2016 DCH Reports Involving Sherpherd Hill Nursing Home

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
Refer to: 5452. comp. 06. 08. 16
IMPORTANT NOTICE— PLEASE READ CAREFULLY

Receipt of this Notice is Presumed to be June 8, 2016- Date Notice E- mailed)
June 8, 2016
Ms. Anggie Chandler, Administrator

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

CMS Certification Number: 11- 5452
Dear Ms. Chandler:
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
Nathan Deal, Governor Clyde L. Reese III, Esq., Commissioner
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404-656-4507 1 www. dch. georgia. gov
IMPORTANT NOTICE - PLEASE READ CAREFULLY
June 7, 2016

Pruitthealth - Shepherd Hills
800 Patterson Rd
La Fayette, GA 30728
Dear Ms. Chandler:
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
cc: Georgia Department of Community Health/ Division of Medical Assistance

Long Term Care Ombudsman
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
May 12, 2016

800 Patterson Rd
Dear Ms. Chandler:
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
Centers for Medicare& Medicaid Services
61 Forsyth Street, SW, Suite 4T20
Atlanta, Georgia 30303- 8909
CENTERS FOR MEDICARE& MEDICAID SERVICES
Refer to: 5452. IJ. ab. 04. 22. 16
IMPORTANT NOTICE— PLEASE READ CAREFULLY

SENT VIA FEDEX AND INTERNET E- MAIL
Receipt of this notice is presumed to be April 22, 2016— date notice e- mailed)
April 22, 2016

Pruitthealth— Shepherd Hills
800 Patterson Road
La Fayette, Georgia 30728
Re: Imposition Notice

CMS Certification Number( CCN#): 11- 5452
Dear Ms. Chandler:
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.
II. DISCRETIONARY REMEDIES
Civil Monev Penalty ( CMP)
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
substantial compliance is achieved or your facility' s Medicare participation is terminated. We

considered factors identified at 42 C. F. R. 488. 438( f) in setting the amount of the CMP being
imposed for each day of your facility' s noncompliance. The daily amount of your facility' s
CMP may be changed in the future, if we find that conditions worsen and noncompliance
continues.
NOTICE OF INTENT TO HOLD YOUR FACILITY' S CMP IN ESCROW
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:
Brittany N. Jones, Legal Officer

Healthcare Facilities Regulation Division
Georgia Department of Community Health

2 Peachtree Street, Suite 31. 430
Atlanta, Georgia, 30303
404- 657- 5705
Bjones5@dch. ga. gov
Please note that an incomplete Independent IDR process will not delay the effective date
of any enforcement remedy imposed on your facility, and it will not delay our collection
of your facility' s CMP for more than ninety ( 90) days. We are authorized by federal law
at 42 C. F. R. 488. 431( b) to collect your CMP in 90 days and place it in escrow, or to do so
when a decision is issued from an Independent IDR proceeding, whichever is earlier.
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.
NOTICE OF RIGHT TO REOUEST HEARING OR WAIVE 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:
CMPWaiversATL@cros. hhs. gov
Discretionary Denial of Pavment for New Admissions ( DPNA)
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.
Substandard Quality of Care ( SQC)
Your facility' s noncompliance with 42 C. F. R. 483. 25 at F329J and F333J has been
determined to constitute substandard quality of care ( SQC) as defined at 42 C. F. R. 488. 301.

Sections 1818( g)( 5)( C) and 1919 ( g)( 5)( C) of the Social Security Act, as well as
implementing regulations at 42 C. F. R. 488. 325( h),

require the State Survey Agency to send
written notice of your facility' s SQC to the attending physician of each resident, as well as
the state board responsible for lnsing the facility' s administrator. In order to satisfy these
notification requirements, you are required to provide the State Survey Agency with the
name and address of the attending physician for each resident found to have received SQC.
The State Survey Agency will advise you of the deadline for providing this information.
Please note that, in accordance federal law at 42 C. F. R. 488. 325( g),

your failure to provide
this information in a timely fashion will result in the termination of your facility' s Medicare
provider agreement, or the imposition of alternative remedies.
Loss of Nurse Aide Training Program ( NATCEP)
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:

Departmental Appeals Board, MS 6132
Director, Civil Remedies Division
330 Independence Avenue, S. W.
Cohen Building— Room G- 644
Washington, D. C. 20201
Alternatively, you may file your hearing request electronically by using the Departmental
Appeals Board' s Electronic Filing System ( DAB E- File) at httvs: l/dab,/.efile. hlis. ov.
Specific instructions on how to file electronically are attached to this notice. A copy of the
hearing request shall be submitted electronically to:
Region4_ DAB_HearingRequest@cros.hhs. gov
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
April 13, 2016

800 Patterson Rd
Dear Ms. Chandler:
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
a revisit to the survey conducted on at which one or more

deficiencies were cited.
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:
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.
F0282 -- S/ S: J -- 483. 20( k)( 3)( ii) --

Services By Qualified Persons/ per Care Plan
The facility failed to ensure that care was provided in accordance with the care plan regarding
medication administration in accordance with physician's orders of only medications ordered for one ( 1)
resident to avoid adverse medication effects. 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.

The facility failed to ensure monitoring of respiratory status and pain level to ensure the safe
administration of Morphine 20 mg SL every two ( 2) hours in accordance with physician orders for one
1) resident. 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.

The facility failed to ensure that two ( 2) residents were free of significant medication errors regarding
licensed nursing staff faileure to sign or initial when a medication was given on the Medication
Administration Record ( MAR) or Controlled Drug Record ( CDR) which resulted in one ( 1) resident
receiving Morphine two ( 2) times within thirty ( 30) minutes, and failed to ensure staff administering
Morphine assessed the resident for pain level and respiratory status prior to continued administration
which resulted in resident found in respiratory distress with an oxygen saturation of 55%; and failed to
ensure that one ( 1) resident who did not have an order for Hydralazine or Procardia was administered
these medications in error by an unsupervised nurse in training, and was emergently transferred to the
hospital with severe hypotension. 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.
F0490 -- S/ S: J -- 483. 75 -- Effective Administration/ resident Well- Being.

The facility administration failed to ensure resident drug therapy was administered safely, accurately
and in accordance with physician' s orders . This failure resulted in a significant medication error for two
2) residents. 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.
F0514 -- S/ S: J -- 483. 75( 1)( 1) -- Res Records- Complete/ accurate/ accessible

The facility failed to accurately document medications administered for two ( 2) residents which caused
one ( 1) resident to receive in error two ( 2) doses of Morphine within a 30 minute time span. 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.
April 12, 2016
Page 3
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.
Substandard Qualitv of Care
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.
Loss of Nurse Aide Traininq Program
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.
A denial of payment for new admissions will be imposed immediately.
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.
Immediate Jeoaardv Removed
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,
April 12, 2016
Page 4
including dates will be included on the CMS 2567.
Plan of Correction ( PoC)
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.
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 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.
Informal Disaute Resolutions ( IDRR
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.
April 12, 2016
Page 5
Disclosure of Survev Results
Public Law 92- 603, section 299 requires that all deficiencies found during surveys shall be made
available to the public. Consequently, the attached list of deficiencies will be on file in this office and will
be available to any interested person upon request. In addition, you are required to make the survey
results readily accessible to your residents.
If you have any questions concerning the instructions contained in this letter or if we may be of
assistance, please do not hesitate to call or write us.
Sincerely,
4 ,--. P-
J
"
cc: Melanie Simon

CMS Regional Office
Charlie Richards, State Health Care Fraud Control Unit
Georgia Department of Community Health/ Division of Medical Assistance
State Long Term Care Ombudsman
Stacey Hillock
Georgia Board of Nursing Home Administrators
Georgia Medical Care Foundation
Lori Person, Agent for Service
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH
Nathan Deal, Governor

David A. Cook, Commissioner
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656-4507 1 www. dch. georgia. gov
March 30, 2016

800 Patterson Rd
Dear Ms. Chandler:
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.
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:
F0425 -- S/ S: J -- 483. 60( a),( b) -- Pharmaceutical Svc - Accurate Procedures, Rph
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.
Substandard Qualitv of Care
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.
Loss of Nurse Aide Traininq Proqram
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.
State monitoring effective February 29, 2016.
A denial of payment for new admissions be imposed immediately.
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.
Plan of Correction ( PoC)
A PoC for all deficiencies cited on the CMS 2667 must be submitted no later than April 1, 2016.
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 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.
Informal Dispute Resolution ( IDR)
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.
Disclosure of Survev Results
Public Law 92- 603, Section 299 requires that all deficiencies found during surveys shall be made
available to the public. Consequently, the attached list of deficiencies will be on file in this office and
will be available to any interested person upon request. In addition, you are required to make the
survey results readily accessible to your residents.
If you have any questions concerning the instructions contained in this letter or if we may be of
assistance, please do not hesitate to call or write us.
Sincerely,
Andrea Sanders
Enforcement Manager
cc: Melanie Simon

CMS Regional Office
Charlie Richards, State Health Care Fraud Control Unit
Georgia Department of Community Health/ Division of Medical Assistance
State Long Term Care Ombudsman
Stacey Hillock
Georgia Board of Nursing Home Administrators
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
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
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE

TAG TAG
DEFICIENCY)
F 000) INITIAL COMMENTS F 0001.
A Health follow- up visit to a complaint

investigation was completed on June 6, 2016. It
was determined that all deficiencies had been
corrected.
LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
Any deficiency statement ending with an asterisk(')

other safeguards
denotes a deficiency which the institution may be excused from correcting providing it is determined that
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: 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
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD HILLS
LA FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'

S PLAN OF CORRECTION Xs)
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 000 INITIAL COMMENTS F 0001 F000
Submission of this plan of correction

AMENDED 04/ 13/ 2016 does not constitute an admission by the 517/ 16
i above signed that the deficiencies were
l
An Abbreviated/ Partiai Extended Survey
1 correctly cited or required correction. c.
investigating ( GA00156430, GA0015B124,
GA00159480) was conducted 02/ 18/ 16 through
02126/ 16. After Supervisory review by the State O
Survey Agency the investigation was re-opened
and concluded on 03/ 21116. GA00158124 and
GA00156430 substantiated with
were
j
deficiencies cited. The facility was not in
j
substantial compliance with Medicare/ Medicaid
regulations at 42 Code of Federal Regulations
C. F. R.) Part 483, Subpart B- Requirements for
s
Long Term Care Facilities. Two( 2) Immediate
Jeopardy situations were identified. The facility r'
census was one- hundred- seven( 107) residents.
i
On February 25, 2016, a determination was made I r
that a situation in which the facility' s i
noncompliance with one or more requirements of
participation had caused, or had the likelihood to i
cause serious injury, harm, impairment or death
to residents. i
The facility' s Administrator, Corporate Clinical

Consultant, Director of Heath Services( DHS) and
Nursing Supervisor" EE" Registered Nurse( RN)
were informed of the Immediate Jeopardy on
February 25, 2016 at 5: 00 p. m.
1. The noncompliance related to the Immediate
i
Jeopardy was identified to have existed on
I
October 14, 2015 the date Resident# 2 was
administered Procardia 30 mg and Hydralazlne
100 mg ( antihypertensive medications) ordered
for a different resident in error. R# 2 experienced '
a significant medication error, when he was
administered medications ordered for a different
resident, and was emergently transferred to the
hospital and admitted to the Intensive Care Unit
ABOPATr PIRECTQR' S OR PR IDER/ SU L REPRES S§ IGNATURE TITLE Xs) D TE
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
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
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
LA ETT
LAFAYETTE A 30728
GA
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER`S PLAN OF CORRECTION

EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX (
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ; TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
F 000 Continued From page 1 F 000

with a diagnosis of Severe latrogenic
Hypotension, and Demand Ischemia. The
diagnosis of Demand Ischemia Indicated
myocardial damage had occurred resulting from
the severe hypotension. On October 15, 2015 a
Physician Progress note indicated an additional
diagnosis of Non ST Segment Elevation
Myocardial Infarction( NSTEMI). The facility
failed to ensure unsupervised newly hired
licensed staff accurately identified R#2 prior to
medication administration who received another
resident' s medications in error and caused actual
harm to the resident.
2. Resident# 1 experienced a significant

medication error an December 20, 2015 when, i 1
due to failure of the off going shift nurse to sign or
Initial the Morphine administered on the j
Medication Administration Record or Controlled
Drug Record, R# 1 was administered the narcotic
Morphine twice within thirty minutes, at 7: 00 a. m.
i
by the night shift nurse and at 7: 30 a. m. by the
day shift nurse. During the night of December 20,
2015, and early morning hours of December 21,
2015, he continued to receive doses of Morphine
20 mg/ ml SL) at two( 2) hour intervals without
assessment of pain level or respiratory status. A
Nurses Note did Identify an ongoing assessment
indicating sedation was present throughout the
7: 00 p. m. to 7: 00 a. m. shift on December 20,
2015. However, he was discovered on the
morning of December 21, 2015 in respiratory
distress, with an oxygen saturation of 55% and
transferred emergently to a hospital where he
required mechanical ventilation. The resident
was admitted to the Intensive Care Unit with a
diagnosis of Acute Chronic Respiratory Failure
and required mechanical ventilation intermittently
until discharge to a Long Term Acute Care facility
FORM CMS- 2567(02- 88) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461200 If Continuation sheet Page 2 of 96
PRINTED: 04/ 13/ 2016
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 e. WING
03/ 21/ 2016
800 PATTERSON RD
PRUITTHEALTH• SHEPHERD HILLS
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

PREFIX ( DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)
on February 4, 2016. The facilityfailed to

administer Morphine, a drug capable of producing
Respiratory Depression, within the scheduled
times, for a debilitated and underweight resident
with a diagnosis of Chronic Respiratory Failure,
and monitor respiratory status, pain level and
adverse reactions.
3. On October 12, 2015, October 13, 2016,

October 29, 2015 and October 30, 2015 at 9: 00
p. m. Resident# 3 received medications which
were not signed or initialed as given on the
Medication Administration Record. On October
12, 2015, October 29, 2015, October 30, 2015 at
9: 00 p. m., and on October 30, 2015 at 9:00 a.m.,
R#3 received Levemir Insulin Injection 70 units
Without documentation on the Medication
Administration Record. R# 3 also received Advair
Diskus inhalation at 9: 00 p. m., on October 13, i
2015 and Fluval 0. 5 milliliter( ml) Injection on the
i
3, 00 p. m. to 11: 00 p. m. shift on October 25, 2016
without documentation of medication given on the
Medication Administration Records. The facility
investigated the failure to document the Levemir
Insulin administrations.
An interview with the Administrator on February
19, 2016 at 2: 30 p. m., revealed the Levemir
Insulin administration without correct
documentation was investigated because insulin
administration was identified as an Issue being
worked on for Quality Assurance. The Fluval and
Advair Diskus administered to Resident# 3
without correct documentation were not
investigated or identified as Quality Assurance
issues.
The Quality Assurance Committee had identified

on October 14, 2015, an issue with nurses
unfamiliar with the residents having difficulty
identifying them for medication administration and
PRINTED: 04/ 13/ 2016
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
800 PATTERSON RD
ID STATEMENT OF PROVIDERS PLAN CORRECTION

PREFIX EACH MUST BE PR
BIES I ED FULL PREFIX
E EACH CORRECTIVE ACTIONSHOULD
C BE
ixsJ
COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION)
TAG j TAG CROSS- REFERENCED TO THEAPPROPRIATE DATE
DEFICIENCY)

identified an intervention of ensuring pictures of
each resident were available on the Medication
Administration Record. Observations of each
residents Medication Administration Record on j
February 19, 2015 at 2: 10 p. m, and February 25,
2016 at 10: 45 a. m. revealed six( 6) residents
whose pictures were not on the Medication
Administration Records.
An interview with the facility Corporate Clinical

Consultant on February 24, 2016 at 2:46 p. m.,
revealed the Medication Discrepancy/Adverse
Reaction Report forms required per Facility Policy
had not been completed for an unknown length of
time because the nurses did not know to
complete the form. The Administrator reported
errors verbally but there was no record of what
errors were reported or the Consultant
Pharmacist' review of the occurrences.
The Immediate Jeopardy was related to the j
facility' s noncompliance with program
requirements at 42 CFR 483. 20( k)( 3)( 1), Services
Provided Meet Professional Standards, F281 at a
Scope and Severity of" J"; 42 CFR 483. 20 ( k)( 3)
11), Services By Qualified Persons/ Per Care Plan,

F282 at a Scope and Severity of" J"; 42 CFR j
483. 25( 1), Unnecessary Drugs, F329 at a Scope i
and Severity of" J"; 42 CFR 483. 25( m)( 2),

Residents Free of Significant Medication Errors,
F333 at a Scope and Severity of" J'; 42 CFR
483. 75, Effective Administration/ Resident
Well- Being, F490 at a Scope and Severity of" J";
42 CFR 483. 75( 1), Clinical Record Contents,
F514 at a Scope and Severity of" J"; 42 CFR
483. 75( o)( 1), Quality Assessment and Assurance
Committee Members/ Meet Quarterly/ Plans, F520 I
at a Scope and Severity of" J".

Additionally, Substandard Quality of Care( SQC) j
I was identified with requirements at 42 CFR j
I
483. 25( 1), Unnecessary Drugs, F329 at a Scope
I
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.
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERiCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION In)

PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
DEFICIENCY)
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
F333 at a Scope and Severity of" J"_

An allegation of jeopardy removal was received
on February 26, 2016. Based on the corrective
plans which had been developed and
implemented by the facility, the Immediacy of the
deficient practice was determined to have been
removed on March 4, 2016 as alleged, and the
facility remained out of compliance at the lower
scope and severity of" D" while the process of
evaluation of the nursing staffs' compliance with
physicians orders, education, and facility policies
and procedures, continued. In- service materials
and records were reviewed, all medication
administration records were reviewed for resident
pictures. Interviews were conducted with nursing
staff to ensure they were knowledgeable about
the administration of resident medication.
F 281 483. 20( k)( 3)( 1) SERVICES PROVIDED MEET F 281 F281
SS-, 1 PROFESSIONAL STANDARDS PH Shepherd Hills will ensure that
in 5/ 7/ 16
The services
nursing services are provided
provided or arranged by the facility
accordance with professional
must meet professional standards of quality.
nursing standards of practice, regard-
ing medication administration for our
This REQUIREMENT is not met as evidenced residents. i
by;
Based on observations, record review and
j
interview the facility failed to ensure that nursing
services were provided in accordance with
professional standards of practice, regarding
i medication administration and monitoring for one
1) resident( R/#1), who incorrectly received two
2) doses of Morphine within a thirty( 30) minute
period and continued to receive Morphine
routinely every two( 2) hours for pain without
or assessment for adverse effects;
monitoring
k
FORM CMS- 2567( 02- 99) Previous Verstons Obsolete Event IO: 72SU11 Fadlity ID: LTC11441209 If continuation sheet Page 5 of 96
I
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDERJSUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03121/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

PREFIX TEACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
i DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
E
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.
Medical Records for the residents 5/ 7/ 16
participation had caused, or had the likelihood to
were reviewed to ensure that the I
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
2- 19- 16 and ongoing. The education
Implemented by the facility, the immediacy of the
i included medication administration
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,
medication pass times, consistent
evaluation of the nursing staffs' compliance with
and accurate documentation of
continued. In- service
medication and acceptance/ refusal
and procedures, materials
and records were reviewed, all medication of medications, medication discrepancies

administration records were reviewed for resident adverse medication reactions, accurate
pictures. Interviews were conducted with nursing transcription of medication orders, and
identification of patients.
the administration of resident medication. a
Cross reference to F333.

l
Findings Include:
k
I i
1. Review of the facility's Medication
FORM CMS• 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 6 of 96
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

A. BUILDING
C.
115462 B. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

w) ID
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD t3E COMPLETION
DATE
TAG
DEFICIENCY)

Newly hired nurses will be educated
Clinical Competency Coordinator and

by
15-
I
7, 4
Administration General Guidelines policy included
mentor nurse on medication admin-
information on identifying residents. The
procedure section documented residents are istration general guidelines, including

identified before medication is administered. A but not limited to, following physicians I
list of methods of identification to use, when in
doubt about the resident' s Identity, Included to
orders, medication pass times, consistent
and accurate documentation of I
check for an identification band, check for
medication and acceptance/ refusal I
photograph attached to the medical record, call
the resident by name and if necessary verify the of medications, medication
resident' s identify with other healthcare staff. discrepancies, adverse medication

Record review for R# 2 revealed an Annual I
reactions, accurate transcription of
Minimum Data Set assessment dated December
medication orders, and
11, 2015 that documented R# 2 as admitted to the i
identification of patients. I
facility on February 5, 2013 with diagnoses that
included Hypertension, Dementia with behaviors, Newly hired nurses will be required to
Alzheimer' s Disease, and Psychotic Disorder. complete the Orientation Skills
Section C, Cognitive Patterns, revealed Resident
Checklist, Medication Administration
1 had severe cognitive impairment with a Brief
Interview for Mental Status Score of five( 5). A Video with post test, and Medication
record review for R# 2 revealed nursing notes Cart Orientation.
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
i
PRINTED: 04/ 13/ 2016
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED

STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
LAFAYETTE, GA 30728
X4) ID STATEMENT OF DEFICIENCIES

SUMMARY 1D PROVIDER'S PLAN OF CORRECTION
PREFIX ( DATE
TAG
DEFICIENCY)
F 2811, Continued From page 7 F 281 Education was provided to 34 nurses

