2017 DCH Reports Involving Shepherd Hill Nursing Home

Department of Health& Human Services ff _ y
Centers for Medicare& Medicaid Services

61 Forsyth Street, SW, Suite 4T20
Atlanta, Georgia 30303- 8909
CENTERS FOR MEDICARE& MEDICAID SERVICES
Refer to: 5452. comp. 10. 04. 17
IMPORTANT NOTICE— PLEASE READ CAREFULLY

Receipt of this Notice is Presumed to be October 4, 2017 - Date Notice E- mailed)
October 4, 2017
Mr. Michael Dykes, Administrator

Pruitthealth— Shepherd Hills
800 Patterson Road
LaFayette, Georgia 30728
Re: Compliance Notice

CMS Certification Number: 11- 5452
Dear Mr. Dykes:
As a result of the 2nd life safety code revisit conducted on September 22, 2017 by the Georgia
State Survey Agency, we have determined that your facility is in substantial compliance with
the Medicare and Medicaid program requirements of participation for skilled nursing facilities,
effective September 19, 2017.
In our letter dated September 19, 2017, we imposed the following enforcement remedies:
Denial of Payment for New Admissions ( DPNA), and termination of Medicare and 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 and 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 Consortium 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
Nathan Deal, Governor Frank Berry, Commissioner
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 I 4Q4- 656- 4507 I www. dch. georgia. gov
IMPORTANT NOTICE - PLEASE READ CAREFULLY
September 28, 2017

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728
Dear Mr. Dykes:
Revisits Surveys were conducted at your facility to verify that your facility had achieved and
maintained substantial compliance. Our revisits conducted on September 6, 2017 for Health
and September 22, 2017 for Life Safety Code 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 September 19, 2017.
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,
kil Ili ‘ I4
Dorothy Joh s•
Enforcement Specialist
Long Term Care Section

Healthcare Facility Regulation Division
cc:
Georgia Department of Community Health/ Division of Medical Assistance
State Long Term Care Ombudsman
Health Information Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan
Equal Opportunity Employer
GEORGIA DEPARTMENT
itonil OF COMMUNITY HEALTH
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 I 404- 656- 4507 I www. dch. georgia. gov
September 8, 2017

800 Patterson Rd
Dear Mr. Dykes:
On September 5, 2017, the Georgia survey agency conducted a Life Safety Code Revisit Survey for
the survey conducted on July 17, 2017 at which one or more deficiencies were cited. The purpose of
this revisit survey was to determine if your facility was incompliance with Federal program
requirements for nursing homes participating in Medicare and/ or Medicaid programs.
This survey found that your facility was not in substantial compliance with the program
requirements. Specific findings of the survey are included on the attached, Form CMS- 2567,
Statement of Deficiencies.
All References to the regulator requirements contained in this letter are found in Title 42, Code of
Federal Regulations.
Plan of Correction ( PoC)
A PoC for the deficiencies cited on the Form CMS- 2567 must be submitted by September 18,
2017. Submit an electronic PoC to dmjohnson@dch. ga. gov and hfrd. poc a( dch. ga. gov and submit
your written PoC to Healthcare Facility Regulation Division LTC, Suite 31. 447, 2 Peachtree St. N. W.,
Atlanta, GA. 30303- 3142, telephone ( 404) 657- 5850.
Failure to submit an acceptable PoC by 09/ 18/ 2017 may result in the imposition of a civil money
penalty.
An acceptable PoC must:
Address how corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
Address how the facility will identify other residents having the potential to be affected by the
same deficient practice;
Address what measures will be put into place or systemic changes made to ensure that the
deficient practice will not recur;
Indicate how the facility plans to monitor its performance to make sure that solutions are
September 8, 2017
Page 2
This plan must be implemented, and the corrective action evaluated for its effectiveness. The
plan of correction is integrated into the quality assurance system; and
Includes dates when corrective action will be completed.
The Plan of Correction will serve as the facility' s allegation of compliance. If a submitted plan
of correction does not adequately address all of these points, it will not be acceptable.
Remedies
Please note that this letter does not constitute formal notice of imposition of alternative
sanctions or termination of your provider agreement. Should the Centers for Medicare &
Medicaid Services determine that termination or any other sanction is warranted, they will
provide you with a separate formal notification of that determination.
Because your facility was not in substantial compliance, we are recommending to the CMS regional
Office and/ or the State Medicaid Agency that the following remedies be imposed.
Civil Money Penalty, in an amount and duration to be determined by CMS.
A mandatory denial of payment for new admissions will be imposed October 20, 2017 if
substantial compliance is not achieved by that time.
Termination of Medicare Agreement. We are recommending to the CMS Regional Office and/ or
State Medicaid Agency that your provider agreement be terminated on January 20, 2018 if
substantial compliance is not achieved by that time.
Informal Dispute Resolution ( IDR)
In accordance with 42 CFR § 488. 331, you have one opportunity to dispute cited deficiencies through
an informal dispute resolution progress. To be given such an opportunity, you are required to
send your written request for IDR, along with the specific deficiencies being disputed, and an
explanation of why you are disputing those deficiencies, including any information or
documentation supporting your refutation. This request and any supporting information must
be sent during the same 10 days you have for submitting a 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 for the Long- Term Care Section in Atlanta. If you request an Informal
Dispute Resolution in writing, you will be contacted by the Regional Director to offer the opportunity
for a face- to- face meeting.
Please note that an incomplete informal dispute resolution process will not delay the effective
date of any enforcement action against the facility.
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.
September 8, 2017
Page 3
Independent Informal Dispute Resolution ( IIDR) -
Only citations which result in the imposition of civil money penalties ( CMPs) are eligible for the
Independent Informal Dispute Resolution process. Details on how to request an IIDR are included in
the providers' " formal notice" that is sent from the Centers for Medicare and Medicaid
Services. Eligible providers may only choose one of the two dispute resolution options ( IDR or IIDR)
for those citations resulting in a CMP. Other citations not subjected to a CMP would only qualify for an
IDR.
Disclosure of Survey Results
Public Law 92- 603, Section 299 requires that all deficiencies found during surveys shall be made
available to the public. Consequently, the attached list of deficiencies will be on file in this office and
will be available to any interested person 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,
11 11
Dorothy John-.
Enforcement Specialist
Long Term Care Section
cc: Melanie Simon, Division Chief

CMS, Regional Office
State Long- Term Care Ombudsman
Georgia Department of Community Health / Division of Medical Assistance
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 I 404-656- 4507 I www. dch. georgia. gov
August 17, 2017

800 Patterson Rd
Dear Mr. Dykes:
On July 20, 2017, a survey was conducted at your facility. In your plan of correction, you
have alleged that the deficiencies cited on that survey have been or will be corrected. Your
latest plan of correction date is September 3, 2017. We are accepting your plan of
correction as your allegation of compliance.
Please be advised that a health only desk revisit will be conducted in lieu of an onsite
revisit.Please submit your POC and all supporting documentation via email to the attention
of hcartwright@dch. ga. gov and janice.dunaway@dch. ga. gov by the 45th day. Failure to
provide all supporting documentation may result in deficiencies being recited.
If you have any questions concerning the instructions contained in this letter, or if we may
be of assistance, please do not hesitate to call or write to us.
Sincerely,
Jan Dunaway
Northern Regional Director
cc: Facility File
6.-- \?/11.
DEPARTMENT
CENTERS
OF HEALTH AND HUMAN SERVICES
FOR MEDICARE& MEDICAID SERVICES

H\
I '
flill &
6 ,f.,0, 1
FORM
08/ 01!
APPROVED
OMB NO. 0938- 0391

201D
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
115452 B. WING
07/ 20/ 2017
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 PROVIDERS PLAN OF CORRECTION X5)
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)
F 000 INITIAL COMMENTS F 000
A standard survey was conducted at This Plan of Correction constitutes my written

