GEC3RG IA DEPARTMENT

OF' COMtwEI1Nrry HEALTm

Nathan Deal, Governor Frank W. Berry, Commissioner

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

IMPORTANT NOTICE - PLEASE READ CAREFULLY

May 9, 2018

Mr. Michael Dykes, Administrator

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728

Dear . Dykes:

A revisit was conducted at your facility to verify that your facility had achieved and maintained
substantial compliance. Our LSC revisit conducted on May 5, 2018 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 April 23, 2018.

If there are any questions concerning the above, or if we may be of assistance, please do not
hesitate to call or write us.

Si, cerely,

e'_ "

J n Levi
ional Director, Northern Region
Long Term Care Section
Healthcare Facility Regulation Division

cc: Georgia Department of Community Health/ Division of Medical Assistance

State Long Term Care Ombudsman

Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
 GCOR01A DEPARTMENT
OF COMMUNITY HEALTH
h

Nathan Deal, Governor Frank Berry, Commissioner

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

IMPORTANT NOTICE - PLEASE READ CAREFULLY

April 19, 2018

Mr. Michael Dykes, Administrator

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728

Dear . Mr Dykes:

On March 29, 2018, a Recertification survey was conducted at your facility. In your plan of
correction, you have alleged that the deficiencies cited on that survey have been or will be
corrected. Your latest plan of correction date is April 23, 2018. 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.

incerely,

an Levi
gional Director, Northern
Long Term Care Section
Healthcare Facility Regulation Division

cc: Facility File

Health Information Technology I Healthcare Facility Regulation 1 Medicaid I State Health Benefit Plan
Equal Opportunity Employer
 GEORGIA DEPARTMENT
t
OF COMMUNrry HEALTH

Nathan Deal, Governor Frank Berry, Commissioner

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

IMPORTANT NOTICE - PLEASE READ CAREFULLY

April 10, 2018

Mr. Michael Dykes, Administrator

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728

Dear . Mr. Dykes:

On March 29, 2018 the Georgia survey agency conducted a Recertification 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 1PoCJ

A POC for the deficiencies cited on the CMS- 2567 must be submitted by April 20, 2018. Submit an
electronic PoC to hfrd. goc(a-)dch. ga. gov and jean. levi@dch. ga. gov 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 Mav 13. 2018.

Failure to submit an acceptable PoC by April 20, 2018 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;
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
Pruitthealth - Shepherd Hills
April 10, 2018
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 adeauately 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 June 29, 2018 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 September 29, 2018 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 reauired to send
vour written request for IDR, along with the specific deficiencies being disputed, and an.
explanation of why you are disoutina those deficiencies. including anv information or
documentation supportinq vour refutation. This request and anv supportinq information must be
the same 10 days you have for submitting PoC for the cited deficiencies. In addition
sent during a

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.
Pruitthealth - Shepherd Hills
April 10, 2018
Page 3

Please note that an incomplete informal dispute resolution process will not delay the effective
date of any enforcement action against the facility.

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 Survev 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 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.

incerely,

n Levi
e ional Director, Northern
L g Term Care Section
Healthcare Facility Regulation Division

cc: Melanie Simon

CMS Regional Office
State Long Term Care Ombudsman
 GEORGIA DEPARTMENT
OFCOMMUNr" HEALTH

Nathan Deal, Governor

Frank Berry, Commissioner

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

IMPORTANT NOTICE - PLEASE READ CAREFULLY

April 10, 2018

Mr. Michael Dykes, Administrator

Pruitthealth -
Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728

Dear Mr. Dykes:

Federal regulations require this office to conduct periodic compliance reviews for Title VI of
the Civil Rights Act of 1964. On March 29, 2018, 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.