T,,7 q
Review of the facility Incident Report for the from 2/ 19/ 16 to 2/ 29/ 16 by the Clinical
medication error that occurred on October 14, Competency Coordinator, Senior
2015 revealed the medication error was identified I Nurse Consultant, and RN Supervisor
after R# 2' s roommate reported to the Certified
regarding the medication discrepancy
Nursing Assistant( CNA) that R# 2 had been
6: 00 a. m. medications that were form and the documentation regarding
incorrectly given
i meant for him( the roommate), and medication discrepancy and
reporting the discrepancy to the
During an interview with the Administrator on Physician and Pharmacist.
February 19, 2016 at 6: 30 p. m. she stated that an
34 Nurses reviewed Medication
inservice was conducted when this medication
error was discovered and she had both nurses in
administration video from the
her office and gave a verbal reprimand to the American Society of Consultant
nurse that was providing training to the new nurse Pharmacists, which included oral
because she( the nurse providing training) was
medications, eye meds/ inhalers/
sitting at the nurses station and allowing the new
nurse to administer medications unsupervised. patches, and meds via G tube

The Administrator further acknowledged that administration of medication with
neither nurse had received a written reprimand on successful completion of post test
this error.
beginning 2/ 26/ 16 through 2/ 29/ 16
In an interview on February 22, 2016 at 9: 30 a. m.
and on going.
the Administrator acknowledged the supervising
Pictures of residents were updated
licensed nurse" HH" had left licensed nurse" BB"
unattended and licensed nurse" BB" did not know and placed in the Medication
the residents.She further acknowledged that Administration Books on October 15,
pictures of the residents were always on the 2015.
MARS but were updated recently.
Pictures of residents will be reviewed
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
jDuring an interview an February 23, 2016 at

PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERlCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03f2112016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Vs)

TAG REGULATORY OR LSO IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
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
nurses weekly times 1 month, then

monthly times 3 months beginning
of the clinical record for Resident# 1
2. Review
revealed he wasadmitted to the facility on
2/ 25/ 16 and ongoing. j
Pharmacy Consultant will observe at =
12/ 18/ 15 after a six( 6) month hospitalization. He 7/4,
was brought to the facility to be closer to his least one random med pass observation
family and was Chronically ill, debilitated and during monthly visit.
underweight, paralyzed in three extremities and i
had minimal movement in his right upper
extremity, allowing him to use a communication
board of numbers and letters because he was i
unable to speak. He had a Percuteneous
Endoscopic Gastrostomy( PEG) tube, a
Peripherally Inserted Central Catheter( PICC
line), a Foley Catheter, a Tracheostomy and
FORM CMS- 2667( 02-99) Previous Versions Obsolete Event ID: Z281.111 Facility ID: LTC11461209 If continuation sheet Page 9 of 96
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. COMPLETED
A. BUILDING
C
115452 S. WING
03/ 21/ 2016
800 PATTERSON
FAYETTE, R
CAA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1 ID PROVIDER' S PLAN OF CORRECTION Xs)

TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TOTHEAPPROPRIATE DATE
DEFICIENCY)

All finding will be taken to the Quality
Assurance Performance improvement
multiplepressure ulcers. The resident' s j
diagnoses included Chronic Respiratory Failure, l Committee for action as needed.
Chronic Deep Vein Thrombosis( DVT),

Transverse Myelitis and Behcet' s Syndrome with
Neurological Involvement.
Review of the admission orders revealed an order

for 20 milligrams per milliliter( mg/ ml) of
Morphine- give 0. 5 ml sublingual( SL) every four
hours( q4h).
On 12/ 19/ 15 at 8 a. m. the order was changed to
Morphine 20 mg/ ml 1 ml sl every three hours
q3h). However, on 12/ 19/ 15 at 3:30 pm, the
order was again changed to Morphine 20 mg/ ml
give 1 ml SL every two hours( q2h) for continued
pain.
A review of the Controlled Drug Record for

12/ 20/ 15 revealed the following:
At 4: 30 a. m. R# 1 received a one( 1) ml dose of
Morphine 20 mg Iml.
At 7: 00 a. m. R# 1 received a one( 1) ml dose of
Morphine 20 mg/ ml.
At 7:30 a. m. R# 1 received a one( 1) ml dose of
Morphine 20 mg/ ml.
A continued review of the Controlled

Drug Record i i
for 12/ 20/ 16 revealed R# 1 did not receive the i
Morphine scheduled for 5:30 p. m. and 7: 30 p. m.
These doses were recorded as refused.
However R# 1 did receive a dose of Morphine, as
ordered, at 9:30 p. m., 11: 30 p.m, and on 12/21/ 15
at 1; 30 a. m., 3; 30 a. m. and 5: 30 a. m.
A review of the back of the Medication

i
Administration Record( MAR) revealed that on
12/ 20/ 15 at 5: 30 p.m. and 7:30 p. m. the Morphine
was held. The 7:30 p. m. dose was documented
by LPN" 1313" as held due to being unable to
FORM CMS. 2667( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 10 of 96
1
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 13. WING
03121/ 2016
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES

X4) ID 1 ID PROVIDER' S PLAN OF CORRECTION X5)
PREFIX ( EACH DEFICIENCYMUST BE PRECEDED BY FULL + PREFIX EACH CORRECTIVEACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TOTHEAPPROPRIATE DATE
i DEFICIENCY)
arouse( the resident).
Review of the Nurses Notes for 12/ 20/ 15

revealed that at 8: 00 p. m. it was discovered that
due to LPN " BB" not documenting
administrations of Morphine at 4:30 a. m. and 7:00
a. m., an administration of Morphine scheduled for
7: 30 a. m. was given by Nurse " AA", thirty
minutes after the previous dose that was

scheduled for 5: 30 a. m., but given at 7: 00 a. m.
There was no indication of assessment of oxygen
saturation, pain level or level of sedation for 7: 00
a. m, to 7: 00 p. m.
Review of Nurses Notes for 12/ 20/ 15 by the 7:00

p. m. to 7: 00 a. m. LPN " 13I3" gave no indication of
oxygen saturation after 2: 00 a. m. when it was
90%, no indication of level of pain or sedation.
f
In an interview with LPN " AA" on 2/ 19/ 16 at
10: 35 a. m. revealed she had not known the
correct way to transcribe the orders for Morphine
20 mg/ ml give 1 ml q 3 hours and Morphine 20
mg/ ml give 1 ml q 2 hours, to the MAR or how to
schedule the Morphine every 3 hours, then
I changed to every 2 hours. She realized the
documentation' s on the front of the MAR could
not be deciphered with administrations
documented on the wrong dates, some before
the order had been taken, and administrations
circled and crossed out. " AA" revealed she had
asked someone, she could not remember who,
for assistance, but they could not help her. She
stated she arrived on 12/ 20/ 15 at 7: 00 a. m. and
counted narcotics with LPN" BB" and the count
for the Morphine had seemed to come out
correct, but it was difficult to see because the
liquid was clear and the count must not have
been correct because ' BB" had failed to
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
FOR MEDICARE& MEDICAID SERVICES OMB NO. 0936- 0391

CENTERS
X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA (
COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING
116452 B. WING 0 3121/ 2 01 6

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE. ZIP CODE
800 PATTERSON RD
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
document administration of Morphine scheduled

I at 3: 30 a.m. and 5: 30 a. m. She left two( 2) lines f
and gave the dose scheduled for 7:30 a. m. She
learned when 086" returned at 7:00 p.m. that the
5: 30 a. m. dose had been administered ninety( 90}
minutes late, at 7: 00 a.m., and " AA" had
I
administered Morphine just 30 minutes later. `
Continued interview with LPN" AA" revealed that J
she had informed the Physician and had been
told that since 12 hours had passed since the
error there would not be any problem because
Morphine was metabolized rapidly and if the
resident were going to have a problem It would
have been within one hour. She acknow) edged
she had recorded the residents lungs were
congested, but had not recorded checking an
oxygen saturation for the entire 12 hours shift,
I
and was unable to remember if she had checked
this. She acknowledged recording Morphine held
I
at 5: 30 p. m. as refused, but she had actually i
requested the assistance of the North Hall
EE" Registered Nurse( RN) I
Supervisor Nurse "
i
to advise her of whether Morphine should be
administered at this time because the resident
was sedated. " EE" RN assessed the resident with
her and they decided to use Nursing Judgement
and hold the medication. She acknowledged she
i
should not have recorded the dose held as
refused. She revealed she had checked on R# 1
when LPN " BB" arrived at 7: 00 p, m. and
Supervisor " EE" was requested to assist again a
with assessment. The Morphine scheduled for I
7: 30 p. m. on 12/ 20/ 15 was also held for sedation

and Supervisor " EE" gave education regarding s
using nursing judgement when administering i
scheduled or as needed( prn) medication and this
was especially important in the case of opioid i
medication that could suppress respiration.
Supervisor " EE" educated both LPN " AA" and i
FORM CMS- 2667(02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 12 of 96
is
S3
i
PRINTED: 04/ 13/ 2016

STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIER/ CLIA ()( 2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/21/ 2016
800 PAITERSON RD
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)
LPN " BB" at this time,
In an interview on 2/ 19/ 16 at 11: 55 a. m. with LPN!

BB" revealed that she had failed to document
administration of Morphine on 12/ 20/ 15 at 4:30
a. m. and 7: 00 a. m. She could not remember why
she gave the 5: 30 a. m. scheduled Morphine at
7: 00 a. m., or why she failed to document, why I
she failed to mention this In report, or why she did II

not note this on the back of the MAR or flag the
MAR to Communicate this information. LPN" BB"
could not explain why she had charted on the

Controlled Drug Administration Record that R# 1
had refused Morphine on 12120/ 15 at 7. 30 p.m.,
when she, LPN " AA" and Supervisor" EE" had
witnessed the resident had been too sedated to
receive the medication. LPN " BB" remembered
that R# 1 was sedated and comprehending less
throughout the entire shift that night. LPN " BB"
acknowledged that she had not assessed a pain
scale, or charted a level of sedation during the
12120/ 15 7: 00 p. m. through 12/ 21/ 15 7: 00 a. m.
shift. She was not able to remember if the
resident had actually indicated refusal of
suctioning at 10: 00 p.m. and 2:00 a.m., or just did
not answer her, as when she charted refusal of
the Morphine at 7: 30 p. m. LPN ' BB" confirmed
that she should have checked an oxygen
saturation after 2: 00 a. m. when It was 90%, and a
pain level to know if the resident could answer
and comprehend every 2 hours with each of the
five( 5) times Morphine was administered. LPN
BB" further revealed that she discovered R# 1 In
respiratory distress about fifteen( 15) minutes
after her last administration of Morphine at 5: 30
a. m. and requested assistance. R# 1 was
i transferred to the hospital.
In an interview on 2/ 22/ 16 at 2: 50 p. m. with

FORM CMS- 2667(02-99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation Sheet Page 13 of 96
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( Xt) PROVIDER/ SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
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
Emergency Medical Service( EMS) Paramedic

who transferred R# 1 to the hospital on 12/ 21/ 15
at 6: 30 a. m. revealed that he assessed the
resident was over sedated due to the facility staff
I reporting he had been administered Morphine
and he noted the resident had pinpoint pupils, I
which Is a sign of Morphine overdose. He further

revealed that he administered Narcan to reverse
the Morphine as soon as possible and the
residents condition improved, with increased level
of consciousness, respiratory rate and effort,
pulse oximetry and a decrease of pupil size.
i
Review of the EMS Patient Care Report, dated

12/ 21/ 15 at 6:41 a. m. revealed that an
administration of Narcan 0. 5 mg to R# 1 with
respirations increasing from 8 and shallow, with
oxygen saturation of 85% on high flow oxygen at
110 liters per minute on first assessment, to
respiratory rate of 16, normal depth and 98%
oxygen saturation after Narcan and suctioning at
7: 16 a.m.
In an interview on 2123/ 16 at 1: 30 p. m. with the

attending Physician of R# 1 revealed that he had
been informed of the resident being administered
Morphine 20 mg/ ml 1 ml at 7: 00 a. m. and 7: 30
a. m. when the situation had been discovered
twelve( 12) hours later but did not consider this as
causing his respiratory distress the following
morning at 5: 55 a. m. The Physician revealed he
would expect the nurses to hold a medication like
Morphine for sedation and check for mentation i
and respiratory status with every administration
F
because this Is a nursing standard.
1
i
Review of Corporate policy entitled Pain j
Management, Lippincott Procedures, indicated f i
that when administering strong opiod

FORM CMS- 2567( 02- 99) Prevlous Versions Obsolete Event 1D_ Z2SU11 Facility 10: LTC11461209 If continuation sheet Page 14 of 96
PRINTED: 04113/ 2016
SERVICES OMB NO, 0938- 0391

CENTERS FOR MEDICARE& MEDICAID
STATEMENT OF DEFICIENCIES ( X1) PROViDERISUPPLIERICLIA (
AND PLAN OF CORRECTION A. BUILDING)
11 M2 B. WING 0312112016
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDERS PLAN OF CORRECTION x5)

X4) ID COMPLETION
EACH CORRECTIVE ACTION SHOULD BE
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
DATE
INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE i
TAG REGULATORY OR LSC IDENTIFYING
DEFICIENCY)
medications, pain level, and adverse reactions

produced by treatment should be assessed in a
timely manner, according to the onset of the
prescribed medication.
On 03/ 21116 a partial extended survey was

conducted the sample was expanded by three
residents( R# 22, R# 23, R# 24) who were all
receiving narcotic and antihypertensive
medications. Clinical record reviews of physician
orders, medication administration records,
controlled drug records and observations
revealed no further indication of deficient practice.
The facility implemented the following actions to

remove the Immediate Jeopardy:
r
1. Education was provided to 34 nurses by the

clinical competency coordinator and Registered
2/ 19/ 16 regarding the I
Nurse supervisor on
general guidelines for medication administration

including following physician orders, medication
pass times, consistent and accurate s
documentation of medication and l
acceptance/ refusal of medications, medication
i
discrepancies, adverse medication reactions, i
accurate transcription of medication orders and
identification of residents.
Education content and sign in sheets were
reviewed t
2. Pictures of residents were audited on 2/ 25/ 16

i
and will be reviewed monthly and updated as
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
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PRINTED: 04113/ 2016
FORM APPROVED
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING COMPLETED
C
115452 B. wING
03121/ 2016
NAME OF PROVIDER OR SUPPLIER
STREETADDRESS, CITY, STATE. ZIP CODE
800 PATTERSON RD
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)
process of residents as needed.

14. Nurses were In serviced by the clinical
competency coordinator and registered nurse
supervisor on 2126/ 16 related to pain Including
observation and documentation of pain with
routine pain medication administration, and
observation of respiratory and sedation status I
with controlled substance pain medication
administration.
l Education content and sign in sheets were

reviewed .
5. nursing education was provided on 2/ 29/ 16 by

the clinical competency coordinator and are in
supervisor regarding errors, omissions and late
entries.

reviewed.
1 S. DHS or RN supervisor will complete daily

review of medication administration records for 1
omissions. i
7. RN supervisor will complete review of
medication administration records monthly during
change over to ensure pictures of residents are in
place.
E 8. DHS or RN supervisor will monitor/ observe
med pass for 10% of nurses weekly for one
month then monthly for three months was

Initiated on 2/ 25/ 16.
9. The pharmacy consultant will observe at least
one random med pass monthly during her visit
10. All findings will be taken to the quality
assurance performance improvement committee
for action as needed
11. 34 nurses reviewed medication administration
video from American Society of consultant
pharmacists, which included oral medications, I
met medications/ inhalers/ patches, and i
medications by G- tube administration of
medication was successful completion of
FORM CMS 2567(0229) Previous Versions Obsolete Event ID: Z2SU11 Facility to: LTC11461209 If confinuatlon sheet Page 16 of 96
ii
i'
it
PRINTED: 04/ 13/ 2016
FORM APPROVED
C
115452 B. wING
03/21/ 2016
800 PATTERSON
PRUITrMEALTH- SHEPHERD HILLS
FAYETTE, GA R30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES I

ID PROVIDER' S PLAN OF CORRECTION
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX EACH CORRECTIVE ACTION SHOULD BE COI LE)
TION
DEFICIENCY)
II
F 281 Continued From page 16 F 281 I
posttests beginning 2/26/ 16

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, E
13 Newly hired nurses will be in serviced by the
clinical competency coordinator and mentor nurse E
on medication administration general guidelines
including following physician orders, med pass
times, consistent and accurate documentation of
medication and acceptancelrefusal of
medications, medication discrepancies, adverse
medication reactions, accurate transcription of
medication orders, and identification of patients

and will be required to complete the orientation
f skills checklists, medication administration video
with posttest, and medication card orientation. i
i Medication pass observation will also be i
completed with each newly hired nurse was

successful completion.
14. Education was provided to 34 nurses
j
completed on 2/ 29116 by clinical competency
coordinator, senior nurse consultant, and RN
I
supervisor regarding medication discrepancy
form and documentation regarding any
discrepancy and reporting of discrepancy to
physician and pharmacist.
reviewed
15. Charge nurses will review medication
administration records and controlled substance
reports at shift change for completion.
F 282 483. 20( k)( 3)( 11) SERVICES BY QUALIFIED F 282
PERSONS/ PER CARE PLAN
I'
The services provided or arranged by the facility
I
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
FORM APPROVED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STRE ET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
X4j 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 i DATE
DEFICIENCY) I

must be provided by qualified persons in F282
accordance with each resident' s written plan of
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
R# 2) on the total survey

resident(
Resident# 2
on October 14, 2015.
was sent to ER and
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
On 25, 2016, a determination

or RN Supervisor for necessary
February was made
interventions.
that a situation in which the facility' s
noncompliance with one or more requirements of Residents medication administration

participation had caused, or had the likelihood to records were reviewed to ensure that
cause serious injury, harm, Impairment or death physicians' orders were correctly
to residents. The facility' s Administrator,
documented on the MAR.
Corporate Clinical Consultant, Director of Heath
Services( DHS) and Nursing Supervisor" EE'
Registered Nurse( RN) were informed of the I

5: 00 p. m.
i
FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: 22SU11 FadIty ID: LTC11451209 If continuation sheet Page 18 of 96
i
PRINTED: 04113/ 2016
FORMAPPROVED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION

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

Newly hired nurses will be educated by
implemented by the facility, the immediacy of the
deficient practice was determined to have been Clinical Competency Coordinator and
removed on March 4, 2016 as alleged, and the mentor nurse on medication admin-

istration general guidelines, including
evaluation of the nursing staffs' compliance with but not limited to, following physicians
physicians orders, education, and facility policies orders, medication pass times, consistent
and records were reviewed, all medication and accurate documentation of
administration records were reviewed for resident medication and acceptance/ refusal
pictures. Interviews were conducted with
of medications, medication
nursing staff to ensure they were knowledgeable
about the administration of resident medication. discrepancies, adverse medication

Cross reference to F 333
medication orders, and
Findings include:
Record review for R# 2 revealed an Annual Newly hired nurses will be required to
Minimum Data Set assessment of 12/ 11/ 2015 complete the Orientation Skills I
which documented, in Section 1- Active
Diagnoses, that the resident had diagnoses which
included Alzheimer' s Disease, Dementia with Video with post test, and Medication
behaviors, Hypertension, and Psychotic Disorder,
Cart Orientation.
Further review of R# 2' s clinical record revealed
that the October PhysicianOrders Form specified Newly hired nurses will have a med
the administration of Namenda XR 28 milligram
mg) daily at 9: 00 a. m, forAlzheimer' s, Vitamin
D3 2000 units daily at 9: 00 a,m. for bone health, RN Supervisor and or DHS and will be
Propranolol 20 mg every 12 hours at 9. 00 a. m. ( required to have a successful
and 9: 00 p. m., Hold for heart rate less than 50, i
for Hypertension,( listed as a Beta blocker), completion before being allowed to
Donepezil 10 mg every evening at 5: 00 p. m. for administer medications to our
Alzheimer' s/ Dementia. Additional record review
residents.
for R# 2, included review of the October Physician
Orders Form, which revealed no evidence of a
current or past Physician' s order for the
administration of the Antihypertensives Procardia
130 mg( listed as Calcium Channel blocker) or i
FORM CMS- Z567(02- 99) Previous Versions Obsolete Event ID: Z2SUi1 Facility ID: LTC11461209 If continuation sheet Page 19 of 96
I
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FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERICL1A ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD

DEFICIENCY)

Hydralazine 100 mg. 34 Nurses reviewed Medication
Review of the Care Plan for R# 2 revealed
Identified Problems American Society of Consultant
multiple involving the
Pharmacists which included oral
administration of drug therapy, and specifying as
Approaches that drug therapy be administered in medications, eye meds/ inhalers/
accordance with Physician' s orders. The Care
patches, and meds via G tube
Plan identified the following:
administration of medication with
Problem: diagnosis of Hypertension with the
specified Approach to Administer medications as successful completion of post test
ordered and updated October 17, 2016 as return beginning 2/ 26/ 16 through 2/ 29/ 16
from hospital- continue plan of care and on going.
Problem:diagnosis of Dementia with behaviors
Pictures of residents were updated
and Psychotic disorder and specified as an
and placed in the Medication
Approach to administer medications as needed
Administration Books on October 15,
as ordered
Problem: risk for constipation and impactions, as 2015.
specified Approach to administer

as an Pictures of residents will be reviewed
laxatives/ stool softeners as ordered by physician.
monthly and updated as needed with
Document effectiveness.
admissions and discharges.
Problem: risk for pain, specified as an Approach
administer medications as ordered as needed
Nurses were educated by Clinical S•
Problem: risk for Respiratory infections and Competency Coordinator and RN
Pneumonia specified as an Approach Supervisor regarding Errors, Omissions
Antibiotics/ medications as ordered
and late entries.
Problem: risk for Urinary Tract Infections,
specified as an Approach Administer Pruitt University class for Medication
antiblotics/ medications as ordered Administration and Avoiding Common
Problem: history of inappropriate behaviors, Errors beginning 2/ 29116 and ongoing.
specified as Approach Medications as needed/ as DHS and or RN Supervisor will completE.
ordered. The Care Plan of R# 2 specifically
directed to give medications as ordered and as
needed by the physician. daily.
I
Record review of Nurses Note( NN) for October
14, 2015 with no time listed; entry for R#2
documented that the resident was in bed this a. m.`
I and was given medications by trainee, that were
l for another resident. R# 2 was given Procardla
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facllity ID: LTC11461209 If Continuation sheet Page 20 of 96
PRINTED: 0411 3/ 2 01 6
STATEMENT OF DEFICIENCIES ( X1) PROVIDERI5UPPLIERtCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A, BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION XS)