Pruitthealth- Shepherd Hills from July 17, 2017 to allegation of compliance for the deficiencies,
July 20, 2017. The standard survey revealed that
however, this submission of Plan of Correction
the facility was not in substantial compliance with
Medicare/ Medicaid regulations at 42 Code of is submitted to meet requirements established by
Federal Regulations( C. F. R.) Part 43, Subpart state and federal law.
B- Requirements for Long Term Care Facilities. Resident# 55 has had a new pain assessment
The following deficiencies resulted from the done. Residents have the potential to be
facility's noncompliance related to the standard
affected. Residents have had a new pain
survey. As indicated on the facility' s Form
CMS- 672, Resident Census and Conditions of assessment completed.
Residents Form, the facility' s census on July 17,

2017 was 105 residents.
F 329 483. 45( d)( e)( 1)-( 2) DRUG REGIMEN IS FREE F 329 DHS or RN Supervisor will monitor MAR 9/ 3/ 17 ••
SS= D FROM UNNECESSARY DRUGS of 50% of all residents receiving pain

medication twice weekly times two weeks
483. 45(d) Unnecessary Drugs- General,
then once weekly times two months to
Each resident' s drug regimen must be free from
ensure that effectiveness of pain medication
unnecessary drugs. An unnecessary drug is any
is documented.
drug when used--
QA committee to meet and discuss monthly.
1) In excessive dose( including duplicate drug
therapy); or
2) For excessive duration; or
3) Without adequate monitoring; or
4) Without adequate indications for its use; or
5) In the presence of adverse consequences

which indicate the dose should be reduced or
discontinued; or
6) Any combinations of the reasons stated in

paragraphs( d)( 1) through( 5) of this section.
LABORATORY DIREC • R' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
Any deficiency statement ending w'" an asterisk(') denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficien 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-e9) Previous Versions Obsolete Event ID: 82J1_ 11 Facility ID: LTC11461209 If continuation sheet Page 1 of 7
PRINTED: 08/ 01/ 2017
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391
X)) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING
115452 B. WING 07120/ 2017
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

X4) ID
EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)
F 329 Continued From page 1 F 329
483. 45( e) Psychotropic Drugs.

Based on a comprehensive assessment of a
resident, the facility must ensure that--
1) Residents who have not used psychotropic

drugs are not given these drugs unless the
medication is necessary to treat a specific

condition as diagnosed and documented in the
clinical record;
9/ 3/ 17
2) Residents who use psychotropic drugs receive

gradual dose reductions, and behavioral
interventions, unless clinically contraindicated, in

an effort to discontinue these drugs;
This REQUIREMENT is not met as evidenced
by:
Based on clinical record review, staff interview
and review of facility policy titled" Lippincott

Procedures- Pain Assessment", the facility failed
to consistently assess one( 1) resident( R), ( R#
55) before and after administration of pain
medication, from a sample of thirty- two( 32)

residents.
Findings include:
Review of facility policy titled" Lippincott

inservice of nurses was done by DHS
Procedures- Pain Assessment", dated 10/2/ 15, on pain assessment documentation of
indicated if an intervention is performed the pain
effectiveness of pain medication, also
level should be assessed before the intervention
and within one hour after the intervention to inservice on adverse reactions of medication.
assess the patient's response.
Review of R# 55' s clinical record revealed that she

was admitted to the facility on 5/ 23/ 16, with
diagnoses including depression, dementia, and
insomnia. Review of her Physician' s Orders
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 2 of 7
I.
PRINTED: 08/ 01/ 2017
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIERICLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD

EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX
DATE
DEFICIENCY)
revealed an order, dated 4/ 5/ 17, for
Hydrocodone/ APAP tab 5- 325 mg one tab by

mouth every six( 6) hours as needed for back
pain. Review of her Quarterly Minimum Data Set
MOS), dated 6/ 8/ 17, revealed a Brief Interview
for Mental Status( BIMS) score of eight( 8),
indicating moderate cognitive impairment, and

she was administered pain medication as needed
PRN).
Review of facility Controlled Drug Record, dated

from 4/ 14/ 17 through 7/ 18/ 17, compared with
Pain Flow Sheets, dated May, 2017, June, 2017

and July, 2017, revealed R# 55 was administered
Hydrocodone/ APAP 5- 325 mg at 5: 00 a. m. on
5/ 19/ 17, at 12: 00 a. m. on 5/ 28/ 17, and at 9: 00
p. m. on 5/ 28/ 17, with no pain assessments

before or after administration, on the Pain Flow
Sheet on the back of the Medication
Administration Record' s( MAR' S) for the month of
May, 2017.
Continued review of the Controlled Drug Record

revealed R# 55 was administered
Hydrocodone/ APAP 5- 325 mg at 7: 00 p. m. on

6/ 16/ 17, at 12: 00 a. m. on 6/ 18/ 17, at 11: 00 p. m.
on 6/ 18/ 17, at 11: 00 a. m. on 6/ 21/ 17, at 9: 00 p. m.
on 6/ 24/ 17, at 9: 00 p. m. on 6/ 25/ 17, and at 6: 00
p. m. on 6/ 30/ 17, with no assessments before and
after administrations recorded on the Pain Flow
Sheets.
Review of the above Controlled Drug Record

revealed administration of Hydrocodone/ APAP
5-325 mg to R# 55 at 8: 00 p. m. on 7/ 8/ 17, at 8:00

p. m. on 7/ 9/ 17, at 5: 00 p. m. on 7/ 11/ 17, at 8: 00
p. m. at 7/ 13/ 17, at 8: 00 p. m. on 7/ 14/ 17, at 8: 00
p. m. on 7/ 15/ 17, and at 8: 00 p. m. on 7/ 16/ 17, with
no pain assessments before or after
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82J1_ 11 Facility ID: LTC11461209 If continuation sheet Page 3 of 7
if
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 2012017
800 PATTERSON RD

X4) ID
DATE
DEFICIENCY)
administering the pain medication.
Review of Nurse' s Notes for May, 2017, June,

2017, and July, 2017 for R# 55 revealed no pain
assessments before and after pain medication
administration were included.
Interview 7/ 20/ 17 at 9: 50 a. m. with Licensed
Practical Nurse( LPN) AA revealed the nursing

staff have received education regarding the
necessity of documenting pain assessments on 9/ 3/ 17
the Pain Flow Sheet on the back of the MAR
before and after administering

Hydrocodone/ APAP 5- 325 mg to R# 55 and after
her review of R# 55's Pain Flow Sheets on the
back of the July MARs there were missing
assessments.
Interview 7/ 20/ 17 at 1: 12 p. m. with the Director of

Health Services( DHS) revealed she expected the
Pain Flow Sheets on the reverse side of the
MAR' s to be completed for each administration of
Hydrocodone/ APAP 5- 325 mg to R# 55 and these

pain assessments were not consistently
completed for the months of May, 2017, June,
2017 and July, 2017. The DHS indicated that
routine pain assessments were conducted every
shift and recorded on the MAR, but this did not
include any information regarding the pain level

preceding medication administration or the
effectiveness of the medication because there
was no time recorded for these assessments.
The DHS confirmed a numerical pain rating was

required by facility policy prior to administration of
pain medication and to indicate the effectiveness
of the medication within one hour following the

administration of medication.
F 514 483. 70( i)( 1)( 5) RES F 514
FORM CMS- 2567(02- 99) Previous Versions Obsolete Event ID: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 4 of 7
PRINTED: 08/ 01/ 2017
MEDICAID SERVICES OMB NO. 0938- 0391

CENTERS FOR MEDICARE&
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING
115452 B. WING 07/20/ 2017
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON RD

X4) ID
COMPLETION
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX DATE
TAG
DEFICIENCY)
SSD RECORDS- COMPLETE/ ACCURATE/ ACCESSIB

