Professional Documents
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2016 DCH Reports Involving Sherpherd Hill Nursing Home
2016 DCH Reports Involving Sherpherd Hill Nursing Home
2016 DCH Reports Involving Sherpherd Hill Nursing Home
June 8, 2016
As a result of the revisit conducted on June 6, 2016, by the Georgia State Survey Agency,
we have dermined that your facility is in substantial compliance with the Medicare/ Medicaid
program requirements of participation nursing facilities, effective May 7, 2016.
In our letter dated April 22, 2016, we imposed the following enforcement remedies: Denial
of Payment for New Admissions ( DPNA), and termination of Medicare/ Medicaid
participation. These remedies did not go into effect because we determined that your facility
achieved substantial compliance before the remedies effective dates. In other words, your
Medicare/ Medicaid provider agreements remain in effect.
If our previous letter imposed a Civil Money Penalty ( CMP) on your facility, the CMP will
be collected in accordance with regulations at 42 C. F. R. 488. 442.
If you have any questions regarding this compliance notice, please contact Tina Holloway at
404) 562- 7468.
Sincerely,
s/
Sandra M. Pace
Associate Regional Administrator
Division of Survey & Certification
cc: State Survey Agency
State Medicaid Agency
Medicare Administrative Contractor
LTCE Branch Manager
HUD— Office of Healthcare Programs
Medicare Advantage Branch
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404-656-4507 1 www. dch. georgia. gov
June 7, 2016
A revisit was conducted at your facility to verify that your facility had achieved and maintained
compliance. Our revisit conducted June 6, 2016 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 May 7, 2016.
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,
j-
D
Andrea Sanders
Enforcement Manager
Long Term Care Section
Healthcare Facility Regulation Division
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
fl-
I
GEORGIA DEPARTMENT
or COMMUNITY HEALTH
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656- 4507 1 www. dch. georgia. gov
Your Plan of Correction ( PoC) for the survey that was completed at your facility on March 21,
2016 has been reviewed and found acceptable with an alleged compliance date of May 7,
2015.
If there are any questions concerning the above, or if we may be of assistance, please do not
hesitate to call or write to us.
Sincerely,
Marsha Allen
Enforcement Specialist
Long Term Care Section
Healthcare Facility Regulation Division
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
Department of Health& Human Services
Centers for Medicare& Medicaid Services
61 Forsyth Street, SW, Suite 4T20
Atlanta, Georgia 30303- 8909
CENTERS FOR MEDICARE& MEDICAID SERVICES
A facility must meet the pertinent provisions of Sections 1819 and 1919 of the Social
Security Act and be in substantial compliance with each of the requirements for long term
care facilities, established by the Secretary of Health and Human Services in 42 C. F. R.
section 483. 1 et sea., in order to qualify to participate as a skilled nursing facility in the
Medicare program and as a nursing facility in the Medicaid program.
On March 21, 2016, a complaint survey was completed to determine if your facility was in
compliance with the Federal requirements for nursing homes participating in the Medicare
and Medicaid programs. This survey found that your facility was not in substantial
compliance with the participation requirements,
and that conditions in your facility
constituted immediate jeopardy and substandard quality of care to residents' health
and safety. The immediate jeopardy situation was identified to exist as of October 14,
2015 and was removed on March 1, 2016. While corrective action taken by your facility
removed the immediate jeopardy, conditions in your facility remained out of substantial
compliance with Program requirements. An amended statement of the deficiencies ( CMS-
2567) has been furnished by the Georgia State Survey Agency ( SAA).
to you Be advised
that this enforcement case was officially sent to CMS on April 19, 2016.
All references to regulatory requirements contained in this letter are found in Title 42, Code
of Federal Regulations.
Remedies Imposed
We have reviewed the 2016 survey findings and the State Survey Agency' s
March 21,
recommendations, and we are imposing the following mandatory and discretionary
enforcement remedies on the dates indicated:
I. MANDATORY REMEDIES
Mandatory Termination
In accordance with federal law at 42 C. F. R. 488. 412( d), we must terminate the Medicare
provider agreement of any facility that remains of out substantial compliance six ( 6) months
after its initial survey identifying noncompliance. Based on your facility' s initial survey
date of March 21, 2016, your facility' s mandatory termination will become effective on
September 21, 2016, if your facility remains out of compliance on the latter date.
A CMP of$ 3, 550. 00 per day from October 14, 2015 through February 29, 2016 and a CMP
of $ 100. 00 per day effective March 1, 2016, which will continue to accrue until either
In accordance with federal law at 42 C. F. R. 488. 431 and based on the scope/ severity
of noncompliance identified during your facility' s survey, we have decided to collect your
facility' s CMP and place it in an escrow account. If you wish to dispute the findings of
noncompliance upon which we have made this decision, you may request an Independent
Informal Dispute Resolution ( Independent IDR) proceeding in accordance with 42 C. F. R.
sections 488. 331 and 488. 431. If you would like to request an Independent IDR, you must
do so in writing within ten ( 10) days of receiving this notice. Your written request should
identify the specific findings of noncompliance you are disputing, as well as an explanation of
why you are
disputing them ( and/ or why you are disputing the scope/ severity of
noncompliance
constituting immediate jeopardy or substandard quality of care). Your request
for an Independent IDR should be sent to the following address:
Please note, furthermore, that an incomplete IDR or Independent IDR process will not
delay any deadline listed below under " Appeal Rights" for requesting a hearing, or for
requesting a waiver of hearing rights.
As explained more
fully below under " Appeal Rights," you have the right to request a
hearing before the Departmental Appeals Board ( DAB) if you wish to dispute the basis and
amount of your facility' s CMP. You also may decide to waive your right to a hearing, in
accordance with regulations at 42 C. F. R. 488. 436.If you would like to waive your right to a
hearing, you must do so in writing within sixty ( 60) days of receiving this notice. If you
waive your right to a hearing, the amount of your CMP will be reduced by thirty-five percent
35%); on the other hand, if you request a hearing or miss the deadline for requesting a
waiver, your CMP will not be reduced by 35 percent.
You must submit your waiver request directly to our Atlanta Regional Office by certified
mail or via Internet e- mail to the CMP Waiver mail box. The Atlanta Regional Office does
not accept CMP waivers via facsimile.
CMP waivers on company letterhead may be submitted via Internet e- mail to the CMP
Waiver mail box. The Internet e- mail address is:
Denial of Payment for New Admissions is effective May 7, 2016, that continues until
substantial compliance is achieved or your provider agreement is terminated.
Please note that filing of Medicare or Medicaid claims for new admissions after the denial of
payment for new admissions ( DPNA) is in effect could result in such claims being
considered " false" claims under applicable federal statutes and thus potentially subjecting the
filing entity to a referral to the appropriate authorities and possibly to the penalties prescribed
under such statutes. An exception possibly applies where a timely appeal of the controlling
certification/ finding of noncompliance is filed ( and remains pending) under 42 C. F. R. Part
498, and where your facility has made arrangements acceptable to your Medicare
Administrative Contractor to submit the claim ( or claims) with prominent flagging clearly
indicating that the claim( s) is/ are being filed not for current payment, but" under protest" and
for the sole purpose of preserving a timely filing should the facility prevail on its
administrative appeal under 42 C. F. R. Part 498. Please note that the Denial of Payment for
New Medicare Admissions includes Medicare beneficiaries enrolled in Medicare managed
care plans. It is your obligation to inform Medicare managed care plans contracting with your
facility of this denial of payments for new admissions.
Your facility' s noncompliance with 42 C. F. R. 483. 25 at F329J and F333J has been
Please note that federal law in the Social Security Act at sections 1819 ( f)(
2)( B) and 1919
f)(2)( B), prohibits approval of Nurse Aide Training and Competency Evaluation Programs
NATCEP) offered by a facility which within the previous two years has operated under a
section 1819 ( b)( 4)( c)( ii)( II) or section 1919 ( b)( 4)( ii) waiver; has been subject to an
extended or partial extended survey; has been assessed a civil money penalty of $5, 000 or
more; or, has been subject to denial of payment, the appointment of a temporary manager,
termination or, in the case of an emergency, has been closed and/ or had its residents
transferred to other facilities. As a result of your facility' s noncompliance, these NATCEP
provisions may be applicable to your facility. You will receive further notification from the
State agency responsible for such matters.
Appeal Rights
If you disagree with enforcement remedies imposed on your facility, you or your legal
representative may request a hearing before an administrative law judge of the Department of
Health and Human Services, Departmental Appeals Board ( DAB). Procedures governing
this process are set out in 42 C. F. R. 498. 40, et seq.
A written request for a hearing must be
filed no later than sixty ( 60) days after receiving this letter, by mailing to the following
address:
Specific instructions on how to file electronically are attached to this notice. A copy of the
hearing request shall be submitted electronically to:
A request for a hearing should identify the specific issues, findings of fact and conclusions of
law with which you disagree. It should also specify the basis for contending that the findings
and conclusions are incorrect. At an appeal hearing, you may be represented by counsel at
your own expense.
If you have any questions regarding this letter, please contact Tina Holloway by phone at
404) 562- 7468 or by e- mail at Leontyne. holloway@cros. hhs. gov.
Sincerely,
s/
Sandra M. Pace
Associate Regional Administrator
Division of Survey and Certification
cc:
State Survey Agency
State Medicaid Agency
Medicare Administrative Contractor
LTCE Branch Manager
HUD— Office of Healthcare Programs
Medicare Advantage Branch
Enclosure
How to Use the Departmental Anneals Board' s Electronic Filing Svstem ( DAB E- File)
h ttns. Ildab/. ertle. hhs. eov.
To file a new appeal using DAB E- File, you first must register a new
by: ( 1) clicking
account
Register the DAB E- File home page; ( 2)
on
entering the information requested on the
Register New Account" form; and ( 3) clicking Register Account at the bottom of the form.
If you have more than one representative handling your appeal, each representative must
register separately to use DAB E- File on your behalf.
How to loa- in to DAB E- File. To access DAB E- File, the e- mail address and
password provided during the registration process must be entered on the Login screen at
https:// dab. efile. hhs. govluser_ sessions/ new. A registered user' s access to DAB E- File is
restricted to the appeals for which s/ he is a party or authorized representative.
How to file an appeal ( reauest for hearing) in DAB E- File. After you have
registered and logged- in to DAB E- File, you
may file an appeal by: ( A) clicking the File
New Appeal link on the Manage Existing Appeals page, then at the next page clicking the
Civil Remedies Division button; then ( B) entering and uploading the requested information
and documents on the form labeled " File New Appeal— Civil Remedies Division."
Basic requirements for using DAB E- File. At a minimum, the DAB' s Civil
Remedies Division ( CRD) appeal
requires a
party filing an to submit the following: ( 1) a
signed hearing request; and ( 2) a copy of the underlying notice letter from CMS which sets
forth CMS' s adverse action and the party' s appeal rights. All documents must be submitted
in Portable Document Format ( PDF).