TAG TAG
DEFICIENCY)

30 mg and Hydralazine 100 mg, vitals were blood
DHS and or RN supervisor will monitor) 5-7• 4
pressure( B/ P) 136/ 58, Pulse 57, Temperature observe Medication pass for 10% of
96.8 and no signs of acute distress. Medical
Doctor( MD) made aware.
Review of NN for October 14, 2015 at 7: 10 a. m.
2/ 25/ 16 and ongoing.
documented R# 2 now starting to fall in blood
pressure( BP) and becoming unresponsive, j Pharmacy Consultant will observe at
called 911,
placed in bed in Trendelenburg; BP least one random med pass observation
now 64138. Resident fading in and out of
during monthly visit.
responsiveness. Very drowsy and not answering
staff. Placed on oxygen( 02) at two liters per Nurses who fail med pass or have a
minute( 2UM) via mask. Eyes are open 68/ 50

i S. 7
medication error will be removed from
manual BP. Awaiting ambulance. On October
14, 2015 at 7: 20 a.m. R# 2 out by ambulance to the medication cart and re educated
Hutcheson Medical Center ( HMC). Responsible
one on one by the Clinic Competency
Party( RP) aware. MD made aware of resident
Coordinator and or RN Supervisor. Once
being sent out.
the re- education is completed the
Review of the hospital' s History and Physical
nurse will be observed an 3 medication
H& P) report documented Cardiology
Consult
a
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
accident, resulting in accidental overdose. The

resident was given 100 mg of Hydralazine and 30
mg of Procardia by mistake and his blood i I
pressure went down Into the 50' s and 60' s
systolic_ On presentation to the Intensive Care
Unit( ICU) the residents' 6/ P was 90164 and he
was alert and responsive. The H& P further
documented the medication error occurred about
6:00 a. m. and his medicines were given by a
nurse who was new to the facility and undergoing
orientation. The hospital Discharge Summary for
FORM CMS4567( 02 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 21 of 96
I'.
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/ 13/ 2016
FORAM APPROVED
C
115452 B. WING
03121/ 2016
800 PATTERSON RD

DEFICIENCY)

R# 2 documented diagnoses which included
latrogenic Hypotension secondary to medications
mistake at the nursing home, Demand Ischemia,
Dementia, Cardiac Hypotension, History of
CoronaryArtery Disease, and History of
Hypertension.
Review of the facility Investigation Report( IR) for

R92 October 14, 2015 at 6: 15 a. m. documented
that Blood Pressure medication had been given in
error during 6: 00 a.m. medpass. The room mate
of R# 2 reported the error to a Certified Nursing
Assistant( CNA) and the CNA reported it to the
Charge Nurse.
Interview conducted on February 19, 2016 at 6: 30

p. m. with the Administrator revealed the
supervising nurse had left Licensed Practical
Nurse( LPN)" BB", who did not know the
residents, unattended and" BB" administered the
6 a. m. medications for another resident to R42.
The Administrator further revealed that when she
was made aware of the medication error she had
both the trainee and the nurse training her in the
office and verbally reprimanded both nurses.
Pictures of residents were placed on the
Medication Administration Records and an in
service was completed on supervision of new
employees during medication administration on
October 14, 2015.

p. m. with LPN" HH" revealed that she was the
nurse training LPN" BB" on the morning of f
October 14, 2015 when the wrong medication
j
was given to R# 2. She further acknowledged that
she did not go into the room with" BB" when the I
medications were administered and that she
should have went with her. " HH" also
FORM CMS- 2587( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facilily# D: LTC11461209 If continuatlon sheef Page 22 of 96
i
PRINTED: 0411312016
STATEMENT OF DEFICIENCIES ( X1) PROVIDERlSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES j ID PROVIDER' S PLAN OF CORRECTION VS)

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) j TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 282! Continued From page 22 F 282

I acknowledged that there were no pictures on the
MARs at the time of the error but the next day
pictures were placed on the MARS identifying the
residents.
I On 03/ 21/ 16 a partial extended survey was

I
I
I

1, Education was provided to 34 nurses by the

Nurse supervisor on 2119/ 16 regarding the
Including following physician orders, medication
pass times, consistent and accurate
documentation of medication and
discrepancies, adverse medication reactions,
accurate transcription of medication orders and I
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
A. BUILDING
C
115452 B. WING
03/ 2112016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION X6)
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS REFERENCED TO THE APPROPRIATE
DEFICIENCY)

staff members to assist with the identification
process of residents as needed,
4. Nurses were in serviced by the clinical
supervisor on 2/ 26/ 16 related to pain including
I routine pain medication administration, and
observation of respiratory and sedation status
administration.

reviewed.
5. nursing education was provided on 2/ 29/ 16 by
the clinical competency coordinator and are In
entries.

reviewed.
6. DHS or RN supervisor will complete daily
review of medication administration records for
I omissions. I

place.
8. DHS or RN supervisor will monitor/ observe
med pass for 10% of nurses weeklyfor one
initiated on 2/ 25116.
I one random med pass monthly during her visit
i
11. 34 nurses reviewed medication administration 1
video from American Society of consultant I
pharmacists, which included oral medications, I i
met medications/ inhalers/ patches, and v
i
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID: Z25U11 Facility ID: LTC11461200 if continuation sheet Page 24 of 96
PRINTED: 04/ 13/ 2016
FORM APPROVED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
PRUITfHEALTH- SHEPHERD HILLS
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION VS)

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

medication was successful completion of I
t
posttests beginning 2/ 26/ 16
I
Education content and sign In sheets were
reviewed
12. The director of health services or registered
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
medication and acceptance/ refusal of
medications, medication discrepancies, adverse I
skills checklists, medication administration video
I
with posttest, and medication card orientation. i
Medication p ass observation will also b e 1
14. Education was provided to 34 nurses I
completed on 2/ 29/ 16 by clinical competency

coordinator, senior nurse consultant, and RN i
supervisorregarding medication discrepancy i
form and documentation regarding any I

j
physician and pharmacist. I
reviewed
reports at shift change for completion. I
F 329 483. 25( 1) DRUG REGIMEN IS FREE FROM F 329€
SS= J_ UNNECESSARY DRUGS
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
FORM APPROVED
A. BUILDING
C
115452 13, WING
03/ 21/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION I ( X5)

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COWLETEDN
DEFICIENCY)
i
F 329 Continued From page 25 i F 329
F329
Pruitt Health Shepherd Hills ensures

Each residents drug regimen must be free from
unnecessary drugs. An unnecessary drug is any that residents are free from unnecessary.
i
drug when used in excessive dose( including drugs, The facility ensures monitoring
duplicate therapy); or for excessive duration; or I of respiratory status and pain level to
without monitoring; or without adequate
adequate
1ensure safe administration of morphine.
indications for its use; or in the presence of
adverse consequences which indicate the dose i Resident# 1 sent to ER and was admitted
should be reduced or discontinued; I to the hospital and did not return to the
or any i
combinations of the reasons above. E facility.
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
general guide lines, including but not

limited to, following physicians orders,
This REQUIREMENT Is not met as evidenced and accurate documentation of
by., medication and acceptance/ refusal
Based on record review, staff, physician, family i
of medications
and Emergency Medical Services ( EMS) medication discrepancies,
interview, the facility failed to ensure monitoring adverse medication reactions, accurate i
of respiratory status and pain level to ensure the transcription of medication orders, and i
safe administration of Morphine
twenty( 20) identification of patients. s
milligrams( mg) sublingual( SL) every( q) two( 2)
hours in accordance with Physician orders, for j
one( 1) resident( R# 1) from a total survey sample i
of twenty-four( 24) residents. The facility census
was 107.
i
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIERICUA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
0312112016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZiP CODE
800 PATTERSON RD
PRUiTTHEALTH- SHEPHERD HiLLS
X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER' S PLAN OF CORRECTION Xe)
TAG TAG
DEFICIENCY)
I

Newly hired nurses will be educated by S 7-
On February 25, 2016, a determination was made
noncompliance with one or more requirements of mentor nurse on medication admin-

cause serious injury, harm, Impairment or death
to residents. The facilitys Administrator, but not limited to , following physicians
orders, medication pass times, consiste it
Services( DNS) and Nursing Supervisor" EE"
Registered Nurse( RN) were Informed of the
Immediate Jeopardy on February 25, 2016 at medication and acceptance/ refusal
5: 00 P. M.
An allegation of jeopardy removal was received i
on February 26, 2016. Based on the corrective discrepancies, adverse medication

implemented by the facility, the immediacy of the
deficient practice was determined to have been medication orders, and
Scope and severity of" D" while the process of Newly hired nurses will be required to S-7- A-
evaluation of the nursing staffs' compliance with complete the Orientation Skills
and procedures, continued. inservice materials
and records were reviewed, all medication Video with post test, and Medication
administration records were reviewed for resident I
Cart Orientation.
pictures.
interviews were conducted with nursing staff to Newly hired nurses will have a med . r
ensure they were knowledgeable

about the
administration of resident medication.
Findings include: required to have a successful
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
diagnoses including Chronic Respiratory Failure residents.

and Behcet' s' Syndrome with Neurological I
I
Involvem ent. He was chronically ill with a i
tracheotomy, Foley catheter, crustaceous s
endoscopies gastronomy( PEG) tube, peripherally

Inserted central catheter( PICC) line, and multiple
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
STATEMENT OF DEFICIENCIES ( X1) PROVIDEWSUPPLIER( CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
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
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
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)
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
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
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
SL every three( 3) hours. R# 1 continued to regarding observation of respiratory

and sedation status with controlled
experience pain after administrations of Morphine
20 mg every 3 hours and the physician increased substance pain medication administration
the frequency of routine scheduled Morphine 20
mg SL to every two( 2) hours on 12/ 19115 at 3: 30
p. m. There was one pulse oximeter oxygen
l
FORM CMS 25e7w- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation shoat Page 28 of 96
4
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
116452 B. WING
03/ 21/ 2016
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
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.
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
the prior shift. He had allowed suctioning and
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.
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
PRINTED: 04/ 1312016
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER( SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE
800 PATTERSON RD

PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE aTION
compl
CROSS- REFERENCED TO THE APPROPRIATE DATE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
DEFICIENCY)

because she could not arouse R# 1. LPN" BB"
also recorded on the MAR that R# 1 had refused
suctioning on 12/20/ 15 at 10:00 p. m. and on
12/ 21/ 15 at 2: 00 a. m.
Review of the Nurses Notes for 12/ 21/ 15 at 2: 00
a. m. records the following vital signs in the date
and time margin:
i 10: 00 p. m.- 11: 00 P. M. : 60, 18, 90/ 60
111: 00 p. m.- 12: 00 p. m. : 61, 16, 92/ 60, 93%
Review of the Nurses Note recorded by LPN" BB"
dated 12121/ 15 at 2: 00 a. m. indicated the vital 1
signs at 2: 00 a. m. was 97. 1, 75, 17, 91153 and an
oxygen saturation of 90%: This Nurses Note
indicated the resident had refused suctioning

twice during the shift, but had been suctioned
orally via Yankauer suction. No assessments
were recorded for level of pain, congestion or
general respiratory status, or level of sedation for
the shift, or oxygen saturation after 2:00 a. m.
The Controlled Drug Record indicated the
resident was administered Morphine 20 mg SL on
12/ 20/ 15 at 9:30 p. m., and 11. 30 p.m. and on
12/ 21/ 15 at 1: 30 a. m., 3:30 a.m. and 5: 30 a. m.
Review of the Nurses Progress Notes dated
12/ 21/ 15 on the Situation Background
Assessment Request( SEAR), with no time
i recorded, LPN" CC' recorded being called to the
residents room due to low oxygen level of 55%.
The physician had been notified at 5:55 a.m.,
ordered transfer to hospital and the EMS system
i arrived for transport at 6. 30 a. m. The resident
had responded to suctioning, breathing treatment
and an increase in the oxygen setting, with an
oxygen saturation of 63%.
Review of EMS Patient Care Report 12/ 21/ 15 at
16: 25 a. m. revealed the following: Upon initial
arrival he seemed very sleepy and had pinpoint
3 pupils. The report revealed once in the
s ambulance he was deep suctioned and large
FORM CMS- 2587( 02- 99) Previous Versions obsolete Event ID: Z2SU11 Facility lb: LTC11461209 If continuation sheet Page 30 of 96
j
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERISUPPLIERICUA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
0312112016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES K) PROVIDER' S PLAN OF CORRECTION X5)

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCEDTOTH£ APPROPRIATE DATE
DEFICIENCY)
amounts of mucous and emesis resulted.

Respiratory rate was eight( 8) and shallow, and j
15 liters of oxygen was applied by mask over I
trach. Narcan 0. 5 mg was administered after

intravenous( IV) access was obtained and the
resident responded with an increase in
respirations to an acceptable rate and volume
and his pupils became less constricted. The
transport was upgraded to urgent after airway
findings and arrived at destination hospital at 7: 32
a. m.
Review of Emergency Department clinical record

12/ 21/ 15 from 7: 43 a. m. through 11: 15 a. m.
revealed on arrival was alert, with emesis and
mucous on gown, skin and dressings on arrival.
His level of consciousness diminished and at 9: 30
a. m. was placed on mechanical ventilation. The
Emergency Department Physician charted
greater than 35 minutes critical care. ICU
admission diagnosis was Acute Respiratory
Failure, Hypotenslon and Leukocytosis.
The facility increased the dosage and scheduling
of Morphine as ordered by the Physician, but
failed to assess the residents pain level and 1
respiratory status, and administered the Morphine
Without regard to the level of sedation for the
doses administered on December 20, 2015 at { i
9:30 p. m., 11: 30 p. m. and on December 21, 2015
i
at 1: 30 a. m. 3: 30 a. m. and
n 5: 30 a. m.
R# 1 was discovered in respiratory distress on
December 21, 2015 at 5: 50 a. m. and was
transferred to the hospital, admitted to the i
Intensive Care Unit, and remained hospitalized
until February 4, 2016. The facility' s failure to
monitor the resident' s level of consciousness, f
respiratory status and paln level resulted in a I
situation which the facility' s noncompliance with 1
the requirements of participation caused, or had
the likelihood to cause, serious harm, injury,
FORM CMS- 2667( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Fadlity ID: LTC11461209 If continuation sheet Page 31 of 98
i
PRINTED: 04/ 13/ 2016
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
X4 ID SUMMARY STATEMENT OF DEFICIENCIES 1 ID PROVIDER' S PLAN OF CORRECTION X5)
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)

impairment or death to residents.
i In an interview on 2/ 18116 at 6:15 p.m. withhe
I Corporate Clinical Consultant revealed the f cility
did not administer Morphine by IV route, so the
attending physician had changed the order to a
corresponding oral dosage. The facility did not
consider the administration of Morphine 20 mg SL
on 12/ 20/ 15 at 7:00 a, m. by LPN' BB" and at
7:30 a.m. by LPN" AA" due to the omission of
documentation by LPN" BB", an error because
after pouring the medication out and measuring
what remained, there was no Morphine missing.
The Consultant then acknowledged there was a
dose unaccounted for on 12/ 19/ 15 between 6: 00
a. m. and 8: 00 a. m. and said this was not an error
either. She revealed that the 2 administrations
within 30 minutes had been reported to the
i physician twelve( 12) hours later, when
discovered, and the physician said the resident
would have had a problem within an hour, by 8: 30
a. m. and so this was not considered to have
caused a problem the next day when he was
found In respiratory distress. The Consultant
acknowledged there were no assessments of
paln on the Nurses Notes, or anywhere on the
chart for twenty four( 24) hours prior to being
discovered in respiratory distress. She also
acknowledged the Morphine had been held at
7: 30 p. m. on 12/ 20/ 16, because he could not be
aroused, but no mention of his level of
consciousness except refusal of suctioning at
10: 00 p. m. and 2:00 a.m. can be found in the
nurses notes for that shift. LPN" BB" had charted
on the Controlled Drug Record the resident had
refused Morphine at 7: 30 p. m. on 12/ 20/ 15 and, 1
on the back of the MAR,
had charted for the j
same time that he could not be aroused. The
Consultant explained R# 1 had refused suctioning
twice during the night of 12/ 20/ 15 through the r
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
FORMAPPROVED
A. BUILDING
C
115452 S. WING
03/ 21/ 201 t3
800 PATTERSON Rn
X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION

ID I xs)
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG € CROSS- RE FERENCED TO THE APPROPRIATE DATE
i DEFICIENCY)
a. m., but was unable to explain that since, with

the Morphine at 7: 30 pm being held because he
could not be aroused, but was charted as a
refusal on the Controlled Drug Record by LPN
TB", If this could have been the reason the
suctioning was charted as refused, when the
resident may have not responded to the request
to suction due to sedation. The Consultant
acknowledged that asking a resident for a level of
pain would be an appropriate method to
determine level of sedation and mentation, as
well as pain.
Interview on 2/ 19/ 16 at 10: 35 a. m. with LPN" AA"
1 revealed she works every weekend from 7:00
a. m. to 7. 00 p. m. She remembered this resident.
She acknowledged she had called the physician
on 12/ 19/ 15 at 8: 00 am, for the residents'
complaints of no pain relief from Morphine 20
mg/ ml 0. 6 ml q 4 hours, and received an order to
1 increase the dose to Morphine 20 mg/ ml give 1
ml q 3 hours. Then she called the physician again
at 3: 30 p. m. because the resident still complained
of pain and the physician Increased the frequency
to Morphine 20 mg/ ml give 1 ml q 2 hours. She
acknowledged the next morning on 12/ 20/ 16 at
7: 30 a. m. she administered a dose of Morphine in
accordance with the physiclans order at the
scheduled time of 7: 30 a. m. and the nurse
working the prior shift, LP N BB" had not
documented her last 2 scheduled administrations
of the Morphine due at 3:30 a.m. and 5:30 a. m.
and she left her spaces to document. LPN " AA"
discovered at 7: 30 p. m. when LPN " BB"
returned and filled in the missing documentation
that LPN " BB" had administered Morphine 20
mg/ml 1 ml at 7:00 p. m. LPN " AA" knew this was
an error to give this Morphine with only 30
minutes between doses and called the physician
and family. LPN " AA" acknowledged the narcotic i
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
AND PLAN OF CORRECTION IDENTIFICAMN NUMBER: COMPLETED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION x5)

X4) ID
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLEnON
PREFIX
DATE
TAG
DEFICIENCY)
i
count was performed on 12/ 20/ 15 at 7:00 a.m.

but the liquid was clear and difficult to see and
she and LPN " BB" had both signed the count
was correct, but with 2 doses not accounted for it
could not have been correct. Continued interview
revealed that the physician had told her since this
had happened twelve hours previously the effects
would have caused a problem within an hour after
the administrations and she conveyed this
information to the family when she notified them.
LPN" AA" indicated she should have called the
supervisor prior to administering the Morphine at
7:30 a. m. and reported the missing
documentation. She revealed on the controlled
drag record at 5: 30 p. m. she had indicated the
resident had refused Morphine but he was
actually sedated and she had not indicated this
on the back of the MAR as she should have or in
the Nurses Notes, She revealed she had not
recorded a pain level or mental status, level of
sedation, and blood pressure, pulse or respiratory
rate or oxygen saturation at all and could not
remember what she had assessed except the
congestion in his lungs and temperature. She
acknowledged these assessments were of
importance when a debilitated resident with
Respiratory Failure was receiving Morphine every
2 hours. LPN " AA" had requested the
assistance of the 7: 00 am to 7:00 p. m.
Registered Nurse Supervisor " EE" from the
North Hall to assist her in determining whether it
was safe to administer Morphine to R# 1 at 5: 30
p. m. and it was determined the scheduled
Morphine should be held due to sedation. LPN
AA" revealed she should have indicated holding
this Morphine on the reverse side of the MAR but
did not record this anywhere except as refused
on the Controlled Drug Record. LPN " AA" then
revealed at 7: 30 p. m. she requested further
FORM CMS- 2567(02- 99) Previous Versions Obsolete Event iD: Z28U11 Facility ID: LTC11461209 If continuation sheet Page 34 of 96
PRINTED04/ 6
FOORM
RM APPRROVEOVE D
STATEMENT OF DEFICIENCIES ( X1) PROVIDER( SUPPLIER/ CLIA ( X2} MULTIPLE CONSTRUCTION K3) DATE SURVEY
C
115452 B. WING
03121/ 2016
800 PATTERSON RD
DEFICIENCY)

assistance when she entered the room of R# 1
with the oncoming nurse " BB" when the next
Morphine was due, and discovered Resident# 1
was still sedated. Supervisor " EE", LPN " AN'
and LPN " BB" decided to hold this dose of
Morphine as well. Supervisor" EE" then gave
education to the nursing staff regarding the
importance of using nursing judgement when
administering medication, and assessing
oxygenation with opiates like Morphine.
Interview on 2119/ 16 at 11: 55 a.m. with LPN" BB"
revealed that she remembered not signing the
MAR or Controlled Drug Record for Morphine 20
mg/ ml one ml to be administered to R# 1 on
12/ 20/ 15 at 3: 30 a. m. and 5: 30 a. m., but actually
administered at 4:30 a.m. and 7: 00 a. m. LPN
BB" was unable to remember why these doses
were administered late. She acknowledged that
omitting this documentation had resulted in 2
doses of Morphine being administered within 30
minutes and this was an error and could have
caused R# 1 oversedation and respiratory
depression. She acknowledged she had not
assessed the resident' s pain level throughout the
12f20115 7 p. m. to 7:00 a.m. shift and had
administered the Morphine at 9:30 p.m., 11: 30
p. m., 1: 30 a. m., 3: 30 a. m. and 5: 30 a.m. because
it was ordered to be given on that schedule. LPN
BB" revealed she could not remember if the
resident actually responded to her request to
suction him or just did not answer her at 10: 00
p.m. and 2:00 a. m. LPN" BB" confirmed she had
not obtained an oxygen saturation after 2:00 a. m.
when it was 90% and she did not know why she
did not check the oxygen level after a low
reading," BB" remembered the resident had
been sedated and comprehending less
throughout the entire shift. She could not explain
why she had recorded on the Controlled Drug
FORM CMS- 2567( 02- 88) Previous Versions Obsolete Event ID: Z2SU41 FacBtty 1D. LTC11461209 If continuation sheet Page 35 of 96
PRINTED: 04/ 13/ 2016
A. BUILDING
C
115452 B. WING
03/ 2112016
800 PATTERSON RD
X4)] D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION XS)
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)