LE
i) Medical records.
1) In accordance with accepted professional
standards and practices, the facility must
maintain medical records on each resident that
are-
i) Complete;
ii) Accurately documented;
iii) Readily accessible; and
iv) Systematically organized
5) The medical record must contain-
i) Sufficient information to identify the resident;
ii) A record of the resident' s assessments;
iii) The comprehensive plan of care and services

provided;
9/ 3/ 17
iv) The results of any preadmission screening
and resident review evaluations and
determinations conducted by the State;
v) Physician' s, nurse' s, and other licensed

professional' s progress notes; and
vi) Laboratory, radiology and other diagnostic

services reports as required under§ 483. 50,
by:
Based on record review, staff interview and
review of facility policy titled" Medication
PRINTED: 08/ 01/ 2017
STATEMENT OF DEFICIENCIES Xi) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
115452 B. WING
07/ 20/ 2017
Boo PATTERSON RD
PREFIX
DATE
DEFICIENCY)
Administration: General Guidelines" the facility Resident# 55 has had a new pain assessment
failed to consistently document administration of done. Residents have the potential to be

Hydrocodone/ APAP 5-325 mg on the Medication 9/ 3/ 17
Administration Record( MAR) for one resident
assessment completed.
R),( R# 55) from a sample of 32 residents.
DHS or RN Supervisor will monitor MAR
Findings include: of 50% of all residents receiving pain

Review of facility policy, revised 1/ 23/ 15, revealed
then once weekly times two months to ensure
after medication administration for facilities using
that effectiveness of pain medication is
paper MAR, the patient/ resident' s MAR is initialed
by the person administering a medication, in the documented.
space provided under the date, and on the line for QA committee to meet and discuss monthly.
that specific medication dose administration,
1n- service of nurses was done by OHS on pair
assessment documentation of effectiveness of
Review of Physician' s Orders for R# 55 revealed
pain medication, also inservice on adverse
an order for Hydrocodone/ APAP 5- 325mg by
mouth every 6 hours as needed( PRN) for back reactions of medications.
pain.
Review of the care plans for R# 55 revealed a
care plan, dated 1/ 3/ 17, indicating she required

administration of analgesic medication as
ordered.
Review of the Controlled Drug Record for

administrations of Hydrocodone 5- 325 mg,
compared with the May, 2017 MAR for R# 55,
revealed the medication was administered on
5/ 19/ 17 at 5: 00 p. m., and on 5/ 28/ 17 at 12: 00

a. m. with no documentation on the MAR.

compared with the June, 2017 MAR revealed no
documentation of Hydrocodone administrations
on 6/ 16/ 17 at 7: 00 p. m., on 6/ 18/ 17 at 12: 00 a. m.,

on 6/ 18/ 17 at 11: 00 p. m., on 6/ 21/ 17 at 11: 00
a. m., on 6/ 24/ 17 at 9: 00 p. m., on 6/ 25/ 17 at 9: 00
p. m. and on 6/ 30/ 17 at 6: 00 p. m. The Controlled
Drug Record was compared with the MAR from
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event 10: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 6 of 7
PRINTED: 08/ 01/ 2017
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
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)
July, 2017 and the MAR did not include

documentation of Hydrocodone on 7/ 17/ 17 at
5: 00 p. m.

2017, and July, 2017 for R# 55 revealed the
administrations of Hydrocodone on the above
dates and times had not been documented in the
notes.
Interview on 7/20/ 17 at 9: 50 a. m. with Licensed

Practical Nurse( LPN) AA confirmed any 9/ 3117
medication should be initialed on the MAR under
the corresponding date, to indicate it had been

administered. LPN AA revealed there were
administrations of Hydrocodone/ APAP 5- 325mg

to R# 55 that had not been documented on the
front of the MAR.
Interview on 7/ 20/ 17 at 1: 12 p. m. with the Director

of Health Services( DHS) revealed she expected
the facility policy for any medication administered
to be recorded on the MAR under the
corresponding date to be followed. The DHS

acknowledged administrations of Hydrocodone
for R# 55 had not been consistently documented

on the MAR' s.
is
DEPARTMENT OF HEALTH AND HUMAN SERVICES Z 0 1 '
P RINTEFORDM\ 08/ 01/
2017PPROVED
CENTERS FOR MEDICARE& MEDICAID SERVICES a 0 : NO. 1938- 0391
X1) PROVIDER/ SUPPLIERICLIA X2) MULTIPLE CONSTRUCTION X3) DAr uRVEY

IDENTIFICATION NUMBER: COM
M LETED
1
115452 WING
07/ 20/ 2017
NAME OF PROVIDER OR SUPPLIER SPREET- ADtl S, CITY, STATE, ZIP CODE
800 PATTERSON RD

X4) ID
COMPLETION
PREFIX
DATE
TAG
DEFICIENCY)

The following deficiencies resulted from the
done by DHS on Friday July 21, 2017. O
facility' s noncompliance related to the standard
Residents have the potential to be
CMS- 672, Resident Census and Conditions of affected. Residents have had a new pain
Residents Form, the facility' s census on July 17, assessment completed.

DHS or RN Supervisor will monitor MAR 9/ 3/ 17
F 329 483. 45( d)( e)( 1)-( 2) DRUG REGIMEN IS FREE F 329

483. 45( d) Unnecessary Drugs- General.
is documented. Staff have been inserviced
drug when used--
on pain medication documentation and the
1) In excessive dose( including duplicate drug adverse effects. Education will be provided
therapy); or
to all nursing new hires during orientation,
2) For excessive duration; or provided by DHS/ CCC.
QA committee to meet and discuss monthly,
Administrator will monitor for completeness.. a>LC -

discontinued; or

TITLE X6) DATE

ABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE
4ny deficiency statement ending with an asterisk(') denotes a deficiency which the institution may be excused from correcting providing it is determined that
3ther safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
allowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
lays following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
rogram participation.
ORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 1 of 7
PRINTED: 01/ 201i
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVE[
A. BUILDING
115452 B. WING
07/ 2012017
800 PAT7ERSON RD
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)


I drugs are not given these drugs unless the
I medication is necessary to treat a specific
clinical record;
9/ 3/ 17

by:

to consistently assess one( 1) resident( R),( R#

residents.
Findings include:
Review of facility policy titled" Lippincott Inservice of nurses was done by DHS
Procedures- Pain Assessment", dated 10/ 2/ 15, on pain assessment documentation of
assess the patient' s response.

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: B2JL11 Facility ID: LTC11461209 If continuation sheet Page 2 of 7
PRINTED: 08/ 01/ 2017
STATEMENT OF DEFICIENCIES X1) PROVIDERISUPPLIERICLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

A. BUILDING
115452 B. WING
07/ 20/ 2017
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION XE)

PREFIX PREFIX
DATE
TAG
DEFICIENCY)

MDS), dated 6/ 8/ 17, revealed a Brief Interview

PRN).

5/ 19/ 17, at 12: 00 a. m. on 5/ 28/ 17, and at 9: 00

Administration Record' s( MAR' s) for the month of
May,2017.


6/ 16/ 17, at 12: 00 a. m. on 6/ 18/ 17, at 11: 00 p. m.
on 6/ 18/ 17, at 11: 00 a. m. on 6/ 21/ 17, at 9: 00 p. m.
on 6/ 24/ 17, at 9: 00 p. m. on 6/ 25/ 17, and at 6: 00
Sheets.

5- 325 mg to R# 55 at 8: 00 p. m. on 7/ 8/ 17, at 8: 00
p. m. on 7/ 9/ 17, at 5:00 p. m. on 7/ 11/ 17, at 8: 00
p. m. at 7/ 13/ 17, at 8:00 p. m. on 7/ 14/ 17, at 8: 00
FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 3 of 7
PRINTED: 08/ 01/ 2017
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD

X4) ID
DATE
TAG
DEFICIENCY)


9/ 3/ 17
necessity of documenting pain assessments on
her review of R# 55' s Pain Flow Sheets on the
assessments.