Any document, including a hearing request, will be
deemed to have been filed on the date it is submitted via DAB E- File ( through 11: 59 p.m.
EST on the date of submission).
A party filing a hearing request via DAB E- File will be
deemed to have consented to receiving and accepting electronic service of appeal- related
documents which CMS subsequently submits via DAB E- File and/ or which the CRD
subsequently submits via DAB E- File on behalf of an Administrative Law Judge. CMS also
will be deemed to have consented to electronic service.
Detailed information re2ardin2 DAB E- File. More detailed instructions for using
DAB E- File in cases before the DAB' s Civil Remedies Division can be found by clicking the
button marked E- Filing Instructions after logging- in to DAB E- File.
For general questions DAB E- File System,
regardingthe y , y
you y call
may the Civil Remedies
Division main telephone line at 202- 565- 9462. If you experience any technical issues with
the DAB E- file System, please contact E- File System support.
This support system may be
reached at OSDABImmediateOf6ceCi;. 11hs. 2ov.
GEORGIA DEPARTMENT
OF COMMUNITY HEALT14
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656- 4507 1 www. dch. georgia. gov
On March 21, 2016, a survey was conducted at your facility by the Georgia survey agency to determine
if your facility was in compliance with Federal Program requirements for nursing homes participating in
Medicare and/ or Medicaid programs. This survey was:
a standard survey.
X a complaint survey
IMMEDIATE JEOPARDY
This survey found that your facility was not in substantial compliance with the program
requirements, and the conditions in your facility constituted immediate jeopardy to resident
health and safety. This office notified you at the time of the exit conference, that this abated
immediate jeopardy to health and safety of residents had been identified and was related to
noncompliance with program requirements at 42 C. F. R. F0281 -- S/ S: J -- 483. 20( k)( 3)( i) -- Services
Provided Meet Professional Standards
F0333 -- S/ S: J -- 483. 25( m)( 2) -- Residents Free Of Significant Med Errors
F0514 -- S/ S: J -- 483. 75( I)( 1) -- Res Records- Complete/ accurate/ accessible
F0329 -- S/ S: J -- 483. 25( I) -- Drug Regimen Is Free From Unnecessary Drugs
F0520 -- S/ S: J -- 483. 75( o)( 1) -- Qaa Committee- Members/ meet Quarterly/ plans
F0282 -- S/ S: J -- 483. 20( k)( 3)( ii) -- Services By Qualified Persons/ per Care Plan
F0490 -- S/ S: J -- 483. 75 -- Effective Administration/ resident Well- Being.
Specifically, the finding of immediate jeopardy was based on noncompliance with program
requirements at:
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
Pruitthealth - Shepherd Hills
April 12, 2016
Page 2
F0281 -- S/ S: J -- 483. 20( k)( 3)( i) -- Services Provided Meet Professional Standards
The facility failed to ensure that nursing services were provided in accordance with nursing professional
standards of practice regarding medication administration and monitoring for one ( 1) resident who
incorrectly received Morphine within a thirty minute period and continued to receive Morphine routinely
every two ( 2) hours without monitoring or assessment for adverse effects; and regarding accurate
resident identification prior to medication administration for one ( 1) resident who received another
resident' s mediactions in error. This resulted in a situation in which the facility' s noncompliance with
requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to
residents.
F0520 -- S/ S: J -- 483. 75( o)( 1) -- Qaa Committee- Members/ meet Quarterly/ plans
The facility failed to have an effective Quality Assessment and Assurance ( QAA) Committee that
developed and implemented a process to ensure medication administration in accordance with
physicians' orders and ensured the ongoing monitoring of plans of action implementedto correct an
identified problem with resident identification by staff nurses during orientation. This resulted in a
situation in which the facility' s noncompliance with requirements of participation caused, or had the
likelihood to cause, serious harm, injury or death to residents.
All references to regulatory requirements contained in this letter are found in Title 42, Code of Federal
Regulations.
Your facility' s noncompliance with the requirements at CFR § F0329 -- S/ S: J -- 483. 25( 1) -- Drug
Regimen Is Free From Unnecessary Drugs; F0333 -- S/ S: J -- 483. 25( m)( 2) -- Residents Free Of
Significant Med Errorshas been determined to constitute substandard quality of care as defined
at§ 488. 301. Sections 1819( g)( 5)( c) and 1919( g)( 5)( c) of the Social Security Act and 42 CFR
488. 325( h) require that the attending physician of each resident who as found to have received
substandard quality of care as well as the state board responsible for licensing the facility' s
administrator be notified of the substandard quality of care.
Because of the finding of substandard quality of care, approval of your nurse aide training program will
be withdrawn. You will receive notice of the withdrawal directly from the Georgia Medical Care
Foundation.
Remedies
As a result of the survey findings that the conditions in your facility constituted a removed immediate
jeopardy, we are recommending to the CMS Regional Office and/ or the State Medicaid Agency that:
A civil money penalty in an amount and duration will be determined by the Centers for
Medicare and Medicaid Services.
Your provider agreement will be terminated on September 21, 2016 if substantial compliance
with all program requirements is not achieved by that time.
Please note that you will be notified directly by CMS and/ or DMA of remedies imposed based on the
above recommendations. Such notice will include information regarding the facility' s right to formal
appeal.
During the survey process the facility was able to demonstrate how and when the immediate jeopardy
was removed. Therefore, the immediate jeopardy was removed. Documentation of the facility' s actions,
Pruitthealth - Shepherd Hills
April 12, 2016
Page 4
A POC for all deficiencies not identified at the immediate jeopardy level cited on the CMS 2567
must be submitted within 10 calendar days after receipt. You must submit your written PoC to
Andrea Sanders, Healthcare Facility Regulation Division LTC, Suite 31. 447, 2 Peachtree St. N. W.,
Atlanta, Ga. 30303- 3142, telephone ( 404) 657- 4585, Fax ( 404) 657- 9724.
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;
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.
Include dates when the corrective action will be completed. The corrective action dates must be
acceptable to the State.
In accordance with 42 CFR§488.331, you have one opportunity to dispute cited deficiencies through an
informal dispute resolution process. To be given such an opportunity, you are required to send
your written request for IDR, along with the specific deficiencies being disputed, and an
explanation of why you are disputing those deficiencies, includinq any information or
documentation surmortinq vour refutation., This request and anv suaportina information must
be sent during the same 10 days you have for submitting a PoC for 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 of 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. 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.
Pruitthealth - Shepherd Hills
April 12, 2016
Page 5
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.
Sincerely,
4 ,--. P-
Long Term Care Section
J
"
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656-4507 1 www. dch. georgia. gov
On March 21, 2016, a survey was conducted at your facility by the Georgia survey agency to determine
if your facility was in compliance with Federal program requirements for nursing homes participating in
Medicare and/ or Medicaid programs. Specific findings of the survey will be included on the CMS Form
2567, Statement of Deficiencies.
IMMEDIATE JEOPARDY
This survey found that your facility was not in substantial compliance with the program
requirements, and the conditions in your facility constituted immediate jeopardy to resident
health and safety. This office notified you on February 25, 2016, that this immediate jeopardy to
health and safety of residents had been identified and was related to noncompliance with program
requirements at 42 C. F. R.
F0281 -- S/ S: J -- 483. 20( k)( 3)( i) -- Services Provided Meet Professional Standards
F0333 -- S/ S: J -- 483. 25( m)( 2) -- Residents Free Of Significant Med Errors
F0514 -- S/ S: J -- 483. 75( I)( 1) -- Res Records- Complete/ accurate/ accessible
F0329 -- S/ S: J -- 483. 25( I) -- Drug Regimen Is Free From Unnecessary Drugs
F0520 -- S/ S: J -- 483. 75( o)( 1) -- Qaa Committee- Members/ meet Quarterly/ plans
F0282 -- S/ S: J -- 483. 20( k)( 3)( ii) -- Services By Qualified Persons/ per Care Plan
F0425 -- S/ S: J -- 483. 60( a),( b) -- Pharmaceutical Svc - Accurate Procedures, Rph.
Specifically, the finding of immediate jeopardy was based on noncompliance with program
requirements at:
F0281 -- S/ S: J -- 483. 20( k)( 3)( i) -- Services Provided Meet Professional Standards
F0282 -- S/ S: J -- 483. 20( k)( 3)( ii) -- Services By Qualified Persons/ per Care Plan
F0329 -- S/ S: J -- 483. 25( I) -- Drug Regimen Is Free From Unnecessary Drugs
F0333 -- S/ S: J -- 483. 25( m)( 2) -- Residents Free Of Significant Med Errors
F0425 -- S/ S: J -- 483. 60( a),( b) -- Pharmaceutical Svc - Accurate Procedures, Rph
F0514 -- S/ S: J -- 483. 75( I)( 1) -- Res Records- Complete/ accurate/ accessible
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
F0520 -- S/ S: J -- 483. 75( o)( 1) -- Qaa Committee- Members/ meet Quarterly/ plans
Surveyors found a situation of immediate jeopardy to patient health and safety, beginning October 14,
2015.
All references to regulatory requirements contained in this letter are found in Title 42, Code of Federal
Regulations.
Your s noncompliance with the requirements at CFR § F0329 -- S/ S: J -- 483. 25( I) -- Drug
facility'
Is Free From Drugs; F0333 -- S/ S: J -- 483. 25( m)( 2) -- Residents Free Of
Regimen Unnecessary
Significant Med Errors has been determined to constitute substandard quality of care as defined
at§ 488. 301. Sections 1819( g)( 5)( c) and 1919( g)( 5)( c) of the Social Security Act and 42 CFR
488. 325( h) require that the attending physician of each resident who was found to have received
substandard quality of care as well as the state board responsible for licensing the facility' s
administrator be notified of the substandard quality of care.
Because of the finding of substandard quality of care, approval of your nurse aide training program will
be withdrawn. You will receive notice of the withdrawal directly from the Georgia Medical Care
Foundation.
Remedies
As a result of the survey findings that the conditions in your facility constituted immediate jeopardy, we
are recommending to the CMS Regional Office and/ or the state Medicaid Agency that:
The facility' s provider agreement be terminated on April 13, 2016, if the immediate jeopardy
to resident health and safety has not been removed.
In addition to termination, a civil money penalty per day be imposed effective 10/ 14/ 2015, the
day the immediate jeopardy to resident health and safety was identified to first exist. If the
Center for Medicare and Medicaid Services decides to impose the recommended civil money
penalty, a notice of imposition will be sent to you. The penalty will continue to accrue until
we verify that your facility has achieved substantial compliance with the program
requirements, or your provider agreement is terminated.
Page 2
Allegation of Removal of Jeopardv
If you believe the immediate jeopardy has been removed, you must submit your written allegation that
the immediate jeopardy has been removed to Andrea Sanders, Enforcement Manager, via e- mail to
asanders@dch. ga. gov, Healthcare Facility Regulation Division, Long Term Care Section, Suite 31. 447,
2 Peachtree Street, N. W., Atlanta, Georgia 30303- 3142.
Your written allegation that immediate jeopardy has been removed must include sufficient detail to
demonstrate how and when the immediate ieovardv was removed. Please note that in order for a
23- day termination to be stopped, the immediate jeopardy must be removed even if the
underlying deficiencies have not been fully corrected.
