Regulations

C. F. R.) Part 483, Subpart B- Requirements for
Long Term Care Facilities. The following
i deficiencies resulted from the facility' s
I noncompliance related to the standard survey, As
L
Indicated on the facility' s Form CMS- 672,
Resident Census and Conditions of Residents
Form, the facility s census on 04/ 15/ 2019 was

106 residents.
F 584 Safe/ Clean/ ComfortablelHomelike Environment F 584, The facility had the maintenance director repair
SS= D CFR( s): 483. 10( 1)( 1)-( 7) sheetrock in room 222- B, he also replaced
blinds in room 215- B. In addition, he replaced
483. 10( i) Safe Environment. the nightstand in room 2212- A. All these areas
The resident has a right to a safe, clean, of concern were addressed to ensure a safe
comfortable and homelike environment, including clean homelike Environment for the residents.
but not limited to receiving treatment and These items were completed on April 19, 2019. I
supports for daily living safety.
To ensure we are in compliance with F 584 the L
maintenance director completed a 100% audit
The facility must provide- I
on Blinds, Nightstands, resident room
483. 10( i)( 1) A safe, clean, comfortable, and
sheetrock and painting on April 26, 2019,
homelike environment, allowing the resident to
use his or her personal belongings to the extent
The Maintenance Director will complete weekly
passible. audits of all. rooms to include Blinds,
I) This includes ensuring that the resident can Nightstandsl resident room sheetrock and
receive care and services safely, and that the I painting. TY ese will be completed on June 3,
physical layout the facility maximizes resident
of 2019.
independence and does not pose a safety risk.
ii) The facility shall exercise reasonable care for PruittHealt Shepherd Hills will bring all of
I. these findin s to our Monthly QAPI meeting x 3
or until subs antial compliance is met to ensure
Compliance lis met with F 584, Pruitt Health
The Administrator will be responsible for

compliance of the monitoring of this plan of
al
PRINTED: 05/ 0612019
CENTERS FOR MEDICARE& MEDICAID SERVICES OMS NO. 093$- 0391

correction. In addition, the administrator will
monitor the compliance of this POC in the
monthly QAPI meetings for 3 months to ensure
we have appropriate corrective action.
Changes will be made to the plan by the

committee as indicated to include but not
limited to further education or immediate
corrective action.
kBORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
iy deficiency statement ending with an asterisk(*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
ifagoafds provide sufficient protection to the patients,( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
Ile of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans ofoorreiction are disclosable 14 days following"
ite these documents are made available to the facility. If def rimes are cited, an approved plan of correction is requisite to confinved program participation.
RM CMS- 2567( 02- 99) Previous versions obsolete Event ID 752011 Facility 10: LTC 11461209 If continuation sheet Page I of 9
iTATEMENT OF DEFICIENCIES Xl) PROVIDERISUPPLIER/ CLIA X3) DATE SURVEY

x2) muL*npLr=CONSTRUCTION COMPLETED
ND PLAN OF CORRECTION IDENTIFICATION NUMBER.
A. BUILDING
B. WING
116452 0411912019
M PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS LAFAYETTE, GA 30728
STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION

X4) 10
PREFIX EACH
SUMMARY
DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE

1COMPLETt ON
OATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
Plq s
ZM CMS- 2567( 02- 99) Previous Versions Obsolete Event 0752G1 I Facility 10LTC111461209 if continuation sheet Page 2 of 11
PRINTED: 05/ 06/ 2019

F 584 F 584 IF 584 The Housekeeping Supervisor has cleaned the
wheelchair for resident# 209.
To ensure future compliance with F 584 the

Housekeeping Supervisor will do 100% audit of all
wheelchairs In the facility, This was completed on
Continued From page I the protection of the iApril 23, 209_
residents prop" from loss or theft.
He has adapted a cleaning schedule to ensure all
residents wheelchairs are cleaned on a weekly basis
483. 10( i)( 2) Housekeeping and maintenance
and as needed. This was completed on April 19,
services necessary to maintain a sanitary, orderly, 2019,
and comfortable interior;
The Housekeeping Supervisor will audit wheelchair
i
483. 10( 1)( 3) Clean bed and bath linens that are cleaning schedules on a weekly basis to be
completed on June 3, 2019.
in good condition;
These findings will be brought to our Monthly OAPI

483. 10( 1)( 4) Private Closet space in each meetings x 3 or until substantial compliance is met to
resident room, as specified in W3. 90( e)( 2)( iv); ensure safety of residents and staff,
483, 10( 1)( 5) Adequate and comfortable The Administrator will be responsible for compliance
lighting
levels in
1o the monitoring of this plan of correction. In i
all areas;
addition, the Administrator will monitor the
compliance of this POC in the monthly WI
483. 10( i)( 6) Comfortable and safe temperature
meetings for 3 months to ensure we have appropriate
levels. Facilities initially certified after October 1, corrective action. Changes will be made to the plan
1990 must maintain a temperature range of 71 to by the committee as Indicated to include but not
81" F; and 1limited to further education or immediate corrective
action,
483, 10( i)( 7) For the maintenance of comfortable

sound levels.
This REQUIREMENT is not met as evidenced
by;
Based on observation and interviews, the facility
failed to ensure that it was maintained in a safe,
clean and comfortable homelike environment in
three rooms on one of three halls( 216 B, 221 A,
222 B); also failed to clean wheelchair for one( 1)
resident(# 209) . The facility census was 106.
Findings include:
Observation on 4/ 15/ 19 at 12: 02 p. m. revealed in

room 222- B, three small patches of ripped
sheetrock, approximately two by two inches in
diameter.
ATEMENT OF DEFICIENCIES Xi) PROVIDERISUPPLIERICLIA X3) DATE SURVEY

D PLAN OF CORRECTION IDENTIFICATION NUMBER: X2) MULTIPLE CONSTRUCTrprjl
COMPLETED
A- BUILDING
B. WING
116462 I 0411912019
AME OF PROVIDER OR SUPPLIER STREFTADDRESS CITY, STATE, ZIP CODE
800 D
IRUITTHEALTH- SHEPHERD HILLS LA FAYETTE, G* 30728
V OMS156702- 199) Previous Versions Obsolete Event 10162011 Facility to: LTC1 1451. 109 If confinuatton sheet Page 3 of II
PRINTED: 05AW019

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X6)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG IDENTIFYING INFORMATION) DATR

REGULATORY OR LSC TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
F 584 F
Continued From page 2 5841

Observation on 4/ 15/ 19 at 12- 02 p. m. revealed
resident( R) R# 209 wheelchair to have heavy
layer of did/dust buildup around the wheels and
spokes.
Observation on 4/ 16/ 19 at 8: 34 a. m. revealed in

room 215- B, two broken slats on wooden window
blinds; also bathroom door knobs were loose and
wobbly.
Observation on 4/ 16119 at 9: 57 a. m. revealed in

room 221- A, top drawer of the nightstand is
broken off track and there are no knobs to pull
the drawer open.
Interview on 4/ 19/ 19 at 11: 00 a. m. with
Maintenance Director, stated his daily duties

include checking the wander guards, exit doors
and water temperatures. He further stated that
staff complete electronic work orders for items
that need to be serviced. He also stated that staff
will tell him things in passing if repairs are
needed. He verified during walking rounds the
concerns identified during the survey, He stated
that he is not certain who is responsible for
washing the resident wheelchairs.
Interview on 4119/ 19 at 11: 43 a. m. with