The OHS confirmed a numerical pain rating was
F 514 483. 70( i)( 1)( 5) RES F 514
PRINTED: 08/ 01/ 2017
X1) PROVIDERJSUPPUERICLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
PROVIDER' S PLAN OF CORRECTION X5)

SUMMARY STATEMENT OF DEFICIENCIES 1D
X4) ID
PREFIX DATE
TAG
DEFICIENCY)
SS= D RECORDS- COMPLETE/ ACCURATE/ ACCESSIB

LE
i) Medical records.
are-
I) Complete;

provided;
I 9/ 3/ 17


services reports as required under§ 483. 50.
by:

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82.IL11 Facility ID: LTD11461209 If continuation sheet Page 5 of 7
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 20/ 2017
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD

X4) ID
DATE
DEFICIENCY)
failed to consistently document administration of done by DHS on Friday July 21, 2017
Hydrocodone/ APAP 5- 325 mg on the Medication 9/ 3/ 17
Residents have the potential to be
affected, Residents have had a new pain
R), ( R# 55) from a sample of 32 residents.
assessment completed,
Findings include: DHS or RN Supervisor will monitor MAR
of 50% of all residents receiving pain

paper MAR, the patient/ resident' s MAR is initialed then once weekly times two months to ensure
by the person administering a medication, in the
space provided under the date, and on the line for documented.
that specific medication dose administration.
QA committee to meet and discuss monthly,
Administrator will monitor for completeness.
an order for Hydrocodone/ APAP 5- 325mg by 1n- service of nurses was done by DHS on pair
mouth every 6 hours as needed( PRN) for back assessment documentation of effectiveness of
pain. pain medication, also inservice on adverse
reactions of medications, this education will be

included into the Nursing Orientation Program
for new hires.
ordered.

5/ 19/ 17 at 5: 00 p.m., and on 5/ 28/ 17 at 12: 00
on 6/ 16/ 17 at 7: 00 p. m., on 6/ 18/ 17 at 12: 00 a. m.,

on 6/ 18/ 17 at 11: 00 p. m., on 6/ 21/ 17 at 11: 00
a. m., on 6/ 24/ 17 at 9: 00 p. m., on 6/ 25/ 17 at 9: 00
p. m, and on 6/ 30/ 17 at 6: 00 p. m. The Controlled
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID' 82JL11 Facility ID: LTC11461209 If continuation sheet Page 6 of 7
PRINTED: 08/ 01/ 2017


A BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
DATE
DEFICIENCY)

5: 00 p. m.

notes.
Interview on 7/ 20/ 17 at 9: 50 a. m. with Licensed

Practical Nurse( LPN) AA confirmed any 9/ 3/ 17

front of the MAR.



on the MAR' S.
PRINTED: 08/ 01/ 2017
A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
PREFIX PREFIX
DATE
DEFICIENCY)

done. Residents have the potential to be

F 329 483. 45( d)( e)( 1)-( 2) DRUG REGIMEN IS FREE F 329 DHS or RN Supervisor will monitor MAR 9/ 3/ 17

483. 45( d) Unnecessary Drugs General.
is documented.
drug when used--
therapy); or
HEALTHCARE FACILITY REGULATION OIV1S1On

5) In the presence of adverse consequences LONG• TERM CARE
discontinued; or AUG 15 2011,
6) Any combinations of the reasons stated in RECEIVED
LABORATORY DIREC • R' S OR PROVIDER/ SUPPLIER REPg)_, SENTATIVE' S SIGNATURE TITLE X6) DATE
Any deficiency statement ending w an asterisk(*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
PREFIX PREFIX
DATE
DEFICIENCY)


clinical record;
9/ 3/ 17


by:

to consistently assess one( 1) resident( R), ( R#

residents.
Findings include:
Review of facility policy titled" Lippincott Inservice of nurses was done by DHS

PRINTED: 08/ 01/ 2017
MEDICAID SERVICES OMB NO. 0938- 0391

CENTERS FOR MEDICARE&
AND PLAN OF CORRECTION
A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD

X4) ID
COMPLETION
PREFIX DATE
TAG
DEFICIENCY)

PRN).


5/ 19/ 17, at 12: 00 a. m. on 5/ 28/ 17, and at 9: 00
May, 2017.


6/ 16/ 17, at 12: 00 a. m. on 6/ 18/ 17, at 11: 00 p. m.
on 6/ 18/ 17, at 11: 00 a. m. on 6/ 21/ 17, at 9: 00 p. m.
on 6/ 24/ 17, at 9: 00 p. m. on 6/ 25/ 17, and at 6: 00
Sheets.

5- 325 mg to R# 55 at 8: 00 p. m. on 7/ 8/ 17, at 8: 00
p. m. on 7/ 9/ 17, at 5: 00 p. m. on 7/ 11/ 17, at 8: 00
p. m. at 7/ 13/ 17, at 8: 00 p. m. on 7/ 14/ 17, at 8: 00
ORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 3 of 7
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
PREFIX PREFIX
DATE
DEFICIENCY)




assessments.

Health Services ( DHS) revealed she expected the


The DHS confirmed a numerical pain rating was


F 514 483. 70( 1)( 1)( 5) RES F 514
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: B2JL11 Facility ID: LTC11461209 If continuation sheet Page 4 of 7
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD
DATE
DEFICIENCY)

LE
i) Medical records.

are-
i) Complete;

provided;
9/ 3/ 17


services reports as required under§ 483. 50.
by:

PRINTED: 08/ 01/ 2017
A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD

DATE
DEFICIENCY)
failed to consistently document administration of done. Residents have the potential to be
9/ 3/ 17
Hydrocodone/ APAP 5- 325 mg on the Medication affected. Residents have had a new pain
Administration Record ( MAR) for one resident

paper MAR, the patient/ resident' s MAR is initialed
documented.
by the person administering a medication, in the
space provided under the date, and on the line for QA committee to meet and discuss monthly.
that specific medication dose administration.
In- service of nurses was done by DHS on pain
mouth every 6 hours as needed ( PRN) for back reactions of medications .
pain.

ordered.

5/ 19/ 17 at 5: 00 p. m., and on 5/ 28/ 17 at 12: 00


on 6/ 16/ 17 at 7: 00 p. m., on 6/ 18/ 17 at 12: 00 a. m.,

on 6/ 18/ 17 at 11: 00 p. m., on 6/ 21/ 17 at 11: 00
a. m., on 6/ 24/ 17 at 9: 00 p. m., on 6/ 25/ 17 at 9: 00
PRINTED: 08/ 01/ 2017
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA
AND PLAN OF CORRECTION
A. BUILDING
115452 B. WING
07/ 20/ 2017
800 PATTERSON RD

X4) ID
COMPLETION
PREFIX
DATE
TAG
DEFICIENCY)

5: 00 p. m.

notes.

9/ 3/ 17
Practical Nurse( LPN) AA confirmed any


front of the MAR.



on the MAR' s.
PRINTED: 09( 08/ 2017
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 038-Q381
STATEMENT OF DEFICIENCIES ( KI} PnowusmuuppusRImm ( X2) MULTIPLE CONSTRUCTION 3) DATE SURVEY
IDENTIFICATION NUMBER; COMPLETED
AND PLAN OF CORRECTION A. BUILDING nc_ BUILDING oo
R
115482 8. WING 09/ 06/ 2017
NAME OF PROViDER OR SUPPLIER STREET ADDRESS CITY, STATE. ZIP CODE
800 PATTERSON RD
PRmTTMEAcTU- SHEPMEmomLua
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION wn

X4) ID
EACH CORRECTIVE ACTION SHOULD BE uvwpLEnov
PREFIX ( EACH DEFICIENCYMvo PRECEDED BY FULL pyepm
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG cRoou' nspcnswosormr* eAppnopmms
DEFICIENCY)
K 000) INITIAL COMMENTS K 000
On89/0512017aFollow- Up Survey was

1
conducted by this FSCO and It was noted that not
all of the previously cited survey tags have been
corrected.
K372} NFRA1O1Subdivision ofBuilding Spaces-