A PoC for all deficiencies cited on the CMS 2667 must be submitted no later than April 1, 2016.
Address how corrective action will be accomplished for those residents found to have been affected
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 systematic changes made to ensure that the
deficient practice will not recur;
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.
Include dates when corrective action will be completed. The corrective action dates must be
acceptable to the State.
Please note that you are not required to submit a PoC in order to get a revisit to verify removal of the
immediate jeopardy. Such revisit is dependent upon submission of the allegation of removal of
immediate jeopardy as described above. Therefore, the PoC may be deferred until the revisit has been
conducted.
In accordance with 42 CFR§488. 331, you have one opportunity to dispute cited deficiencies through an
informal dispute resolution process. To be given such an opportunity, you are required to send
your written request for IDR, along with the specific deficiencies being disputed, and an
explanation of why you are disputing those deficiencies, including anv information or
documentation su000rtina vour refutation. This request and anv supporting information must
be sent during the same 10 days you have for submitting a PoC for the cited deficiencies. In
addition to submitting your refutation in writing, you will be given an opportunity for a face-to-face
Page 3
meeting with the Director of 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 than 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.
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
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,
Andrea Sanders
Enforcement Manager
Long Term Care Section
Healthcare Facility Regulation Division
Page 4
PRINTED: 06/ 07/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
R- C
115452 B. WING
06/ 06/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH - SHEPHERD HILLS
FAYETTE, GA R 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU12 Facility ID: LTC11461209 If continuation sheet Page 1 of 1
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
A, BUILDING COMPLETED
C.
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
NTATIV'
Any de eciency ent ending with an asterisk('}
other safegu
denotes a deficiency which the Institution may be' excused from correcting providing it is determined that
ovida sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are diseiosable 90 days
following the
to of survey whether or not a plan of correction Is provided. For nursing homes, the above findings and plans of correction are diselosable 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- 2667( 02-99) Previous Versions Obsolete Event ID: T2SU11 FacIINy ID: LTC11461209 If continuation sheet Page 1 of 96
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391,
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE
P
PRUITTHEALTH- SHEPHERD HILLS
LA ETT
LAFAYETTE A 30728
GA
C.
115452 e. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH• SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
FORM CMS- 2s67( o2- 99) Previous versions Obsolete Event ID: Z2SU11 Faalllly 10: LTC11461209 If continuation sheet Page 4 of 96
PRINTED: 04/ 13/ 2016.
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERiCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
F 000
1 Continued From page 4
and Severity of" J";
42 CFR 483. 25( m)( 2),
Residents Free of Significant Medication Errors,
F 000
I
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERJSUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
F 281 Continued From page 5 F 281 Resident# 1 was sent to the ER and 5/ 7/ 16
and regarding accurate resident identification was admitted to the hospital and did
prior to medication administration for one( 1) inot return to Pruitt Heath Shepherd
p
resident( R# 2), who received another resident' s i
Hills.
medications in error, from a total sample size of
Resident# 2 was sent to ER and admittec 5/ 7/ 16
twenty- four( 24) residents.
on October 14, 2015. Resident# 2
On February 25, 2016, a determination was made returned to Shepherd Hills October 17,
that a situation In which the facility' s 2015, and still resides in the facility.
non- compliance with one or more requirements of
Medical Records for the residents 5/ 7/ 16
participation had caused, or had the likelihood to
were reviewed to ensure that the I
cause serious injury, harm, impairment or death
to residents.The facility' s Administrator, Physician' s Orders were correctly
Corporate Clinical Consultant, Director of Heath transcribed to Medication Administration
Services( DHS) and Nursing Supervisor" EE"
Record. M
Registered Nurse(
RN) were informed of the
Education to 34 nurses 5/ 7/ 16
Immediate Jeopardy on February 25, 2016 at
was provided
5, 00 P. M. by the Clinical Competency Coordinator
An of jeopardy removal was received
allegation and RN Supervisor related to
on February 26, 2016. Based on the corrective medication administration for nurses on
plans which had been developed and
2- 19- 16 and ongoing. The education
Implemented by the facility, the immediacy of the
i included medication administration
deficient practice was determined to have been
removed on March 4, 2016 as alleged, and the general guide lines, including but not
facility remained out of compliance at the lower limited to, following physicians orders,
scope and severity of" D" while the process of
medication pass times, consistent
evaluation of the nursing staffs' compliance with
and accurate documentation of
physicians orders, education, and facility policies
continued. In- service
medication and acceptance/ refusal
and procedures, materials
pictures. Interviews were conducted with nursing transcription of medication orders, and
staff to ensure they were knowledgeable about
identification of patients.
the administration of resident medication. a
C.
115462 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
dated October 14, 2015 documenting that the Newly hired nurses will have a med
resident was given 30 mg of Procardia and 100
pass observation completed by a
mg Hydralazine In error by( newly hired) Licensed
RN Supervisor and or DHS and will be
Practical Nurse( LPN)" BB" during the 6:00 a. m.
A further review of the 10114[ 15 required to have a successful
medication pass.
nurses notes revealed that, after the medications completion before being allowed to
were administered in error, the resident' s blood administer medications to our
pressure( B/ P) began to drop and the resident residents.
faded in and out of consciousness. The B/ P was
documented at 64/38. R# 2 was placed in
Trendelenburg position and Oxygen at 2 liters per
minute via mask was administered. R# 2 was
transferred to the hospital and admitted to the
Intensive Care Unit( ICU) with diagnosis of
Hypotension and Medication Poisoning. There I
was no evidence of how LPN" BB" verified R# 2's
identity prior to administering him the incorrect
medications.
I I
i
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If Continuation sheet Page 7 of 96
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LAFAYETTE, GA 30728
Observations conducted on February 19, 2016 at monthly and updated as needed with
2: 10 p. m. of the Medication Administration admissions and discharges.
Record' s( MAR' s) for one hundred eight residents Clinical Competency Coordinator and
residing in the facility that day, located on the
RN on 2126/ 16 and ongoing educated
medication carts revealed six( 6) pictures were
nurses related to pain including o
not on the MAR' s. On February 24, 2016 at
10: 40 a. m. the same 6 resident pictures remained
observation and documentation
missing on the MAR' s, with these residents still of pain with routine pain medication
residing at the facility. administration.
I
C
115452 B. WING
03f2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
PRUITTHEALTH• SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
F 281 Continued From page 8 F 281 Nurses were also in serviced by the
10: 00 a. m. Licensed Practical Nurse( LPN)" HH", Clinical Competency Coordinator
the nurse who was supervising newly hired LPN regarding observation of respiratory
BB" on October 14, 2016 when R# 2 received and sedation status with controlled
the wrong medications, stated that she thought
substance pain medication administration
LPN" BB" had been working with the residents
long enough to know who they were. LPN HH
I Nurses were educated by Clinical
I
further revealed that she was at the medication
I
Competency Coordinator and RN
cart when the medications were prepared and f Supervisor regarding Errors, Omissions
also acknowledged there were no pictures of and late entries.
these two residents on the MARS.
Pruitt University class for Medication
An attempted telephone Interview on February
26, 2016 at 11: 25 a. m. with LPN" BB" who had
Administration and Avoiding Common
resigned was unsuccessful. A messasge was left Errors beginning 2/ 29/ 16 and ongoing.
to call surveyor with no response from LPN" BB" DHS and or RN Supervisor will complete
a review of the MAR' s for omissions
Review of the National Council of State Boards of
daily.
Nursing Model Nursing Practice Act and Model
RN Supervisor and or DHS will complete 5/ 7/ 16
Nursing Administrative Rules revealed that the
Model Nursing Administrative Rules, Chapter 2- a review of the MAR' s monthly during
Standards of Nursing Practice, Section 2. 3. 2( c), change over to ensure resident
specified that the nurse demonstrate
pictures are in place.
attentiveness and provide resident surveillance
DHS and or RN supervisor will monitor/ 5/ 7/ 16
and monitoring.
observe Medication pass for 10% of
C
115452 S. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, R
CAA 30728
DEFICIENCY)
1
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 13. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS 2567(02- 99) Previous Verslons Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 11 of 96
PRINTED: 04/ 13/ 201 B
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
PROVIDER' S PLAN OF CORRECTION X5)
X4) ID j SUMMARY STATEMENT OF DEFICIENCIES I ID
COMPLETION
EACH DEFICIENCY MUST BE PRECEDED BY FULL { PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX ( DATE
CROSS- REFERENCED TO THE APPROPRIATE
TAG REGULATORY DR LSC IDENTIFYING INFORMATION)
I TAG
DEFICIENCY)
1
1
F 281 Continued From page 11 F 281
FORM CMS- 2667(02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 12 of 96
is
S3
i
C
115452 B. WING
03/21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PAITERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID
i SUMMARY STATEMENT OF DEFICIENCIES
EACH DEFICIENCY MUST BE PRECEDED BY FULL
ID
PREFIX
PROVIDER'$ PLAN OF CORRECTION
EACH CORRECTIVE ACTION SHOULD eE !
X5)
PREFIX Kin
TAG
i
I
(
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE COMPLEE
DEFICIENCY)
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
SUMMARY
X4) ID STATEMENT OF DEFICIENCIES
I ID PROVIDERS PLAN OF CORRECTION W
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL ! PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS- REFERENCED TO THE APPROPRIATE OATE
I jj
t DEFICIENCY)
i
11 M2 B. WING 0312112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
needed
3. The clinical competency coordinator provided
education to nurses regarding utilization of other
j staff members to assist with the identification
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID: Z2SU11 Facifity lD: LTC11461209 If continuation sheet Page 15 of 96
i
i
2
I}
t
i
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PRINTED: 04113/ 2016
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
A. BUILDING COMPLETED
C
115452 B. wING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER
STREETADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) to SUMMARY STATEMENT
OF DEFICIENCIES ID PROVIDERZS KAN OF CORRECTION
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCEDTO DATE
THE APPROPRIATE
DEFICIENCY)
i'
it
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115452 B. wING
03/21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITrMEALTH- SHEPHERD HILLS
FAYETTE, GA R30728
ORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID: Z2SU11 Fadity ID: LTC11401209 If continuation sheet Page 17096 j
i
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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 COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STRE ET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY) I
care.
I PH Shepherd Hills provides care ,
I
i related to medication administration as
4 per physician' s orders and in a manner
This REQUIREMENT is not met as evidenced 1 to avoid adverse medication effects, as I
1
by specified by the residents care plan.