Record that R# 1 had refused the 7: 30 p. m. dose
of Morphine
rP and
a then
e chartedd on the back of the
MAR that he could not be aroused when she and
2 other nurses had not been able to awaken him.
LPN" BB" acknowledged receiving education
from Registered Nurse( RN) Supervisor" EE"
regarding using nursing judgement even when a
medication was scheduled and the need to use
data such as vital signs and subjective
objective
E
data such as the resident' s ability to use a pain
scale to determine whether it was safe to l
administer a prescribed medication. LPN" 813"
remembered signing an education roster for this
discussion but could not remember why she did
not apply this education to administering
Morphine to R# 1." BB" further revealed that she
had been told to document her medications after
she gave them and not to wait until the and of the
I shift to chart.
In an Interview with a family member of R# 1 on j
2/ 19116 at 2:00 p.m, revealed the resident had
been in and out of the Intensive Care Unit for
about two months, needing mechanical
ventilation most of the time and multiple IV
medications. The resident had communicated to
the family member, who was unable to give an
exact date, by using his letter board that at some I
point during the night before he was transferred
from the facility to the hospital he had awakened
to medication being administered in his mouth,
without any one speaking to him, and did not
remember anything after that.
In an interview on 2/ 22116 at 2: 50 p.m. with the
EMS Paramedic that transferred Resident# 1 to I
i
the hospital on 12/ 21/ 15 at 6. 30 a. m. stated he
remembered the resident was very sedated with I
pinpoint pupils that are classic in a Morphine

it overdose. The respiratoryandrate was 6 to 8 breaths J
I per minute and shallow the resident was
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
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDEPJSUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A_ BUILDING
C
115452 13, WING
03/ 21/ 2016
00 PATTERSON RD
DEFICIENCY)
i

lethargic. The Paramedic revealed he attended to
clearing the residents` airway, administering high
flow 02 and suctioning. He applied the cardiac
monitor, started an IV and gave Narcan 0. 5 mg IV E
as soon as he possibly could because he was
sure this would improve the residents' condition.
The residents' condition did improve with
increased respiratory rate and depth and pupil
size, but he had to suction copious amounts of
secretions constantly and the resident was I
vomiting as well, so the transfer was upgraded to

urgent and the resident reached the Emergency 1
Department at 7: 30 a.m.
Interview on 2123116 at 1: 30 p. m. with the
attending Physician of R# 1 revealed that he had
changed the original transfer order for Morphine
from Intravenous ( IV) to sublingual( SL)
administration because the facility did not i I
administer IV Morphine. He revealed this required'',.
an increased dose because Morphine is i
metabolized very differently when administered I
I
SL. The Physician revealed he had been called E
I
twice after his original order because R# 1 had
complained of no pain relief. He had, on the
morning of 12/ 19115, first increased the 10 mg
Morphine dose to 20 mg and decreased the I
schedule from every 4 hours to every 3 hours,
and on the second call the afternoon of 12/ 19/ 15
had again decreased the scheduling from every 3
hours to every 2 hours. He had been made aware
of the resident receiving 2 doses of Morphine 20 1
mg SL within 30 minutes on the morning of

12/ 20/ 15, but indicated due to the rapid
E
metabolism of Morphine this would not have 1
caused the Resident a problem i
with respiratory
I depression the next day. The Physician indicated

he would expect a nurse to hold a scheduled
dose of Morphine for sedation and to evaluate a
resident' s respiratory status prior to
FORM CMS-2567( 02. 99) Previous Versions Obsolete Event ID: Z2SU11 Facillty ID: LTC11461209 If continuation sheet Page 37 of 96
i
R
a
PRINTED: 04/ 1312016
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391 ,

XI) PROVIOEPJSUPPLIERJCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION A BUILDING
C
115452 B. WING
03122112016

Sao RD
ILA FAYETYETTE, GA
A 3072$
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER` S PLAN OF CORRECTION X6)

CX4) to
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX FACE( CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX ( BATE
TAG
DEFICIENCY)
i
I
F$ 29 Continued From page 37 F 329!

administration of Morphine, whether it is
scheduled or as needed.
In an Interview on 2/ 23/ 16 at 9:45 a. m. with the
Clinical Competency Coordinator( CCC) revealed i
there was no Clinical Competency Coordinator i
during the orientation of LPN" BB" who. was hired
i
i
on 10/ 1115. The orientation program consisted of
2 checkiists, a medication test, computer learning
modules and learning medication pass with
another nurse supervising. The Nurse in charge
of completing Minimum Data Set Assessments
was given the extra duty of being responsible for
orienting new nurses. She resigned in December
2015. The Clinical Competency Coordinator was
hired for this position on December 16, 2015, The i
CCC further revealed that she teaches orienting
nurses that an actual pain level may not be
needed for each dose of a scheduled pain
medication but for a narcotic being administered
every 2 hours an in- depth assessment of
f respiratory status and level of consciousness
should be assessed with each dose.
I
On 03/ 21/ 16 a partial extended survey was
residents( R# 22, R#23, R#24) who were all
medications. Clinical record reviews of physician l
Interview conducted on 3/21/ 16 at 1: 30 p. m. with

the Administrator revealed there had been one( 1)
2/ 29t16. Resident# 22 had E
medication error on
an order change to Ativan 0.5 mg by mouth( po)

twice daily( BID) and Nurse" AA" had
administered Ativan on 2129/ 16 at 9: 00 p. m. The
Administrator revealed this had been identified as
an error as the Director of Health service( DHS) i
z
FORM CMS- M7(02- 99) Previous Varaiatis Obsolete Event] D: Z2SU11 Facility ID: LTC11401209 if continuation sheet Page 38 of 96
PRINTED: 04/ 13/ 2016
Xi) PROVIDEWSUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

IDENTFICATION NUMBER: COMPLETED
C
115452 B. WING 03/ 2112016
800 PATTERSON RD
PRUIT7HEAi. TH• SHEPHERD HILLS
t.A FAYETTE, GA 30728
SUMMARY STATEMENT OF DEFICIENCIES ID ' PROVIDER' S PLAN OF CORRECTION X5)

X4) ID COMPLETION
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I ( EACH CORRECTIVE ACTION SHOULD BE
PREFIX (
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS- REFERENCED TO THE APPROPRIATE
TAG
DEFICIENCY)
had monitored the Controlled Drug Records the

next day and an Incident report was made, family I
and physician were notified and a Medication
Discrepancy and Adverse Reaction form was
completed according to corporate policy. These
records were reviewed and found to be complete.
R# 22 was observed according to physician order
through the next twenty- four hours and had no
adverse reactions. The Quality Assurance I
Committee had not held a meeting but would be l
Informed at the next meeting. Nurse" AN' had

terminated her employment with the facility during
a disciplinary discussion of the Incident with the
DHS. i
Afamily Interview was conducted With the son of
R# 22 on 3/ 21116 at 3:45 p. m. revealed he was
not concerned that she received an extra Ativan a
month ago. He indicated she was quite used to 3
them and he had confidence in the facility to give
his mother medications correctly. He confirmed
her symptoms were well controlled and she did j
not have any adverse reactions or side effects.


f Nurse supervisor on 2/ 19/ 16 regarding the
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
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPUEFVCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115462 B. WING
03/ 2112016
800 PATTERSON RD
X4) to SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION xg)
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COmP1- TION
DEFICIENCY)
1
I
Identification of residents.
i
reviewed
2. Pictures of residents were audited on 2125M6 3
needed
supervisor on 2126t16 related to pain including
t
administration.

reviewed .
5. nursing education was provided on W29116 by
entries.

reviewed.
omissions.

change over to ensure pictures of residents are In
place.
s<
8. DHS or RN supervisor will monitorlobserve
FORM CMS- 2567( 02. 99) Pfevtous Verstans Obsatete Event ID: Z2SU11 Facility 0: LTC11461209 If continuation Sheet Page 40 of 96
i
PRINTED: 04/ 13/2016
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO, 0938- 0391 ,

OF DEFICIENCIES ( X1) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
AND PLAN OF CORRECTION IDENTIFICATIONNUM13ER: COMPLETED
A. BUILDING
C
115452 S. WING_
03/ 21/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION j Ixs)

EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX (
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
i
TAG
DEFICIENCY)
I I
I
F 329 Continued From page 40 IF 329 i I

i assurance performance improvement committee
met medicationsrnhal ers/ patches and
G4ube administration of I
medications by I
of i
medication was successful completion I
posttests 9 innin g 2126/ 10
beginning
reviewed I
12. The director of health services or registered k
i
clinical competency coordinator and mentor nurse I
on medication ad ministration general

g guidelines
Including following physician orders, med pass
with posttest, and medication card orientation.

Medication pass observation will also be
14, Education was provided to 34 nurses
completed on 2/ 29/ 16 by clinical competency [
supervisor regarding medication discrepancy i
E
physician and pharmacist,
FORM CMS-2567( 02-99) Previous Versions Obsolete Event ID: 22SUI I facility ID: LTC11461209 If continuation sheet Page 41 of 96
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION x3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 2112016
800 PATTERSON RD
X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION

PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPIE) rfON
DEFICIENCY)
F 329
1i
Continued From page 41 f
F 3291
reviewed I
15. Charge nurses will review medication I

administration records and controlled substance s
reports at shift change for completion. 1
F 333 483. 25( m)( 2) RESIDENTS FREE OF F 333 F333
Ss= J SIGNIFICANT MED ERRORS PH Shepherd Hills will ensure that
The facility must ensure that residents are free of

nursing services are provided in
I
any significant medication errors. accordance with professional
I nursing standards of practice, regard-

ing medication administration for our
This REQUIREMENT Is not met as evidenced residents.
by.
Resident# 1 was sent to the ER and
Based on observations, facility and clinical record
review, and staff interviews, the facility failed to was admitted to the hospital and did
ensure that two( 2) residents( R# 1, R# 2) were not return to Pruitt Heath Shepherd
free of significant medication errors, when Hills.
licensed nursing staff failed to signor initial when
Resident# 2 was sent to ER and admittcW
a medication given on the Medication
was 1
on October 14, 2015. Resident# 2
Administration Record( MAR) or Controlled Drug 1 I
Record( CDR) which resulted in R# 1 receiving returned to Shepherd Hills October 17,
I
the narcoticMorphine two( 2) times within thirty I 2015, and still resides in the facility.
30) minutes, and failed to ensure that licensed
Medical Records for the residents
1 staff administering Morphine assessed R# 1 for
were reviewed to ensure that the
pain level and/ or respiratory status prior to
continued administration of the narcotic which physician' s Orders were correctly
resulted in R# 1 found in respiratory distress with I transcribed to Medication Administration
an oxygen saturation of 55% and was transferred i Record.
emergently to a hospital where he required
mechanical ventilation; and the administration
of Antihypertensive medications administered to
R# 2, who did not have a Physician' s order for
t
Procardia or Hydralazine, received both
I
medications in error. The sample size was
twenty-four( 24) residents.
FORM CMS- 2567(02- 99) Previous Versions Obsolete Event ID: Z2SUt1
i
FacilltylD: LT011461209 If
i
continuation Sheet Page 42 of 96
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( x1) PROViDER/ SUPPUERICLIA ( XF) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A BUILDING
C
115452 S. WING
03/ 2112016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, TIP CODE
00 PATTERSON RD
I
X4) ID SUMMARY STATEMENT OF DEFICIENCIES to PROVIDERS PLAN OF CORRECTION Xs)
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

F 333
participation had caused, or had the likelihood to by the Clinical Competency Coordinator
cause serious injury, harm, impairment or death and RN- Supervisor related to
to residents.The facility' s Administrator,
medication administration for nurses on
Services( DHS) and Nursing Supervisor" EE"
Registered Nurse( RN) were informed of the included medication administration
lmmediate. Jeopardy on February 25, 2016 at general guide lines, including but not
5: 00 P. M.
implemented by the facility, the immediacy of the medication and acceptance/ refusal
deficient practice was determined to have been of medications, medication discrepancies,
removed on March 4, 2016 as alleged, and the adverse medication reactions, accurate
facility remained out of compliance at the lower transcription of medication orders, and
evaluation of the nursing staffs compliance with identification of ppatients.
physicians orders, education, and facility policies Newly hired nurses will be educated by
administration records were reviewed for resident
is#ration general guidelines, including ,
pictures. Interviews were conducted with nursing
staff to ensure they were knowledgeable about but not limited to, following physicians
the administration of resident medication. orders,medication pass times, consistent
Cross reference to F281, F329, F490, and F514
Findings include:
discrepancies, adverse medication

l
1. Review of the clinical record for Resident# 1 medication orders, and
revealed he was flown to a landing strip in the
area of the facility on 12/ 18/15 by Medivac
Helicopter, then transferred to the facility by
ambulance. He had been hospitalized for six( 6)
months. He was thirty-four( 34) years old and
weighed one hundred ten( 110) pounds( tbs.). His
diagnoses on admission to the facility was
FORM CMS- 2557( 0299) Previous Versions Obsolete Event IO: Z2SU11 Facility to, LT011461209 if Continuation sheet Page 43 of 96
i
PRINTED: 0411 3/ 2 0 1 6

X1) X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( PROVIDERISUPPLIERICLIA (
IDENTIFICATION NUMBER: COMPLETER
C.
115462 B. WING 03121/ 2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE
800 PATTERSON RA
PRt1tTTHEALTN- SHEPHERD HILLS
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
TAG
DEFICIENCY)

Newly hired nurses will be required to ; 5444
Chronic Respiratory Failure, Decubitus Ulcer of complete the Orientation Skills
Right Knee, Behcet' s Syndrome with Neurological
Involvement, Chronic Deep Vein Thrombosis
DVT), Transverse Myelitis and Major Depressive Video with post test, and Medication
Disorder. He arrived with a Peripherally Inserted Cart Orientation.
Central Catheter( PICC Line), a Percutaneous Newly hired nurses will have a med 5` 74
Endoscopic Gastrostomy( PEG) tube, a Foley pass observation completed by a
Catheter, multiple pressure ulcers, a
tracheostomy, paralysis in three extremities and
minimal movement in the right upper extremity
required to have a successful
and could not speak. He used a communication completion before being allowed to
board with numbers and letters to communicate, administer medications to our
Continued review of the transfer record from the residents.
hospital revealed he had been diagnosed with
Meningitis two( 2) years ago, then eighteen
months ago returned to the hospital with severe from 2/ 19/ 16 to 2129116 by the Clinical
weakness in ail extremities, incontinence, visual Competency Coordinator, Senior
disturbances and ulcerations of his mucous Nurse Consultant, and RN Supervisor
membranes and was subsequently diagnosed
With Beheet' s Syndrome.
form and the documentation regarding
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
four( 4) hours. Another Physician order was
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
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
given by LPN" BB" and took place on 12119/ 15 at

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID. Z2SU11 Facility ID: LTC11461209 if continuation sheet Page 44 of 96 E
1
FORM APPROVED
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
X4) iR SUMMARY STATEMENT OF DEFICIENCIES
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)
F 333 Continued From page 44 Pictures of residents were updated

F 333
8: 00 p. m., 10: 00 p. m., on 12/ 20/ 15 at 12: 00 a. m., and pieced in the Medication
2: 00 a. m., 4: 30 a. m. and 7: 00 a. m. LPN" AA" Administration Books on October 15,
returned and administered the next dose of 2015.
Morphine at 7: 30 a. m. Further review of the
Pictures of residents will be reviewed
Controlled Drug Record revealed that on
monthly and updated as needed with
12/20/ 15 at 5.30 p.m. and 7:30 p.m. Morphine 20
mg/ ml, 1 mi q 2 hours was not administered, i admissions and discharges.
indicated as" refused" on the I
corresponding line. Clinical Competency Coordinator and
Morphine was administered as scheduled on
RN on 2/ 26/ 16 and ongoing educated
12/ 20/ 15 at 9: 30 p. m., 11: 30 p. m., on 12/ 21/ 15 at
1: 30 a. m., 3: 30 p. m., and 5: 30 a. m. nurses related to pain including o
Review of the reverseside of the Medication of pain with routine pain medication
Administration Record dated 12/ 20/ 16 revealed administration.
that LPN" BB" had recorded R# 1 could not be
Nurses were also in serviced by the
aroused at 7: 30 p. m. and the Morphine was held.
There is no other documentation on the reverse
Clinical Competency Coordinator i
side of the MAR for subsequent doses. regarding of respiratory

observation

Review of the Nurses Notes for R# 1 dated substance pain medication administration
12/ 20/ 15 revealed no indication of an assessed
Nurses were educated by Clinical i - 7--A.
pain level, blood pressure, pulse, oxygen i
saturation or efforts to provide tracheal suctioning
for the 12/ 20115 7: 00 a. m. to 7: 00 p. m. shift by Supervisor regarding Errors, Omissions
LPN" AA". The Nurses notes for that time period and late entries.
did reveal that due to omission of documentation
of Morphine administration by LPN" BB" for 4! 30
Administration and Avoiding Common
a.m. and 7:00 a. m., a dose of Morphine had been
administered at 7:30 a. m. Further review of the Errors beginning
9 g 2/ 29/ 16 and ongoing.
Nurses Notes for 12/ 20/ 15 7: 00 p. m. through DHS and or RN Supervisor will complete
j:
12/ 21/ 15 at 7: 00 a. m. indicated that R# 1 had a review of the MAR' s for omissions
refused suctioning at 10: 00 p. m. and 2: 00 a. m.
daily.
There was no mention of his sedation level, pain
RN Supervisor and or DHS will complete
level, for the twelve( 12) hour night shift or R#11 s-7-/ 2
a review of the MAR' s monthly

respiratory status after 2:00 a. m. A pulse during 3
oximeter reading was recorded at 2: 00 a. m. change over to ensure resident

revealing an oxygen saturation of 90%. At 5: 65 1

a. m. the resident' s physician was notified that he l
had been found in respiratory distress with an

FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation street Page 45 of 96
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FORM APPROVED
STATEMENT OF DEFICIENCIES ( XI) PROVIDER/ SUPPLIEF/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD

X4) ID
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL
I ID
PREFIX EACH
PROVIDER' S PLAN OF CORRECTION
CORRECTIVE ACTION SHOULD BE
X5)
COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
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
g g
saturation was 63%. EMS was called, and
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
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.
Review of the Corporate policy entitled

Medication Administration: General Guidelines, I
Procedure, revealed the following:

10, Medications are to be administered within
sixty( 60) minutes before or after scheduled time.
11, After medication administration the residents j
MAR Is Initialed by the person administering the i
medication.
19, Signal stickers that denote important

Information regarding the medications are used to
assist in accurate medication administration
2. Record review for Resident# 2 revealed an

Annual Minimum Data Set( MDS) assessment
having an Assessment Reference Date of
12/ 11/ 15 which documented Section I- Active I i
Diagnoses that Resident# 2 had diagnoses which ;
included Alzheimer' s disease, Psychotic Disorder
Order, Dementia, and Hypertension; Section C- i
Cognitive Patterns documented that the resident i=
had both short- term and longterm memory i
FORM CMS 2567(02- 99) Previous Versions Obsolete Event ID: Z2SU19 Facility ID: LTClWI209 If continuation sheet Page 46 of 86
I!
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDER( SUPPLIER( CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
0312112016
800 PATTERSON
FAYETTE, GA R 30728
X4) ID SUMMARY STATEMENTOF DEFICIENCIES ID €€ PROVIDER' S PLAN OF CORRECTION Xs)

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

problems with a Brief Interview Mental Status
Score of 05 indicating that the resident had
severe cognitive impairment; Section G- I
jFunctional Status documented that R#2 was

extensive assist of one( 1) person with Activities
of Daily Living( ADLs).
I
In comparison, review of the medical record for

the roommate of R# 2 revealed a Quarterly MDS
i assessment having an Assessment Reference
Date of 12/ 21/ 15 which documented Section I
Active Diagnoses of the roommate as having
Congestive Heart Failure, Hypertension, Cerebral
Vascular Disease, and Depression; Section
C- Cognitive Patterns documented the resident as
having a BIMS of 15 which indicated that the
resident was cognitively intact; Section G
Functional Status documented that the resident j
was independent to supervision( set up help only)
with ADLs. j
l
A Nurse' s Notes( NN) entry for R# 2 dated
10/ 14/ 15 with no time listed documented that the
resident was in bed this a. m. and was given meds
that were for another resident by trainee.
Resident was given Procardia 30 mg and
l
Hydralazine 100 mg. Vitals are 136/ 58, 57, 96. 8
and no signs of acute distress. Doctor made
aware.
A NN entry dated 10/ 14/ 15 at 7: 10 a. m.