1( 372} Pruitt Health Shepherd Hills to maintain compliance
OO= E Smoke Barrie
has made arrangement with Life Safety Services to identify
Subdivision of Building Spaces- Smoke Barrier and make corrections to the recent findings of the State Fire
Construction
2012 EXISTING
Marshals Life Safety Survey revisit on09/ V5/ ZO17. Concornin8
Smoke barriers shall be constructed to a 1/ 2- hour smoke barrier walls on North and South halls originally
fire resistance rating per 8. 5. Smoke barriers shall conducted and cited onO7/ 17/ 2Ol7. Corrections will be
be permitted to terminate at art atrium wall,
completed by Life Safety Services by 09/ 19/ 2017. Facility
Smoke dampers are not required In duct
Maintenance Director will inspect other smoke/ fire barrier
penetrations In fully ductedHVACmystwmawbem
an approved sprinkler system is Installed for walls to ensure penetrations are properly sealed. Facility
smoke compartments adjacent to the smoke Maintenance Director will inspect walls every three months
barrier.
and after any contractor work performed In facility. QA
1S8788 71)
committee will m* etandrevlewmonth ho, threemonths
Dnachbeonymenhnn| om| umokeoontm| oymtem
in REMARKS.
This STANDARD is not met as evidenced by:
Based on observation and staff interviews it was
determined the facilIty failed to ensure that all
smoke barrier walls are properly maintained. i
This could place all residents at risk In the event
of a fire emergency.
The findings include:
During follow- up inspection tour of the facility

with Staff K4onO80@2D17between 1: OOP/ Nand
3: 00 PM observation revealed numerous
unsealed or improperly sealed penetrations in the

smoke barrier wails that were sampled. i
It was also noted durithis inspection that two

new sets of fire doors have been added at the
iTheyai DAT://
LABORATORY DIRE TO S OR PROV
Sap,'N,A ..__:.REPRESENTATIVES SIGNATURE
TITLE i
e (
Any deficiency slat ment ending

C h, a. • : k( 1 denotes a deficiency which the Institution may be excused from correcting providing it Is etermlned hal
other safeguards provide sufficient protect 4n to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the dale of survey whether or not a plan of correction Is provided. For nursing homes, the above findings and plans of correction are disclosable 14
FORM CMS- 2567( 02- 99) Previous Versions Obsolote Even( ID: 02JL22 Facility ID: om, 401mo If continuation sheet Page 1 of 2
PRINTED; 09/ 08/ 2017

X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES (
AND PLAN OF CORRECTION A. BUILDING 02- BUILDING 02
R
115452 B. WING_
09/ 05/ 2017
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION 1X51

PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE •
DEFICIENCY)
K 372) Continued From page 1 K 372) Pruitt Health Shepherd Hills to maintain compliance
Northside and Southside Halls. These doors were
with the State Regulations in reference to the Fire Marshals
installed as a result of the K200 tag( head
Life Safety Survey revisit on 09/ 05/ 2017 concerning the result
clearance deficiency) that was listed on the
previous survey report dated 07/20/ 2017. The two of the original K 200 tag Cited on 07/ 17/ 2017 has made
separate walls that these doors have been arrangements with a new contractor, American Dock an
Installed in are designed, constructed, and
Doors LLC to take out and replace doors and frames that
Identified by the facility as two-hour fire barriers.
were cited and found not in compliance. Doors will be
Neither set of fire doors currently meet the
requirements of the 2012 NFPA 101, chapter 8, installed and operable by 09/ 19/ 2017. QA committee to meet
section 8. 3. 3 and discuss monthly for two months.
1. Unapproved sills have been installed( 8. 3. 3. 1)
2. Doors failed to close properly( 8. 3. 3. 3)
These findings were confirmed by Staff M at the

time of discovery.
Reference: 2012 NFPA 101, chapter 19, section

19. 3. 7. 3, chapter 8, section 8. 5, 8. 5. 6. 3
FORM CMS. 2587( 02. 99) Previous Versions Obsolete Event ID: 82JL22 Facility ID: LTC11481209 If continuation sheet Page 2 of 2
PRINTED: 08/ 01/ 2017
A. BUILDING 02- BUILDING 02
115452 B. WING
07/ 17/ 2017
800 PATTERSON RD
DATE
DEFICIENCY)
K 000 INITIAL COMMENTS K 000
Stories: 1
Construction Type: V( 111)
Constructed: 1966
Fully Sprinkled: Yes

Census: 105
Certified beds: 112
During a Life Safety Code Survey conducted on

07/ 17/ 2017, Pruitt Health of Shepherd Hills was
found not in substantial compliance with the
requirements for participation in
Medicare/ Medicaid at 42 CFR Subpart 483. 70( a),
Life Safety from Fire, and the related National

Fire Protection Association ( NFPA) standard
NFPA 101 Life Safety Code 2012 edition.
The requirements of 42 CFR, Subpart 483. 70( a)
are NOT MET as evidenced by:

K 200 NFPA 101 Means of Egress Requirements- K 200
SS= D Other
Means of Egress Requirements- Other
List in the REMARKS section any LSC Section

18. 2 and 19. 2 Means of Egress requirements that
are not addressed by the provided K-tags, but are
deficient. This information, along with the
applicable Life Safety Code or NFPA standard
citation, should be included on Form CMS- 2567.
18. 2, 19. 2

determined the facility failed to provide a

minimum head clearance of 6 ft. 8 in. ( 2030 mm)
LABORATORY DI- C OR' S OR rEPRESENTATIVE' S SIGNATURE TITLE X6 DATE

Air• -- '
41&' lArrej / • 9
Any deficiency sta' denotes a deficiency which the institution may be excused from correcting providing it is determined that
nsk(*)
other safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
PRINTED: 0
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM D,

115452 B. WING
07/ 17/ 2017
800 PATTERSON RD
DATE
DEFICIENCY)
K 200 Continued From page 1 K 200

Pruitt Health Shepherd Hills, in order to
alongthe entire designated
9 means of egress
9 09/ 03/ 2017
to maintain compliance with State
path.
This could place 27 residents at risk in the event Regulations, has contacted a licensed
of fire emergency. construction contractor and arrangements
were made to address and repair the fmclings

of the recent 07/ 17/ 2017 State Fire Marshall
During a tour of the facility with Staff M on
07/ 17/ 2017 between 11: 00 AM and 4: 00 PM Life Safety Survey; concerning the height of
observation revealed that the door frames in the doors on the North and South Back hall egress
egress corridor of the North and South Back Halls corridors .
only provided 6 ft. 3 1/ 2 in. of head clearance.

Prints are being finalized for the project and
the work will be completed by 09/ 03/ 2017
time of discovery.
Reference: 2012 NFPA 101, chapter 19, section QA Committee to meet and discuss monthly.
19. 2. 1, chapter 7, section 7. 13. 3. 5
K 372 NFPA 101 Subdivision of Building Spaces- K 372
SS= E Smoke Barrie
Subdivision of Building Spaces- Smoke Barrier

Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/ 2- hour
fire resistance rating per 8. 5. Smoke barriers shall

be permitted to terminate at an atrium wall.
Smoke dampers are not required in duct
penetrations in fully ducted HVAC systems where

an approved sprinkler system is installed for
smoke compartments adjacent to the smoke
barrier.
19. 3. 7. 3, 8. 6. 7. 1( 1)
Describe any mechanical smoke control system

in REMARKS.

determined the facility failed to ensure that all

smoke barrier walls are properly maintained.
This could place all residents at risk in the event
PRINTED: 08/ 01/ 2017

115452 B. WING
07/ 17/ 2017
800 PATTERSON RD
COMPLETION
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
DATE
DEFICIENCY)

07/ 17/ 2017 between 11: 00 AM and 4: 00 PM
observation revealed numerous unsealed or
improperly sealed penetrations in the smoke

barrier walls of the Northside Hall and the
Southside Hall.

time of discovery.
19. 3. 7. 3, chapter 8, section 8. 5, 8. 5. 6. 3
Harris, Johnetta
From: Dunaway, Janice

Sent: Sunday, August 13, 2017 3: 30 PM
To: Miranda, Andrea; Harris, Johnetta
Cc: Levi, Jean; kshadix@sfm. ga. gov