Based on record review, and staff interviews, the I 1
Resident# 1 sent to ER and was
facility failed to provide care, related to j
medication administration per physician' as s 1 1 admitted to the hospital and did not return
1 to the i
orders and in a manner to avoid adverse facility.
medication
of one( 1)
specified by the Care Plan
effects, as
Resident# 2
admittO , f' 74
sample of twenty- four( 24) residents.
returned to Shepherd Hills October 17,
This failure of the facility to administer to Resident 2015, and still resides in the facility.
observed for any
2 only those medications which were ordered, to Patients were change . 7-/ 4
avoid adverse effects from medications as of condition by RN Supervisor and or
specified by the Care Plan, resulted in a situation
DHS.
in which the facility' s noncompliance with the
Pruitt Health Shepherd Hills will ensure
requirements of participation caused, or had the
likelihood to cause, serious harm, injury, I that any alleged violations, including
impairment, or death to residents. The census medications not being received as
was 107 residents. ordered, will be reported to the DHS and
i
PRINTED: 04113/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORMAPPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
I
PRINTED: 04113/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERICL1A ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
requested due to increase in Troponin level which passes before taking the medication
revealed Demand Ischemia with minimal Left
Ventricle damage and diagnosis of Non ST cart indepentently.
Segment Elevated Myocardial Infarction. All findings will be taken to the Quality
Medications given Procardia( Calcium Channel Assurance Performance Improvement
blocker) and Hydralazine. The resident was
Committee for action as needed.
given the medications of another resident by I
I'.
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/ 13/ 2016
FORAM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
i
PRINTED: 0411312016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERlSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) j TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
I identification of residents.
Education content and sign in sheets were j
reviewed
2. Pictures of residents were audited on 2125116 I
and will be reviewed monthly and updated as I
needed
1
3. The clinical competency coordinator provided j
FORM CMS- 2667( 02- 99) Previous Versions Obsolete Event 1D: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 23 of 96
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
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
DEFICIENCY)
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITfHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
E
F 2821 Continued From page 24 F 282
reviewed
12. The director of health services or registered
nurse supervisor will review medication
administration records weekly to ensure that level
of pain is being monitored.
13 Newly hired nurses Will be in serviced by the
clinical competency coordinator and mentor nurse
on medication administration general guidelines
including following physician orders, med pass
times, consistent and accurate documentation of
medication and acceptance/ refusal of
medications, medication discrepancies, adverse I
medication reactions, accurate transcription of
medication orders, and identification of patients
and will be required to complete the orientation
skills checklists, medication administration video
I
with posttest, and medication card orientation. i
Medication p ass observation will also b e 1
completed with each newly hired nurse was
successful completion.
14. Education was provided to 34 nurses I
FORM CMS-2667(02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: 1-TC11461209 If continuation sheet Page 25 of 96
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 13, WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
i
F 329 Continued From page 25 i F 329
F329
Based
Meeting was held with the facility Medical 6%7-4-
on a comprehensive assessment of a
Director related to the family concerns.
resident, the facility must ensure that residents
Observations of residents for change of i
who have not used antipsychotic drugs9 are not
given these drugs unless antipsychotic drug conditions were completed by the RN
therapyis necessary to treat a specific condition Supervisor and or DHS.
as diagnosed and documented in the clinical Education was provided to 34 nurses ! S
record; and residents who use antipsychotic I
by the Clinical Competency Coordinator
drugs receive gradual dose reductions, and f
behavioral interventions, unless
and RN Supervisor related to
clinically
contraindicated, in an effort to discontinue these medication administration for nurses on I
1 drugs. 2- 19- 16 and ongoing. The education I
included medication administration
C
115452 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZiP CODE
800 PATTERSON RD
PRUiTTHEALTH- SHEPHERD HiLLS
LA FAYETTE, GA 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)
I
Record review for Resident# 1 revealed that he completion before being allowed to
was admitted to thefacility on 12118/ 15 with administer medications to our
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event I0: Z23U11 Facility ID: LTC11461209 if continuation sheet Page 27 of 86
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDEWSUPPLIER( CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
0 3121/ 201 6
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CRY, 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 Xs)
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)
l
1
F 329
l
Continued From page 27 F 329
pressure ulcers. He was completely paralyzed In
Education was provided to 34 nurses
5-7- 1
three extremities and had minimal movement in from 2/ 19116 to 2129/ 16 by the Clinical
the right upper extremity. He was unable to speak
Competency Coordinator, Senior
1 and used a communication board to point to
Nurse Consultant, and RN Supervisor
letters. He weighed one hundred ten( 110)
regarding the medication discrepancy
pounds( lbs). He required humidified oxygen at 5 i
Litersby Trach mask, mobilized breathing form and the documentation regarding
treatments and tracheal suctioning. He was able
and medication discrepancy and
to perform his own oropharyngeal suctioning by reporting the discrepancy to the
yankauer suction catheter. On admission his I
o Physician and Pharmacist. I
oxygen saturation was ninety six percent( 95 Ja).
Review of transferring hospital records revealed 34 Nurses reviewed Medication is /
1 an order for Morphine 2 mg intravenous( IV) q 4 administration video from the
hours while awake. Additional review of transfer
American Society of Consultant
records revealed R# 1 had completed a course of
Pharmacists, which included oral
Vancomycin for Methicillin Resistant
medications, eye meds/ inhalers/
Staphylococcus Aureus and Pseudomonas
Pneumonia. patches, and meds via G tube
Review of facility admission orders revealed an administration of medication with
order for Morphine 20 mg/ ml give 0. 5 ml SL q 4 I successful completion of post test 1
I hours.
beginning 2/ 26/ 16 through 2/ 29/ 16
Review of the Admission Nurses Notes, date
and on going. i
12/ 18/ 15 at 10: 30 p. m., revealed R41 had been
transferred from out of state by a Medivac flight Clinical Competency Coordinator and
and had required the administration of Fentanyl RN on 2/ 26/ 16 and ongoing educated I
100 mg IV for pain and a nebulized respiratory
nurses related to pain including o
treatment enroute. Nurse' s notes on 12119/ 15 at
observation and documentation
8: 20 a. m., written by the night shift nurse,
of pain with routine pain medication j
indicated the resident did not experience
i
sufficientpain relief with the admission order of administration.
I
Morphine
P 10 rn 8 SL q 4 hours the physician
PY was Nursess
Nu were also in serviced b Y the
s- 7—/b
notified on 12/ 19/ 15 at 8: 00 a. m. and the order
Clinical Competency Coordinator
was changed to Morphine 20 mg/ 1 ml give 1 ml
4
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER; COMPLETED
A. BUILDING
C
116452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHI" AtTH- SHEPHERD HILLS
FAYETTE, GA 30728R
I
X4) ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xs)
PREFIX EACH(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
I DEFICIENCY)
F 329 Continued
saturation
From page 28
of 93%, recorded at 3: 30 p• m. on
F 3291 Nurses were educated by Clinical
5- 7- A.
Competency Coordinator and RN
12/ 19115 and one recorded pain level of eight( 8).
He He had allowed suctioning four times.
regarding Errors, Omissions
and late entries.
Review of the Nurses Note on 12/ 20/ 15 at 1: 30
a. m. revealed the resident denied pain and Pruitt University class for Medication
allowed suctioning and tracheostomy care as Administration and Avoiding Common
ordered. The next entry at 8: 05 p. m. by the day
Errors began on 2/ 29/ 16 and ongoing.
shift nurse Licensed Practical Nurse( LPN)" AA"
DHS and or RN supervisor will monitor/
revealed that the resident had experienced a
I Medication of
fever of 102, was congested, and had received observe pass for 10%
I
Morphine 20 mg SL at 7: 00 a. m. and again at nurses weekly times 1 month, then
7: 30 a. m. due to a documentation omission by
monthly times 3 months beginning
the prior shift. He had allowed suctioning and
2/ 25/ 16 and ongoing.
tracheostomy care as ordered. The physician had
pharmacy Consultant will observe at b
been notified of the fever and gave orders for lab
work. The fever had lowered to 99. 0 at 0: 00 p. m. least one random med pass observation
No further vital signs except for temperature were 1 during monthly visit.
recorded for the 7: 00 a. m. to 7: 00 p. m. shift and DHS and or RN Supervisor will
no pain scale or oxygen saturation were
monitor the controlled drug sheets and
recorded. The facility had not assessed pain
level, blood pressure, pulse, or oxygen saturation the MAR daily times 90 days beginning
levels for R# 1. The physician was notified of the 2/ 26/ 16 then weekly times 8 weeks.
medication 12/ 20/ 15 at 8: 00 p. m. and
error on All findings will be taken to the Quality
gave orders for vital signs to be checked every Assurance Performance Improvement
hour until midnight.
Committee for action as needed.
I Review of the Controlled Drug Record revealed
R# 1 received Morphine 20 mg SL on 12120/ 15 at
7: 00 a. m. and again at 7: 30 a. m. He then
received Morphine 20 mg SL every 2 hours until
3: 30 p. m. as scheduled. Morphine was not
administered on 12/20/ 16 at 5: 30 p. m. and 7: 30
p. m. The Controlled Drug Record has these i
doses listed as refused. The reverse side of the
I Medication A d ministration Record MAR
indicated the 5: 30 p. m. dose was refused and this
I was signed by LPN " AA". Continued review of f
the reverse side of the MAR revealed an entry by i I
LPN " BB" that she had not been able to
administer the 7: 30 p. m. dose of Morphine
FORM CMS- 2557( 02- 99) Previous Versions Obsolete Event ID: Z25Ui1 Facility ID: LTC11461209 If continuation sheet Page 29 of 96
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER( SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
i
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FUEL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY ORLSG IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 32 of 06
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORMAPPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 S. WING
03/ 21/ 201 t3
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON Rn
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility 1D! LTC11461209 If continuation sheet Page 33 of 96
is
PRINTED: 0411 3/ 2 01 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICAMN NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
i
F 329 Continued From page 33 F 329
C
115452 B. WING
03121/ 2016
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 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)
C
115452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THEAPPROPRiATE DATE
TAG TAG
DEFICIENCY)
FORM CMS 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 36 of 96
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO, 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDEPJSUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A_ BUILDING
C
115452 13, WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
00 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
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 REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
i
i
R
a
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
115452 B. WING
03122112016
FORM CMS- M7(02- 99) Previous Varaiatis Obsolete Event] D: Z2SU11 Facility ID: LTC11401209 if continuation sheet Page 38 of 96
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
115452 B. WING 03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUIT7HEAi. TH• SHEPHERD HILLS
t.A FAYETTE, GA 30728
FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event I0: Z2SU91 Factity ID: LTC11A61209 If continuation sheet Page 39 of 96
I
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPUEFVCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115462 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COmP1- TION
CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
DEFICIENCY)
1
I
F 329 Continued From page 39 F 329
accurate transcription of medication orders and
Identification of residents.
i
Education content and sign in sheets were
reviewed
2. Pictures of residents were audited on 2125M6 3
and will be reviewed monthly and updated as
needed
3. The clinical competency coordinator provided
education to nurses regarding utilization of other
staff members to assist with the identification
process of residents as needed.