Housekeeping Supervisor, stated that the 3: 00
p. m. to 11: 00 p. m. floor tech washes wheelchairs
on Mondays, Wednesdays and Fridays. He
further stated the floor tech is washing six- eight

wheelchairs each day. He stated there is no
documentation being done as far as the washing
of the wheelchairs. He stated that he does get a
list of all new admits, and stated that he was not
aware of R# 209 having a wheelchair. He verified
the dust buildup on R# 209 wheelchair and stated
he would have the floor tech wash it.
rATEMENT OF DEFICIENCIES XI) PROVIDER/ SUPPLIERICUA X3) DATE- SURVEY

X2) MULTIPLE CONSTRUCTION
14D PLAN OF CORRECTION IDENTIFICAnON NUMBER: COMPLETED
A. BUILDING
B. WING
116452 0411912019
JAME OF PROVIDER OR SUPPLIER
STREET ADDRES1, CITY, STATE, ZIP CODE
800 PATTERSON' RD
DRUITTHEALTH- SHEPHERD HILLS LA FAYETTE, t4A 30728
M CMS- 2567( 02- 99) Previous versions Obsolete Event 10: 752GI I Facility to- LTC 11461 it09 If continuation Sheet Page 4 of 11
PRINTED: 05106A2019
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO, 0938- 0391
X4) Q STATEMENT OF DEFICIENCIES
SUMMARY ID i PROVIDER' S PLAN OF CORRECTION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE PATS
DEFICIENCY)
F F 657 Residents Affected: All residents have the
6571
SS= D potential to be affected by this citation. Residents R
1# 58, R# 86 and R# 1104 had care plan meeting
invitations sent to family Members. These residents
I had care plan letters sent to the family members, and
the residents were invited to attend. These meetings
are scheduled for this month and will be completed by,
j5/ 30/ 20%
A system has been implemented where residents are

invited to attend their rare plan meeting and if they I
Care Plan Timing and Revision decline to attend, the MDS and Case Mix
CFR( s): 483. 21( b)( 2)( i)-( iii) Coordinators or a nurse will each document this In the
resident' s medical record to show they declined to
483. 21( b) Comprehensive Care Plans iparticipate in the meeting. Family members will
483. 21( b)( 2) A comprehensive care plan must
continue to receive care plan meeting invitations by
mail two weeks prior to the meeting.
be-
i) Developed within 7 days after The IDT team members will be provided a schedule
completion of the Comprehensive assessment. of upcoming care plan meetings and if they are
ii) Prepared by an interdisciplinary team, unable to attend, they will notify the MDS and Case
that includes but is not limited to-(A) TheMix Coordinators and another employee from their
department will attend in their place.
attending physician.
B) A registered nurse with
responsibility for
MDS and Case Mix Coordinator will audit each care
the resident.
1plan meeting for 4 weeks to ensure residents have
I
C) A nurse aide with responsibility for the been invited to attend, and also to document
resident, attendance of IDT team members. To be completed
D) A member of food and nutrition services 1 by June 3, 2019
staff,( E) To the extent practicable, the participation
j Education was completed on 5/ 16/ 2019 with the MDS
of the resident and the resident' s
tand Case Mix Coordinators as well as with the IDT
representative( s). An explanation must be
I team members concerning the changes in procedure
included in a resident' s medical record if the 1 for care plan meetings. Any applicable employee not
participation of the resident and their resident receiving education due to FMLA, PTO, or other time
representative is determined not practicable for Toff reason will be educated prior to their next
the development of the residents care plan, scheduled shift in the facility. Additionally, this
education will be included in all new partner
F) Other appropriate staff or professionals in
orientation for IDT team members and MDS and
disciplines as determined by the resident' s needs Case Mix team members.
or as requested by the resident. i
iii) Reviewed
team after each
and revised
assessment,
by the interdisciplinary
including both the
1wiTheth DHS will be responsible for ensuring compliance
this POO is met by reviewing, tracking, and
comprehensive and quarterly review I trending the results and ensure that this is brought
assessments,
lbefore the QAPI committee and that a Performance
i Improvement Plan is implemented or revised as
necessary,
by:
Based on observation, record review, policy The Administrator will be responsible for the
review titled" Patient/ Resident Bill of Rights", staff compliance of the monitoring if this plan of correction,
and resident interviews, the facility failed to invite In addition, the Administrator will monitor the
three residents( R) R# 58, R# 86, R# 104, to compliance of this POO in the monthly DAPI
in meetings for 3months to ensure we have appropriate
participate Quarterly care plan meetings, The
failed to provide revision of quarterly
corrective action. Changes will be made to the plan i
facility also
care plans by the complete

by the committee as indicated to include by not
Interdisciplinary Team limited to furthol r education or irnmediate corrective
IDT) for the three residents. The sample size I j action,
DEMENT OF DEFICIENCIES XI) PROVIOERISUPPLIER/ cuA X3) DATE SURVEY

PLAN OF CORRECTION IDENTIFICATION NUMBER: X2) MULTIPLE CONSTRUCTION
COMPLETED
A. BUILDING
6 CMS- 2567( 02- 99) Previous Versions Obsoiete Event 0162011 Facility ID: LTC1 1461209 If continuation sheet Pop 5 of I I
PRINTED: 05/ 0612019
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NCI. 0938- 0391

B. WING
116452 0411912019
NAME OF PROVIDER OR SUPPLIER PET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
X4) 10 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

COMPLETION
DA Tr
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCIED TO THE APPROPRIATE
DEFICIENCY)
F 657= F 657
Continued From page 4
was 51
Findings include.,
Review of the facility policy titled

Patient/ Resident Bill of Rights" with revision date
of 2/ 27/ 181, 2: you have the right to participate in

the development and periodic revision of the plan
of care/ service.
1. A review of the clinical record for R# 58

revealed resident was admitted to the facility on
11/ 2/ 15 with diagnoses of but not limited to
hyperlipidemia, urinary tract infection( UTI),
diabetes, schizophrenia, depression, dysphagia,
seizure disorder and hypertension( HTN).
The resident' s most recent Minimum Data Set

MDS) dated 12/ 25/ 18, revealed a Brief Interview
for Mental Status( RIMS) was coded as 13, which
indicated no cognitive impairment.
Interview on 4/ 16/ 19 at 8: 32 a. m. with revealed

that he used to get invited to care plan meetings,
but hasn' t been invited in over one year.
A review of R# 58' s clinical record did not reveal
any documented evidence that the resident had

been invited to any care plan meetings in the past
year.
Review of the Multidisciplinary Care Conference

Meeting dated 118/ 19, revealed the last meeting
was held on 113/ 19. The meeting was attended
by Activities Director and Case Mix Director,
There is no evidence that the full Interdisciplinary
team attended this quarterly care plan
conference. 2. A review of the clinical record for
R# 86
ATEMENT OF DEFICIENCIES XI) PROVIDERISUPPLIERICLIA X3) DATE SURVEY

NUMBER: X2) MULTIPLE CONSTRUcno
COMPLETED
413 PLAN OF CORRECTION IDENTIFICATION
A. BUILDING
B. WING
116452 0411912019
M CMS- 2567( 02- 99) Previous versions Obsotate Event ID152GII Fa6W to- LTC1 1461209 If contriusibori sheet Page 6 of 11
PRINTED: 05/ 06019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS. CITY, STATE, ZIP CODE
00 PATTERSON RD
X6) 10 1 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN 0F CORRECTION

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL
toI
PREFIX EACH CORRECTIVE ACTION SHOULD OE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) DATE
TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
I
F 657 F 657;
Continued From page 5 revealed resident was

admitted to the facility on 1/ 10/ 18 with
diagnoses of but not limited to dysphagia,
Spondylolisthesis, hypothyroidism, anemia,
anxiety, depression, chronic obstructive
pulmonary disease( COPD), cirrhosis of liver,
diabetes, gastro, esophageal reflux disease
GERD). hypertension( HTN), acute resp
failure, neuromuscular dysfunction of bladder
and neuropathic pain.