Subject: FW: 2567 POC
Attachments: F329 & F514. pdf; 2567 K Tags 200. pdf; 2567 K tags 372 and 232. pdf
Pruitt health Shepard Hills. Could Jean review the POC please. Keith has his tags which can be move forward since the
IDR has nothing to do with the LSC tags. The IDR does not change the process.
Jan
From: Michael Dykes [ mailto: mdykes@pruitthealth. com]
Sent: Friday, August 11, 2017 1: 47 PM

To: Dunaway, Janice< janice. dunaway@dch. ga. gov>
Subject: RE: 2567 POC
Mrs. Dunaway,
Please find the attached CMS 2567 Plan of Corrections for the Survey conducted on July 20, 2017. We are requesting a
desk top review. We have also sent an overnight copy to the HFRD Mailbox.
Michael Dykes
Administrator
PruittHealth - Shepherd Hills
17
Phone: ( 706) 633- 4112 f
Email: moykes s Druitthealth. com

Pruitt ;:
i
i :-
EA ii:r3yE; 1 pruitthealth. corn
i lease consider the environment before printing this email message.
Confidentiality Notice: this ma' mewshote, ratuoind any , I". ac= rr s: 1 . ; irs if t,'.. ise z f. . ie ' irsiE t,,.,) sir
tattrottsaett a- arra bort. ty oaf loth: A: arta review, use, dis.. os i, at sfis . anion tt:;l: il.:7 feo. II y are r .,.'; 1tortdat<
destioy al pi is of t) (. _ i ,=. ri. message. :'} . 7. Elr contact , sC £ i y F , P at- the numbet ! idiots, en the se: total' s
n+ e ,- , ,
I r atop
IE 1, .,_. ,
t rat 1 Pruitt 7C, l 1 rt. to » "; l tree' £ Stt t< ,:}. r. F : T, k ` tY', son 1 a.` r.
1
Harris, Johnetta

Sent: Monday, August 14, 2017 1: 28 PM
To: Harris, Johnetta; Miranda, Andrea
Subject: FW: Message from " RNP002673B175DC"

Attachments: 20170814132454849. pdf
Original Message
From: Michael Dykes [ mailto: mdykes@pruitthealth. com]

To: Dunaway, Janice < janice. dunaway@dch. ga. gov>
Subject: FW: Message from " RNP002673B175DC"
Please see the attached letterhead requesting an IDR.
Michael Dykes
Administrator
PruittHealth - Shepherd Hills
Phone: ( 706) 638- 4112

Email: mdykes@pruitthealth. com
Please consider the environment before printing this email message.
Confidentiality Notice: This email message, including any attachments, is for the sole use of the intended recipients( s)
and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is
prohibited. If you are not the intended recipient, destroy all copies of the original message, and immediately contact the
sender by phone at the number listed on the sender' s email signature block, OR call PruittHealth at 770- 279- 6200 or toll
free at 1- 800- 222- 0321 and ask for the person by name.
Original Message
From: pwalker@uhs- pruitt. com [ mailto: pwalker@uhs- pruitt. com]

To: Michael Dykes< mdykes@pruitthealth. com>
Subject: Message from " RNP002673B175DC"
This E- mail was sent from " RNP002673B175DC" ( MP 4054).
Scan Date: 08. 14. 2017 13: 24: 54 (- 0400)
Queries to: pwalker@uhs- pruitt. com

Michael Dykes
From: Dunaway, Janice < janice.dunaway@dch. ga. gov>

Sent: Tuesday, August 08, 2017 1: 38 PM
To: Kristie Hughes
Cc: Tracy Cochran; Michael Dykes
Subject: FW: 2567s and Letters
Attachments: PH SHEPARD HILLS CIVIL RIGHTS LETTER. RTF; ph shepard hills health 2567. pdf; PH
SHEPARD HILLS INITIAL LETTER. RTF; ph shepard hills Isc bl 2567. pdf; ph shepard hills
Isc b2 2567. pdf; ph shepard hills st 2567. pdf; PH SHEPARD HILLS STATE LETTER. RTF
This was sent last week and need to make certain someone has this please.
Jan

Sent: Wednesday, August 2, 2017 7: 49 AM
To: ' mdykes@pruitthealth. com' < mdykes@pruitthealth. com>
Subject: 2567s and Letters
Mr. Dykes you may receive this twice, if so, I apologize in advance.
Good Morning,
Please find attached to this email your Federal Letter, State Letter, Civil Rights Letter and CMS 2567 for the Survey
conducted at your facility on July 20, 2017. Your facility was found not in substantial compliance with the program
requirements.
We ask that you send your POC directly to the HFRD mailbox and to my email address. We are no longer using fax to
receive the POCs.
If you have any questions feel free to contact me at 404- 404- 719- 8223. Please confirm that you have received this
email.
Jan Dunaway R. N.
Northern Regional Director
DCH- H FRD
2 Peachtree Street
Atlanta, GA 30303
Office cell: 404- 719- 8223
HEALTHCARE FACILITY
LONG-TERIIREGULATIONIHVBIOF
CARE
AUG152017
RECEfVE0
1
1
sea
g rCAjtE FACIL[ R REGULATION DIVISION

Shepherd NiffsLONG- TERM CARE
AUG 1622017
1 1
MUM
August 11, 2017
Please accept my request for an IDR, desktop review for the following tags, F329 and F514. If you need
any further information or have any questions please feel free to contact me at the number listed
below.
Sincerely, 1
Zeut---12‘..
Michael Dykes, LNHA
Administrator
Soo Patterson Road 706- 638- 4112 Phone pruitthealth. com
LaFayette, GA 30728 706- 638- 4151 Fax

PruittHealth— Shepherd Hills
800 Patterson RD, Lafayette
Georgia, 30728
706- 638- 4112
Mrs. Dunaway,
I would like to request an IDR for the following Tags. F 329 and F 514. Please see the attached no
deficiency State tag as well.
Sincerely,
Michael E. Dykes
Administrator— PruittHealth- Shepherd Hills.
ylG y + Li
th-e-
ppoitz,
t. evryloo
fnastaze42_
lt
PRINTED: 08/ 01/ 2017
FORM APPROVED
State of GA, Healthcare Facility Regulation Division


A. BUILDING:
B. WING
1- 146- 1671 07/ 20/ 2017
800 PATTERSON RD
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE

TAG TAG
DEFICIENCY)
N 000 Initial Comments N 000
No deficiencies were identified during the

licensure survey of 7/ 20/ 17.
State of GA Inspection Report

LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE Xs) DATE
STATE FORM 6899

B2JL11 If continuation sheet 1 of 1
PruittHealth— Shepherd Hills
800 Patterson RD, Lafayette
Georgia, 30728
706- 638- 4112
Mrs. Dunaway,
Sincerely,
Michael E. Dykes
Administrator— PruittHealth- Shepherd Hills.