Si icerely,

J n Levi
e ional Director Northern
Ithcare Facility Regulation Division

cc: Facility File

Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
 PRINTED: 04/ 10/
DEPARTMENT
CENTERS
OF HEALTH AND HUMAN SERVICES
FOR MEDICARE &
APPROVED 2
MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED

115452 B. WING
03/ 29/ 2018
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID I PROVIDER' S PLAN OF CORRECTION x5)
PREFIX ' ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

F 000 INITIAL COMMENTS F 000'

A standard survey was conducted at Pruitt Health

Shepherd Hills from March 26, 2018- March 29,
2018. The standard survey revealed that the
facility was in substantial compliance with the
Health portion of Medicare/ Medicaid regulations
at 42 Code of Federal Regulations ( C. F. R.) Part
43, Subpart B- Requirements for Long Term Care
Facilities. As indicated on the facility' s Form CMS
672, Resident Census and Conditions of
Residents Form, the facility' s census on March
26, 2018 was 105 residents.

LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6 DATE

Any deficiency statement ending with an asterisk(")

other safeguards provide sufficient
denotes a deficiency which the institution may be excused from correcting providing it is determined that
to the patients. (
protection See instructions.)
Except for nursing homes, the findings stated above are disclosable 90 days
following 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
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: L81 E11 FacilityID: LTC11461209
If continuation sheet Page 1 of 1
 PRINTED: 04/ 10/ 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES b
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING 01 - MAIN BUILDING 01 COMPLETED

115452 B. WING
03/ 28/ 2p1$
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE

i DEFICIENCY)

r
3
i
K 000; INITIAL COMMENTS i K 000
i
l
Stories: 1
Construction Type: V( 111)
Constructed: 1966
Fully Sprinkled; Yes
Census: 105
Certified beds: 112

During a Life Safety Code Survey conducted on

03128/ 2018, 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 I
i
I Fire Protection Association ( NFPA) standard
I
i NFPA 101 Life Safety Code 2012 edition.
l I
The requirements of 42 CFR, Subpart 483. 70( a)
are NOT MET as evidenced
by: f
K 321 Hazardous Areas- Enclosure K 3211
i
SS= E. CFR( s); NFPA 101
i
I 1

Hazardous Areas- Enclosure

Hazardous areas are protected by a fire barrier
having 1- hour fire resistance rating ( with 3/ 4 hour
fire rated doors) or an automatic fire extinguishing
system In accordance with 8. 7. 1 or 19. 3. 5. 9.
When the approved automatic fire extinguishing
system option is used, the areas shall be I
separated from other spaces by smoke resisting
partitions and doors in accordance with 8. 4. i
Doors shall be self- closing or automatic- closing
and permitted to have nonrated or field- applied
protective plates that do not exceed 48 inches
from the bottom of the door.
Describe the floor and zone locations of
hazardous areas that are deficient in REMARKS.
19. 3. 2. 1, 19. 3. 5. 9

LABORATORY DI CTOR' S R PR vTn

V— St1 ENTATIVE' S SIGNATURE TITLE X6) ATE

Any deficiency Ong W

statement asterisk(*)
an
denotes a deficiency which the institution maybe excused from correcting providing it is delermineethat
other safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following 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
days following the date these documents are made available to the facility. if deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event 1D: L81E21 Facility ID: LTC11461209 If continuatlon sheet Page 1 of 4
 PRINTED: 04/ 10/ 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA (
NUMBER: COMPLETED
PLAN OF CORRECTION IDENTIFICATION 01
AND A. BUILDING 01 - MAIN BUILDING

115452 B. WING 03/ 2812018

OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

NAME
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5I

X4) to COMPLETION
ION
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)

i
Pruitthealth Shepherd Hills to maintain compliance 4/73/2018
K 321 ! Continued From page 1 f K 321;
i with State regulations in reference to the State Fire i
Marshals recent Life Safety Code Survey visit
Area Automatic Sprinkler conducted on 3/ 28/2018 concerning the results of
Separation NIA K321 tag. Requirements of 42 CFR, Subpart 483. 70
a. Boiler and Fuel- Fired Heater Rooms a) has identified and addressed the two large
b. Laundries( larger than 100 square feet) openings in the ceiling of the bulk
c. Repair, Maintenance, and Paint Shops combustible storage area by obtaining a
d. Soiled Linen Rooms( exceeding 84 gallons) Licensed contractor to replace the damaged
e, Trash Collection Rooms i i Drywall with proper material to comply with
exceeding 84 gallons) life safety code. Work to be performed and
f. Combustible Storage Rooms/ Spaces completed by 4/ 2312018. Maintenance
over 50 square feet) Director along with Administrator and Environmental'
Consultant will follow up to make sure work is
g, Laboratories ( if classified as Severe
Hazard- see K322) I completed and meets Life Safety Codes.
Maintenance Director created a Quarterly tog on
This REQUIREMENT is not met as evidenced
3/ 28/ 2018 to inspect this area for Life Safety
by: compliance which will began no later than 4/ 23l20181
i
Based On and staff interviews it
Observation was
date of work to be completed twice a month x three
determined the facility failed to ensure that all
months. Placed in QAPI to review monthly x three
hazardous roam are maintained properly with months.