MDS) dated 12/ 4118, revealed a Brief Interview
for Mental Status( BIMS) was coded as 13, which
Interview on 4/ 15/ 19 at 12, 35 p.m. with R# 86

revealed that she has not been invited to her
II
quarterly care plan meetings.
A review of R# 86s clinical record did not reveal

year.

Meeting dated 3/ 19119, revealed the last meeting
was held on 3/ 14/ 19. The meeting was attended
by Activities Director, Social Services Director and
Case Mix Director. There is no evidence that the
full Interdisciplinary team attended this quarterly
care plan conference.

subdural hematoma, chronic pain, chronic
obstructive pulmonary disease( COPD), diabetes,
Mononeuropathy, gastroesophageal reflux
disease( GERD), bipolar disorder, hyperlipidemial
ATEMENT OF DEFICIENCIES XI) PROVIDERISUPPLIEMLIA X3) DATE SURVEY

D PLAN OF CORRECTION IDENTIFICATION NUMBER' X2) MULTIPLE CONSTRUCTION
COMPLETED
A. BUILDING
B. WING
116462 0411912019
AME OF PROVIDER OR SUPPLIER STREET ADDRESS! CITY, STATE, ZIP CODE
800 PATTERSON RD
RUITTHEALTH- SHEPHERD HILLS LAFAYETTE, GA 30728
M GMS- 2567( 02. 99) Previous versions Obsolete Event 10; 762G1 I Facility 0 LTC1 1461209 It continuation sheet Page 7 of 11
PRINTED: 0510612019
CENTERS FOR MEDICARE& MEDICAID SERVICES
X4) ID
OMB NO. 0938- 0391
SUMMARY STATEMENT OF DEFICIENCIES to PROVIDER1 PLAN OF CORRECTION ois)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLFTION
TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) TAG OATS
CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
F 657 F 6571
Continued From page 6 dementia, anxiety,

depression, history of deep vein thrombosis
DVT) and dysphagia.

MDS) dated 111/ 19, revealed a Brief Interview for
Mental Status( RIMS) was coded as 14, which
An interview on 4/ 15/ 19 at 2*40 p. m. with R# 104

revealed that he has not been invited to his
A review of R# 104' 6 clinical record did not reveal

year.

Meeting undated, revealed the last meeting was
held on 3128/ 19. The meeting was attended by
Activities Director and Case Mix Director. There is
no evidence that the full Interdisciplinary team
attended this quarterly care plan conference.
Interview on 4118119 at 7: 44 a. m. with Case Mix

Director( CMD) stated she keeps a paper
calendar of when assessments are due. She
gives a list to the Social Services Director( SSD)
who sends invitations to the residents responsible
party. She further stated that the care conference
meetings are held on Thursday' s, and all
members of the interdisciplinary team( IDT) are
given a copy of the monthly list of scheduled
conferences.
During further interview, she confirmed there was

no evidence that the three residents were invited
to participate. She further stated that she did not
invite the residents herself.
ATEMENT OF DEFICIENCIES XI) PROVIDERISUPPLIERICLIA X3) DATE SURVEY

D PLAN OF CORRECTION IDENTIFICATION NUMBER: X2) MULTIPLE CONSTRUCTION COMPLETED
A. BUILDING
B. WING
116452 0411912019
AME OF PROVIDER OR SUPPLIER STREET ADDRESSI ITY, STATE, ZIP CODE
800 PATTERSON D
RUITTHEALTH- SHEPHERD HILLS LA FAYETTE, OA 30728
A
kS1
A OMS- 2567( 02- 99) Previous Versions Obsoiete Eventll): 7= 11 Facility ID: LTC( 1461209 It continuation sheet Page 8 of I4
PRINTED: 06/ 06/ 2019
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO0938- 0391

X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER' S PLAN OF CORRECTION X)—
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX COMPLETION

EACH CORRECTIVE ACTION SHOULD BE
DATE
TAG 3REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
F 657 F 6571
interview on 4t18/ 19 at 8: 05 a. m. with Social

Services Director( SSD) stated she mails a letter
1 to the residents responsible party, two weeks in
advance, inviting them to the residents quarterly
core plan meeting.
She further stated that she gives the residents a
copy of the letter as well, and residents will sign
acknowledgement of the meeting. During further
interview, she stated she was unable to locate
evidence that any of the three residents were
invited to the quarterly care plan conferences.
F 914 Bedrooms Assure Full Visual Privacy F 914 The housekeeping supervisor will replace
SS= D CFR( s): 483. 90( o)( 1)( iv)( v) privacy curtains in rooms 222- A, nd
2211"
226- A, To ensure visual privacy to a residents
483. 90( e)( 1)( iv) Be designed or equipped to and substantial compliance with F 914, This will
assure full visual
privacy for each resident, be completed on 4/ 15/ 2019.
83, 90( e)( 1)( v) In facilities initially certified after The Housekeeping supervisor will do a 100%
March 31, 1992, except in private rooms, each audit on the facility to ensure residents have
bed must have ceiling suspended curtains, which privacy curtains in their rooms. Also to ensure
extend around the bed to provide total visual compliance with F 914. He will also do weekly
privacy in combination with adjacent walls and iaudits.. To be completed by June 3, 2019.
curtains.
This REQUIREMENT is not met as evidenced These findings will be brought to our monthly
QAPI meetings x 3 or until substantial
by:
Based on observation and staff interview the compliance is met to ensure residents privacy
has been achieved,
facility failed to ensure that privacy curtains
provided full visual privacy, which included a total
of three beds( 222A, 225A, 226A) of 106 beds on
one of three halls. The 106 compliance of the monitoring of this plan of
facility census was
correction, In addition, the administrator will
residents.
monitor the compliance of this POC In the
monthly QAPI meetings for 3 months to ensure i

Findings include:
we have appropriate corrective action.
Changes will be made to the plan by the
Observationon 4/ 15/ 19 at 3: 11 p. m. revealed
committee as indicated to include but not
room 222 bed A did not have a privacy curtain, to
limited to further education or immediate
provide full visual privacy during care,
corrective action.
ovs
ON
M CMS. 2567( 02- 99) Previous Versions Obsolete Event ID: 752G1 I FacMyID: LTC114612M ff continuation sheet Page 9 of 11
PRINTED: 05M6A2019
IATFEMENT OF DEFICIENCIES XI) PROVIDER/ SUPPLIEPJCLLA X3) DATE SURVEY

ND PLAN OF CORRECTION IDENTIFICATION NUMBER, X2) MULTIPLE CONSTRUCTION
COMPLETED
A. BUILDING
B, WING
116452 0411912019
I3AME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS LA FAYETTE, OA 30728
X4) 15 SUMMARY STATEMENT OF DEFICIENCIES to PROVIDERS PLAN OF CORRECTION I In)

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COWtETON
TAG CROS& REFERENCED TO THE APPROPRIATE
DEFICIENCY)
V-
4 CMS- 2567( 02- 90) Previous Versions Obsolete Event 10: 752GI 1 Facility 10: LTC11461209 If continuation sheet Page 10 of 11
PRINTED: 05/ 0612019
F 914 Continued From page 8 F 914'
Observation on 4/ 15119 at 4:06 p. m. revealed
provide full visual privacy during care.
Observation on 4/ 15/ 19 at 4:20 p. m, revealed