4. Nurses were in serviced by the clinical
competency coordinator and registered nurse
supervisor on 2126t16 related to pain including
observation and documentation of pain with
routine pain medication administration, and
t
observation of respiratory and sedation status
with controlled substance pain medication
administration.
i
PRINTED: 04/ 13/2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
115452 S. WING_
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
i
TAG
DEFICIENCY)
I I
I
F 329 Continued From page 40 IF 329 i I
C
115452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
F 329
1i
Continued From page 41 f
F 3291
Education content and sign in sheets were
reviewed I
FORM CMS- 2567(02- 99) Previous Versions Obsolete Event ID: Z2SUt1
i
FacilltylD: LT011461209 If
i
continuation Sheet Page 42 of 96
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( x1) PROViDER/ SUPPUERICLIA ( XF) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING
C
115452 S. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, TIP CODE
00 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
I
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED 13Y FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE E
TAG TAG
DEFICIENCY)
F
3331 Continued From page 42
i
PRINTED: 0411 3/ 2 0 1 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C.
800 PATTERSON RA
PRt1tTTHEALTN- SHEPHERD HILLS
LA FAYETTE, GA 30728
I
SUMMARY OF DEFICIENCIES
STATEMENT iD PROVIDER' S PLAN OF CORRECTION xs)
X4) ID
EACH DEFlGIENCY MUST BE PREGEElEO BY FULL PREFIX EACH CORRECTIVEACTION SHOULD BE COMPLETION
PREFIX { DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)
Review of the Physician orders for R# 1 revealed and medication discrepancy and
he had an admisslon order, dated 12( 18/ 16 at reporting the discrepancy to the
9:00 p.m., for Morphine 20 milligrams( mg) per Physician and Pharmacist.
milliliter( mi) sublingual( SL) give 0. 5 mi every
34 Nurses reviewed Medication
four( 4) hours. Another Physician order was
administration video from the
i received by the facility on 12/ 19/ 15 at 8:00 a. m.
Indicating that due to continued pain Morphine 20 American Society of Consultant
mg/ ml give 1 ml every 3 hours was to be Pharmacists, which included oral
administered. On 12/ 19/ 15 at 3: 30 p. m. an order medications, eye meds/ inhalers/
to increase the Morphine to 20 mg/ ml give 1 ml
patches, and meds via G tube
every 2 hours was received due to pain level administration of medication with
eight of ten( 8/ 10).
f
successful completion of post test
Review of the Controlled Drug Record revealed beginning 2/26/ 16 through 2129/ 16
that the Morphine 20 mg Iml 1 ml SL was
and on going.
i administered on 12/ 19/ 15 at 3: 30 p. m., 5: 30 p. m.
r
by LPN" AA". The next administrations were
1
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/ 13/ 2016
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) iR SUMMARY STATEMENT OF DEFICIENCIES
EACH DEFICIENCY MUST BE PRECEDED BY FULL
ID j PROVIDER' S PLAN OF CORRECTION
PREFIX ( 1 PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ? TAG f CROSS- REFERENCED TO THE APPROPRIATE ATE
DEFICIENCY)
d
PRINTED: 04/ 1 312 0 1 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( XI) PROVIDER/ SUPPLIEF/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
F 333? Continued From page 45 F 333 DHS and or RN supervisor will monitor/
oxygen saturation of 55%, had been suctioned, observe Medication pass for 10% of
oxygen setting increased, a nebulized breathing nurses weekly times 1 month, then
treatment administered, and the oxygen
monthly times 3 months beginning
g g
saturation was 63%. EMS was called, and
2/ 25/ 16 and ongoing.
transported R# 1 to the hospital where he was
emergently placed on mechanical ventilation and I
Pharmacy Consultant will observe at s- 7-/ 4
admitted to Intensive Care Unit. i least one random med pass observation
during monthly visit.
Review of the EMS Patient Care Report dated
12/ 21/ 15 revealed that R# 1 had been
All finding will be taken to the Quality
Assurance Performance improvement
administered Narcan 0. 5 mg intravenous( IV) at
6: 41 a.m. with rapid response of increased level Committee for action as needed.
of consciousness, increased level of oxygenation,
increased rate of respirations and increased pupil
size.
I!
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
DEFICIENCY)
i'
i
z
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO, 0938- 0391 ,
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTt tEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
I
I
i
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DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
600 PATTERSON
PRUITrHEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
FORM CMS 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 49 of 96
i
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/ 13/ 2016
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERiSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115462 S. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
I
F
3331 Continued From page 49
B
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
115452 a. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 FATTERSON RO
PEtUlTTHEAl. TH- SHEPHERD HILLS
LA FAYETTE, GA 30728
it
I
I
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED
800 PATTERSON RD
PRUITTHEALTH• SHEPHERD HILLS
LA FAYETTE, GA 30728
Hypotension)..
L
Y
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PRINTED: 04/ 13/ 2016
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES
OMB NO, 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
A BUILDING COMPLETED
C.
113452 e. wlNo
03/ 2112016
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON Rb
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETI"E, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION
ID
Ply))
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)
I
FORM CMS- 2587( 02- 99) Previous versions Obsolete Event ID: Z2SU11 Facility ID: LTC11481209 If continuation sheet Page 53 of 96
F
e
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115452 B. WING
0 3/ 2 112 0 1 6
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, CAAR 30728
1 DEFICIENCY)
C
115452 8. WING 03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE
BOB PATTERSON RD
PRUITfHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
l
Interview on 2119/ 16 at 11: 55 a. m. with LPN" B8"
revealed that she had not signed the MAR or f
Controlled Drug Record for two administrations of
Morphine to R# 1 scheduled at 3. 30 a. m. and 5:30
a.m. and given late at 4: 30 a. m. and 7.00 a.m.
and she had not communicated this to LPN" AA"
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 55 of 96 T
I
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING_
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
i
X4) ID I SUMMARY STATEMENT OF DEFICIENCIES
EACH DEFICIENCY MUST BE PRECEDED BY FULL
ID
PREFIX I (
PROVIDERS PLAN OF CORRECTION
EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX ! (
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ` CROSS- REFERENCED TO THE APPROPRIATE
I I
DEFICIENCY)
i
I
s
PRINTED: 04113/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
115452 B. WING
03/ 21/ 2016
800 PATrERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
I
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETi' EE, GA 30728
prescribed medication.
fi
I
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLIER/ CLA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
needed
s' 3. The clinical competency coordinator provided
education to nurses regarding utilization of other
staff members to assist with the Identification
process of residents as needed.
4. Nurses were in serviced by the clinical
competency coordinator and registered nurse
supervisor on 2t26/ 16 related to pain including
observation and documentation of pain with
routine pain medication administration, and
observation of respiratory and sedation status I
C
115452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEAt_TH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Ix5)
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)
C
115452 B. WING 03/ 2112016
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
L. A FAYETTE, GA 30728
SUMMARY STATEMENT OF DEFICIENCIES iD I PROVIDER' S PLAN OF CORRECTION
X4) ID
PREFIX
TAG
( EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
EACH CORRECTIVE ACTION SHOULD
CROSS- REFERENCED TO THE APPROPRIATE
SE eo
onrE oN
DEFICIENCY)
I
z
1
f
CCURATE PROCEDURES,
ACCURATE RPH w
i
t
ii
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/ 13/ 2016
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLiER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C.
115452 S. wlNc
03/ 21/ 2016
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 PROVIDER' S PLAN OF CORRECTION
PREFIX ' ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE i COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE ATE
DEFICI IQ)
t i
resulted in a significant medication error for two on October 14, 2015. Resident# 2
2) residents(# 1 and# 2) from a total survey returned to Shepherd Hills October 17,
sample of twenty- four( 24) residents. Resident
2015, and still resides in the facility.
1, with a physician order for Morphine
FORM CMS- 260( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 FacllitylD: LTC11461209
If continuation sheet Page 82 of 96
r
DEPARTMENT OF HEALTH AND HUMAN PRINTED: 0411 3/ 2 0 1 6
SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIEWCLIA ( X2) MULTIPLE CONSTRUCTION X3} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
116452 B. WING
030/ 2016
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
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL EACH CORRECTIVE ACTION SHOULD BE
PREFIX COMPLMON
TAG i REGULATORY ORLSCIDENTIFYINGINFORMATIpN) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 490 Continued From page 62 F 490 Medical Records for the residents
sublingual( SL) every two hours, received two were reviewed to ensure that the
administrations of Morphine 20 mg SL within thirty
Physician' s Orders were correctly
minutes on December 20, 2015 at 7: 00 a. m., and
transcribed to Medication Administration
i
7: 30 a. m. Then, on December 20, 2015,
Record.
beginning at 9: 30 p.m. Resident# 1 was
administered Morphine 20 mg SL every 2 hours ! Education was provided to 34 nurses
without appropriate assessment of respirations, by the Clinical Competency Coordinator
paln level, or level of consciousness, until on
and RN Supervisor related to
December 21, 2015 at 5: 45 a. m. he was
medication administration for nurses on
discovered In respiratory distress and transferred i
to the hospital, treated in the
Emergency 2- 19- 16 and ongoing. The education
Department, requiring mechanical ventilation and included medication administration
transferred to the Intensive Care Unit( ICU) where
general guide fines, including but not
he remained intermittently on a ventilator until
4, 2016, when he was transferred
limited to, following physicians orders,
February to an
acute longterm care facility. Resident# 2, who did medication pass times, consistent
not have an order for 2 antihypertensive and accurate documentation of
medications, Procard€a and Hydralazine, was medication and acceptance/ refusal
administered these medications in error on
of medications, medication discrepancies,
October 14, 2015 at 6: 00 a. m. Resident# 2 then
became severely hypotensive and experienced
adverse medication reactions, accurate j
diminished level of consciousness and was transcription of medication orders, and
transferred emergenity to the hospital and identification of patients.
admitted to the ICU. These errors were not Newly hired will be educated
recorded Medication
nurses by IS- -7-
on Discrepancy and Adverse
Clinical Competency Coordinator and
Reaction Reports and submitted to the
pharmacy, mentor nurse on medication admin-
or consultant pharmacist, for tracking and
istration general
9 a guidelines,
9 inclu ding9
trending p p
purposes, or review
v'Iw o
f the
e Quality
E Assurance Committee as required by corporate but not limited to, following physicians
policy for Medication Discrepancies and Adverse orders, medication pass times, consistent
Reactions.
and accurate documentation of I
d
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIEWC41A ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115452 a, WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xs)
I
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)
r
F 4901 Continued From page 63 F 490 Newly hired nurses will be educated by , S
Director of Health Services( DHS) and Nursing Clinical Competency Coordinator and
Supervisor" EE" Registered Nurse( RN) were
mentor nurse on medication admin-
informed of the Immediate Jeopardy on February
istration general guidelines, including
25, 2016 at 5: 00 p. m. The Immediate Jeopardy
was identified to have existed on October 14, but not limited to, following physicians
2015, when the facility failed to ensure the j orders, medication pass times, consistent
accurate administration of medication to Resident and accurate documentation of
2.
i medication and acceptance/ refusal
An allegation of jeopardy removal of medications, medication
was received
on February 26, 2016. Based on the corrective discrepancies, adverse medication
plans which had been developed and reactions, accurate transcription of
Implemented by the facility, the Immediacy of the medication orders, and
deficient practice was determined to have been
identification of patients.
removed on March 4, 2016 as alleged, and the
facility remained out of compliance at the lower Newly hired nurses will be required to S•7-
scope and severity of" D" while the process of complete the Orientation Skills
evaluation of the nursing staffs' compliance with Checklist, Medication Administration
physicians orders, education, and facility policies
Video with post test, and Medication
and procedures, continued. In- service materials
Cart Orientation,
and records were reviewed, all medication
administration records were reviewed for resident Newly hired nurses will have a med l5- 7-/
pictures. pass observation completed by a
Interviews were conducted with nursing staff to RN Supervisor and or DHS and will be
ensure they were knowledgeable about the
required to have a successful
of resident medication..
administration
j completion before being allowed to
Findings include: administer medications to our
residents.
r:
i
s
i
PRINTED: 04113/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
116452 S. WING 0312112016
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LAFAYETTE, GA 30728
and on the line for that specific medication dose Pictures of residents will be reviewed
administration. monthly and updated as needed with
admissions and discharges.