construction capable of resisting the passage of

smoke,

This could place all residents at risk in the event

of a fire emergency. I

The findings include:

During a tour of the facility with Staff M on i
and 3: 00 pm
11: 00 I
03/ 28/ 2018 between am

observation revealed that the ceiling in the bulk

1
combustible storage area of the basement was
not properly maintained. Two large openings were
observed in the sheetrock ceiling. This storage
i
area directly below a resident room.
is
These findings were confirmed by Staff M at the
time of discovery.
Reference: 2012 NFPA 101, chapter 19, section
19. 3. 2. 1. 2, chapter 8, section 8. 4. 1 and 8. 4. 2 ( a) i
I

K 324 Cooking Facilities K 324;

SS= E CFR( s): NFPA 101

FORM CMS- 2567( 42- 99) Previous Versions Obsolete Event ID: L81E21 Facility ID: LT011461209 If continuation sheet Page 2 of 4
 PRINTED: 04/ 10/ 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

MEDICAID SERVICES OMB NO, 0938- 0391

CENTERS FOR MEDICARE&
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERICLIA (
COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING 01- MAIN BUILDING 01

116462 B. WING 03128/ 2018

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYE' TTE, GA 30728

OF DEFICIENCIES ID PRODDER' S PLAN OF CORRECTION XS)

X4) ID SUMMARY STATEMENT
EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
GATE
GROSS• REFEREDNC E APPROPRIATE
OR LSO IDENTIFYING INFORMATION) TAG
TAG REGULATORY
DC ENCY
1
i

K 324, Continued From page 2 K 324

Cooking Facilities
equipment is protected in accordance
E
Cooking l
with NFPA 96, Standard for Ventilation Control ;
and Fire Protection of Commercial Cooking
Operations, unless.

residential cooking equipment( i. e., small

appliances such as microwaves, hot plates,
toasters) are used for food warming or limited
cooking in accordance with 1& 3.2, 5.2, 19. 3, 2.52
cooking facilities open to the corridor in smoke
compartments with 30 or fewer patients comply
with the conditions under 18. 3. 2.5. 3, 19. 3. 2. 5. 3,
or

cooking facilities in smoke compartments with

30 or fewer patients comply with conditions under
18. 3. 2. 5.4, 1 9.3, 2.5.4.
Cooking facilities protected according to NFPA 96 I

per 9. 2. are not required to be enclosed as

3 s
I
hazardous areas, but shall not be open to the
corridor.

18. 3.2. 5, 1 through 18. 3, 2.5, 4, 19,3.2.5. 1 through

19. 3. 2. 5. 5, 9. 2. 3, TIA 12- 2
I
i
I

This REQUIREMENT is not met as evidenced I

by:
Based on observation and staff interviews it was r
determined the facility failed to ensure that all I
l
cooking equipment is properly aligned
underneath the hood suppression system.
This could place all residents at risk in the event ;
i of a fire emergency. i

The findings include: i ti

During a tour of the facility with Staff M on
03/28/ 2018 between 11: 00 am and 3:00 pm
F observation, revealed that the deep fat fryer was
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event Ira: L81E21 Facfttty to: LTC11461209 If continuation sheet Page 3 of 4
 DEPARTMENT OF HEALTH AND HUMAN PRINTED: 04/ 10/ 2018
SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO, 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLiA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING 01- MAIN BUILDING 01 COMPLETED