Interview on 4119119 at 11: 43 a. m. with

Housekeeping Supervisor, stated that privacy
curtains are inspected daily by the housekeeping
staff, and are laundered only when visibly soiled
or dirty. The staff take down the soiled or dirty
curtain, and replace with a temporary curtain, until
the original curtain is washed and ready to be re-
hung, He stated he is not sure why replacement
curtains were not placed when they were taken
down to be laundered. He verified during walking
rounds the rooms identified during the survey that
were missing privacy curtains.
IC)
li
A CMS- 2567'(02- 99) Previous Versions Oteolete Event ID152GI I Facility 0: LTC1 1461209 If continuation sheet Page 11 of 11
PRINTED: 05/ 0212019
MEDICAID SERVICES OMB NO. 0938- 0391

CENTERS FOR MEDICARE&
X1) PROVIDER/ SUPPLIERICLIA X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
NUMBER:
X2) MULTIPLE CONSTRUCTION COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION
A. BUILDING 01- MAIN BUILDING 01
B. WING
115452
0411712019
800 PATTERSON RD
PROVIDER' S PLAN OF CORRECTION X6)

X4) 0 SUMMARY STATEMENT OF DEFICIENCIES 10
COMPLETION
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX
DATE
DEFICIENCY)
K 000 K 000
INITIAL COMMENTS
Stories: 1
Construction Type: V( 111)
Constructed: 1966
Fully Sprinkled: Yes

Census: 108
Certified beds: 112
During a Life Safety Code Survey conducted on

04/ 17/ 2109, PruittHealth Shepherd Hills was
found not in substantial compliance with the
requirements for participation In
Medicare/ Medicaid at 42 CFR Subpart 483. 70( a),
Life Safety from Fire, and the related National
Fire Protection Association( NFPA) standard
NFPA 101 Life Safety Code 2012 edition,
The requirements of 42 CFR, Subpart 483. 70( a)

are NOT MET as evidenced by:
K 2001 Means of Egress Requirements- Other K 200 The Maintenance Director obtained an outside
4 contractor to dispose of the old rotten porch
SS= E CFR( s): NFPA 101
and replace it with concrete and new metal
Means of Egress Requirements- Other railings, to ensure safety of residents and staff
List in the REMARKS section any LSC Section in the event of an emergency. Exterior landing
18. 2 and 19, 2 Means of Egress requirements that remodel was completed on May 20, 2019.
are not addressed by the provided K- tags, but are
deficient. This information, with the To ensure future compliance with K 200 the
along
applicable Life Safety Code or NFPA standard maintenance director will do weekly audits of
citation, should be included on Form CMS- 2587.
all exits to ensure none pose any potential
risks to residents and staff in the event of an
18. 2 19 2
emergency. Completion Date for audits June
3, 2019.
These findings will be brought to our Monthly

compliance is met to ensure safety of
by, residents and staff.
f3ased on observation and staff interviews it was
I determined the facility failed to maintained the

s
i
PRINTED: 05102/ 2019

ABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
ny deficiency statement ending with an asterisk(`) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
sate of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the
late these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
ORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G21 Facility ID: LTC 11461209 if continuation sheet Page 1 of 4
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIERICLIA X3) DATE SURVEY

X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
B. WING
115452 04/ 1712819

800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION x3)

COMPLETION
DATE
DEFICIENCY)
K 200 K 200
exit discharge area at the 200 Hall.

This could place 46 of 106 residents at risk in the
event of a fire emergency.
The findings include:
During a tour of the facility with Staff M on

04117/ 2019 between 9: 30 AM and 1: 00 PM,
observation revealed that the exterior landing at

the exit door of the 200 Hall has deteriorated and
poises a tripping hazard. The railing at this area

has also deteriorated and is unstable.
These findings were confirmed by Staff M at the

time of discovery.
Reference: 2012 NFPA 101, Chapter 19, Section
19. 2. 1, Chapter 7, Section 7. 1. 6. 2
ORM CMS- 2587( 02- 99) Previous Versions Obsolete Event ID: 752G21 Facility 10: LTC11461209 If continuati n sheet Pg 2 of 6
PRINTED: 05/ 02! 2019
K 281 Illumination of Means of Egress K 281 The Maintenance Director installed a

SS= E CFR( s): NFPA 101 Continuous Exit light on the breezeway next to
the kitchen to ensure compliance is met with
Illumination of Means of Egress K281 and to prevent potential injury to residents
Illumination of means of egress, including exit and staff in the event of an emergency. This
discharge, is arranged in accordance with 7. 8 and was completed on 4130/ 2019.
shall be either continuously in operation or

capable of automatic operation without manual To ensure future compliance is met the
intervention. Maintenance director will do weekly audits to
18 2 8, 19 2 8 ensure all exit lighting is functioning properly to
This REQUIREMENT is not met as evidenced ensure safety of residents and staff. Completion
date for the audits June 3, 2019.
by:
Based on observation and staff interviews it was
determined the failed to ensure that the
These findings will be brought to our Monthly
facility
is continuously
j entire means of egress
compliance is met.
illuminated.
This could place 64 of 106 residents at risk in the
event of a fire emergency.
During a tour of the facility with Staff M on i

04/ 17/ 2019 between 9: 30 AM and 1: 00 PM,
observation revealed that the required exit
STATEMENT OF DEFICIENCIES XI) PROVIDERISUPPLIERICLIA X3) DATE SURVEY

NUMBER:
AND PLAN OF CORRECTION IDENTIFICATION
B. WING
115452 04117/ 2019

800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN CORRECTION

COMPLETtON
PLE
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX E'
EACH CORRECTIVE C I
ACTION SHOULD
D BE
DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
K281 _ K281
Continued From page 2 discharge through the
breezeway near the kitchen was not provided

with illumination that is continuous.

time of discovery.
19. 2. 8
ORM CMS- 2667( 02. 99) Previous Versions Obsolete Event ID: 752G21 Facility ID: LTC11481209 Ir cont lctl." eel Page 3 of 5
PRINTED: 05/ 02/ 2019

K 741 Smoking Regulations K 741 The Maintenance Director has ordered new smoking
SS= F CFR( s): NFPA 101 receptacles this includes, Butt can with self- closing lid
and labeled butts only, hand held smoking ashtrays.
Also a garbage can for garbage only. This was
Smoking Regulations completed on 51312019.
Smoking regulations shall be adopted and shall
include not less than the following provisions: These findings will be brought to our Monthly QAPI
1) Smoking shall be prohibited in any room,
meetings x 3 or until substantial compliance is met.
ward, or compartment where flammable liquids,

combustible gases, or oxygen is used or stored
and in any other hazardous location, and such

area shall be posted with signs that read NO
SMOKING or shall be posted with the
international symbol for no smoking.

2) In health care occupancies where smoking is
prohibited and signs are prominently placed at
all major entrances, secondary signs with
language that prohibits smoking shall not be
required. ( 3) Smoking by patients classified as
not responsible shall be prohibited.
4) The requirement of 18, 7. 4( 3) shall not I
apply where the patient is under direct supervision.