PRINTED: 08/ 01/ 2017
FORM APPROVED
State of GA, Healthcare Facility Regulation Division

STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIERJCLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

A. BUILDING:
B. WING
1- 146- 1671 07/ 20/ 2017
800 PATTERSON RD
DATE
DEFICIENCY)


LABORATORY DIRECTORS OR PROVIDER/ SUPPLIER REPRESENTATIVES SIGNATURE TITLE X6) DATE
STATE FORM 6899

82JL11 If continuation sheet 1 of 1
Shepherd Hills
Mrs. Dunaway,
Sincerely,
Michael E. Dykes
Administrator— PruittHealth- She herd Hills.
800 Patterson Road 706- 638- 4112 Phone pruitthealth. com
LaFayette, GA 30728 706- 638- 4151 Fax

PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 2012017
800 PATTERSON RD

REGULATORY OR LSC IDENTIFYING INFORMATION) CATE

TAG TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Pruitthealth- Shepherd Hills from July 17, 2017 to
allegation of compliance for the deficiencies,
1 Federal Regulations ( C. F. R.) Part 43, Subpart state and federal law.
B- Requirements for Long Term Care Facilities. Resident/ 155 has had a new pain assessment
done. Residents have the potential to be
survey. As indicated on the facility' s Form affected. Residents have had a new pain

F 329 483. 45( d)( e)( 1)-( 2) DRUG REGIMEN IS FREE F 329 DHS or RN Supervisor will monitor MAR 9/ 3/ 17

483. 45( d) Unnecessary Drugs- General.
drug when used-- is documented.
QA committee to meet and discuss monthly

therapy); or

discontinued; or

LABORATORY D1REC • R' S OR PROVIDER/ SUPPLIER REPEESENTATIVE' S SIGNATURE TITLE X6) DATE
Any deficiency statement ending w " an asterisk(') denotes a deficiency which the institution may be excused from correcting providing it is determined that
days following the dale these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82411 Facility ID: LTC11461209 If continuation sheet Page 1 of 7
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. wING
07/ 20/ 2017
800 PATTERSON RD
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE I COMPLETION
DATE
DEFICIENCY)



clinical record;
9/ 3/ 17


by:

to consistently assess one( 1) resident( R),( R#

residents.
Findings include:
Review of facility policy titled" Lippincott inservice of nurses was done by DHS
effectiveness of pain medication, atso

PRINTED: 08/ 01/ 2017

A. BUILDING
115452 ft IMNG
07/ 20/ 2017
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION I ( X5)
DATE
DEFICIENCY)


PRN).


5/ 19/ 17, at 12: 00 a. m. on 5/ 28/ 17, and at 9: 00

May, 2017.


6/ 16/ 17, at 12: 00 a. m. on 6/ 18/ 17, at 11: 00 p. m.
on 6/ 18/ 17, at 11: 00 a. m. on 6/ 21/ 17, at 9: 00 p. m.
on 6/24/ 17, at 9: 00 p. m. on 6/ 25/ 17, and at 6: 00
Sheets.

5- 325 mg to R# 55 at 8: 00 p. m. on 7/ 8/ 17, at 8: 00
p. m. on 7/ 9/ 17, at 5: 00 p. m. on 7/ 11/ 17, at 8: 00
p. m. at 7/ 13/ 17, at 8: 00 p. m. on 7/ 14/ 17, at 8: 00
PRINTED: 08101/ 2017
STATEMENT OF DEFICIENCIES X1) PROVIDER( SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

A. BUILDING
115452 B. WING
07/ 20/ 2017
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CIN, STATE, ZIP CODE
800 PATTERSON RD
DATE
DEFICIENCY)



assessments.


2017 and July, 2017. The OHS indicated that

The OHS confirmed a numerical pain rating was


I administration of medication.
F 514 483. 70( i)( 1)( 5) RES F 514
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82, 111 Facility ID: LTC11461209 If continuation sheet Page 4 of 7
PRINTED: 08/ 01/ 2017

A. BUILDING
115452 B. WING
07/ 20/ 2017
BOO PATTERSON RD
X4) to SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)
REGULATORY OR LSC IDENTIFYING INFORMATION) DATE

TAO TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)

LE
i) Medical records.

are-
i) Complete;
0 Sufficient information to identify the resident;

provided;
9/ 3/ 17


services reports as required under§ 483. 50,
by:
review of facility policy titled' Medication

FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: 82J01 Facility ID: LTC11481209 If continuation sheet Page 5 of 7
PRINTED: 08/ 01/ 2017
A. BUILDING
115452 B. WING
07/ 20/ 2017
NAME OF PROVIDER OR SUPPLIER STREEr ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE CCMPLE1ION
REGULATORY OR LSC IDENTIFYING INFORMATION) DATE
TAG TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
failed to consistently document administration of done. Residents have the potential to he
Hydrocodone/ APAP 5- 325 mg on the Medication 9/ 3/ 17

Review of facility policy, revised 1/ 23115, revealed
paper MAR, the patient/ resident' s MAR is initialed that effectiveness of pain medication is
by the person administering a medication, in the documented.

space provided under the date, and on the line for
that specific medication dose administration,
In-service of nurses was done by DHS on pair
mouth every 6 hours as needed( PRN) for back reactions of medications .
pain.

ordered.

5/ 19/ 17 at 5: 00 p. m., and on 5/ 28/ 17 at 12: 00


on 6/ 16/ 17 at 7: 00 p. m., on 6/ 18/ 17 at 12: 00 a. m.,
on 6/ 18/ 17 at 11: 00 p. m., on 6/ 21/ 17 at 11: 00
a. m., on 6124/ 17 at 9: 00 p. m., on 6/ 25/ 17 at 9: 00
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82JL11 Facility ID: LTC11461209 If continuation sheet Page 6 of 7 j',
PRINTED: 08/ 01/ 2017
FORM APPROVED
A. BUILDING
115452 B. WING
07/ 20/ 2017
NAME OF PROVIDER OR SUPPLIER
STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

P
DEFICIENCY)

5: 00 p. m.

notes.

Practical Nurse ( LPN) AA confirmed any 9/ 3/ 17

front of the MAR.

of Health Services( OHS) revealed she expected

on the MAR' s.
PRINTED: 08/ 01/ 2017
STATEMENT OF DEFICIENCIES Xt) PROVIDERJSUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
115452 B. WING
07/ 17/ 2017
800 PATTERSON RD
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 DALE
DEFICIENCY)
K 000 INITIAL COMMENTS K 000
Stories: 1
Constructed: 1966

Census: 105
Certified beds: 112


K 200 NFPA 101 Means of Egress Requirements- K 200
SS= D Other
Means of Egress Requirements- Other

List in the REMARKS section any LSC Section
18. 2 and 19. 2 Means of Egress requirements that
are not addressed by the provided K- tags, but are
deficient. This information, along with the
applicable Life Safety Code or NFPA standard
citation, should be included on Form CMS- 2567.
18. 2, 19. 2

determined the facility failed to provide a
minimum head clearance of 6 ft. 8 in. ( 2030 mm)
LABORATORY DI• C OR'S OR•=• -. - PPL-LER- REPRESENTATIVE' S SIGNATURE TITLEE X6 DATE,/
7' 6 1C"/ Kioi) J 4' /

L)
OJT
7
Any deficiency sta - •- denotes a deficiency which the institution may/ be excused from correcting providing it is determined that
risk(*)
other safeguards provide sufficient protection to the patients.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
PRINTED: 2017
115452 B. WING
07/ 17/ 2017
800 PATTERSON RD
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE GATE
DEFICIENCY)

Pruitt Health Shepherd Hills, M order to
alongthe entire designated
g means of egress
g 09/ 03/ 2017
path. to maintain compliance with State
This could place 27 residents at risk in the event Regulations, has contacted a licensed
of fire emergency. construction contractor and arrangements
were made to address and repair the findings

of the recent 07/ 17/ 2017 State Fire Marshall
07/ 17/ 2017 between 11: 00 AM and 4: 00 PM Life Safety Survey; concerning the height of
observation revealed that the door frames in the doors on the North and South Back hall egress
egress corridor of the North and South Back Halls corridors .
only provided 6 ft. 3 1/ 2 in. of head clearance.
Prints are being finalized for the project and
the work will be completed
p by09/ 03/ 2017
time of discovery.
Reference: 2012 NFPA 101, chapter 19, section QA Committee to meet and discuss monthly.
19. 2. 1, chapter 7, section 7. 13. 3. 5
SS= E Smoke Barrie

Construction
2012 EXISTING

barrier.
19. 3. 7. 3, 8. 6. 7. 1( 1)

in REMARKS.