115452 B. WING
03/ 2812018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUtTTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) 10 SUMMARY STATEMENT OF DEFICIENCIES ID
I
PROVIDER' S PLAN OF CORRECTION X5)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL i i (
PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ! TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
I j DEFICIENCY)

K 324 i Continued From page 3 K 324; Pruitthealth Shepherd Hills to maintain 4/ 23/ 2018

not properly alleged with the hood suppression ' compliance with Stale Regulations in
nozzle, 1 reference to the State Fire Marshals Life
These findings were confirmed by Staff M at the 1Safety Code survey conducted on 3/ 28/2018
time of discovery, i concerning the results of K324 tag- Cooking
Reference: 2012 NFPA 101, chapter 19, section Facilities CFR( s) NFPA 101 deep fat Fryer
19. 3. 2. 5. 1, chapter 9, section 9. 23, chapter 2, not properly aligned with kitchen hood
section 2. 2, 2011 NFPA 96, chapter 10, section ; suppression system nozzle has identified and
10. 3. 1 and chapter 12, section 12. 1 corrected the problem on 3128/ 2018.
Maintenance Director created a weekly
check list on 3/ 28/ 2018 to make sure required
equipment is aligned with kitchen hood
suppression nozzles to maintain life safety i
I
1
compliance and will monitor weekly x 3 weeks.
i Maintenance director and Director

i of Dietary Services conducted a Life safety

In- service with dietary staff on 3128118 to
j address this issue. In- service completed
with dietary staff on or by 4/ 6/ 2018. Placed in
QAPI for review monthly x three months.

I t
1

r
l
i Lf
i

I
i
I

i
i

FORM CMS- 2567( 02. 99) Previous Versions Obsolete

Event 10. L81 E21 Facility 10: LTC11461209 If continuation sheet Page 4 of 4
 PRINTED: 0411 0/ 2 0 1 8
AND HUMAN SERVICES FORM APPROVED
DEPARTMENT OF HEALTH
SERVICES OMB NO. 0938- 0391 ,
CENTERS FOR MEDICARE& MEDICAID
XS) SURVEY
MULTIPLE CONSTRUCTION
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
( X1) PROVIDERISUPPLIERJCLIA
IDENTIFICATION NUMBER:
( X2)

A. BUILDING
CATE

115452 s. WING 0312812018

OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NAME OF PROVIDER
00 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
PROVIDER' S PLAN OF CORRECTION xs)
X4) ID i SUMMARY STATEMENT OF DEFICIENCIES ID
COMPLETION
BY FULL i PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX 1 ( EACH DEFICIENCY MUST BE PRECEDED
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED 70 THE APPROPRIATE
TAG DEFICIENCY)

E 000• Initial Comments E O00

C i

A review of the Emergency preparedness plan

for Pruitthealth Shepherd Hills was conducted on
03128/ 2018, This showed that the plan was In i
substantial compliance with the requirements set
forth in appendix Z. I

1
i

i I
i
PROVIDER/ L iER REPRESENTATIVE' S SIGNATURE TITLE X6) OAT
LABORATORY DIRECTOR' S SUP
05
a
ny deficiency statement eking> ntfri an asterisk(") denote's afletictency which the institution may be excused from correcting providing it is fleterm( ned 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 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
days following the date these documents are made available to the facility. if deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: L81 E21 Facility ID; LTC11461209 If continuation sheet Page 1 of 1
 PRINTED: 04/ 10/
DEPARTMENT
CENTERS
OF HEALTH AND HUMAN SERVICES
FOR MEDICARE &
APPROVED 2
MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING 01 - MAIN COMPLETED
BUILDING 01

115452 B. WING
03/ 28/ 2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

K 000 INITIAL COMMENTS K 000

Stories: 1
Construction Type: V( 111)
Constructed: 1966
Fully Sprinkled: Yes
Census: 105
Certified beds: 112

During a Life Safety Code Survey conducted on

03/ 28/ 2018, 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 321 1
Hazardous Areas- Enclosure K 321
SS= E ' CFR( s): NFPA 101