5) Ashtrays of noncombustible material and
safe design shall be provided in all areas where
smoking is permitted.
6) Metal containers with self- closing cover
devices into which ashtrays can be emptied shall
be readily available to all areas where smoking is

permitted.
118. 7. 4, 19. 7. 4
i
STATEMENT OF DEFICIENCIES X1) PROVIDERISUPPLIERlCLIA X3) DATE SURVEY

IDENTIFICATION NUh1BER:
AND PLAN OF CORRECTION
B. WING
1. 15452 04/ 17/ 2019

800 PATTERSON RD
PRUITTHEALTH• SHEPHERD HILLS LA FAYETTE, GA 30728
X4) ID ID PROVIDER' s PLAN CORRECTION X51

1 SUMMARY STATEMENT OF DEFICIENCIES OF
COMPLETION
PREFIX I EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
DATE
TAG j REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
OR'M` CMS• ( 32- 9 3J Pravbous? slons Ohsal Event ID: 752G2Facile D: LTC111481209 If ntinuafion sheet Page 4 of 5
PRINTED: 05/ 02/ 2019
K 741 Continued From page 3 K 741
by:
Based on observation and staff interviews it was
determined the facility failed to provide approved
smoking receptacles.
This could place all residents at risk in the event
of a fire emergency with a census was 106

residents.
During a tour of the facility with Staff M on

04/ 17/ 2019 between 9: 30 AM and 1: 00 PM,
observation revealed that the designated smoking
areas were not provided with approved ashtrays
and metal containers with self- closing lids into

which ashtrays can be emptied,
time of discovery.
19. 7. 4
1
I
ORM CMS- 2587( 02- 99) Previous Versions Obsolete Event ID: 752G21 Facility ID: LTC11461209 If continuation sheet Page 5 of 5
PRINTED: 05/ 06/ 2019
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
AND PLAN
A. BUILDING
115452 B. WING
0411912019
RD
PRUITTHEALTH- SHEPHERD HILLS
A FAYETTE,
LA GA 30728
MUST BE PRECEDED BY FULL EACH CORRECTIVE ACTION SHOULD BE COMPLETION

PREFIX EACH DEFICIENCY PREFIX
DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
AMENDED 5/ 6/ 19
A standard survey was conducted at Pruitthealth

Shephard Hills from 04/ 15/ 2019 through
04/ 19/ 2019. In addition, Complaint Intake
Number ( GA00195764) were investigated in
conjunction with this standard survey. The
standard survey revealed that the facility was not
in substantial compliance with Medicare/ Medicaid
regulations at 42 Code of Federal Regulations
C. F. R.) Part 483, Subpart B- Requirements for
Long Term Care Facilities. The following
deficiencies resulted from the facility's
noncompliance related to the standard survey. As
indicated on the facility' s Form CMS- 672,
Resident Census and Conditions of Residents
Form, the facility' s census on 04/ 15/ 2019 was

106 residents.
F 584 Safe/ Clean/ Comfortable/ Homelike Environment F 584
SS= D CFR( s): 483. 10( i)( 1)-( 7)
483. 10( 1) Safe Environment.

The resident has a right to a safe, clean,
comfortable and homelike environment, including
but not limited to receiving treatment and
supports for daily living safely.
The facility must provide-

483. 10( i)( 1) A safe, clean, comfortable, and
homelike environment, allowing the resident to

use his or her personal belongings to the extent
possible.
i) This includes ensuring that the resident can

receive care and services safely and that the
physical layout of the facility maximizes resident
independence and does not pose a safety risk.
ii) The facility shall exercise reasonable care for
X5) DATE
BORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE
y deficiency statement ending with an asterisk(") denotes a deficiency which the institution may be excused from correcting providing it is determined that
ier safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
owing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
s following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
gram participation.
RM GMS- 2567( 02- 99) Previous Versions Ot) sotate Event to: 752G11 Facility ID: LTC11461209 If continuation sheet Page 1 of 9
PRINTED: 05/ 06/
DEPARTMENT OF HEALTH AND HUMAN SERVICES
APPROVED 2
STATEMENT OF DEFICIENCIES Xt) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
115452 B. YANG
04/ 19/ 2019
STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
LA FAYETTE, GA 30728

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL EACH
PREFIX CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO DATE
TAG THE APPROPRIATE
DEFICIENCY)
F 584 Continued From page 1 F 584
the protection of the resident's property from loss

or theft.
483. 10( i)( 2) Housekeeping and maintenance

services necessary to maintain a sanitary, orderly,
and comfortable interior;
483. 10( i)( 3) Clean bed and bath linens that are
in good condition;
483. 10( i)( 4) Private closet space in each

resident room, as specified in§ 483. 90( e)( 2)( iv);
483. 10( i)( 5) Adequate and comfortable lighting

levels in all areas;
483. 10( i)( 6) Comfortable and safe temperature

levels. Facilities initially certified after October 1,
1990 must maintain a temperature range of 71 to
81° F; and
483. 10( i)( 7) For the maintenance of comfortable

sound levels.
by:
Based on observation and interviews, the facility
failed to ensure that it was maintained in a safe,
clean and comfortable homelike environment in
three rooms on one of three halls( 215 B, 221 A,
222 B); also failed to clean wheelchair for one( 1)
resident(# 209). The facility census was 106.
Findings include.-
nclude:
Observation
Observation on 4/ 15/ 19 at 12: 02 p. m. revealed in
room 222- B, three small patches of ripped
sheetrock, approximately two by two inches in
diameter.
DRM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11 Facility ID: LTC114 1209 If Continuation sheet Page 2 Of 9
PRINTED: 05/ 06/ 2019
FORM APPROVED
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION
AND PLAN OF X3) DATE SURVEY
CORRECTION IDENTIFICATION NUMBER:
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES
ID PROVIDER' S PLAN OF CORRECTION x5)
PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Observation on 4/ 15/ 19 at 12: 02 p. m. revealed

resident( R) R# 209 wheelchair to have heavy
layer of dirt/ dust buildup around the wheels and
spokes.
Observation on 4/ 16/ 19 at 8: 34 a. m. revealed in

room 215- 13, two broken slats on wooden window
blinds; also bathroom door knobs were loose and
wobbly.
Observation on 4/ 16/ 19 at 9:57 a. m. revealed in

room 221- A, top drawer of the nightstand is
broken off track and there are no knobs to pull
the drawer open.

Maintenance Director, stated his daily duties
include checking the wander guards, exit doors
and water temperatures. He further stated that
staff complete electronic work orders for items
that need to be serviced. He also stated that staff
will tell him things in passing if repairs are
needed. He verified during walking rounds the
concerns identified during the survey. He stated
that he is not certain who is responsible for
washing the resident wheelchairs.

Housekeeping Supervisor, stated that the 3: 00
P. M. to 11: 00 p. m. floor tech washes wheelchairs
on Mondays, Wednesdays and Fridays. He
further stated the floor tech is washing six-eight
wheelchairs each day. He stated there is no
documentation being done as far as the washing
of the wheelchairs. He stated that he does get a
list of all new admits, and stated that he was not
aware of R# 209 having a wheelchair. He verified
the dust buildup on R# 209 wheelchair and stated
he would have the floor tech wash it.
RM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11 ID LTC11461209
Facility If continuation sheet Page 3 of 9
PRINTED: 05/ 06/
DEPARTMENT
CENTERS
OF HEALTH AND HUMAN SERVICES
FOR MEDICARE&
APPROVED 2
MEDICAID SERVICES
OMB NO. 0938- 0391
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLENON
DEFICIENCY)
F 657 Care Plan Timing and Revision F 657

SS= D CFR( s): 483. 21( b)( 2)( i)-( iii)
483. 21( b) Comprehensive Care Plans

483. 21( b)( 2) A comprehensive care plan must
be-
i) Developed within 7 days after completion of

the comprehensive assessment.
ii) Prepared by an interdisciplinary team, that

includes but is not limited to--
A) The attending physician.
B) A registered nurse with responsibility for the
resident.
C) A nurse aide with responsibility for the

resident.
D) A member of food and nutrition services staff.