Review of Lippincott Procedures- Pain
Clinical Competency Coordinator and S. 7- 14,
management, provided by the administrator when
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
800 PAATTERSON RO
PRUITTHEALTH- SHEPHERD HILLS
A FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDER' S PLAN OF CORRECTION Xe)
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
I
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION I VO
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLE-rloN
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
j
j
F 490 Continued From page 67 F 490
i
administered his room mates medications. The
Administrator revealed she had verbally informed l
the Consultant Pharmacist and the QA
Committee of these situations, but there was no i
record of this. The facility had not completed
interventions such
and determine the need for
as staff education.
ji
She acknowledged she had received a verbal E
report when Resident# 2 received 2
antihypertensive medications and she had offered
to observe a medication pass by" BB" LPN, but
since" BB' LPN was only in the building at night
and on weekends she was not able to do this.
The Consultant Pharmacistindicated she had i I
also been made aware of Resident# 1 receiving 2 l
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
C
115462 B. WING 03/ 21/ 2016
FORM CMS- 2567(82-89) Previous Versions Obsdeie Event ID: 22SU11 FacII1ty1D: LTC11461209 If continuation sheet Page 69 of 96
I
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING COMPLETED
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITI" HEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID ( SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xti)
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)
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERJSUPPLIEPJCUA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTEERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
f
f
entries.
FORM CMS- 2667(02-99) Previous Versions Obsolete Event ID: Z2SU11 Fadlily to: LTC11461209 If continuation sheet Page 71 of 96
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUM3ER: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
00 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
I
FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: Z2SU11
If
I
i
PRINTED: 04/ 13/ 20 t 6
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
the next day ICU Physician Progress notes regarding the medication discrepancy
indicated he was diagnosed with Demand form and the documentation regarding
Ischemia and Non ST Segment Elevation and medication discrepancy and
Myocardial Infarction( NSTEMI). The immediate
reporting the discrepancy to the
Jeopardy continued through December 20, 2015,
Physician and Pharmacist,
the date Resident# 1 received, due to an
omission of documentation, two( 2) doses of 34 Nurses reviewed Medication
Morphine 20 mg SL within 30 minutes, at 7: 00 administration video from the
and 7: 30 a. m, The night of 12/ 20/ 15 and the
a. m.
American Society of Consultant
morning of 12/ 21/ 15, from 9: 30 p. m. through 5: 30 Pharmacists, which included oral
a. m. Resident# 1 received Morphine 20 mg SL
medications, eye meds/ inhalers!
every 2 hours without assessment of respiratory
status, pain level and without regard to sedation patches, and meds via G tube
level and education provided by a Nursing I administration of medication with
Supervisor advising the use of nursing
i successful completion of post test
judgement, the residents ability to use a pain
scale to assess sedation, and the passibility of
beginning 2/ 26/ 16 through 2/ 29/ 16 r
and on going, i
respiratory depression with the use of oplold
medication.
r
PRINTED: 0411 3/ 20 1 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21 12 01 6
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDEWSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
0 3121/ 2 0 1 6
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYIETTE, GA 30729
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE ? COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) ! CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG TAG I
DEFICIENCY)
i
C
116462 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
If
C
116452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA LAYETTE, GA 30728
S PLAN OF CORRECTION
W)
PREFIX
ID ' SUMMARY STATEMENT
OF DEFICIENCIES
EACH DEFICIENCY MUST BE PRECEDED BY FULL
I ID
PREFIX
PROVIDER'
C
115452 B. WING
0 3121 1201 6
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHI; ALTH- SHEPHERD HILLS
FAYETTE, R
GA 30728
i
F 514 Continued From page 78 F 514
the Controlled Drug Report on 12/ 19/ 15 without a
time between 6: 00 a. m. and 8: 00 a. m. had been
questioned with LPN " AA' and she had been
unable to give an explanation of this entry, but
this was also not considered an error.
Review of Nurses Notes for R# 1 dated 12/ 23/ 15
revealed an entry as follows: Investigation
completed byAdmin SR RN Consultant, DHS
DON). All meds, doses accounted for. No med
error. This entry was signed by the Corporate
Clinical Consultant.
Interview on 2/ 19116 at 10: 35 a. m. with LPN " AA"
revealed that when writing the orders for the
increased doses of Morphine she did not know
she needed to Include the concentration and
milligrams. " A" indicated she also had not known
the time of the order, concentration, and I
milligrams needed to be transcribed on the MAR,
but she had received clarification of the last order
on 12/ 19/ 15 at 3: 30 p. m, by calling the physician I i
J
PRINTED: 04113/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 093" 391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERJCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADORESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUlTTHEALTM- SHEPHERD HILLS
FAYETTE, R
GA 30728
DEFICIENCY)
1
2. Record review for Resident# 3 revealed a j
re- entry date of 6/ 29/ 15, with an admission
diagnosis including Congestive Heart Failure i
CHF), Hypertension, and Diabetes. Review of
the October Physician orders for Resident# 3
Included orders for Advalr Diskus 250/ 50 one puff
po q 12 hours, Levemir Insulin 70 units sq q a. m.
and bedtime( hs), and Fluvall 0. 5 ml IM to left
deltoid times( X) 1,
Review of the MAR for Resident# 3 for the month
of October revealed Levemir Insulin 70 units had
not been Initialed as given on 10/ 12/ 15 at 9: 00 I
r
PRINTED: 0411312016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 e- WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD FALLS
LA FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT
OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xs)
PREFIX
TAG
( EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
EACH CORRECTIVE
CROSS- REFERENCED
ACTION SHOULD BE
TO THE APPROPRIATE {
I COWLETION
DATE
DEFICIENCY)
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIf RICUA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 e, WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, LP CODE
300 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
I
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility to,.I-TC11461209 If continuation sheet Page 63 of 96
I
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 2112016
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 PROVIDER' S PLAN OF CORRECTION
X4) ID
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FILL i Ip
PREFIX EACH CORRECTIVE ACTION SHOULD BE cOMPLE TIoN
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
I
F 614 Continued From page 83 F 514
1
I
i
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( XI) PROVIDER/ SUPPLIER/CLiA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENrIFfCATION LIMBER:
A. BUILDING COMPLETED
C
115452 B. WING
03/21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
PRUITTHEAf TH- SHEPHERD HILLS
LA FAYETTE:, GA 30728
r
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 S. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, R
GA 30728
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event I1D: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 86 of 96
Y
PRINTED: 0411 3/ 2 0 1 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, GAR 30728
DEFICIENCY)
F 520 Continued From page 86 F 520 Resident# 2 was sent to the ER and
with Physicians' orders, and failed to continue i limited to, following physicians orders,
quality assurance monitoring of plans of action medication pass times, consistent
implemented to correct an Identified problem with I and accurate documentation of
resident identification by staff nurses during medication and acceptancelrefusal
orientation. Additionally the facility failed to of medications, medication discrepancies,
I
provide oversight to a newly hired nurse
adverse medication reactions, accurate
administering medications without supervision.
This failure resulted in a significant medication j transcription of medication orders, and
error Involving the administration of two( 2) identification of patients
antihypertensive medications to the wrong
resident( R# 2) on 10/ 14/ 15, when a photograph
was not available on the Medication
Administration Record( MAR) for an i
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility 9h LTC11461209 If continuation sheet Page 87 of 96
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLiERICLIA ( X2) MULTIPLE CONSTRUCTION M) DATE SURVEY
IDENTIFICATION NUMBER COMPLETED
AND PLAN OF CORRECTION A. BUILDING
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
and comply with established policies and medication and acceptance/ refusal
procedures related to medication management. of medications, medication discrepancies,
Resident# 1 was administered Morphine 20 mg
Due to adverse medication reactions, accurate
SL twice within thirty( 30) minutes. an j
omission of documentation on December 20,
4 transcription of medication orders, and
2016, on the MAR and Controlled Drug Record of
a dose of Morphine 20 mg SL scheduled for 5: 30 identification of patients.
a. m. and not given until 7: 00 a. m., Resident# 1 Newly hired nurses will be educated by 3"- 7- Av
recieved a second dose of Morphine 20 mg SL at
Clinical Competency Coordinator and
7: 30 a. m. This was not identified as an error
i
despite the Medication Administration Guidelines mentor nurse on medication admin-
i
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER; COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
the facility, the immediacy of the deficient practice form and the documentation regarding
was determined to have been removed on March and medication discrepancy and
4, 2016 as alleged, and the facility remained out reporting the discrepancy to the
of compliance at the lower scope and severity of physician and Pharmacist.
D" while the process of evaluation of the nursing A.
34 Nurses reviewed Medication
staffs compliance with physician' s orders, 1 administration video from the
education, and facility policies and procedures,
continued. In- service materials and records were American Society of Consultant
reviewed. Interviews were conducted with nursing Pharmacists, which included oral
staff to ensure they were knowledgeable about
medications, eye meds/ inhalers/
the administration of resident medication.
patches, and meds via G tube
Findings include: administration of medication with
f
Cross refer to F333, F329, F490, and F514 successful completion of post test
beginning 2/ 26/ 16 through 2/ 29/
An interview with the Corporate
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PA'rTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
DEFICIENCY)
home. " BB" then revealed she had not signed for
the Morphine on the Controlled Drug Record and
daily.
had not initialed on the MAR that she had RN Supervisor and or DHS will complete
administered the medication. She acknowledged
a review of the MAR' s monthly during
she had not indicated why the administration was F
90 minutes late, flagged the MAR with this change over to ensure resident
for Resident# 2
record -
Is
least one random med pass observation
revealed he was administered Procardia 30 mg
during monthly visit.
and Hydralazine 100 mg by mouth on 10/ 14/ 15 at
6, 00 a. m., and did not have orders for these Medication discrepancy/ adverse Reaction S`_-hp
medications, discovered to be severely
He was
Observation of the MAR books conducted an reports that have been determined to have i
2/ 19/ 16 at 2: 10 p. m. and on 2/ 25116 at 10: 40 a. m. an adverse reaction or cause harm to a I
revealed six( 6) resident pictures missing.