Hazardous Areas- Enclosure

Hazardous areas are protected by a fire barrier
having 1- hour fire resistance rating ( with 3/ 4 hour
fire rated doors) or an automatic fire extinguishing
system in accordance with 8. 7. 1 or 19. 3. 5. 9.
When the approved automatic fire extinguishing
system option is used, the areas shall be
separated from other spaces by smoke resisting
partitions and doors in accordance with 8. 4.
Doors shall be self-closing or automatic-closing
and permitted to have nonrated or field- applied
protective plates that do not exceed 48 inches
from the bottom of the door.
Describe the floor and zone locations of
hazardous areas that are deficient in REMARKS.
19. 3. 2. 1, 19. 3. 5. 9

ABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE

Any deficiency statement ending with an asterisk(*)

other safeguards sufficient
denotes a deficiency which the institution may be excused from correcting providing it is determined that
provide protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following 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
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: L81 E21 Facility ID: LTC11461209 If continuation sheet Page 1 of 4
 PRINTED: 04/ 10/ 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

MEDICAID SERVICES OMB NO. 0938- 0391

CENTERS FOR MEDICARE &
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA
COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 01 - MAIN BUILDING 01
A. BUILDING

115452 B. WING 03/ 28/ 2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728

STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

X4) ID SUMMARY
SHOULD BE CO ioN
EACH CORRECTIVE ACTION
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
CROSS- REFERENCED TO THE APPROPRIATE
DATEMPLET
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
TAG
DEFICIENCY)

I'

K 321 '', Continued From page 1 K 321

I

Area Automatic Sprinkler

Separation N/ A
a. Boiler and Fuel- Fired Heater Rooms
b. Laundries ( larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms( exceeding 64 gallons)
e. Trash Collection Rooms
exceeding 64 gallons)
f. Combustible Storage Rooms/ Spaces
over 50 square feet)
g. Laboratories ( if classified as Severe
Hazard- see K322)
This REQUIREMENT is not met as evidenced
by:
Based on observation and staff interviews it was
determined the facility failed to ensure that all
hazardous room are maintained properly with
construction capable of resisting the passage of
smoke.

This could place all residents at risk in the event

of a fire emergency.

The findings include:

During a tour of the facility with Staff M on
03/ 28/ 2018 between 11: 00 am and 3: 00 pm
observation revealed that the ceiling in the bulk
combustible storage area of the basement was
not properly maintained. Two large openings were
observed in the sheetrock ceiling. This storage
area is directly below a resident room.
These findings were confirmed by Staff M at the
time of discovery.
Reference: 2012 NFPA 101, chapter 19, section
19. 3. 2. 1. 2, chapter 8, section 8.4. 1 and 8. 4. 2 ( a)
K 324
K 324 Cooking Facilities i
SS= E CFR( s): NFPA 101

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: L81 E21 Facility ID: LTC11461209 If continuation sheet Page 2 of 4
 PRINTED: 04/ 10/ 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391

CENTERS
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA
COMPLETED
IDENTIFICATION NUMBER:
AND PLAN OF CORRECTION A. BUILDING 01 - MAIN BUILDING 01

115452 B. WING 0312812018

STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728

OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

X4) ID SUMMARY STATEMENT
ACTION SHOULD BE COMPLETION
MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE
PREFIX EACH DEFICIENCY DATE
OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG REGULATORY
DEFICIENCY)

K 324 ' Continued From page 2 K 324

Cooking Facilities
Cooking equipment is protected in accordance
with NFPA 96, Standard for Ventilation Control
and Fire Protection of Commercial Cooking
Operations, unless:
residential cooking equipment( i. e., small
appliances such as microwaves, hot plates,
toasters) are used for food warming or limited
cooking in accordance with 18. 3.2. 5. 2, 19.3.2. 5. 2
cooking facilities open to the corridor in smoke
compartments with 30 or fewer patients comply
with the conditions under 18. 3. 2. 5. 3, 19.3.2. 5.3,
or

cooking facilities in smoke compartments with

30 or fewer patients comply with conditions under
18. 3. 2. 5. 4, 19. 3. 2. 5. 4.
Cooking facilities protected according to NFPA 96
per 9. 2. 3 are not required to be enclosed as
hazardous areas, but shall not be open to the
corridor.