E) To the extent practicable, the participation of
the resident and the resident' s representative( s).
An explanation must be included in a resident' s
medical record if the participation of the resident
and their resident representative is determined
not practicable for the development of the
resident' s care plan.
F) Other appropriate staff or professionals in

disciplines as determined by the resident's needs
or as requested by the resident.
iii) Reviewed and revised by the interdisciplinary
team after each assessment, including both the
comprehensive and quarterly review
assessments.

by:
Based on observation, record review, policy
review titled" Patient/ Resident Bill of Rights", staff
and resident interviews, the facility failed to invite
three resident' s( R) R# 58, R# 86, R# 104, to
participate in Quarterly care plan meetings. The
facility also failed to provide revision of quarterly
care plans by the complete Interdisciplinary Team
IDT) for the three residents. The sample size
RM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11
Facility to: LTC11461209 If continuation sheet Page 4 of 9
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 05/ 06/ 2019
FORM APPROVED
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION X3) DATE SURVEY
IDENTIFICATION NUMBER:
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD
PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
DEFICIENCY)
F 657 Continued From page 4

F 657
was 53.
Findings include:
Review of the facility policy titled

Patient/ Resident Bill of Rights" with revision date
of 2/ 27/ 18, 2: you have the right to participate in
the development and periodic revision of the plan
of care/ service.

hyperlipidemia, urinary tract infection( UTI),
diabetes, schizophrenia, depression, dysphagia,
seizure disorder and hypertension( HTN).

Interview on 4/ 16/ 19 at 8: 32 a. m. with revealed

that he used to get invited to care plan meetings,
but hasn' t been invited in over one year.

year.

Meeting dated 1/ 8/ 19, revealed the last meeting
was held on 1/ 3/ 19. The meeting was attended by

RM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11 ID LTC11461209
Facahty If continuation sheet Page 5 of 9
PRINTED: 05/ 06/ 2019
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES _-_ OMB NO. 0938- 0391
A. BUILDING
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD
DEFICIENCY)

dysphagia, Spondylolisthesis, hypothyroidism,
anemia, anxiety, depression, chronic obstructive

pulmonary disease( COPD), cirrhosis of liver,
diabetes, gastro esophageal reflux disease
GERD), hypertension( HTN), acute resp failure,

neuromuscular dysfunction of bladder and
neuropathic pain.

Interview on 4/ 15/ 19 at 12: 35 p. m. with R# 86

revealed that she has not been invited to her

year.

Meeting dated 3/ 19/ 19, revealed the last meeting
was held on 3/ 14/ 19. The meeting was attended
by Activities Director, Social Services Director and
Case Mix Director. There is no evidence that the
full Interdisciplinary team attended this quarterly
care plan conference.

subdural hematoma, chronic pain, chronic
obstructive pulmonary disease( COPD), diabetes,

Mononeuropathy, gastroesophageal reflux
disease( GERD), bipolar disorder, hyperlipidemia,
DRM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11 ID LTC11461209
PRINTED: 05/ 06/ 2019
FORM APPROVED
A. BUILDING
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD

DEFICIENCY)
dementia, anxiety, depression, history of deep

vein thrombosis( DVT) and dysphagia.

MDS) dated 1/ 1/ 19, revealed a Brief Interview for
Mental Status( RIMS) was coded as 14, which
An interview on 4/ 15/ 19 at 2: 40 p. m. with R# 104

revealed that he has not been invited to his

year.

Meeting undated, revealed the last meeting was
held on 3/ 28/ 19. The meeting was attended by
Interview on 4/ 18/ 19 at 7: 44 a. m. with Case Mix

Director( CMD) stated she keeps a paper
calendar of when assessments are due. She
gives a list to the Social Services Director( SSD)
who sends invitations to the residents responsible
party. She further stated that the care conference
meetings are held on Thursday' s, and all
members of the interdisciplinary team( IDT) are
given a copy of the monthly list of scheduled
conferences.
During further interview, she confirmed there was

no evidence that the three residents were invited
to participate. She further stated that she did not
invite the residents herself.
SRM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11 113 LTC114101209
PRINTED: 05/ 06/
APPROVED 2
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD

DEFICIENCY)
Interview on 4/ 18/ 19 at 8: 05 a. m. with Social

Services Director( SSD) stated she mails a letter
to the residents responsible party, two weeks in
advance, inviting them to the residents quarterly
care plan meeting.
She further stated that she gives the residents a
copy of the letter as well, and residents will sign
acknowledgement of the meeting. During further
interview, she stated she was unable to locate
evidence that any of the three residents were
invited to the quarterly care plan conferences.
F 914 Bedrooms Assure Full Visual Privacy F 914
SS= D CFR( s): 483. 90( e)( 1)( iv)( v)
483. 90( e)( 1)( iv) Be designed or equipped to

assure full visual privacy for each resident;
483. 90( e)( 1)( v) In facilities initially certified after

March 31, 1992, except in private rooms, each
bed must have ceiling suspended curtains, which
extend around the bed to provide total visual
privacy in combination with adjacent walls and
curtains.

by:
Based on observation and staff interview the
facility failed to ensure that privacy curtains
one of three halls. The facility census was 106

residents.
Findings include:

RM CMS- 2567 02- 99 Previous Versions Obsolete Event ID: 752G11 ID. LTC114d1209
PRINTED: 05/ 06/ 2019
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID_ SERVICES OMB NO. 0938- 0391
A. COMPLETED
BUILDING
115452 B. WING
04/ 19/ 2019
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION XS)

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE DATE
APPROPRIATE
DEFICIENCY)



the original curtain is washed and ready to be
re- hung. He stated he is not sure why
replacement curtains were not placed when they
were taken down to be laundered. He verified
during walking rounds the rooms identified during

the survey that were missing privacy curtains.
RM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 752G11 Facility ID: LTC11461209 If continuation sheet Page 9 of 9
PRINTED: 05/ 02/ 2019

A. BUILDING
115452 B. WING
04/ 17/ 2019
800 PATTERSON RD
REGULATORY OR LSC IDENTIFYING INFORMATION) DATE

TAG TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
E 000 Initial Comments E 000
A review of the Emergency Preparedness plan

for Pruitthealth Shepherd Hills was conducted on
04/ 17/ 2019. This showed that the plan was in
substantial compliance with the requirements set
forth in appendix Z.
ABO DRY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
1ny deficiency statement ending with an asterisk(*)

denotes a deficiency which the institution may be excused from correcting providing it is determined that
ether safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
ollowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings And plans of Correction are disclosable 14
lays following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
rogram participation.
ORM CMS- 2567( 02- 9 9) Previous Versions Obsolete Event ID: 752G21 Facility ID: LTC11461209 If continuation sheet Page 1 of 1
Harris, Johnetta
From:
Dunaway, Janice
Sent:
Tuesday, June 18, 2019 2: 58 PM
To:
Johnson, Dorothy
Cc:
Morgan, Natalie; Harris, Johnetta
Subject:
FW: PH Shepard Hills Compliance Letter
Attachments:
PH SHEPARD HILLS COMPLIANCE LETTER. RTF; ph shepard hills health 2567b- signed. pdf,
ph shepard hills state 2567b- signed. pdf, ph shepard hills Isc 2567b- signed. pdf; ph
shepard hills survey closure 1539- signed. pdf, ph shepard hills Isc fu 670.pdf, ph shepard
hills health fu 670. pdf
rom: Dunaway, Janice

ent: Tuesday, lune 18, 2019 2: 57 PM
io: dhoang@pruitthealth. com
c: Levi, Jean< jean. levi@dch. ga. gov>
ubject: PH Shepard Hills Compliance Letter
vlr. Hoang,
ettached is the Compliance Letter for the Recertification Survey of 4/ 19/ 19 with a compliance date of 6/ 3/ 19.
lease let me know should you have any questions or concerns.
incerely,
n Dunaway
n Dunaway R. N.
CH
ealthcare Facility Regulation Division

entral Regional Director
Peachtree, NW
Ate 31. 447
tlanta, GA 30303
4- 719- 8223
1
Harris, Johnetta
From: Dunaway, Janice