PRINTED: 08/ 01/ 2017
FORM APPROVED
115452 B. WING
07/ 17/ 2017
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION PX

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE I COMPLETION
DEFICIENCY)

07/ 17/2017 between 11: 00 AM and 4: 00 PM
improperly sealed penetrations in the smoke
barrier walls of the Northside Hall and the
Southside Hall.

time of discovery.
19. 3. 7. 3, chapter 8, section 8. 5, 8. 5. 6. 3
t,
PRINTED: 08101/ 2017
FORM APPROVED
OMB NO. 0938- 0391
X3) DATE SURVEY
RV Y
XI) PROVIDER/ SUPPLIERICLIA X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER:
AND PLAN OF CORRECTION A. BUILDING 01- MAIN BUILDING 01
115452 B. WING 07/ 17/ 2017

STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS LA FAYETTE, GA 30728
X5)
ID PROVIDER'S PLAN OF CORRECTION
IDCOMPLETION SUMMARY STATEMENT OF DEFICIENCIES
X4) EACH CORRECTIVEACTION SHOULD BE
PREFIX
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL DATE
TAG CROSS- REFERENCED TO THE APPROPRIATE
REGULATORY OR LSC IDENTIFYING INFORMATION)
TAG DEFICIENCY)
K 000
K 000 INITIAL COMMENTS
Stories: 1
Constructed: 1966

Census: 105
Certified beds: 112


K 232
K 232 NFPA 101 Aisle, Corridor, or Ramp Width
SS= D
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors( clear or
unobstructed) serving as exit access shall be at
least 4 feet and maintained to provide the
convenient removal of nonambulatory patients on
stretchers, except as modified by 19. 2. 3. 4,
exceptions 1- 5.
19. 2. 3. 4, 19. 2. 3. 5
means of egress corridors are clear and
unobstructed.
This could place 56 residents at risk in the event

of fire emergency.
DATE
TITLE
LABORATORY DIRECR' OR PROV• ' -- PPHER- REPPBESENTATIVE' S SIGNATURE
Any deficiency stalem: dingng with an a - sk(') deno=- a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficien • - • - •• lents.( See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
Event ID: 82JL21 Facility ID: LTC11461209 If continuation sheet Page 1 of 3

FORM CMS- 2567( 02- 99) Previous Versions Obsolete
PRINTED: 08/ 01/ 2017
FORM APPROVED
OMB NO. 0938- 0391
X3) DATE SURVEY
X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION
COMPLETED
IDENTIFICATION NUMBER:
115452 B, VENG 07/ 17/ 2017

STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD FULLS
PROVIDER' S PLAN OF CORRECTION X5)

SUMMARY STATEMENT OF DEFICIENCIES ID
X4) ID COMPLETION
PREFIX EACH CORRECTIVE ACTION SHOULD BE

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL I DATE
TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
REGULATORY OR LSC IDENTIFYING INFORMATION)
DEFICIENCY)
K 232 Continued From page 1 K 232 Pruitt Health Shepherd Hills to maintain 9/ 3/ 2017
compliance identified the means of egress,
During a tour of the facility with Staff M on path in the front lobby noted by the State
07/ 17/ 2017 between 11: 00 AM and 4: 00 PM Fire Marshall and moved to the two guest
observation revealed that furniture has been
chairs that were obstructing the means of
placed in the main corridor leading to the front
egress path on 7/ 17/ 2017. Staff was
exit doors. The placement of the furniture
reduced the width of the corridor to less that the inserviced and the front lobby will be
required six feet, 19. 2. 3. 3( 5)( b), and the monitored and documented by the
furniture was not securely attached to the floor or Maintenance and Safety Director on a
wall, 19. 2. 3. 3( 5)( a).
weekly basis for 6months
QA committee to meet and discuss
time of discovery.
Reference: 2012 NFPA 101, chapter 19, section monthly .
19. 2. 3. 4, subsection 5.
SS= E Smoke Barrie

Construction
2012 EXISTING

barrier.
19. 3. 7. 3, 8. 6. 7. 1( 1)
in REMARKS.
Event ID: B2JL21 Facility ID: LTD114B1209 If continuation sheet Page 2 of

FORM CMS- 2567( 02- 99) Previous Versions Obsolete
PRINTED: 08/ 01/ 2017

X3) DATE SURVEY
STATEMENT OF DEFICIENCIES X1) PROVIDERISUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION
115452 S. WING 07117/ 2017
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION x5I

X4) ID
COMPLETION
PREFIX DATE
TAG f REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
K 372 Continued From page 2 K 372 Pruitt I-Iealth Shepherd Hills to maintain
9/ 3/ 2017
The findings include: compliance contacted a Life Safety Engineer
During a tour of the facility with Staff M on Corporation to identify and make corrections to
07/ 17/ 2017 between 11: 00 AM and 4: 00 PM
recent findings of the State Fire Marshals Life
improperly sealed penetrations in the smoke Safety Survey concerning smoke barrier walls
barrier walls of the Northside Hall and the on the North and South halls conducted On
Southside Hall. 07/ 17/ 2017.
A license Fire and Life safety
time of discovery.
contractor has been notified to make the
19. 3. 7. 3, chapter 8, section 8. 5, 8. 5. 6. 3 corrections to comply with State Fire Marshall
Life Safety codes and work will be completed
by 09/ 03/ 2017. Facility Maintenance Director
will inspect other smoke/ fire barrier walls to
ensure penetrations are properly sealed.
Maintenance Director will inspect walls every

three months and after any contractor work
which might be detrimental to the ensure
barrier walls are properly sealed.

QA Committee will meet and review this
monthly.
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: 82J121 Facility ID: LTC11481209 If continuation sheet Page 3 of 3
PRINTED: 08/ 01/ 2017
FORM APPROVED
State of GA, Healthcare Facility Requlation Division

A. BUILDING:
B. WING
1- 146- 1671 07/ 20/ 2017
800 PATTERSON RD
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)


LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE xs) DATE
STATE FORM 6899

82JL11 If continuation sheet 1 of 1

2017 DCH Reports Involving Shepherd Hill Nursing Home

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Department of Health& Human Services ff _ y

Centers for Medicare& Medicaid Services

Refer to: 5452. comp. 10. 04. 17

IMPORTANT NOTICE— PLEASE READ CAREFULLY

Mr. Michael Dykes, Administrator

Re: Compliance Notice

Dear Mr. Dykes:

HUD— Office of Healthcare Programs

Medicare Advantage Branch

Nathan Deal, Governor Frank Berry, Commissioner

IMPORTANT NOTICE - PLEASE READ CAREFULLY

September 28, 2017

Mr. Michael Dykes, Administrator

Dear Mr. Dykes:

Long Term Care Section

Nathan Deal, Governor Frank Berry, Commissioner

IMPORTANT NOTICE - PLEASE READ CAREFULLY

Mr. Michael Dykes, Administrator

Dear Mr. Dykes:

Plan of Correction ( PoC)

An acceptable PoC must:

Includes dates when corrective action will be completed.

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

Informal Dispute Resolution ( IDR)

Independent Informal Dispute Resolution ( IIDR) -

Disclosure of Survey Results

cc: Melanie Simon, Division Chief

Nathan Deal, Governor Frank Berry, Commissioner

IMPORTANT NOTICE - PLEASE READ CAREFULLY

August 17, 2017

Mr. Michael Dykes, Administrator

Dear Mr. Dykes:

Healthcare Facility Regulation Division

cc: Facility File

FOR MEDICARE& MEDICAID SERVICES

OMB NO. 0938- 0391

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION X5)

F 000 INITIAL COMMENTS F 000

A standard survey was conducted at This Plan of Correction constitutes my written

Residents Form, the facility' s census on July 17,

SS= D FROM UNNECESSARY DRUGS of 50% of all residents receiving pain

2) For excessive duration; or

3) Without adequate monitoring; or

4) Without adequate indications for its use; or

5) In the presence of adverse consequences

6) Any combinations of the reasons stated in

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

115452 B. WING 07120/ 2017

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

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

F 329 Continued From page 1 F 329

483. 45( e) Psychotropic Drugs.

resident, the facility must ensure that--

1) Residents who have not used psychotropic

medication is necessary to treat a specific

2) Residents who use psychotropic drugs receive

interventions, unless clinically contraindicated, in

and review of facility policy titled" Lippincott

medication, from a sample of thirty- two( 32)

Review of facility policy titled" Lippincott

Review of R# 55' s clinical record revealed that she

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

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION X5)