documented Resident now starting to fall in Blood
Pressure( B/ P) and becoming unresponsive.
Called 911, placed in bed in Trendelenburg. B/ P
now 64/ 38. Resident fading in and out of R
staff. Placed on oxygen( 02) at 2 liters( L) per
minute via mask. Eyes are open. 68/ 50 manual
B/ P, Awaiting ambulance.
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheeE Page 47 of 96
i'
i
z
PRINTED: 04113/ 2016
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
800 PATTERSON
PRUITTt tEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION j ( Ns)

INFORMATION)
PREFIX
f COMPLETION
DATE
TAG REGULATORY OR LSC IDENTIFYING TAG
I
DEFICIENCY)
f
I
I
Further review of a NN entry dated 10/ 14/ 16 at

7: 20 a. m. documented Resident out by i
ambulance to Hutcheson Medical Center. l
Responsible party( RP) aware. MD made aware i
of resident being sent out
l
The facility presented an Investigation Report( IR)
I related to the facility's investigation into R#2's
significant medication error involving the
antihypertensive medications given to the wrong
resident. in this IR, the facility documented that,
based on its investigation, it was found that on
10/ 14/ 16 R#2 had received antihypertensive
medications during the 6,00 a.m. med pass that
were prescribed for the roommate. The residents
roommate reported the medication error to a
Certified Nursing Assistant( CNA) who reported It
to the Charge Nurse.
A hospital History and Physical( H& P) report for

R# 2 documented the resident' s 10/ 14115
i admission to the hospital. This H& P
documented, in the History of Present Illness
section, R# 2 presented to the hospital with
complaints of hypotension. The patient is
currently a resident of Shepherd Hill Nursing
Home and was given the medications of another
resident by accident, resulting in accidental l
overdose. The patient was given 100 mg of
I Hydralazine and 30 mg of Procardia by mistake
and his blood pressure went down into the Ws
and 60's systolic. The patient was transferred to
the emergency department where Poison Control
was callers and they recommended IV fluid
resuscitation with close monitoring of blood
pressure in ICU. There is no antidote required or
recommended by Poison Control and he was
transferred up the ICU for further monitoring, on
presentation to the ICU his blood pressure Is
FORM CMS2367( 02-99) Previous Versions Obsolete Event 10. Z2SU11 Fa Vlty iD: LTC114Q1209 If continua Page 48 of 98
0
i
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLiA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03121/ 2016
600 PATTERSON
PRUITrHEALTH- SHEPHERD HILLS
FAYETTE, GA R 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER' S PLAN OF CORRECTION

REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
F 333 Continued From page 48 F$ 33

90/ 64 and he is alert and responsive without any
focal neurologic deficits. The medication error i
occurred about 6: 00 a. m. and his medicines were

given by a nurse who was new to the facility and f
undergoing orientation. Past Medical History
documented Dementia, Hypertension and History
of Coronary Artery Disease. Assessment
i documented Accidental overdose with
antihypertensive medications Including
Hydralazine and Procardia, Severe Hypotension,
Dementia, and History of Hypertension and
Coronary Artery Disease.
Review of the Cardiologist Progress Note dated

10/ 15/ 15 documented Demand Ischemia with
minimal Left Ventricle damage.
I
Review of the hospital Discharge Summary for I

R# 2 documented a hospital discharge date of
10/ 17/ 15. The Discharge Diagnoses section of
this Discharge Summary listed diagnoses for R# 2 1
which included, among others, latrogenic

j Hypotension secondary to medication mistake at
the nursing home, Demand Ischemia, Dementia, j
I Cardiac Hypotension, History of Coronary Artery
Disease, and History of Hypertension.
Review of the Incident Report for the medication

error that occurred on October 14, 2015 revealed
the roommate reported to the Certified Nursing
Assistant( CNA) that R#2 had been given 6:00
a. m. medications that were meant for him.
1
Interview with the former roommate of R# 2 on i
2/ 18116 at 4:20 p. m. revealed that he
remembered very clearly the day R# 2 received j
his blood pressure medications. He said he woke
up to to the sounds of his roommate receiving I
medication and knew he received medication at i
FORM CMS 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 49 of 96
i
FORM APPROVED
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERiSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115462 S. WING
03/ 21/ 2016
800 PATTERSON RD
X4) ID I 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 ORLSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCF_ DTO THE APPROPRIATE DATE
DEFICIENCY)
I
F
that time of day and his roommate did not. He

F 333;
revealed he was scared and told the CNA right

away to get help for his roommate. He said the ;
nurses checked on his roommate and then a little
while later sent him to the hospital.
Interview with the Administrator on 2/ 19116 at

6: 30 p. m. revealed that an inservice was
conducted when this medication error was
discovered and she had both nurses in her office
i and wrote up the nurse that was training the new
nurse because she was sitting at the nurse' s
station leaving the new nurse to administer
medications alone.
Interview with the Administrator on 2/ 22/ 16 at

1: 00 p.m., she acknowledged that the supervising
nurse had left LPN BB unattended to administer
medications and that" BB" did not know the
residents. She further acknowledged that
pictures of the residents were always on the F
MARS but had been recently updated.

1
Review of the facility policy: Medication

Administration: General Guidelines, revised
1/ 23/ 2015 and reviewed 1/ 26/ 2016, revealed:
Policy Statement: Medications are administered
as prescribed, in accordance with good nursing
principles and practices and only by persons
legally authorized to do so. Personnel authorized I
to administer medications do so only after they
have familiarized themselves with the medication.
Procedure: ( 2) Medications are administered in
accordance with written orders of the attending
physician. If a dose seems excessive
considering the patient/ resident' s current i
diagnosis or condition, the physician is contacted l
for clarification prior to the administration of the

medication. This interaction with the physician is
documented in the nursing notes and elsewhere
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID. Z2SU11 Foollity iD: LTC11461209
If continuation sheet Page 50 of 96
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STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPUVVCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A BUILDING
C
115452 a. WING
03/ 2112016
800 FATTERSON RO
PEtUlTTHEAl. TH- SHEPHERD HILLS
X4) ID 1 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

I
PREFIX ( DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) t TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG
t DEFICIENCY)
in the medical record as appropriate.

Procedure:( 7) Patients/ residents are Identified
before medication is administered. When in
doubt:( a) Check identification band( b) Check
j photograph attached to medical record.( c) Call
j patient/ resident by name.( d) If necessary, verify
1 patient/ resident identification with other
healthcare center personnel.
Procedure:( 14) Medications supplied for one
patient/ resident are never administered to
another patient/ resident,
I I.
Review of the Lexl- Comp's Drug Reference
Handbook 12th Edition, revealed on page, 1100 i.
Procardia, a Calcium Channel Blocker, used for
treatment of angina( vasospestic, chronic stable),
Hypertrophic Cardiomyopathy, Hypertension r
sustained release only), Pulmonary
Hypertension, Contraindications; Serious i
adverse events( cerebrovascular ischemla,

syncope, heart block, stroke, sinus arrest, severe
hypotension, acute myocardial Infarction, and
EKG changes) have been reported in relation to
each use. Blood pressure lowering should be
done at a rate appropriate for the patient's
condition. Rapid drops in blood pressure can
lead to arterial Insufficiency, Increased angina
and/ or MI has occurred with initiation or dosage I
titration of calcium channel blookers.

Hypersensitivities to Nifedipine( Procardia) or any
component of the formulation, Immediate release I
preparation for treatment of urgent or emergent

hypertension, acute Mi. Warnings/ Precautions: I
The use of sublingual short- acting nifedipine in
hypertensive emergencies and
pseudoemergencies Is neither safe nor effective
and should be abandoned! Severe hypotenslon N
may occur in patients taking immediate release

nifepine concurrently with beta blockers when
FORM CMS- 2667( 02- 99) Previous Versions Obsolete Event iD: Z2SU11 FecUity ID: LTC11461209 if continuation sheet Page 51 of 96
it
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MEDICAID SERVICES OMB NO. 0938- 0391,

CENTERS FOR MEDICARE&
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERISUPPLIERICLIA (
COMPLETED
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING
116462 B. WING 03121/ 2016

STREET ADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
ID PROVIDER' S PLAN OF CORRECTION IN

X4) ID SUMMARY STATEMENT OF DEFICIENCIES
CO ION
TAG CROSS• APPROPRIATE oET
TAG I REFERENCEDEFI TC
F 333 Continued From page 51 F 333 j

undergoing CABG with high dose fentanyl
t
anesthesia. page. 1311 Propranolcl, a

Beta- Blocker, used for management of
Hypertension, Angina Pectoris, essential tremors, i
l arrhythmias, and prevention of Myocardial
Infarction. Contraindications: Hypersensitivity to i
Propranolol, beta- blockers, or any component of
the formulation; uncompensated Congestive
Heart Failure. Warnings/ Precautions: Administer
cautiously In compensated heart failure, and
monitor for worsening of the condition( U. S.
Boxed Warning): Beta- block therapy should not
be withdrawn abruptly( particularly in patients,with
CAD), but gradually tapered( over 2 weeks) to
avoid acute tachycardia, hypertension, and/ or
ischemia, pgs 739- 740 Hydralazine, Vasodilator,
Used for management of moderate to severe
Hypertension, Congestive Heart Failure,
Warning/ Precautions: Use with caution In i
CAD( increase In tachycardia may increase
Myocardial Oxygen Demand), Use In caution with
Pulmonary Hypertension( may cause
Hypotension) and, pgs 739- 740 Hydralazine,
Vasodilator, Used for management of moderate
to severe Hypertension, Congestive Heart
Failure, Warning/ Precautions: Use with caution in
CAD( increase in tachycardia may increase
I Myocardial Oxygen Demand), Use in caution with I
I
Pulmonary Hypertension( may cause I:
Hypotension)..
L
Observations conducted February 19, 2016 of

on
the MARS located on the medication carts

revealed six( 6) resident pictures were not
available on the MARS. On February 24, 2016
the same 6 resident pictures remained missing.
Interview conducted on 2123/ 16 at 10:00 a. m. with a

LPN " HH" , who was the nurse supervising LPN
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID: Z2SU11 Fadity ID: LTC11461209 If continuation sheet Page 52 of 86
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PRINTED: 04/ 13/ 2016
FORM APPROVED
OMB NO, 0938- 0391
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A BUILDING COMPLETED
C.
113452 e. wlNo
03/ 2112016
800 PATTERSON Rb
LA FAYETI"E, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION
ID
Ply))
DEFICIENCY)
I

BB" on October 14, 2015 when R# 2 received
the wrong medications revealed that she thought
BB" had been working with the residents long I
t
enough to know who they were. LPN" HH"
cart when the medications were prepared and
also acknowledged that there were no pictures of
these two residents on the MARS. i
Interview with the Administrator on 2/ 22/ 16 at i
2: 30 p. m. revealed that the supervising nurse had
left LPN" BB" unattended. The Administrator
further revealed that" BB" did not know the
residents and gave the 6:00 a. m. doses
belonging to the roommate to R# 2 by accident. i
She further revealed that pictures of the residents
are to identify the residents.
In an Interview conducted on 2124/ 16 at 10: 00

a. m. with the Administrator revealed that the next
day when she was made aware of the medication
error she had both the trainee and the nurse
training her in the office and verbally reprimanded
both of them, she further acknowledged that the
Medical Director was made aware and
recommended pictures identifying residents
placed on all MARS, and a revamp of the
orientation process for nurses required to
i administer medications. Observations conducted
on February 19, 2016 at 2: 10 p. m. revealed four
4) residents on the North Hall and two( 2) i
t
residents on the South Hall did not have pictures
identifying the residents. Subsequent
observations conducted on February 25, 2016 at
10: 40 a. m. of the books containing the MARS
revealed six( 6) residents did not have pictures of
residents.
FORM CMS- 2587( 02- 99) Previous versions Obsolete Event ID: Z2SU11 Facility ID: LTC11481209 If continuation sheet Page 53 of 96
F
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PRINTED: 04/ 13/ 2016
FORM APPROVED
C
115452 B. WING
0 3/ 2 112 0 1 6
800 PATTERSON
FAYETTE, CAAR 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 COMPLETION
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG I CROSS- REFERENCED TO THE APPROPRIATE ATE
1 DEFICIENCY)

i
1. interview on 2/18116 at 5:15 p. m. with the

Corporate Clinical Consultant revealed on
12/ 20/ 15 Resident# 1 received 2 doses of
I
Morphine 30 minutes apart, at 7: 00 a. m. and 7:30
a. m., resulting from an omission of
a documentation for the 7:00 a.m. administration.
The Consultant indicated this was investigated by
pouring out the Morphine and measuring it and
determining after Nurse" BB" had signed out the
previously undocumented doses that no
Morphine was missing and no extra
administrations had occurred. The Consultant
acknowledged that this concluded the
investigation and that despite the low level of
tolerance for a timing discrepancy with Morphine,
with the resulting administration 30 minutes
beyond what the corporate policy allowed, with
the resident history of Chronic Respiratory
Failure, and with the weight of 110 lbs. and
general debility placing the resident at higher risk
of adverse reaction, this was not considered a
medication error. The five( 5) doses of Morphine
that occurred on 12/ 20/ 15 beginning at 9: 30 p. m.
through 12/ 21/ 15 at 5: 30 a. m., without
assessment of pain level for 24 hours, no record F
of oxygen saturation after 2: 00 a. m. and with 2
doses at 5: 30 p. m. and 7: 30 p. m. held due to j
sedation witnessed by 2 additional nurses, that
were charted as refused, and the residents
subsequent respiratory depression less than 30
minutes after the last dose, were also not
identified as an error.
I
Interview on 2/ 19/ 16 at 10:35 a. m. with LPN" AA"

revealed she had administered scheduled
Morphine 20 mg 1 ml SL at 7:30 a. m. and left 2
spaces for the 7:00 p. m. to 7 a. m. LPN" BB" to fill
in. She acknowledged the MAR was not
FORM CMS 2567( 02M) Previous Versions Obsolete Event ID: Z25U11 Facility ID: LTC11461209 If continuation sheet Page 54 of 96
PRINTED: 04/ 13/ 2016

XI) PROVIDERISUPPLIER/ CUA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT DEFICIENCIES
OF (
C
115452 8. WING 03/ 21/ 2016
BOB PATTERSON RD
PRUITfHEALTH- SHEPHERD HILLS
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER` S PLAN OF CORRECTION X5)

X4) ID
PREFIX (
TAG
DEFICIENCY)
decipherable, due to her errors in scheduling and

recording doses on the wrong time and date,
circling doses that had actually been
administered and crossing out her initials to
attempt to correct errors. She acknowledged she
had not questioned LPN" BB" until 7:00 p. m.
about the missing documentation on the MAR
and Controlled Drug Record and she should have
reported this to the supervisor immediately before
administering the 7:30 a.m. dose. LPN" AA"
I revealed she had received no mention in report of
LPN" BB" s administration of Morphine at 7: 00
a. m. when it was scheduled for 5: 30 a. m., 30
minutes outside the one hour allowed by policy,
and therewas no flag on the MAR or any other
i
indication this had been administered late. LPN
AA" revealed at 5: 30 p. m. when it was time to
administer a scheduled dose of Morphine she
had indicated on the back of the Controlled Drug
record that the resident had refused Morphine.
She had called the Registered Nurse( RN)
Supervisor" EE" from the North Hall and the
resident had been evaluated as being too y
sedated to receive the Morphine. The resident
did not actually not respond to her when she i
asked if he was going to take his pain medication
I
orthe level of his pain. She acknowledged she
1
should have recorded an oxygen saturation,
blood pressure, pulse, pain level and level of i
sedation for this 12 hour shift. She acknowledged
she should have recorded the Morphine was held
for sedation and not recorded that It was refused.
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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A. BUILDING
C
115452 B. WING_
03/ 21/ 2016
800 PATTERSON RD
i
X4) ID I SUMMARY STATEMENT OF DEFICIENCIES
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
LPN" AA" further revealed that she should have

signed and initialed the well as
medication as
4
reported and flagged the MAR with the
information. " BB" acknowledged this failure I
resulted in R# 1 receiving 2 doses of Morphine

within 30 minutes and for a Resident with Chronic
Respiratory Failure, this resulted in a high
likelihood of an adverse reaction. LPN" 1313"
revealed she had recorded holding the Morphine l
at 7: 30 p. m. as refused on the Controlled Drug
Record and a n the back of the MAR a s hid
e i
because she and LPN" AA" and Supervisor" EE"
had not been able to arouse the resident." B13"
revealed that she could not remember why she
wrote refused, and could not remember if the
resident had actually responded to refuse the
suctioning at 10: 00 p. m. or 2: 00 a. m., or if he Just
did not respond at all. Continued interview
i revealed that she did remember R# 1 had been
sedated and comprehending less throughout the
shift. LPN" BB" acknowledged that she had not
assessed a pain level, or assessed respiratory
status throughout the 12120/ 15 7: 00 p. m. to
12/ 21/ 15 7: 00 a. m. shift and she did not check
oxygen saturation after 2:00 a. m. when it was
90%. She revealed she should have evaluated
I this resident for respiratory depression and she
had not performed these assessments. LPN" BB"
acknowledged she gave the Morphine every 2
hours because it was ordered to be given every 2
hours.
Interview with the parent and responsible party for

i
R41 on 2/ 19/ 16 at 2: 00 p.m. revealed that his son
had Communicated to him using his letter board, i
during his most recent hospitalization, he had

awakened during his last night at the facility, with
medication being administered in his mouth, with s
no one explaining what they were doing or what

FORM CMS- 2667( 02- 99) Previous Versions Obsolete Event ID: 72SUtt Facility ID: LTC11461209 If continuation sheet Page 56 of 96
s
PRINTED: 04113/ 2016

PROVIDEWSUPPLiER1CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1)
C
115452 B. WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE
800 PATrERSON RD
SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER' S PLAN OF CORRECTION Xs)

X4) ID
EACH DEFICIENCY MUST BE PRECEDED BY FULL pREFpC EACH CORRECTIVE ACTION SHOULD BE COWLETiON
PREFIX { DATE
TAG
DEFICIENCY)

I
the medication was. He did not remember
anything after that.
Interview on 2/22116 at 1: 00 p. m. with the

Administrator revealed she had discussed with
the Medical Director, who was also R# Vs
Physician, the order changes for Morphine, the
administration of two doses within 30 minutes,
and the hospitalization of R# 1 for respiratory
s distress and the Medical Director responded by
saying the only thing he could have done
differently would have been to add to the
Morphine order to hold for sedation, but he I
thought that was standard nursing practice.

i
Interview on 2/23/ 16 at 1: 30 p. m. with the

Physician of R# 1, revealed that he had changed
the order for Morphine twice because the resident I
continued to complain of pain. He had been made

I
1 aware of the administration of two doses of
I Morphine within 30 minutes on 12/20/ 15, but this iI
was not discovered until 12 hours after the I i
administrations and because Morphine Is

metabolized so rapidly this would not have
caused the residents respiratory distress 24
hours later. The Medical Director acknowledged j
he expected any nurse administering Morphine to
assess the resident' s respiratory status and to
I check for any adverse reactions with every
administration whether it was scheduled or as i
i
needed( prn).
t
Review of corporate policy entitled Pain M

Management, Lippincott Procedures, Indicated
i
that safe medication practices should be followed
when administering strong aploid medications

such as Morphine, Pain and adverse reactions
f timely manner according to the onset of the i
FORM CIS- 2667(42-99) Previous versions Obsolete Event ID: ZZSUII Facility ID: 1, TC11461209 If continuation sheet Page 57 of 96
I
PRINTED: 04/ 13/ 2016
CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 0938- 0391 .