Sent: Tuesday, May 28, 2019 12: 38 PM
To: Morgan, Natalie; Harris, Johnetta
Cc: Johnson, Dorothy; Dunbar, Robbie; Levi, Jean; kshadix@sfm. ga. gov
Subject: FW: Acceptable POC letter
Attachments: PH SHEPARD HILLS APOC LETTER. RTF; ph shepard hills apoc 1539- signed. pdf, PH
Shepard Hills State APOC- signed. pdf, PH Shepard HIlls Health APOC- signed. pdf
All,
I was finally able to approve the Health POC.
an

Sent: Tuesday, May 28, 2019 12: 35 PM
lo: ' Marcus Oates'< MOates@pruitthealth. com>
c: ' Linda Brock'< LBrock@pruitthealth. com>
ubject: Acceptable POC letter
Ar. Oates and Ms. Brock,
lease find attached the Acceptable POC letter for the Recertification Survey of 4/ 19/ 19 with an alleged compliance date
if 6/ 3/ 19.
eel free to contact me should you have any questions or concerns.
sincerely,
an Dunaway R. N.
CH
ealthcare Facility Regulation Division

entral Regional Director
Peachtree, NW
uite 31. 447
tlanta, GA 30303
04- 719- 8223
1
Harris, Johnetta
From:
Dunaway, Janice
Sent: Monday, May 06, 2019 10: 22 AM
Cc:
Johnson, Dorothy
Subject: FW: PH Shepard Hills Amended 2567 and Initial Letter
Attachments:
PH SHEPARD HILLS AMENDED INITIAL LETTER. RTF; ph shepard hills amended 2567.pdf
Please add to the suspense file.
Jan

Sent: Monday, May 6, 2019 10: 21 AM
To: moates@pruitthealth. com; Ibrock@pruitthealth. com
Subject: PH Shepard Hills Amended 2567 and Initial Letter
Mr. Oates,
Attached is the Amended Initial Letter and the Health 2567 for the Recertification and Complaint survey of
4/ 19/ 19. Please let me know should you have any questions or concerns.
Sincerely,
Jan Dunaway
Jan Dunaway R. N.
DCH

Central Regional Director
2 Peachtree, NW
Suite 31. 447
Atlanta, GA 30303
404- 719- 8223
1
Harris, Johnetta
From: Levi, Jean
Sent: Friday, May 03, 2019 9: 36 AM

To: Morgan, Natalie
Cc: Harris, Johnetta
Subject:
FW: Pruitt Health Shepherd Hills supporting documents
Attachments: PruittHealthShepherdHillssupportingdocs. pdf
FYI
From: Dean, Cheryl
Sent: Sunday, April 28, 2019 10: 27 PM

To: Levi, Jean< jean. levi@dch. ga. gov>
Subject: Pruitt Health Shepherd Hills supporting documents
I have had the citations in ACO since Wednesday, but was on survey and did not have a chance to send you the
supporting documents until now. Let me know if you have any questions. I will be mailing the paperwork Monday
morning on my way out to survey.
heryl Dean, RN, BSN, Nurse Manager 2

State of Georgia, Department of Community Health
Llealthcare Facility Regulation Division
Peachtree St; Suite 31. 447
tlanta, Ga 30303
Jfc: 404- 657- 5700
Nork Cell 404- 991- 0937
ax: 404- 657- 9724
eryl. dean dch ga. gov
ollow us on Twitter at http:// twitter. com/ gadch and Facebook

it http:// bit. ly/ blGcXl
reader Advisory Notice: E- mail to and from a Georgia state agency is generally public record, except for content that is confidential under specific laws.
security by encryption is applied to all confidential information sent by e- mail from the Georgia Department of Community Health.
1
Harris, Johnetta

Sent: Thursday, May 02, 2019 12: 16 PM
Cc: Johnson, Dorothy
Subject: FW: PH Shepard Hills 2567 and letters
Attachments: PH SHEPARD HILLS INITIAL LETTER. RTF; PH SHEPARD HILLS STATE LETTER. RTF; PH
SHEPARD HILLS CIVIL RIGHTS LETTER. RTF; ph shepard hills Isc k 2567. pdf; ph shepard
hills Isc e 2567. pdf; ph shepard hills st 2567. pdf, ph shepard hills health 2567. pdf, PH
Shepard Hills new QA form. pdf, ph shepard hills Isc 670. pdf, ph shepard hills co 670. pdf,
ph shepard hills health 670. pdf

Sent: Thursday, May 2, 2019 12: 13 PM
To: moates@pruitthealth. com; Ibrock@pruitthealth. com
Subject: PH Shepard Hills 2567 and letters
Good Morning/ Afternoon,
Please find attached to this email your Federal Letter, State Letter, Civil Rights Letter and CMS 2567 for the Survey
conducted at your facility on April 19, 2019. Your facility was found not to be in substantial compliance with the
program requirements.
We ask that you send your POC directly to the HFRD mailbox and to my email address. If your POC is received via email it
is not necessary to mail a copy directly to the office. We are no longer using fax to receive the POCs.
You may be eligible for a desk review, therefore please ensure the POC is as detailed as possible. You will be informed
via email when the POC is accepted as to your eligibility for a Health desk review. Please only send the POC and do not
send documents until they are requested once the POC is accepted.
I will be processing this survey on behalf of Jean Levi, RD Northern Regional Director. If you have any questions, feel free
to contact me at 404- 404- 719- 8223. Please confirm that you have received this email.
Jan Dunaway R. N.
DCH

Central Regional Director
2 Peachtree, NW
Suite 31. 447
Atlanta, GA 30303
404- 719- 8223
1
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH

2 Peachtree Street, NW I Atlanta, GA 30303- 3159 404- 656- 4507

1 1 www. dch. georgia. gov
VIA EMAIL
May 2, 2019

800 Patterson Rd
Dear Mr. Oates:
On April 19, 2019, staff from the Department Health ( DCH),

of
Community Healthcare Facility
Regulation Division ( HFRD) Long Term Care Section, conducted a of Pruitthealth - Shepherd
survey
Hills. Based on the survey, violations of the Rules and Regulations for Nursing Homes, Chapter
111- 8- 56, or the Rules and Regulations for Long- Term Care Facility: Bill of Rights were cited.
Attached is a copy of the Survey Report.
Pursuant to the Rules and Regulation for Nursing Homes, Chapter 111- 8- 56, and the Rules and
Regulations for General Licensing and Enforcement Requirements, Chapter 111- 8- 25, the
Department may impose a sanction for the violation of any rule. Notice to the governing body
regarding the imposition of a sanction will be sent under separate cover. Failure to correct violations
or failure to maintain compliance once corrections are made may result in further sanctions,
including revocation of your permit.
You must submit a plan of correction ( POC) for each deficiency cited in this report. Your plan to
correct these deficiencies should be entered in the right hand column entitled Providers Plan of
Correction Date. After you have completed the form( s), sign and date them in the space provided,
return the ORIGINAL to our office no later than May 12, 2019.
Pursuant to the Rules and Regulations for Enforcement of Licensing Requirements, Chapter
111- 8- 25, the facility must post this notice and a copy of the violations in a place readily accessible
and continuously visible to persons in care and their representatives. The attached survey report will
be on file in this office. Rules and Regulations require that all survey reports will be available to any
interested person upon written request.
Statement of Disagreement
If you disagree with the any of the survey findings in this report, you may send a written statement of
disagreement, identifying the specific deficiencies with which you disagree and an explanation of the
basis disagreement,
of your
including any information or
supporting documentation. This statement
and any supporting information must be submitted within ten ( 10) days of receipt of this report and,
must be separated from the plan of correction ( POC).
If you have any questions or if we may be of assistance, please do not hesitate to call or write us.
Sincerely,
DW&W04Y R 72,