In an interview conducted with Nurse HH 1 i resident will have a Performance
i
Licensed Practical Nurse( LPN) on 2/ 24/ 16 at Improvement Plan developed by the Quality
3: 00 p. m. she revealed she had oriented LPN
Assessment and Assurance Committee.
BB" to pass medications on the North Hall from
11: 00 p. m. on 10/ 13/ 15 to 7: 00 a. m. on 10/ 14/ 16.
She remembered observing LPN" BB" preparing
FORM CMS- 2567(02. 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If sheet Page
continuation 90 of 96
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVID£ R/ SUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING
C
115452 B. WING_
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETCE, GA 30728
C
115452 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH. SHEPHERD HILLS
FAYETTE, GA R
30728
DEFICIENCY)
i
I I
I
I 3
F 520 Continued From page 91 F 5201
MAR' s had been equipped with pictures. The
Administrator then acknowledged there were six
C
115452 B. WING_
03121/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
00 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
C
115452 B. WING
03/ 211201 6
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
aeo PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
F 520
i Continued From page 93
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PA IiD
PRUITTHEALTH- SHEPHERD HILLS
LAFAYETTEETTE,
LA GA 30728
i
PRINTED; 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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 COMPLETED
C
116452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
is
i
FORM CMS• 2667( 02. 99) Previous Versions Obsolete Event ID: Z2SU11 FacilityID: LTC11461209
If continuation sheet Page 98 of 96
r
PRUITT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Issue: F333- J: related to allegation of significant Medication administration records reviewed to ensure
med error. that MAR' s are correct. Completed on 2- 20- 16. Positive
identification of residents will be validated before
medications are administered. Ongoing
Immediate Action Taken for Residents:
MD notification
resides in facility
Date Certain 3/ 4/ 16
Monitoring:
Re- education of nurses on medication
administration. 2- 19- 16 ongoing. 34 nurses
PR UI TT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Date Certain 3/ 4/ 16
Monitoring:
DHS or RN Supervisor will review MAR' s weekly
to ensure that level of pain is being monitored.
QA committee will meet and discuss monthly
Issue: F282- J: related to care plan by qualified
Care plan Medication Action Taken to assure no other residents will be
professional. reads: as
Monitoring:
DHS or RN Supervisor will monitor/ observe
med pass for 10% of nurses weekly x 1 month,
then monthly x 3 months 02- 25- 16 ongoing
Pharmacy consultant will observe at least 1
random med pass monthly during her visit.
Completed 2- 1- 16.
Monitoring:
Charge nurses will review MAR and controlled
completion.
Allegation that nurse failed to monitor the pain affected in the future:
Date Certain 3/ 4/ 16
Monitoring:
DHS or RN Supervisor will complete weekly
monitoring of MAR to ensure that pain level is
being documented when routine controlled
substance pain medication are administered.
QA committee will meet and discuss monthly
Issue: F425- 1: related to pharmaceutical services Action Taken to ensure no other residents will be
Allegation that facility failed to provide pharmaceutical affected in the future:
services to review, track and trend medication errors,
and determine the need for intervention Nurses were in serviced on
the completion of medication
PR UI TT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Monitoring:
Date Certain 3/ 4/ 16
Issue: F520- J: related to QAA committee members, Action Taken to ensure no residents will be affected in
meetings and plans the future:
Date Certain 3/ 4/ 16
PRUITT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Issue: F333- J: related to allegation of significant Medication administration records reviewed to ensure
that MAR' s are correct. Completed on 2- 20- 16. Positive
med error.
identification of residents will be validated before
medications are administered. Ongoing
Immediate Action Taken for Residents:
MD notification
Monitoring:
Re- education of nurses on medication
administration. 2- 19- 16 ongoing. 34 nurses
completed the education by 2/ 29/ 16.
DHS or RN Supervisor to complete daily review
of MAR' s for completion.
RN Supervisor to complete review of MAR' s
94-
PRUITT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Date Certain 3/ 4/ 16
Monitoring:
DHS or RN Supervisor will review MAR' s weekly
to ensure that level of pain is being monitored.
QA committee will meet and discuss monthly
Issue: F282- J: related to care plan by qualified
Care Medication Action Taken to assure no other residents will be
professional. plan reads: as
affected in the future:
ordered- allegation that one resident received
Nurses were in- serviced related to medication
medication that wasn' t ordered for him.
administration. 02- 19- 16 ongoing. . 34 nurses
Monitoring:
DHS or RN Supervisor will monitor/ observe
med pass for 10% of nurses weekly x 1 month,
then monthly x 3 months 02- 25- 16 ongoing
Pharmacy consultant will observe at least 1
random med pass monthly during her visit.
Completed 2- 1- 16.
Monitoring:
Charge nurses will review MAR and controlled
substance sheets at shift change for
completion.
Date Certain 3/ 4/ 16
Monitoring:
DHS or RN Supervisor will complete weekly
monitoring of MAR to ensure that pain level is
being documented when routine controlled
substance pain medication are administered.
QA committee will meet and discuss monthly
Issue: F425- J: related to pharmaceutical services Action Taken to ensure no other residents will be
Allegation thatfacility failed to provide pharmaceutical affected in the future:
services to review, track and trend medication errors,
and determine the need for intervention
Nurses were in serviced on
the completion of medication
discrepancy Adverse reaction
Policy. . 02- 19- 16 ongoing. 34 nurses
completed education by 2/ 29/ 16
PRUITT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Monitoring:
Date Certain 3/ 4/ 16
Issue: F520- J: related to QAA committee members, Action Taken to ensure no residents will be affected in
meetings and meeting the future:
Date Certain 3/ 4/ 16
PR UI TT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638-4151
issue: F333- J: related to allegation of significant Medication administration records reviewed to ensure
med error. that MAR' s are correct. Completed on 2- 20- 16.
Monitoring:
Re- education of nurses by Clinical
Competency Coordinator and RN Supervisor
on medication administration. 2- 19- 16
assessment and monitoring of resident that was Observation of patient for change of
needed with allegation that it was not done. condition
Monitoring:
DHS or RN Supervisor will review MAR' s
weekly to ensure that level of pain is being
monitored.
resides in facility
Nurses were educated to ensure that nurses
in orientation were not left unattended
during medication administration. 20 nurses
completed training on 10- 14- 15
Administrator had a verbal discussion with
both the nurse in orientation and the mentor
nurse related to medication administration
and consistent observation of any newly hired
nurse during the orientation process on
10/ 14/ 15, related to resident number 2
Monitoring:
DHS or RN Supervisor will monitor/ observe
med pass for 10% of nurses weekly x 1 month,
then monthly x 3 months 02- 25- 16 ongoing
Pharmacy consultant will observe at least 1
random med pass monthly during her visit.
Completed 2- 1- 16.
Issue: F514- J: Allegation that pain medication was Immediate Action Taken for Residents:
return to facility
Resident# 3— no harm, patient no longer
resides in facility— Nurse was counseled
related to failure to document on MAR
Monitoring:
Charge nurses will review MAR and controlled
substance sheets at shift change for
completion.
Monitoring:
DHS or RN Supervisor will complete weekly
monitoring of MAR to ensure that pain level is
being documented when routine controlled
substance pain medication are administered.
All findings will be taken to the Quality
Assurance Performance Improvement
Issue: F425- J: related to pharmaceutical services Immediate Action Taken for Residents:
return to facility
Res# 2 sent to ER and admitted on 10/ 14/ 15,
returned to Shepherd Hills 10/ 17/ 15, and still
resides in facility
Nurses were educated to ensure that nurses
in orientation were not left unattended
during medication administration. 20 nurses
completed training on 10- 14- 15
Administrator had a verbal discussion with
both the nurse in orientation and the mentor
nurse related to medication administration
Monitoring:
Date Certain 3/ 4/ 16
PRUITT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 41 S1
Issue: F520- J: related to QAA committee members, Immediate Action Taken for Residents:
meetings and plans
Observation of patient for change of
condition
in the future:
Monitoring:
Date Certain 3/ 4/ 16
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING
02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRIJITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
Any 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 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: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 1 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PA N RD
PRUITTHEALTH- SHEPHERD HILLS
LAFAYETTEETTE,
LA GA 30728
NSTEMI).
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 2 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 SQN RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYET
LA YETTE, A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 3 of 67
i
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If Continuation sheet Page 4 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
Ci
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
Findings include:
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 5 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
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115452 B. WING 0212612016
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
r
During a n interview with the Administrator on
February 19, 2016 at 6: 30 p. m. she stated that an
inservice was conducted when this medication
error was discovered and she had both nurses in
her office and gave a verbal reprimand to the
nurse that was providing training to the new nurse
because she ( the nurse providing training) was
sitting at the nurses station and allowing the new
nurse to administer medications unsupervised.
The Administrator further acknowledged that
neither nurse had received a written reprimand on
this error.
C
115452 B. WING
02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PA NRD
PRUITTHEALTH- SHEPHERD HILLS
LAFAYETTE, GA 30728
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING
0212612016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461: 209 If continuation sheet Page 8 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
C
115452 B. WING 02/ 26/ 2016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING 0212612016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 11 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
NUMBER: COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION
A. BUILDING
C
115452 B. WING 02/ 2612016
800 PA N RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYETTEETTE
LA A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 12 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING
02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PA N RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYETTEETTE,
LA GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 13 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 .
CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/
NUMBER: COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION
A. BUILDING
C
115452 B. WING 0212612016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
Findings include:
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation Sheet Page 14 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES (
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING 0212612016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 15 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
0212612016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 SON RD
PRUITTHEALTH - SHEPHERD HILLS
LAAFAYET
LYETTE, A 30728
GA
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
02/ 2612016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PA RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYETTEETTE
LA A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 17 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 18 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES (
COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING
C
115452 B. WING 02/ 26/ 2016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
Ci
115452 B. WING
02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 SON RD
PRUITTHEALTH - SHEPHERD HILLS
LA YETTE,
LAFAYET A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 20 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
DEFICIENCY)
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LAA FAYETYETTE,
L GA 30728
EACH DEFICIENCY MUST BE PRECEDED BY FULL EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 22 of 67
I
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 2612016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
02/ 26/ 2016
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)
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 .
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
NUMBER: COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION
A. BUILDING
C
115452 B. WING 02/ 2612016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 25 of 67
PRINTED: 03/ 17/ 2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
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:
A. BUILDING
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 .