X1) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
11W2 B. WING 03/21/ 2016

800 PATTERSON RD
LA FAYETi' EE, GA 30728
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION xs)

X4) ID
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED 70 THE APPROPRIATE
i
DEFICIENCY)
I
Review of Nursing Drug Guide, Nursing 2014,

Drug Handbook, by Lippincott, Williams and
Wilkins, 34th edition, Copyright 2014, page 953,
Morphine Sulfate, Adverse reactions Include
Apnea, Respiratory Arrest and Respiratory
Depression. The onset of Morphine administered
by oral route is takes place in 30 minutes, peak
action in 1- 2 hours and duration of action is 4- 12 i
i
hours.
Based on the above findings the facility failed to

administer Morphine, a drug capable of producing 1
Respiratory Depression, with in the scheduled
With a diagnosis of Chronic Respiratory Failure,
pain level and
k
and monitor respiratory status,
adverse reactions.
partial extended survey was

On 03/ 21/ 16 a i
receiving
orders, medication administration records, ij
I controlled and I
drug records observations
i}
Interview on 3/21/ 16 at 6:00 p. m. with the Director

of Health Services( DHS) revealed all nurses are
I to monitor the MAR' s for pictures and unsigned
ILI
medications on the MAR' s. The unit managers
are also monitoring daily and the DHS monitors at I
least once weekly and checks the Controlled i
Drug Records against the MAR' s, physician

orders and checks assessments when narcotic or
sedating medication Is administered. He further
revealed he has not found any noncompliance.
FORM CMS- 2W7( 82. 99) Previous Versions Obsolete Event ID:= U11 Faclbty to. LTC11461209 If continuation sheet Page fib of 96
fi
I
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLIER/ CLA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03121/ 2016
800 PATTERSON RD
X4) ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION V5)

BE PRECEDED BY LL PREFIX RECTIVE ACTION SHOULD BE COMPLETION
PREFIX
ORLSCIIDENTIFYINGINFORMATST
RGCULATORYIENCY I)ON) CROSS- REFERENCEDTOTHEAPPROPRIATE DATEDATE
DEFICIENCY)
Medication pass is observed weekly for three( 3)

nurses, and the consultant pharmacist observes
i
medpass monthly.

remove the Immediate Jeopardy., i

Nurse supervisor on 2/ 19116 regarding the i

I
reviewed
2. Pictures of residents were audited on 2125/ 16
needed
s' 3. The clinical competency coordinator provided
staff members to assist with the Identification
supervisor on 2t26/ 16 related to pain including
observation of respiratory and sedation status I
With controlled substance pain medication

administration. I
Education content and sign in sheets were i
reviewed . f
5. nursing education was provided on 2/ 29116 by i
FORM CMS 2567(D2- 99) Previous Versions Obsolete Event ID: ZZSU11 Facility to: LTC11461209 if continuation sheet Page 69 of 96
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A BUILDING COMPLETED
C
115452 B. WING
03/ 2112016
800 PATTERSON RD
PRUITTHEAt_TH- SHEPHERD HILLS
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Ix5)
DEFICIENCY)

entries.

reviewed.
6. OHS or RN supervisor will complete daily

omissions.
I
place.
8. OHS or RN supervisor w)II monitor/ observe
initiated on 2125/ 16. j
k
assurance performance improvement committee i
met medications/ inhalers/ patches, and
I
medications by G- tube administration of i
medication was successful completion of l
posttests beginning 2/ 26/ 16

reviewed
nurse supervisor will review medication 1
of pain is being monitored. I
13 Newly hired nurses will be in serviced by the i
on medication administration general guidelines f
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID: Z28U11 Facility ID: LTC11461209 If continuation sheet Page 60 of 96
PRINTED: 04113i2016
MEDICAID SERVICES OMB NO. 0938- 0391 ,

STATEMENT OF DEFICIENCIES ( X1) PROVIDERiSUPPLIERICLIA (
COMPLETED
A. BUILDING
C
115452 B. WING 03/ 2112016
800 PATTERSON RD
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
PREFIX
TAG
EACH CORRECTIVE ACTION SHOULD
SE eo
onrE oN
DEFICIENCY)
I
z
1
f
F 333 Continued From page 50 F 333 Y

medication and acceptanceirefusal of
J
and will be required to complete the orientation j


successful completion. i
j completed on 2129/ 16 by clinical competency J

form and documentation I
regarding any
physicianand pharmacist. j
l
reviewed
IS. Charge nurses will review medication
I
WAGE w
CCURATE PROCEDURES,
ACCURATE RPH w
i
t
The facility mu t vide routine and emergen i

I
drugs and bio{ icals s residents, or obtai j
them under an ! ement cribed in
part. The fa ' ity m
483. 75( h) of thi
persoet ti adminis r d s rm
if
p but o y under the e S
supervision of a Ii sed n e.
A facility must pro e pharmaceutical services

including procedures that assure the accurate
acquiring, receiving, dispensing, and
administering of all drugs and biologicals) to meet
the needs of each resident.
4
FORM CMS- 2567( 02- 99) Previous Versions Obsolete

FO Event ID: Z2SU11 114612. 9- _
Facility ID: LTC114&1209 If continuation sheet Page 61 of 96
ii
FORM APPROVED
OMB NO. 0938- 0391
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLiER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C.
115452 S. wlNc
03/ 21/ 2016
STREETADDRESS, CITY, STATE, ZIP CODE
800 PATTERSON RD
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
Continued From page 61 ( F 4

I
The facility must employ or btainth servi

licensed pharmacist whos ansult e tion
on all aspects of the provistSa acy
services in the facility.
This REQUIREMENT is not met as evidenced

I
I
F 490 483. 75 EFFECTIVE F 490
SS= J ADMINISTRATION/ RESIDENT WELL- BEING F490
I Pruitt Health Shepherd Hills is
Afacility must be administered in a manner that
administered in a manner that
enables it to use its resources effectively and
efficiently to attain or maintain the highest enables it to use it resources effectively
practicable physical, mental, and psychosocial i and efficiently. Pruitt Health Shepherd
well- being of each resident.
Hills attains and maintains the highest
practicable physical, mental
I This REQUIREMENT is not met as evidenced psychosocial well being of each resident.:
by: Pruitt Health Shepherd Hills ensures that
Based on clinical record review, staff interview, I resident drug therapy is administered
and review of established
policy and
corporate
safely, accurately and in accordance
procedures,. the facility failed to be administered
1
in a manner that enabled It to use Its resources
with physician' s orders. i
Resident# 1 was sent to the ER and
effectively and efficiently, to attain or maintain the S. 7-/
highest practicable physical, mental and was admitted to the hospital and did i
psychosocial well- being of each resident. The not return to Pruitt Heath Shepherd
facility failed to ensure resident drug therapy was Hills.
administered safely, accurately, and in Resident# 2 was sent to ER and
accordance with physician' s orders. This failure admittedS.)-/( a
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
r
DEPARTMENT OF HEALTH AND HUMAN PRINTED: 0411 3/ 2 0 1 6
SERVICES
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIEWCLIA ( X2) MULTIPLE CONSTRUCTION X3} DATE SURVEY
116452 B. WING
030/ 2016
800 PATTERSON RD
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
December 21, 2015 at 5: 45 a. m. he was
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
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
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

On February 25, 2016, a determination was made I
that a situation In which the facility' s of medications, medication discrepancies,;
noncompliance with one or more of the adverse medication reactions, accurate
requirements of participation had caused or had transcription of medication orders, and !
the likelihood to cause serious injury, harm,
identification of patients. i
or death to The facil€ty' s
iimpairment residents.
i
f Administrator, Corporate Clinical Consultant,
u
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facillty lD: LTC11461209 If continuation sheet Page 63 of 96
d
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIEWC41A ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 a, WING
03/ 2112016
800 PATTERSON RD
X4) ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xs)
I
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
informed of the Immediate Jeopardy on February
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
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
Video with post test, and Medication
Cart Orientation,
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.
Review of the Corporate policy entitled

Medication Discrepancies and Adverse Reactions i I
revealed medication discrepancies and adverse
reactions are to be reported to the
patient/ residents attending physician, the 1,
consultant and provider pharmacists, and the
Pharmaceutical Services Subcommittee and/ or
the Quality Assurance Committee. Review of
Procedure, Section 5 indicated a Medication
Discrepancy/ Adverse Drug Reaction Report is to
FORM CMS 2567(02-99) Previous Versions Obsolete Event iD:= U11 Faclilty ID: LTC11461209 If continuation sheet Page 64 of 96
r:
i
s
i
PRINTED: 04113/ 2016

PROVIDEWSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( Xi)
COMPLETED
A. BUILDING
C
116452 S. WING 0312112016
800 PATTERSON RD
LAFAYETTE, GA 30728
SUMMARY STATEMENT OF DEFICIENCIES 10 I PLAN OF CORRECTION

PROVIDERS VS)
X4) ID
OA7F
TAG
DEFICIENCY)
F 490 Continued From page 64 F 49()

Education provided to 34 nurses
was J.7-/
be completed, Section 8 revealed the report is to from 2/ 19/ 16 to 2/29/ 16 by the Clinical
be reviewed by the consultant pharmacist and on
a quarterly basis by the Pharmaceutical Services Nurse Consultant, and RN Supervisor
Subcommittee and/ or the Quality Assurance
Committee and acted upon as appropriate. In regarding the medication discrepancy
addition to reporting discrepancies that result in j form and the documentation regarding
the patient receiving Incorrect medication,
an
medication discrepancies that have the potential

i and medication discrepancy and
for but do not actually result in the patient reporting the discrepancy to the
Physician and Pharmacist.
receiving an Incorrect medication are
documented and reported. 34 Nurses reviewed Medication

Review of the Corporate Policy entitled American Society of Consultant
Medication Administration; General Guidelines,
Pharmacists, which included oral
Procedure# 7 revealed patients/ residents are
Identified before medication is administered, medications, eye meds/ inhalers/

Procedure# 9 indicated that In no case should the patches, and meds via G tube
I
individual who administered the medications administration of medication with j
report off duty Without first recording the successful completion of post test
administration of any medications,
Procedure# 10 revealed medications are to be beginning 2/ 26116 through 2/ 29/ 16
administered within 60 minutes before or after and on going.
scheduled time. Pictures of residents were updated S' 7—
Procedure# 11 revealed after medication
and placed in the Medication
administration the patient1residents MAR Is
Administration Books on October 15,
Initialed by the person administering the
the date 2015.
medication In the space provided under
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
a pain management policy was requested, RN on 2/ 26/ 16 and ongoing educated

revealed under subheading of Giving i nurses related to pain including o
Medications: If the patient needs still more pain observation and documentation
relief administer a strong oplold( such as
of pain with routine pain medication
morphine or hydromorphone) following safe
administration.
medication administration practices. Reassess
pain in a timely manner according to the onset of
FORM CMS- 2567( 02- 99) Previous Versions Obsolete EventID: 72SUll Facility ID: LTC11461209 It continuation sheet Page 65 of 96
PRINTED: 04/ 8
FORM APPROVEDD
STATEMENT OF DEFICIENCIES ( XI) PROVIDERISUPPLIERJCLtA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
03121/ 2016
800 PAATTERSON RO
A FAYETTE, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDER' S PLAN OF CORRECTION Xe)
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 490 Continued From page 65 F

Nurses were also in serviced by the I, S_
the prescribed medication. Reassessment should
4901f Clinical Competency Coordinator
include not only pain relief but also adverse regarding observation of respiratory
reactions or events produced by treatment. and sedation status with controlled
substance pain medication administration

Nurses were educated
by Clinical 5-7-1
Cross refer to F329 regarding the facility' s failure '
to administer Morphine according to the Competency Coordinator and RN
Corporate Policy entitled Medication Supervisor regarding Errors, Omissions
Administration: General Guidelines and late entries.
Cross to F333 regarding the

refer
facility' s failure
to administer medication correctly to Resident# 7 Administration and Avoiding Common
and Resident# 2, according to physicians orders, Errors beginning 2/ 29/ 16 and ongoing.
and according to the Corporate Policy entitled I DHS and or RN Supervisor will complete
Medication Administration General Guidelines, i a review of the MAR' s for omissions
Cross refer to F 520 regarding the failure of the
daily.
RN Supervisor and or DHS will complete
Facility' s Quality Assurance Committee to
adequately monitor a plan of action to ensure an a review of the MAR' s monthly during
accurate and easily accessible method for staff change over to ensure resident
r unfamiliar with the resident' s names to
identify pictures are in place. i
them for safe medication administration.
DHS and or RN supervisor will monitor/ -/-/ i
In an Interview conducted on 2118/ 16 at 5: 16 p. m, observe Medication pass for 10% of
with the facility Corporate Clinical Nurse nurses weekly times 1 month, then
Consultant revealed she had investigated the
administration of Morphine 20 mg SL twice within
2/ 25/ 16 and ongoing,
thirty( 30) minutes to Resident# 1 on 12/ 20/ 15,
but did not think this was an error because
not receive dose. The Corporate
did II least
Pharmacy Consultant will observe at
one random med pass observation
an extra Clinical
Nurse Consultant acknowledged the Medication during monthly visit.
Administration:General Guidelines policy i DHS and or RN Supervisor will monitor the .?_/(
o
indicates medications are to be given within one
Controlled drug sheets with the MAR to
hour before or after the scheduled dose and this
medication was administered ninety minutes fate, proper medication administration.
but she did not think this was an error. The

Consultant acknowledged" BB" LPN had not
signed for 2 doses of Morphine on the MAR or
l Controlled Drug Record and this had resulted in a
FORM CMS- 2567( 02 99) Previous Versions Obsolete Event ID: Z2SU11 Facility 1D: LTC11401209 if continuation sheet Page 66 of 96
PRINTED: 0411312016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERISUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD
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
DEFICIENCY)
DNS and or RN Supervisor will notify !

F 490 Continued From page 66 F 490 physician and pharmacy of any w
potential for Resident# 1 to experience
j medication discrepancies.
respiratory depression. The Corporate Clinical
I
All findings will be taken to the Quality
Consultant confirmed Morphine administration to
Assurance Performance Improvement
a debilitated resident with a diagnoses of
Respiratory Failure should be monitored carefully, 1
and could result in respiratory depression. She ! i
acknowledged the Morphine 20 mg SL had been
administered every 2 hours on 12/ 20/ 16 i
beginning at 9:30 p. m. until the resident was
discovered in respiratory distress with an oxygen
saturation of 55%, and the only assessment for
the 7:00 p. m. to 7: 00 a. m, shift appeared on the

reverse side of the MAR at 7: 30 p. m. and i
recorded the resident could not be aroused.
Interview conducted on 2/ 24/16 at 2: 30 p.m. with

the Administrator revealed the administration of 2
antihypertensive medications ordered for
Resident# 4 and administered to Resident# 2 on
10114/ 15, was considered an error. The Medical
Director had been notified and the error had been
reported In the October QA meeting. The
intervention of assuring pictures of all the
residents were on the MAR's had already been
initiated and this was supposed to be monitored
monthly by the unit managers. The Administrator
I acknowledged that on observations on 2/ 19116 at
2: 10 p. m. and on 2/ 25/ 16 at 10; 40 a. m., of the
one hundred eight( 108) MAR's in the facility,
there were six( 6) missing pictures. The l
administrator indicated the unit managers must
not be checking the MAR's for pictures.
Continued interview revealed that Medication
Discrepancy and Adverse Reaction forms were
not completed for Resident# 1 after receiving 2
doses of Morphine within 30 minutes, or receiving
scheduled doses of Morphine every 2 hours
without assessment of respiratory status or level
of consciousness, or for Resident# 2 who was
FORM CMS- 2567( 02- 99) Previous Versions Obsotete Event ID: Z2SU11 Facility ID: 127CM461209 If continuation sheet Page 67 of 96
PRINTED: 04/ 13/ 2016
FORM APPROVED
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD

X4) ID
f ID PROVIDER' S PLAN OF CORRECTION
PREFIX I PREFIX EACH CORRECTIVE ACTION SHOULD BE COM( PL5ETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DAM
DEFICIENCY)
j
j
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
these reports for any medication error for an

i
unknown length of time.
I
f[
In an interview conducted on 2124/ 16 at 3: 00 p. m.
with the Consultant Pharmacist, she revealed the
Medication Discrepancy and Adverse Reaction j
reports were to review, track and trend
medication errors
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
doses of Morphine within 30 minutes and his

subsequent respiratory failure the next morning
and since he was admitted to the hospital she did
not review any documentation for Resident# 1.
The Consultant Pharmacist acknowledged she
had consulted for the facility since 2007 and had
never received a completed Medication
Discrepancy and Adverse Reaction Report. She
confirmed these reports should be completed for
any deviation from the Five Rights of Medication
Administration, including right resident, right
medication, right route, right time and right dose.
i
j Interview with the Clinical Competency

Coordinator( CCC) on 2123/ 16 at 9: 45 a. m.
revealed when" BB" LPN and" AA" LPN were
oriented in October there was no CCC. The
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 if continuation sheet Page 68 of 96
r
PRINTED: 04/ 13/ 2016
X1) PROVIDER( SUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY

C
115462 B. WING 03/ 21/ 2016
800 PATI' ERSON RD

LA FAYEq I' E, GA 30728
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION 0)

X4) ID ODWPLF-TiON
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)
1 TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
F 490 Continued From page 68

Minimum Data Set( MDS) Coordinator had to
F
41111
oversee staff education and orientation in addition
duties. She resigned in
to other assigned 1
December, 2015. The CCC acknowledged the j

orientation of nurses has always consisted of a
general orientation checklist, a skills checklist,
computer learning modules, a medication test,
and[ earning med pass with a preceptor. i
i
On 03/ 21/ 16 an extended survey was conducted I
the sample was expanded by three residents
R# 22, R# 23, R# 24) who were all receiving
narcotic and antihypertensive medications.
Clinical record reviews of physician orders,
j
medication administration records, controlled
revealed
drug records and observations
further indication of deficient practice.
no
I
1
Interview conducted on 3/21/ 16 at 1: 30 p. m. with

medication error on 2129/ 16. Resident# 22 had I
an order change to Ativan 0. 5 mg by mouth( po)
1 twice daily( BID) and Nurse" AA" had
administered Ativan on 2/29/ 16 at 9:00 p.m. The
f
Administrator revealed this had been Identified as
an error as the DHS had monitored the Controlled

Drug Records the next day and an incident report j
was made, family and physician were notified and
a Medication Discrepancy and Adverse Reaction
form was completed according to corporate
policy. These records were reviewed and found
to be complete. R# 22 was observed according to 1
jphysician order through the next twenty-four ' f:
hours and had no adverse reactions. The Quality
I
Assurance Committee had not held a meeting but
would be informed at the next meeting. Nurse
AA" had terminated her employment with the r
I
facility during a disciplinary discussion of the
Incident with the DHS. i
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
FORM APPROVED
C
115452 B. WING
03121/ 2016
800 PATTERSON RD
PRUITI" HEALTH- SHEPHERD HILLS
X4) ID ( SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xti)
DEFICIENCY)

i


Nurse supervisor on 2119/ 16 regarding the I
for medication administration i
general guidelines
acceptanceirefusal of medications, medication
i
reviewed i
2. Pictures of residents were audited on 2/ 25/ 16

needed E I
supervisor on 2126/ 16 related to pain including
i
observation and documentatio n of painn with
routine pain medication administration and
administration.
i
reviewed. i
15. nursing education was provided on 2/29/16 by

the clinical coordinator and are in i
competency
FORM CMS- 2567( D2. 99) Previous Versions Obsolete Event ID: Z2SU11 Facility to: LTC11461209 If continuation sheet Page 70 of 96
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PRINTED: 04/ 13/ 2016
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
800 PATTEERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION xs)

PREFIX ( EACH ED BY I PREFIX EACH CORRECTIVE ACTION co MPLETioN
TAG REGULATORY LS OC IDENTIFYING IF ORMATION) TAG CR S

CROSS- RENC D TO
REFERENCED RO DATE
DEFICIENCY)
f
f
F 4901 Continued From page 70 F 490 I
entries.

reviewed.
omissions.

1 change over to ensure pictures of residents are in
place.
8. DHS or RN supervisor will monitor/ observe j
initiated on 2/ 25/ 16.
i assurance performance improvement committee
I for action as needed i
video from American Society of consultant i
met medicationslinhalers/ patches, and
i
successful
medication was completion of
f
posttests beginning 2126116
reviewed
i i
on medication administration general guidelines j
including following physician orders, med pass j
and accurate documentation
times, consistent of j
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
FORM APPROVED
AND PLAN OF CORRECTION IDENTIFICATION NUM3ER: COMPLETED
A. BUILDING
C
115452 B. WING
03121/ 2016
00 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION V5)

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

medication orders, and identification of patients i
and will be required to complete the orientation 1


Medication pass observation will also be i

completed on 2129/ 16 by clinical competency
reviewed
F 514' 483. 75 1 1 RES F 514 F514
SS J RECORDS- COMPLETE IA CCURATE/ ACCESSIB S
Pruitt Health Shepherd Hills accurately ! fir±
LE
documents medications administered
The must maintain clinical records on each to their residents. i
facility
resident in accordance with accepted professional Resident# 1 was sent to the ER and S. 7—!
standards and practices that are complete;
was admitted to the hospital, but never
accurately documented; readily accessible; and
returned to the facility,
systematically organized.
Resident# 3 had no physical harm and 1
The clinical record must contain sufficient the patient no longer resides in the facility.
information to identify the resident; a record of the i
resident' s assessments; the plan of care and
services provided; the results of any
preadmission screening conducted by the State;
and progress notes.
FORM CMS- 2567( 02. 99) Previous Versions Obsolete Event ID: Z2SU11
If
I
Facillry ID: LTC11461209 If continuatlon sheet Page 72 of 96

I!
i
PRINTED: 04/ 13/ 20 t 6
A. BUILDING
C
115452 B. WING
03121/ 2016
800 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDER' S PLAN OF CORRECTION Xs)

EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE CO ION
PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE dtT
DEFICIENCY)
F 514 Continued From page 72 Medical Records for the residents

F 514 5- 7-
This REQUIREMENT is not met as evidenced were reviewed to ensure that the
by. Physician' s Orders were correctly

Based on clinical record review, staff interview, transcribed to Medication Administration
ControlledDrug Record review, and Medication Record.
Administration Record( MAR) review, the facility
failed to accurately document medications I
administered for two( 2) residents( R# 1 and R# 3), by the Clinical Competency Coordinator
from a sample of twenty- four( 24) residents. and RN Supervisor related to
1. Specifically for Resident# 1, who had
diagnoses including Chronic Respiratory Failure,
i included medication administration
Neurological Behcet' s Syndrome, Chronic Deep
Vein Thrombosis( DVT) and Transverse Myelitis, general guide lines, including but not
the resident received Morphine twenty( 20)
milligrams( mg) by mouth( po) at 7: 00 a. m. and
again received Morphine 20 mg po at 7: 30 a. m.
related to failure to document the 7:00 a. m. dose
the resident' s MAR or Controlled Record medication and acceptance/ refusal
on Drug
after administration. R# 1 had been admitted with of medications, medication discrepancies,
an order for Morphine ten( 10) mg po every( q) adverse medication reactions, accurate
four( 4) hours routinely for pain and had failed to
transcription of medication orders, and
achieve pain control with this dose. The Physician
was contacted two( 2) times with the residents' identification of patients.
complaints of ongoing pain and the facility Newly hired nurses will be educated by
received 2 additional physician orders for Clinical Competency Coordinator and
increases to the Morphine dosage and frequency, mentor nurse on medication admin-
The facility failed to record the subsequent
physician orders on the physician order form or
the MAR in conformance with the corporate policy but not limited to, fallowing physicians
to include the time of the order, the strength of orders, medication pass times, consistent
the Morphine liquid, and the actual dose to be and accurate documentation of
administered. medication and acceptance/ refusal
2. Additionally, Resident# 3 received Levemir
Insulin seventy( 70) units subcutaneously( sq)
adverse medication reactions, accurate
four( 4) times, administration of Advair Diskus
one( 1) inhalation 1 time and Fluvall 0, 5 ml transcription of medication orders, and
intramuscular IM 1 time, during9 the month of I identification of patients. I
October, without the accompanying
documentation on the MAR. This resulted in a i
FORM CMS 2667( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility to: LTC11461209 If continuation sheet Page 73 of 96
PRINTED: 04/ 13/ 2016
FORMAPPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDERiSUPPLIERJCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD

PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLEITION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THEAPPROPRIATE DATE
DEFICIENCY)

Newly hired nurses will be educated by
situation in which the facility' s noncompliance
with the requirements of participation caused, or
had the likelihood to cause, serious harm, injury,
impairment or death to residents. istration general guidelines, including l
The facility' s Administrator,
Director of Health but not limited to, following physicians
Services( DHS), Corporate Clinical Consultant,
orders, medication pass times, consistent i
and Nursing Supervisor" EE" Registered Nurse
RN) were informed of the Immediate Jeopardy
on February 25, 2016 at 5: 00 p. m. The
noncompliance related to the Immediate of medications, medication discrepancies,
Jeopardy was identified to have existed on adverse medication reactions, accurate
October 14, 2015, the date another resident(# 2)
of medication orders, and
received two( 2) antihypertensive medications Itranscription
with no order for these medications and was identification of patients.
transferred Education was provided to 34 nurses ::
emergently to the hospital, according F—- 7
to Nurses notes, fading In and out of from 2/ 19/ 16 to 2/29/ 16 by the Clinical
consciousness with a blood pressure of 64138. He
was subsequently admitted to the ICU with a
Nurse Consultant, and RN Supervisor
diagnoses of Severe latrogenic Hypotension and
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.
An interview with the Corporate Clinical

I
FORM CMS- 2667(02- 99) Previous Versions Obsolete Event ID: 22SU11 Facility ID: LTC11481209 If continuation sheet Page 74 of 96
r
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A. BUILDING
C
115452 B. WING
03/ 21 12 01 6
800 PATTERSON RD
X4) ED SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

TAG i. REGULATORY OR L5C IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
i.
F 614 Continued From page 74 F 514 Clinical Competency Coordinator and

Consultant 2/ 18116 at 5: 00 p. m. revealed the
on RN on 2/26/ 16 and ongoing educated
investigation of these events had not resulted in nurses related to pain including o
identifying a problem with narcotic administration
and monitoring or medication administration and
documentation. The Immediate Jeopardy i
of pain with routine pain medication
remained going, pending the acceptance of a
on I administration.
final Credible Allegation of Jeopardy Removal. Nurses were also in serviced by the
Observations
administration
were made of medication
to assess staff s conformance with

lClinical Competency Coordinator
regarding observation of respiratory
accurate documentation of medication
administration. Record reviews were conducted
to assess staffs conformance with correct substance pain medication administration
scheduling of medications when transcribing Nurses were educated by Clinical
orders to the Medication Administration Records.
An allegation of
I Competency Coordinator and RN
jeopardy removal was recieved
I Supervisor regarding Errors, Omissions
on February 26, 2016. Based on corrective plans i
and late entries.
which had been developed and implemented by
j the facility, Immediacy of the deficient practice

the Pruitt University class for Medication
was determined to have been removed on March Administration and Avoiding Common
4, 2016 as alleged, and the facility remained out
Errors beginning 2/29/ 16 and ongoing.
compliance at the lower scope and severity of
Hof DHS and or RN Supervisor will complete
D while the process of evaluation of the nursing
staffs compliance with physician' s orders,
education, and facility policies and procedures, daily.
continued. In- service materials and records were RN Supervisor and or DHS will complete
reviewed. Interviews were conducted with nursing
a review of the MAR' s monthly during
change over to ensure resident
Findings include DHS and or RN supervisor will monitor/
1, Record review for Resident# 1 revealed an
observe Medication pass for 100/o of
admission date of 12/ 18/ 15. Physician orders
included on admission
facility, on 12/ 18/ 15
to the
at 10: 30 p. m., Morphine 10 mg po q 4 hours monthly times 3 months beginning

routinely for pain. Review of Physician orders 2125/ 16 and ongoing.
dated 12/ 19/ 15 at 8: 00 a. m. revealed a telephone
order to increase to 1 milliliter( ml) q 3
Morphine
1 Pharmacy Consultant will observe at
least one random med pass observation
hours( hrs) due to( d/ t) unrelieved pain. This order
did not specify the
concentration or mg to be i
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID; Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 75 of 96
r
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDEWSUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
0 3121/ 2 0 1 6
800 PATTERSON RD
LA FAYIETTE, GA 30729
X4) ID i SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER' S PLAN OF CORRECTION Xs)
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
F 514 Continued From page 75

DHS and or RN Supervisor will monitor the f,'( o
The next telephone order on the Physician

F 514[ Controlled drug sheets with the MAR to
given. i
order form was timed at 11: 30 a.m. and was to I proper medication administration.
increase Morphine 1 ml q 2 hours due to DHS and or RN Supervisor will monitor for
unrelieved pain. This order does not specify holes in the MAR daily.
concentration of the liquid, route of administration
All Findings will be taken to the Quality
or number of mg to be given.
Review of the MAR for R# 1 revealed the
admission order for Morphine had been
transcribed with the concentration of 20 mg per
mI, give 0. 5 ml q 4 hours routinely. No time for the
order appeared on the MAR and the times
administered were recorded correctly. The next
order transcribed to the MAR had no time when €
the order was received and was transcribed as
Morphine Sulfate 1 ml q 3 hrs, with no
concentration, mg, route or date. Two doses were '
signed as given on 12119/ 15 at 8: 00 a. m. and
11: 00 a. m. The next order was written on the
MAR as Morphine 1 ml SL q 2 hours routine

12/ 19115. No time of the order, concentration or
mg was included. The order was initialed as given
at 1: 00 p. m. This order was marked as changed
and rewritten with a concentration and no date or
time and was initialed as given on 12/ 19/ 15 at
1: 30 a.m., 3: 30 a. m., 5:30 a.m., 7: 30 a. m., and
9: 30 a. m. These doses were recorded as
administered before the order existed. The next
four doses on 12/ 19/ 16 at 11: 30 a. m., 1: 30 p, m.,

3. 30 p, m, and 5: 30 p. m. were correctly recorded
on the MAR then at 7: 30 p. m. and 9: 30 p. m. j
initials were crossed out. The 11, 30 p.m. dose
was initialed as given. Continued review of the
MAR for 12/ 20/ 15 revealed Morphine 20 mg/ ml 1
ml was initialed as administered every 2 hours
until the initials were circled at 3: 30 p. m., 5:30
p. m., 7:30 p.m. and 9: 30 p.m., indicating these
doses were not administered. At 11: 30 p. m. the
Morphine was initialed as administered. On
12/ 21/ 15 at 1: 30 a. m., 3:30 a. m. and 5: 30 a. m.
i
FORM CMS- 2567(02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 76 of 96
PRINTED: 04/ 13/ 2016
A. BUILDING
C
116462 B. WING
0312112016
800 PATTERSON RD
X4) IA SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

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 PATE
DEFICIENCY)
If
the Morphine was initialed as administered.

Review of the Controlled Drug Record for R# 1
revealed Morphine was correctly signed as given
on 12119/ 16 at 2: 00 a. m. and 6: 00 a. m. Then a
0. 5 ml/ 10 mg dose had been signed out without
a time. The next dose on 12/ 19/ 15 at 8: 00 a. m. Is
a 1 ml 20 mg dose in conformance with the order. 1
According to review of the Controlled Drug
Record the next doses of Morphine were
administered as ordered until a 20 mg Morphine
dose was given on 12/ 20/ 15 at 7: 00 a. m. and 4
another was administered at 7, 30 a. m.
j
Review of Corporate policy entitled Physician
Orders indicated as follows: A physician order for
medication or treatment must include the
following Information: Date and time of order,
name of medication, strength of medication
where indicated, dosage, route of administration
and frequency of administration.
Review of Corporate policy entitled Medication
Administration: General Guidelines revealed if a
dose of regularly scheduled medication is
withheld, refused i
or given at other than the
scheduled time the space provided on the front of j
the MAR is initialed and circled and an I
explanatory note is entered on the reverse side of
the record. Continued review revealed after
I
medication administration the MAR is initialed by
the person administering the medication.
Record review of Nurses Notes dated 12/20/ 15 at
1: 30 a. m. by Licensed Practical Nurse ( LPN)
BB" revealed no indication that medication was
not given at the scheduled times. Review of the
reverse side of the MAR revealed no note
regarding a variation in the time Morphine was
I administered.
The following note written by the 7:00 a. m. to 7:00
p. m. LPN " AA" on 12/20/ 15 at 8:05 p. m. revealed
that upon
P checkingg narcotic count at 7: 00 .P m. a
FORM CMS- 2567( 02-99) Previous Versions obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If Continuation sheet Page 77 of 96
PRINTED: 0 411 3/ 2 0 1 6
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPUERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A, BUILDING
C
116452 B. WING
03/ 2112016
800 PATTERSON RD
LA LAYETTE, GA 30728
S PLAN OF CORRECTION
W)
PREFIX
ID ' SUMMARY STATEMENT
OF DEFICIENCIES
I ID
PREFIX
PROVIDER'

I
I i COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THEAPPROPRIATE ;
DEFICIENCY)

i medication error was found. The 7:00 p. m. to
7: 00 a. m. LPN " 1313" had not signed out the j
doses of Morphine administered at 4: 30 a. m. or j
7: 00 a. m. and the day shift nurse " AA" had
assumed the Morphine had been administered at
the correct time, which would have been 5: 30
a. m. and administered a dose of 20 mg Morphine
thirty( 30) minutes later at 7: 30 a. m. " AA" i

documented notification of the physician and
family, and an assessment of the residents
respiratory status. LPN " AA" noted the physician
had responded that since the two doses within 30
minutes had occurred twelve hours previously
any adverse reaction would have already
occurred.
Interview on 2118/ 16 at 5: 16 p. m. with the
Corporate Clinical Consultant revealed that this
incident had been investigated and since there
were no doses of Morphine missing and it had
measured out correctly this was not considered to
be an error. The Corporate Clinical Consultant
revealed that the policy for medication
administration allows for a one hour variation I
before or after the medication is due, the
administration of a dose of Morphine due at 4: 30 1
p. m. and given ninety( 90) minutes later at 7: 00 1
a. m., even though it was thirty( 30) minutes past E
the allotted hour, was not considered an error.

The Corporate Clinical Consultant acknowledged
that the omission of documentation for the doses i
administered at 4: 30 a. m. and 7: 00 a. m. had
resulted In 2 doses being administered within 30 i

minutes and the resident, already with a
diagnoses of Chronic Respiratory Failure and
very debilitated, could have a high likelihood of
experiencing an increased degree of Respiratory
Failure as an adverse reaction to the Morphine. j
The Clinical Consultant indicated the
unaccounted for dose of Morphine recorded on j
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC114612O9 If continuation sheet Page 78 of 96
PRINTED: 04113/ 2016
FORM APPROVED
A. BUILDING
C
115452 B. WING
0 3121 1201 6
800 PATTERSON
PRUITTHI; ALTH- SHEPHERD HILLS
FAYETTE, R
GA 30728
M) ID SUMMARY STATEMENTOF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION

PREFIX
TAG
I(
I
PREFIX
TAG
EACH CORRECTIVE ACTION SHOULD 9t;
COWLETION
DATE
DEFICIENCY)
i
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
and she rewrote the order with the concentration

and mg at that time. LPN " AA" revealed that she
had difficulty writing the scheduled times and this
resulted in doses being initialed that were not
I
given, before the order was written, and the MAR
really could not be deciphered due to crossed out
Initials, circled doses, missing documentation on j
the back of the MAR, as well as doses initialed
that were not actually given. LPN " AA" revealed
that she had asked another nurse on duty on
12/ 19/ 15 how to correct the MAR and they did not
have any suggestions. " AA" was asked about
the extra dose signed on the Controlled Drug
Report on 12/ 19/ 15 between 6: 00 a. m. and 8: 00
a.m. and she was unable to account for this. LPN
I " AA" revealed that when she arrived for work on
12/ 20/ 15 at 7: 00 a. m. she discovered two doses i
of Morphine for R# 1, scheduled for 3: 30 a. m. and
5: 30 a.m, were not initialed as given on the MAR
FORM CMS- 2567( 02-99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 79 of 96
J
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CENTERS FOR MEDICARE& MEDICAID SERVICES OMB NO. 093" 391
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIERJCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03121/ 2016
800 PATTERSON RD
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 COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE ( DATE
TAG TAG
DEFICIENCY)
f

I
or signed on the Controlled Drug Report. She
reported she assumed they had been
administered as scheduled and the next dose due l
at 7: 30 a.m. was administered as scheduled.
LPN " AA" further revealed that she should have
called LPN" BB" but did not. She acknowledged iI
the narcotic count had been performed that
morning before LPN " BB" left and it had looked
correct but it was difficult to see the liquid i
because it was clear and it must not have been
counted correctly. Continued interview revealed
that she left 2 spaces on the Controlled Drug
Report and asked LPN " BB" to fill in the spaces
as well as the empty spaces on the MAR, when
she returned on 12/ 20/ 15 at 7: 00 p.m. When
LPN ' BB" filled in the time for her administration
due at 5: 30 a. m. as 7: 00 a. m. " AA" reported to
the physician, family and facility. LPN " AA"
revealed that she should not have left empty
spaces on the Controlled Drug Record. i
Interview with LPN " BB" on 2/ 19/ 16 at 11: 55
a. m. revealed that she remembers not signing the
MAR and Controlled Drug Record on 12/ 20/ 15 for
i
the 3: 30 a. m. and 5: 30 a. m. doses she had
administered late at 4: 30 a. m. and 7: 00 a. m. She
was unable to remember why she had
administered these doses late or why she had not i i
reported this to LPN " AA", or why she had not

signed as having administered the Morphine. She i
acknowledged leaving the spaces blank on the
MAR and not documenting them on the
Controlled Drug Report, and not reporting giving I
the last dose 90 minutes late to the oncoming
Nurse had resulted in 2 doses of Morphine being
administered 30 minutes apart and this could
have caused the resident to have a serious
adverse reaction. LPN " BB" revealed there was
no disciplinary action regarding the missing
i documentation, but someone had told her to be
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event 0): ZZSU11 Facility ID: LTC11461209 If continuation sheet Page 80 of 96
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIOER/ SUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
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

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)
sure to document medication administration.

i
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
I p. m., on 10/ 29/ 15 at 9:00 p. m., on 10/ 30/ 15 at

9:00 a. m. and 9: 00 p. m. Advair Diskus 250/ 50
one puff q 12 hours had not been Initialed on I
10/ 13/ 15 at 9:00 p. m. and Fluvall 0. 6 ml IM to left
deltoid was to be administered on 10/ 26/ 15 and
was not Initialed.
Continued review of the clinical record revealed f
Resident# 3 had been in the facility on the dates
the above medications were to be administered
and there was no clinical indication not to
administer the medications. The back of the MAR
I
for the month of October does not indicate the
Levemir Insulin, Advair Diskus and Fluvall were
held for any reason. The Nurses Notes for the j
month of October were reviewed and no

indication of holding these medication on the
above dates could be found.
Interview with the Administrator on 2119/ 16 at
2: 30 p. m. revealed the documentation omissions I
for Levemir Insulin 70 units sq a. m. and hs had l
been investigated by the facility as a follow up to

a Quality Assurance Intervention that was
considered resolved In August, 2016. The facility
had determined the insulin had been I
administered and the nurses had received written

FORM CM5- 2567( 02-99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 IF continuation sheet Page 81 or 96
r
PRINTED: 0411312016
FORM APPROVED
A. BUILDING
C
115452 e- WING
03/ 21/ 2016
800 PATTERSON RD
PRUITTHEALTH- SHEPHERD FALLS
X4) ID SUMMARY STATEMENT
OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION Xs)
PREFIX
TAG
PREFIX
TAG
EACH CORRECTIVE
CROSS- REFERENCED
ACTION SHOULD BE
TO THE APPROPRIATE {
I COWLETION
DATE
DEFICIENCY)

disciplinary action for not documenting according
to policy. The MAR' s are supposed to be
checked by the unit manager at the end of each
shift but there was no unit manager on the South
Hall for the month of October and the MAR' s did '
not get checked. The administration of Fluvall
was documented In the Nurses' notes but never
was documented on the MAR and the missing
initials were not addressed and the administration
of the Advair Discus on 10/ 13/ 15 at 9:00 p.m. was
never investigated. The Administrator confirmed
that nurses are expected to initial the MAR
3 according to policy, as soon as a medication has

been administered.
Interview on 2/25/ 16 at 1: 35 p. m. with LPN" LL"
revealed that she received counseling regarding
missing documentation of Levemfr Insulin on
10/ 12/ 15 at 9: 00 p. m. and 10/ 30/ 15 at 9: 00 a. m.
and remembered she had administered the
insulin but had not documented. " LL"
acknowledged also giving the Advair Discus

260/ 50 one puff q 12 hours on 10/ 13/ 15 at 9: OD
p. m. but failed to document. LPN " LL" confirmed
that she was aware that not documenting the
administration of medications could lead to
serious harm to the residents.
Interview on 2/ 26/ 16 at 1. 30 p.m. with LPN " FF"
revealed that she had administered Levemfr
Insulin 70 units to R# 3 on 10/ 29/ 16 and 10/ 30/ 15
at 9: 00 p. m. and had not initialed the MAR. She j
indicated she received counseling and was aware
that missing documentation could have serious
consequences for the resident.
Based on the above findings omission of j I
documentation on the MAR immediately fallowing

medication administration had a high likelihood of i
causing harm to two residents, Resident# 3 with
undocumented insulin administration, and I
Resident# 1, with undocumented Morphine
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID Z2SU11 Faculty ID: LT011461209 if continuation sheet Page 82 of 06
r
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDERISUPPLIf RICUA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 e, WING
03/ 21/ 2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, LP CODE
300 PATTERSON RD
X4) to SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLET)ON
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ! TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
I
F 514 ti Continued From page 82 F 5141

administration resulting in 2 doses being
administered in thirty minutes.
i
Interview conducted on 3/ 21/ 16 at 1: 30 p. m. with i
medication error on 2/ 29/ 16. Resident# 22 had
an order change to Ativan 0. 5 mg by mouth( po)
administered Ativan on 2/ 29/ 16 at 9: 00 p. m. The
I
Administrator revealed this had been identified as s

Drug Records the next day and an incident report
form was completed according to corporate i
policy. These records were reviewed and found I
to be complete. R# 22 was observed according to
physician order through the next twenty- four

t
hours and had no adverse reactions. The Quality
Assurance Committee had not held a meeting but I
AA" had terminated her employment with the I

Incident with the DHS.
Interview on 3/ 21/ 16 at 6: 00 p. m. with the Director

of Health Services( DHS) revealed all nurses are I
to monitor the MAR'S for pictures and unsigned
medications on the MAR' s. The unit managers ?
are also monitoring daily and the DHS monitors at j
least once weekly and checks the Controlled
Drug Records against the MAR' s, physician
orders and checks assessments when narcotic or
sedating medication is administered. He further +
revealed he has not found any noncompliance. i
Medication pass is observed weekly for three( 3)
nurses, and the consultant pharmacist observes
medpass monthly.
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
A. BUILDING
C
115452 B. WING
03/ 2112016
800 PATTERSON RD
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
1
I

remove the Immediate Jeopardy: t
1. Educatlon was provided to 34 nurses by the I

Nurse supervisor on 2M9/ 16 regarding the j
general guidelines for medication administration I
including following physician orders, medication

s


I
reviewed
2. Pictures of residents were audited on 2/ 25116 1

I
needed I

coordinator and registered nurse i
competency
supervisor on 2/ 26116 related to pain including
I routine pain medication administration, and
administration.
reviewed .
5, nursing education was provided on 2/29116 by i
entries.
I
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LT011461209 If continuation sheet Page 84 of 96
i
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( XI) PROVIDER/ SUPPLIER/CLiA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
AND PLAN OF CORRECTION IDENrIFfCATION LIMBER:
C
115452 B. WING
03/21/ 2016
800 PATTERSON RD
PRUITTHEAf TH- SHEPHERD HILLS
LA FAYETTE:, GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDER' S PLAN OF CORRECTION

VS)
I PREFIX EACH CORRECTIVEACTION SHOULD BE COMPLETION
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
1 DEFICIENCY)

reviewed.

omissions.