Long Term Care
Enclosures
cc: Facility File
Page 2
Approved 5/ 28/ 19 LPOC: 6/ 3/ 19 JA411 PRINTM 05/ 02/ 2019
FORM APPROVED
State of GA, Healthcare Facility Regelation Division
STATEMENT OF DEFICIENCIES XI) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER* COMPLETED
A, BUILDING:
B. WING
1- 146- 1671 04/ 1912019
1AME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH. SHEPHERD HILLS
LAFAYETTE, GA 30720
X4) ID SUMMARY STATEMENT DEFICIENCIES

OF 10 PROVIDERS PLAN OF CORRECTION
DATE
DEFICIENCY)
N1807 N1807
N1807 The housekeeping supervisor will replace
111- 8- 56-. 18( 8) Physical Plant Standards. privacy curtains in rooms 222- A, 225- A and 226- A.
To ensure visual privacy to all residents and
Each patient room having more than one bed i substantial compliance with F 914.
shall have permanently installed curtain tracks to
permit dosing each bed with curtains to allow for
The Housekeeping supervisor will do a 100% audit
the privacy of each patent without obstructing the
on the facility to ensure residents have privacy
passage of other patients either to the corridor or
curtains in their rooms. Completed on 5/ 13/ 2019.
to the toilet or lavatory adjacent to the patient
room. Curtains used for enclosing patient beds Also to ensure compliance with F 914. He will also
shall be rendered and maintained lame resistant.
do weekly audits x 3 months. Completion date will
be June 3, 2019
This RULE is not met as evidenced by:

These findings will be brought to our monthly QAP1 i
The facility failed to ensure that privacy curtains
meetings x 3 or until substantial compliance is met
of three beds( 222A, 226A, 226A) of 106 beds on to ensure residents privacy has been achieved.

residents.
compliance of the monitoring of this plan of

Findings include. correction. In addition, the administrator will
monitor the compliance of this POC In the monthly

Observation 4115/ 19 at 3: 11 p. m. revealed
on CIAPI meetings for 3 months to ensure we have
I room 222 bed A did not have a privacy curtain, to appropriate Corrective action. Changes will be
provide full visual
privacy during care. made to the plan by the committee as indicated to
include but not limited to further education or
Observation on 4/ 15/ 19 at 4: 06 p. m. revealed immediate corrective action,

Observation on 4/ 15/ 19 at 4:20 p. m. revealed


staff, and are laundered only when visibly soiled q
the original curtain is washed and ready to be re-
hung. He stated he is not sure why
of GA InS0466n Report
RATORY DIRECTORS OR PROVIOERtSUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
TE FORM 69% 7521311 If continuation sheet I of 2
PRINTED: 05/ 02/ 2019

FORM APPROVED
Late of GA, Healthcare Facility Regulation Division
FATEMENT OF DEFICIENCIES XI) PROVIDERISUPPLIEPJCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
40 PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
1- 146- 1671 04/ 19/ 2019
IE OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
RUITTHEALTH- SHEPHERD HILLS
0) to
PRE,— I SUMMARY STATEMENT OF DEFICIENCIES
EACH DEFICIENCY MUST BE PRECEDED BY FULL
to
PREFIX
PROVIDER' S PLAN OF CORRECTION
EACH CORRECTIVE ACTION SHOULD BE
xs)
COMPLETE
TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) DATE

OEFICIENCY)
N1807 Continued From page I N1807

All
J
t of GA Inspeoton Report
TE FORM 752GI 1 It continuation sheet 2 of 2

PRINTED: 05/ 02/ 2019
FORM APPROVED
State of GA, Healthcare Facility Regulation Division
A. BUILDING: COMPLETED
B. WING
1- 146- 1671
04/ 19/ 2019
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S

ID PLAN OF CORRECTION X5)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE
DEFICIENCY)
N1807 111- 8- 56-. 18( 8) Physical Plant Standards. N1807
Each patient room having more than one bed

shall have permanently installed curtain tracks to
permit closing each bed with curtains to allow for
the privacy of each patient without obstructing the
passage of other patients either to the corridor or
to the toilet or lavatory adjacent to the patient

room. Curtains used for enclosing patient beds
shall be rendered and maintained flame resistant.
This RULE is not met as evidenced by:

The facility failed to ensure that privacy curtains
residents.
Findings include:


Observation on 4/ 15/ 19 at 4:20 p. m. revealed


the original curtain is washed and ready to be
re- hung. He stated he is not sure why
to of GA Inspection Report
ORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
TE FORM 6899
752G11 If continuation sheet 1 of 2
PRINTED: 05/ 02/ 2019
FORM APPROVED
State of GA, Healthcare Facility Re ulation Division
A. BUILDING: COMPLETED
1- 146- 1671 B. WING

04/ 19/ 2019
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' SPLAN OF CORRECTION
X5)
PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)
TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N1807 Continued From page 1 N1807

e of GA Inspection Report
TE FORM 6898
752G11 If continuation sheet 2 of 2

2019 DCH Reports Involving Shepherd Hill Nursing Home

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GEORGIA DEPARTMENT

Brian P. Kemp, Governor

IMPORTANT NOTICE - PLEASE READ CAREFULLY

June 18, 2019

Mr. Dustin Hoang, Administrator

Dear Mr. Hoang:

6 D" aufacy R,72.

Jan Dunaway RN for Jean Levi

Brian P. Kemp, Governor

IMPORTANT NOTICE - PLEASE READ CAREFULLY

May 28, 2019

Mr. Dustin Hoang, Administrator

Dear Mr. Hoang:

cc: Facility File

Brian P. Kemp, Governor

AMENDED May 6, 2019

Mr. Marcus Oates, Administrator

Dear Mr. Oates:

Plan of Correction ( PoC)

An acceptable PoC must:

Includes dates when corrective action will be completed.

Civil Money Penalty, in an amount and duration to be determined by CMS.

Informal Dispute Resolution ( IDR)

In accordance with 42 CFR §

A copy of our informal dispute resolution process is available

Disclosure of Survey Results

Public Lawto 92-

Jan Dunaway for Jean Levi

cc: Melanie Simon

Brian P. Kemp, Governor

IMPORTANT NOTICE - PLEASE READ CAREFULLY

Mr. Marcus Oates, Administrator

Dear Mr. Oates:

Plan of Correction ( PoC)

An acceptable PoC must:

Includes dates when corrective action will be completed.

The Plan of Correction facility' s allegation of compliance.

Civil Money Penalty, in an amount and duration to be determined by CMS.

Termination of Medicare Agreement.

Informal Dispute Resolution ( IDR)

In accordance with 42 CFR §

A copy of our informal dispute resolution process is available upon request.

Disclosure of Survey Results

Jan Dunaway for Jean Levi

cc: Melanie Simon

Brian P. Kemp, Governor

IMPORTANT NOTICE - PLEASE READ CAREFULLY

Mr. Marcus Oates, Administrator

Dear Mr. Oates:

Jan Dunaway for Jean Levi

cc: Facility File

CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION 05)

A standard survey was conducted at Pruittheafth

E regulations at 42 Code of Federal Regulations

Form, the facility s census on 04/ 15/ 2019 was

The Administrator will be responsible for

CENTERS FOR MEDICARE& MEDICAID SERVICES OMS NO. 093$- 0391