18. 3. 2. 5. 1 through 18. 3. 2. 5. 4, 19. 3. 2. 5. 1 through

19. 3. 2. 5. 5, 9. 2. 3, TIA 12- 2

This REQUIREMENT is not met as evidenced

by:
Based on observation and staff interviews it was
determined the facility failed to ensure that all
cooking equipment is properly aligned
underneath the hood suppression system.
This could place all residents at risk in the event
of a fire emergency.

The findings include:

During a tour of the facility with Staff M on
03/ 28/ 2018 between 11: 00 am and 3: 00 pm
observation revealed that the deep fat fryer was
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: L81 E21 Facility ID: LTC11461209 If continuation sheet Page 3 of 4
 PRINTED: 04/ 10/ 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

STATEMENT OF DEFICIENCIES X1)
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING 01 - MAIN BUILDING 01

115452 B. WING 03/ 28/ 2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION x5)

X4) ID i
COMPLETION
MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX EACH DEFICIENCY
DATE
OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG REGULATORY
DEFICIENCY)

K 324 Continued From page 3 K 324

not properly alleged with the hood suppression

nozzle.

These findings were confirmed by Staff M at the

time of discovery.
Reference: 2012 NFPA 101, chapter 19, section
19. 3. 2. 5. 1, chapter 9, section 9. 2. 3, chapter 2,
section 2. 2, 2011 NFPA 96, chapter 10, section
10. 3. 1 and chapter 12, section 12. 1

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FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: L81 E21 Facility ID: LTC11461209 If continuation sheet Page 4 of 4
 PRINTED: 04/ 10/
DEPARTMENT
CENTERS
OF HEALTH AND HUMAN SERVICES
FOR MEDICARE &
APPROVED 2
MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED

115452 B. WING
03/ 28/ 2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION x5)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

E 000 Initial Comments E 000

A review of the Emergency Preparedness plan

for Pruitthealth Shepherd Hills was conducted on
03/ 28/2018. This showed that the plan was in
substantial compliance with the requirements set
forth in appendix Z.

AB ORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE

Any deficiency statement ending with an asterisk(')

other safeguards provide sufficient
denotes a deficiency which the institution may be excused from correcting providing it is determined that
to the patients.(
protection See instructions.)
Except for nursing homes, the findings stated above are disclosable 90 days
following the date of surrey 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 date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: L81 E21 Facility ID: LTC11461209 If continuation sheet Page 1 of 1
eozks GEORGIA. 0EPARTME
OF COMMUNrry HEALTH
it

Nathan Deal, Governor Frank Berry, Commissioner

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

April 10, 2018

Mr. Michael Dykes, Administrator

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728

Dear Mr. Dykes:

Enclosed is a copy of the report pertaining to the Licensure Inspection conducted at your facility
onMarch 29, 2018 by surveyors of this office. The report indicates that no deficiencies were noted.
We appreciate the courtesies extended to our representatives during this visit. If we may be of
assistance at any time, please do not hesitate to call us at ( 404) 657- 5850.

Si; icerely,

i1
Attachment
i
Director, Northern
m Care Section
1thcare Facility Regulation Division

Enclosures

Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
 PRINTED: 04/ 10/ 2018
FORM APPROVED

State of GA, Healthcare Facilitv Requlation Division

PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1)
NUMBER: COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION
A. BUILDING:

B. WING 03/ 29/ 2018

1- 146- 1671

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728

SUMMARY STATEMENT OF DEFICIENCIES ID I PROVIDER' S PLAN OF CORRECTION X5)

X4) ID
EACH CORRECTIVE ACTION SHOULD BE COMPLETE
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)

N 006 Initial Comments p N 000

No deficiencies were identified during the

licensure survey on March 29, 2018

lu
N
I

lu
n

State of GA Inspection Report

DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
LABORATORY

STATE FORM 6899

L81 E11 If continuation sheet 1 of 1