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES (
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING 02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING 02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PA RD
PRUITTHEALTH - SHEPHERD HILLS
L
LAA FAYETTEETTE A 30728
GA
C
115452 B. WING 02/ 26/ 2016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING 02/ 26/ 2016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
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PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Findings include:
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 SON RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYET
LA YETTE, A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 33 of 67
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
I
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA
NUMBER: COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION
A. BUILDING
Ci
115452 B. WING 02126/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If Continuation sheet Page 38 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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 COMPLETED
C
115452 B. WING
02/ 26/ 2016
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)
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
C
115452 B. WING
02/ 26/ 2016
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)
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH - SHEPHERD HILLS
FAYETTE, R
GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
C
115452 B. WING 0212612016
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH - SHEPHERD HILLS
FAYETTE, GAR 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) DATE
TAG TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
02/ 2612016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 45 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Findings include:
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 47 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH - SHEPHERD HILLS
FAYETTE, GAR 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
C
115452 B. WING
02/ 26/ 2016
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)
C
115452 B. WING 0212612016
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
02/ 26/ 2016
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)
Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 52 of 67
FORM CMS- 2567( 02- 99) Previous Versions
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
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115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH - SHEPHERD HILLS
FAYETTE, GA R 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH- SHEPHERD HILLS
FAYETTE, GAR 30728
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 SON RD
PRUITTHEALTH - SHEPHERD HILLS
YETTE,
LAFAYET
LA GA
A 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 61 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES (
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 SON RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYET
LA YETTE, A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 62 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LAA FAYETYETTE,
L GA 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 63 of 67
PRINTED: 03/ 17/ 2016
DEPARTMENT OF HEALTH AND HUMAN 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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA
LA FAYETTE, GA 30728
EACH DEFICIENCY MUST BE PRECEDED BY FULL EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
Findings include:
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS
LA FAYETTE, GA 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PA RD
PRUITTHEALTH - SHEPHERD HILLS
LAFAYETTEETTE
LA A 30728
GA
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 66 of 67
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED D
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: COMPLETED
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON
PRUITTHEALTH - SHEPHERD HILLS
FAYETTE, GAR 30728
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If Continuation sheet Page 67 of 67
Sanders, Andrea
Subject: new nurses since 10/ 1/ 15, who was interviewed, who was checked for employee files for
abuse protocol and some of the checklists
Attachments: Shephillschecklists.pdf, Shephillsnewemployeeandchecklists.pdf
1
Sanders, Andrea
Ladies,
The employee files I did are located in the first attachment: PHShepherdHill Abuse a. pdf. There are only five employees
because on the Prohibition protocol that is all that was required We did look at the employees that were involved with
the errors on the complaints. Hope this helps.
Kathy
Sanders, Andrea
Importance: High
Attached is your 2567& letter from the complaint survey, if you have any questions please contact Andrea Sanders,
who is copied on this e- mail. Please submit an AoC as soon as possible so that the revisit to remove the termination may
be completed.
1
Meyer, William
Hi Bill, I received this from Cathy and I need to give you some information regarding the question from Stephanie Davis
to you and Melanie-
Resident# 2 was administered his roommates antihypertensive medications on 10/ 14/ 15.
Resident# 1 was administered 2 doses of Morphine within 30 minutes, and it was ordered q 2 hrs on 12/ 20/ 15, at 7 AM
and again at 7: 30 AM. This was a result of the night nurse giving her last dose an hour and a half late and not signing it
out on the narcotic book or the MAR. The next morning at 5: 45 AM he was found in respiratory distress, after being
administered Morphine every 2 hours from 9: 30 PM on 12/ 20/ 15 through 5: 30 AM on 12/ 21/ 15. There were no
assessments of LOC, and there were no 02 sats after 2AM when it was 90% on ? 4 liters. The significant med error of the
2 doses in 30 minutes was almost 24 hours before he de satted and I am citing F333 for the med error. I am citing F329
for the failure to monitor while giving the MS q 2 hrs. I asked Andrea about this and she referred me to Marsha and she
agreed that the failure to monitor belongs under 329. The physician ( and of course I agree) said the 2 Morphine doses
within 30 minutes did not cause the respiratory distress almost 24 hours later. We all know it is metabolized much faster
than that. But getting repeated doses without assessment that night and the next AM certainly did. He had a DX of
respiratory failure a trash, history of MRSA and pseudomonas pneumonia, to begin with. I hope this clears up and
confusion of what happened when and what we are citing and why.
The next clarification for the next paragraph of the email : We were asked to consider the following tags-
F157- this did not apply- everyone was notified appropriately.
F223- there was no abuse- Kathy worked abuse protocol for the self reported complaint. There was no abuse.
F490- we cited professional standards under 281
F501- we interviewed the medical director and there was not a problem with his suggestions for QA- he wanted an
educator hired ASAP and pictures of all the residents available for new employees. These were both appropriate
interventions for the 2 residents who experienced harm. I am simplifying of course. But this was not a citation that I
would write. They did not follow his recommendations- the educator did not start until 12/ 16/ 15, due to recovering
from surgery- they could have appointed a temp dedicated to education only but instead were using the MDS nurse in
that capacity as well as having other duties. And there were 6 residents whose pictures were not on the MARs when I
checked on 2 different days during the complaint investigation. So I cited F520.
F514- I was always going to write this, right from the start. It is written.
F 520- again, this was considered right from the start. it is written.
You will find in my citations multiple interviews with the Medical Director, Pharmacy Consultant, DON, supervisor,
educator, administrator and personnel involved in the citations- these are CIA committee. Plus an EMS paramedic. I also
I interviewed Nurse BB who had administered the Morphine every 2 hrs without assessment and who had not
documented correctly the night before, then she resigned before we knew she was the same nurse who had on
orientation administered BP meds to the wrong resident. There were attempts made to call her, both by the facility and
by Kathy but she did not return our calls. We did interview the nurse who was precepting her and who admitted she left
Nurse BB unattended to give a medication when she did not know the residents and there were no pictures in the MAR
book. I have identified the education given after not signing for the Morphine administered to Resident# 1, to Nurse BB
in my citation F329- she was educated to document her medications after giving them. I received also, from the
administrator, sign in sheets for education given before Nurse BB administered the Morphine without regard to
Resident# 1' s low 02 sat and diminished LOC and she simply did not take the advice. I have the content of that
education and described it in F 333 and F 329. It was good education and could have saved her a lot of problems. The
education given after was on opiod administration and I don' t know what the actual content was but it was different. I
I
r
will find the answer. li was identified and I have requested and received education content and rosters for all education
given since the IJ was conveyed to the administrator, DON, consultant and weekend supervisor and it is the policies.
When I questioned the administrator she explained that is what they are teaching and they are using computer based
learning modules as well from Pruitt University.
These citations have all been QAd now and I don' t know the content anymore because the remote system is down, but
when I wrote them all this was addressed. I actually tried to think of everything before the questions started.
Thank You
Jeanne MKees| er
Davis, Cathy
Sent: Friday, March 1O' 201611: 34AK8
To: Kees| er, Jeanne ^ jkees| er@doh. ga. gov>
Subject: F»v: UotPH Shepherd_Hills
eannie,
I just received this from Melanie -- Please see the email from CIVIS that Melanie has forwarded to us.
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From: " Davi3, Stephanie K4. ( CK4S/ CQISC{])" « Stephanie. Davis@crns. hbs. gov>
Date: February 25, 3Ol6at6: 2O: S4P& 4EST
Cc: " Holloway, Leontyne J. ( CMS/ CQISCO)" < Leontvne. Hollowav@cms. hhs. gov>, " Meyer,
Based on our conversation today, it was my understanding that the incident whereby a resident was
erroneously given hypertensive medications occurred on 10/ 14/ 2015. This resident was hospitalized
and subsequently sustained an Mi. A second resident was given two doses of morphine on
12/ 20/ 2015. This significant medication error also resulted in the resident experiencing a drop in
oxygen saturation levels and being sent to the ER.
It was not my understanding that both incidents occurred on the same day. Please clarify.
in addition, the tags listed below were a preliminary listing. We discussed the investigation and
additional interviews that may strengthen this complaint investigation. CMS asked the SSA to evaluate
C.0n* iaj ce_w th_FA57,_ F= 514,_F- 52Q,_ F7490, F7I501_ and F- 223- Jnte_rv ews_o_Uth_e nurse that- allegedly
administered the incorrect medication would be helpful, as well as, interviews with the Medical
Director, Pharmacy consultant, DON, administrator and staff person( s) involved in quality assessment
and assurance. it is important for the SSA to determine what in- service education, if any, was
conducted between the medication errors, and who conducted the training. If IJ is identified, the SSA
should not accept the same training again, if it proved ineffective.
We will wait on the SSA' s clarification of both incidents, as this will be one of the items determining the
start date of any enforcement remedies.
Thank you,
00,1,07070.........-
ANN*
3
From: Simon, Melanie Finailto: msimonPdch. Ra. Rovl
Sent: Thursday, February 25, 2016 5: 44 PM
To: Davis, Stephanie M. ( CMS/ CQISCO)
Cc: Holloway, Leontyne J. ( CMS/ CQISCO); Meyer, William
Good evening, Stephanie. As a follow-up to your conversation with Bill, below is the
information on the Immediate Jeopardy situation at Shepherd Hills. We will have a surveyor at
the facility tomorrow and will pass along the additional information you requested as soon as it is
received.
During a complaint survey investigation at Pruitt Health Shepherd Hills ( Provider number 115452) an
ongoing immediate jeopardy was called on 2/ 25/ 2016 at 4pm. The investigating surveyors entered the
facility on 2/ 18/ 2016 and are expected to exit on 2/ 26/ 2016. The current census is 106.
Walker County
Beds certified= 112
Tags: F333 ( J), F309 ( D), F281 ( J), F282 ( J), F514 ( J), F329 ( J)
On 12/ 20/ 15, Resident A( cognitively impaired, dependent for ADLs, aggressive bx patient) was given
HTN medication that was intended for the resident' s roommate. An hour later, the BP dropped and the
resident was lethargic. On the same day, resident B( total care trach patient) received 20 mg morphine
twice within a 30 minute period and again that same day while sedated five more times without
assessing pain level, level of sedation or respiratory status. The following morning, resident B was found
nonresponsive with 02 sat 55%. Both residents were transferred to the hospital and spent time in
ICU. Per conversation with the Administrator, the nurse overseeing the trainee who medicated Resident
A was sitting at the nurse' s station and received a reprimand. The overseeing nurse revealed there
should have been pictures in the MAR book and there were none.
Best Regards,
Melanie
Melanie Simon
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confidential under specific laws. Security by encryption is applied to all confidential information sent by email from the Georgia
Department of Community Health.
4
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH
VIA e- mail
On 3/ 21/ 16, staff from the Department of Community Health ( DCH), Healthcare Facility Regulation
Division ( HFRD) Long Term Care Section, conducted a survey of Pruitthealth - Shepherd 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 April 4, 2016.
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 of your disagreement, 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).
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
If you have any questions or if we may be of assistance, please do not hesitate to call or write us.
Sinc rely,
A41
Andrea Sanders
Enforcement Manager,
Long Term Care
Healthcare Facility Regulation Division
Enclosures
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