i medication administration records monthly during I
place.
med pass for 10% I
of nurses weekly for one
initiated on 2/ 26/ 16.
I one random med pass monthly during her visit
I
pharmacists, which included oral medications, I i
met medications/ inhalers/ patches, and G
medications by G4ube administration of E
medication was successful completion of
posttests beginning 2126/ 16
reviewed

an medication administration general guidelines
times, consistent and accurate documentation of 1
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID22SU11 Facility ID: LT011461209 If Continuation sheet Page 85 of 96
r
PRINTED: 04/ 13/ 2016
FORM APPROVED
A. BUILDING
C
115452 S. WING
03/ 21/ 2016
800 PATTERSON
FAYETTE, R
GA 30728
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION 1

q5)
PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE CCMPLETiON
DEFICIENCY)
F 614 Continued From page 85 F 5141 i

medication orders, and identification of patients I
and will be required to complete the orientation i
checklists,
skills medication administration video j
i
successful completion. j
completed on 2/29/ 16 by clinical competency
supervisorregarding medication discrepancy i I
physician and pharmacist. j
reviewed
l reports at shift change for completion.
i
On 03/ 21/ 16 an extended was conducted I
survey
R# 22, R#23, R# 24) who were all receiving
narcotic and antlhypertensive medications.
Clinical record reviews of physician orders,
medication administration records, controlled
drug records and observations revealed no
further Indication of deficient practice.
F 520 483. 75( o)( 1) QAA F 6201 F520
SS. j COMMITTEE- MEMBERS/ MEET
I Pruitt Health Shepherd Hills has an
QUARTERLY/ PLANS
f effective Quality Assessment Committee
I
i that develops and implements a process
Afacility must maintain a quality assessment and I I to ensure medication administration is in
assurance committee consisting of the director of accordance with Physicians orders, and
nursing services; a physician designated by the i continues to monitor the plans of action
facility; and at least 3 other members of the
facility' s staff. I implemented to correct the problems
k identified.
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
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPUER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON
FAYETTE, GAR 30728
X4) iD SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X6)

PREFIX i ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
DEFICIENCY)
F 520 Continued From page 86 F 520 Resident# 2 was sent to the ER and
I admitted on 10/ 14/ 15 and returned to

The quality assessment and assurance
our facility on 10/ 17/ 15, and still resides
committee meets at least quarterly to identify
at Pruitt Health Shepherd Hills.
Issues with respect to which quality assessment
and assurance activities are and DHS and or RN Supervisor will observe
necessary;
develops and implements plans of
appropriate residents for any change of condition.
action to correct identified quality deficiencies. Pictures of residents were audit on
10/ 14/ 15 to ensure all residents had
A State or the Secretary may not require
disclosure of the records of such committee a picture on the MAR.
except insofar as such disclosure is related to the Administrator had a verbal discussion
I
compliance of such committee with the with both the nurse in orientation and the
requirements of this section. mentor nurse related to medication
administration and consistent
Good faith attempts by the committee to identify
and correct quality deficiencies will not be used as observation of any newly hired nurse
a basis for sanctions. during the orientation process.
by the Clinical Competency Coordinator
by.
Based on record review and staff interview the
facility failed to have an effective Quality j 2- 19- 16 and ongoing. The education
Assessment and Assurance( QAA) Committee included medication administration
that developed and implemented a process to
general guide lines, including but not
ensure medication administration in accordance
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
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
STATEMENT OF DEFICIENCIES ( Xi) PROVIDER/ SUPPLiERICLIA ( X2) MULTIPLE CONSTRUCTION M) DATE SURVEY
IDENTIFICATION NUMBER COMPLETED
115452 B. WING 03/ 21/ 2016
800 PATTERSON RD
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION vs)

X¢) ID
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE i COMPLETION
PREFIX ( DATE
DEFICIENCY) i
hired will be educated by ,

Newly nurses 7•(,
unsupervised orienting nurse to use for
Identification. Photographs were not available for mentor nurse on medication admin-
six( 6) residents(# 16,# 17,# 18.# 19,# 20, and
21) residing in the facility when the MAR books

i istration general guidelines, including
but not limited to, following physicians
were reviewed on 2119/ 16 at 2: 10 p. m. and on
f
2126/ 16 at 10: 40 a. m.
i orders, medication pass times, consistent
i The facility failed to provide accurate identification and accurate documentation of
and investigation of medication errors
adequate
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
7: 30 a. m. This was not identified as an error
i
despite the Medication Administration Guidelines mentor nurse on medication admin-
Policy specifying medications must be given

within one hour before or after they are i
scheduled. The Policy further specifies that but not limited to, following physicians
administered medications must be recorded on
orders, medication pass times, consistent
the MAR before the nurse goes home and should
I and accurate documentation of
be initialed on the MAR after the administration.
The medication errors and adverse reactions medication and acceptance/ refusal
involving Resident# 1 and Resident# 2 were not i
reported as required by the Medication
Discrepancy and Adverse Reaction Report Policy. adverse medication reactions, accurate
The total survey sample was twenty- four( 24) transcription of medication orders, and
residents.
The facility' s Administrator, Corporate Clinical identification of patients.

Consultant, Director of Health Services ( DHS)
and Nursing Supervisor" EE" Registered Nurse t
on February 25, 2016 at 6. 00 p. m. The i
noncompliance related to the Immediate
I Jeopardy was Identified to have existed as of
October 14, 2015, the date Resident# 2 was
FORM CMS- 207( 02- 99) Previous Versions Obsolete Event ID; z2Su11 Facility ID: LTC11461209 if confinualion sheet Page 68 of 96
i
PRINTED: 04/ 13/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( Xi) PROVIDERISUPPLIERICLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PATTERSON RD

OF DEFICIENCIES ID PROVIDER's PLAN OF CORRECTION vo
REGULATORY OR LSC IDENTIFYING INFORMATION) I DATE
TAG TAG CROSS- REFERENCED TO THEAPPROPRIATE
DEFICIENCY)
i
I
F 520. Continued From page 88 Education to 34 nurses
administered another residents antihypertensive

F F 520 was provided
from 2/ 19/ 16 to 2/ 29/ 16 by the Clinical
1,I_ S 7- Al
medications. Competency Coordinator, Senior
An allegation of jeopardy removal was recieved Nurse Consultant, and RN Supervisor
on February 26, 2016. Based on corrective
plans j l
which had been developed and implemented by
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.
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
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
Consultant on 2118116 at 6: 00 p. m. revealed the

Clinical
on going. 1
investigation of Resident# 1 being administered
ClinicalCompetency Coordinator
and S 7- A,
Morphine 20 mg Sublingual( SL) on 12/ 20/ 15 at RN on 2/26/ 16 and ongoing educated
7: 00 a. m. and again at 7: 30 a. m, had not resulted nurses related to pain including o
in identifying a problem with narcotic observation and documentation
administration and monitoring or medication of pain with routine pain medication
i administration and documentation. The Corporate 1
1 Clinical Consultant administration.
acknowledged the Corporate
Medication Administration General Guidelines Nurses were also in serviced
by the L5--7-/.
clearly state that medications are to be signed for Clinical Competency Coordinator
on the MAR as soon as they are administered
regarding observation of respiratory
and that In no case should a nurse go off duty and sedation status with controlled
without signing for administered medications and
this policy had not been followed.Licensed substance pain medication administration
Practical Nurse( LPN)" BB" had been educated Nurses were educated by Clinical
to sign for the medications she administered on Competency Coordinator and RN
12/ 20/ 15 and since no Morphine was
Supervisor regarding Errors, Omissions
unaccounted for the facility did not identify this as
and Iata antriac
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility IQ! L, TC11461209 If continuation sheet Page 69 of 96
PRINTED: 04/ 13/ 2016
A. BUILDING,
C
115452 B. WING
03/ 21/ 2016
800 PA'rTERSON
FAYETTE, GA R 30728

X4) ID
ID PROVIDER' S PLAN OF CORRECTION
1 vs)
PREFIX ( PREFIX COMPLETION
DEFICIENCY)
F 520 Continued From Pruitt University class for Medication

page 89 i F 520'
an error. Administration and Avoiding Common

LPN" BB" was Interviewed on 2/ 19/ 16 at 11: 55 !
Errors beginning 2/ 29/ 16 and ongoing.
a. m. and revealed she had administered a dose of
DHS and or RN Supervisor will complete
Morphine 20 mg SL to Resident# 1 ninety
minutes late, at 7: 00 a. m. just prior to going a review of the MAR' s for omissions i
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
information or communicated this to the

pictures are in place,
oncoming nurse. LPN" BB" confirmed her failure
to follow the Medication Administration:
DHS and or RN supervisor will monitor/ 3"-7/( v
General
Guidelines Policy had resulted in LPN" AA" observe Medication pass for 10% of
administering a second dose of Morphine on
schedule at 7: 30 a, m., which should not have nurses weekly times 1 month, then
been administered because Resident# 1 was monthly times 3 months beginning
diagnosed with Respiratory Failure and was in a
i 2/ 25/ 16 and ongoing.
very weakened and debilitated condition and
Pharmacy Consultant will observe at
could
Review
have caused
of the clinical
an adverse reaction.
for Resident# 2
record -
Is
least one random med pass observation
revealed he was administered Procardia 30 mg
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
hypotensive at 7: 10 a. m., and transferred reports will be reviewed at each Quality

emergently to the closest hospital and admitted to Assessment and Assurance meeting.
the Intensive Care Unit( ICU) with a diagnosis of
Medication D€serepancy/ Adverse Reaction
latrogenicHypotension. I
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
STATEMENT OF DEFICIENCIES ( X1) PROVID£ R/ SUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A BUILDING
C
115452 B. WING_
03/ 21/ 2016
800 PATTERSON RD
LA FAYETCE, GA 30728
X4) iD ' SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION

EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX kk (
TAG f REGULATORY ORLSC IDENTIFYING INFORMATION) E TAG
DEFICIENCY)
The Quality Assurance Committee will

meet monthly.
two( 2) antihypertensive medications at the cart
All finding will betaken to the Quality
for Resident# 4 to be given at 6: 00 a. m., she did Jr { o
not enter the room with LPN " BB". She further
revealed there were no pictures of R# 2 or R# 4 Committee for action as needed.
the roommate) on the Medication Admnistration
Record' s ( MARS) because the pictures had not
been changed on October 1, 2015 from the
previous months MAR book, in the medication
room. LPN" HH" acknowledged that she thought
LPN" BB" had been on orientation long enough
to remember who the two( 2) residents in that
room were and which one received medications
at 6: 00 a. m., but should not have left her to give
any medication unattended. LPN" HH" revealed
she had been notified by a Certified Nursing
Assistant( CNA) that R#4 said he did not get his
usual 6:00 a. m. medication and his roommate,
R# 2 might have received It.
2:30 p. m. revealed the medication errors and
adverse reactions involving Resident# 1 and
Resident# 2 were not reported on Medication
Discrepancy and Adverse Reaction reports as
required by this Policy. These reports had not
been completed for an unknown length of time.
Interview conducted on 2125f16 at 10: 40 a. m, with i
Nursing Supervisor " EE" Registered Nurse( RN)
revealed that the six( 6) missing resident pictures
had either fallen out of the sleeves they are kept
in or left in the last months MAR books kept in the
medication rooms on both the North and South
Halls. Supervisor" EE" acknowledged that each
book should have a picture of each resident.
In an interview on 2/25/ 16 at 3:30 p.m. the
Administrator revealed the QAA Committee had j
identified the issue involving identification of I
residents by photographs on 10/ 14116, and this I
was considered to be resolved on 10/ 14115, after

R# 2 had been transferred to the hospital and all j
FORM CMS- 2667(02-99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11451209 If continuation sheet Page 91 of 96
PRINTED: 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/ CLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 2112016
800 PATTERSON
PRUITTHEALTH. SHEPHERD HILLS
FAYETTE, GA R
30728
Xq) ID SUMMARY STATEMENT OF DEFICIENCIES t0 PROVIDER' S PLAN OF CORRECTION Xi)

PREFIX ( EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE = COMPLETION
DEFICIENCY)
i
I I
I
I 3
MAR' s had been equipped with pictures. The
Administrator then acknowledged there were six
6) residents whose pictures were missing on I

2/ 25/16 at 10: 40 a. m. and additional monitoring
and auditing of the MAR' s was necessary. MARS I
were monitored for pictures of residents and staff I
Interview were conducted. Continued interivew
with the Administrator on 2125116 at 3: 30 p. m.
I
related to the facility QAA Committee, the
s 1
Administrator was asked about the QAA
Committee' s oversight of the facility' s
compliance with the corporate policy entitled
Medication Administration: General Guidelines,
revised on 1/ 23/ 15. The policy indicated
Patients/ Residents are to be identified before
medication is administered. When In doubt:
Check photograph attached to the medical 1
record. The Administrator acknowledged the
pictures were to be on all MAR' s according to her
decision following the administration of
antihypertensive medication to the wrong resident
on 10/ 14115. The pictures had been moved from
the previous months MAR books on 10/ 14/15 to
the current MAR books and the QAA committee
I
and Medical Director had recommended two( 2)
sets of pictures be available for each resident,
one on each MAR book. The Administrator
I
revealed the committee had not continued the i
process of monitoring this identified problem and l
acknowledged there were six( 6) residents who
did not have pictures available in the current MAR,
book. The Administrator revealed there had not
been any errors resulting from lack of
identification for these six( 6) residents, and
acknowledged It there had been any new nurses

orienting and they were left unsupervised, this
I may have been a problem. The Administrator
revealed the QAA committee with the Medical
Director also recommended hiring a Clinical
PRINTED: 04/ 13/ 2016
A. BUILDING
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115452 B. WING_
03121/ 2016
00 PATTERSON RD
X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION I

PREFIX
TAG
PREFIX
TAG
I COMP
DATE
LE)
DEFICIENCY)
Competency Coordinator( CCC) as soon as

possible and the position was filled on December
16, 2015.
Based on the above, the facility s QAA
Committee failed to ensure the necessary
monitoring of a plan of action, developed by the
facility In response to an Identified problem with
the identification of residents by staff who are
unfamiliar with them, when passing medication, to
ensure the implementation of the newly
developed Intervention. The facility's failure to
follow established policy and procedure for
Medication Administration resulted in a significant
medication error. The facility' s failure to identify
and report errors and adverse reactions as
required by the Medication Discrepancy and
Adverse Reaction Report Policy resulted in failure
to provide continuing surveillance and identify
potential educational needs related to medication
issues by the Consultant Pharmacist and the
Quality Assurance Committee. i
Interview conducted on 3121/ 16 at 1: 30 p. m. with
I
the Administrator revealed there had been one( 1) I
medication error on 2/ 29/ 16. Resident# 22 had s

i
an order change to Ativan 0. 5 mg by mouth ( po)
administered Ativan on 2/ 29/ 16 at 9:00 p. m. The i
Administrator revealed this had been Identified as
Drug Records the next day and an incident report
form was completed according to corporate
policy. These records were reviewed and found
to be complete. R# 22 was observed according to
physician order through the next twenty- four
hours and had no adverse reactions. The Quality i
I
Assurance Committee had not held a meeting but
PRINTED. 04/ 13/ 2016
STATEMENT OF DEFICIENCIES ( X1) PRO" DERfSUPPLIERlCLIA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 211201 6
aeo PATTERSON RD
Xq) ID SUMMARY STATEMENT OF DEFICIENCIES ID E PROVIDER` S PLAN OF CORRECTION XS)

EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX 1 ( EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX ( j
REGULATORY OR LSC IDENTIFYING INFORMATION) TAO CROSS- REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
F 520
i Continued From page 93
AA" had terminated her employment with the

F 520

Incident with the DHS.

i

Nurse supervisor on 2119/ 16 regarding the i
acceptance/ refusal of medications, medication ;
i discrepancies, adverse medication reactions, E
i

identification of residents.
reviewed
2, Pictures of residents were audited on 2125/ 16
needed

I education to nurses regarding utilization of other
supervisor on 2/26/ 16 related to pain including
observation and documentation of pain with i

administration. j
reviewed.
5. nursing education was provided on 2/29/ 16 by .
FORM CMS-2667( 02-99) Previous Versions Obsolete Event ID; Z2SU11 Facility ID: LTC1140209 If continuation sheet Page 94 of 96
PRINTED04/ 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOORM
RM APPRROVEOVE D
STATEMENT OF DEFICIENCIES ( X1) PROViDERISUPPLIERICLiA ( X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
C
115452 B. WING
03/ 21/ 2016
800 PA IiD
LAFAYETTEETTE,
LA GA 30728
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION i ( X5)

X4) ID i
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE coMPLEnoN
CROSS- REFERENCED TO THE APPROPRIATE DA76

DEFICIENCY)
F 620 Continued From page 94 F

5201
entries.

reviewed.
i
I
omissions.
I
place.
for action as needed i
video from American Society of consultant j
met medications/ inhalers/ patches, and I
j medication was successful completion of
posttests beginning 2126/ 16
reviewed
12, The director of health services or registered
I of pain is being monitored.
13 Newly hired nurses will be in serviced by the 1 j
I on medication administration general guidelines I
Including following physician orders, med pass

times, consistent and accurate documentation of I I
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facili€y ID: LTC11461209 If confinuallon sheet Page 95 of 96
i
PRINTED; 04/ 13/ 2016
FORM APPROVED
C
116452 B. WING
03/ 21/ 2016
800 PATTERSON RD

1 IO PROVIDER' S PLAN OF CORRECTION X6
PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETioN
TAG REGULATORY OR LSO IDENTIFYING INFORMATION) ; TAG CROSS- REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

f completed with each newly hired nurse was
completed on 2/ 29/ 16 by clinical competency
farm and documentation regarding any
reviewed
On 03/ 21/ 16 an extended conducted

survey was
t
R#22, R# 23, R# 24) who were all receiving
narcotic and antihypertensive medications.
Clinical record reviews of physician orders, I
medication administration records, controlled 1
drug records and observations revealed no i
further indication of deficient practice.

E
is
i
FORM CMS• 2667( 02. 99) Previous Versions Obsolete Event ID: Z2SU11 FacilityID: LTC11461209
r
PRUITT HEALTH SHEPHERD HILLS
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Pruitt Health Shepherd Hills
ALLEGATION of CREDIBLE COMPLIANCE:
February 26, 2016
COMMENTS PROVIDER' S PLAN OF CORRECTION
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
Monitor resident status, to include vital signs

Sent to ER for evaluation— Res.# 1 sent to ER
and was admitted— did not 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
Action Taken to ensure no other residents will be

affected in the future:
Education related medication administration
for nurses 02- 19- 16 ongoing. 34 nurses
completed the education by 2/ 29/ 16.
Nurses were educated to ensure that nurses in
orientation were not left unattended during

medication administration. 20 nurses
competed this on 10- 14- 15
Completion of medication discrepancy in-

service for nurses. 02- 19- 16 ongoing. 34
nurses completed education by 2/ 29/ 16
Nurses review Medication administration
video, with successful completion of posttest

beginning 2- 26- 16 and ongoing. 34 nurses
Pictures updated and placed in MAR. 10- 15- 16
and audited on 02- 25- 16.
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

DHS or RN Supervisor to complete daily review
of MAR' s for completion.
RN Supervisor to complete review of MAR' s
monthly during change over to ensure pictures
are in place.
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
QA committee will meet and discuss monthly

Issue: F3294: related to unnecessary medications. Action Taken to ensure no residents will be affected in
of assessment and the future:
Having an expectation
monitoring of resident that was needed with

allegation that it was not done.
Nurses were educated to monitor for pain
prior to administering controlled substance
pain medications. 02- 26- 19 ongoing. 34 nurses
Nurses were educated on side effects and or
adverse reactions related to controlled
substance pain medications. 02- 26- 16 ongoing.
34 nurses completed the education by
2/ 29/ 16..
Monitoring:
DHS or RN Supervisor will review MAR' s weekly
to ensure that level of pain is being monitored.
Issue: F282- J: related to care plan by qualified
Care plan Medication Action Taken to assure no other residents will be
professional. reads: as
received affected in the future:

ordered- allegation that one resident
Nurses were inserviced related to medication
medication that wasn' t ordered for him.
administration. 02- 19- 16 ongoing. . 34 nurses

Monitoring:
Completed 2- 1- 16.

800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Issue: F514- J: Allegation that pain medication was not

signed when administered Action Taken to ensure no other residents will be

beginning. 02- 26- 16 and ongoing. . 34 nurses

Monitoring:
Charge nurses will review MAR and controlled
substance sheets at shift change for
completion.
DHS or RN Supervisor to monitor MAR and
controlled substance sheets every day for

completion.

Issue: F281- 1: related to professional standards. Action Taken to ensure no other residents will be
Allegation that nurse failed to monitor the pain affected in the future:
level of one resident when giving routine pain

medication.
Nurses were educated related to observation
and documentation of pain prior to

administering controlled substance pain
medication. 02- 16- 16 on going. . 34 nurses

adverse reactions related to Controlled
substance pain medications. 02- 26- 16 on
going. . 34 nurses completed the education by
2/ 29/ 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.
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
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
discrepancy Adverse reaction

Policy. . 02- 19- 16 ongoing. 34 nurses
completed education by 2/ 29/ 16
Medication discrepancy form

Will be completed as identified
and scanned to pharmacy consultant
For review.
Pharmacy consultant will sign and fax back

To facility administrator or DHS
Monitoring:
DHS or RN supervisor will monitor/

observe medication pass for 10%
of nurses weekly times one month,
Then monthly times 3 months.
Pharmacy consultant will observe at

least one random med pass monthly
during her visit.
QA committee will meet and discuss

Monthly
Issue: F520- J: related to QAA committee members, Action Taken to ensure no residents will be affected in
meetings and plans the future:


beginning. 2- 26- 16 and ongoing. 34 nurses
Monitoring:
Medication discrepancy/ Adverse Reaction

Reports will be reviewed at each Quality
Assessment and Assurance meeting.
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Medication Discrepancy/ Adverse Reaction

Reports that have determined to have an
adverse reaction or cause harm to a resident
will have a Performance Improvement plan
developed by the Quality Assessment and
Assurance committee.

Monthly
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
February 26, 2016
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
MD notification
Monitor resident status, to include vital signs

Sent to ER for evaluation

Education related medication administration
for nurses 02- 19- 16 ongoing. 34 nurses
Nurses were educated to ensure that nurses in
orientation were not left unattended during
medication administration. 20 nurses
competed this on 10- 14- 15

beginning 2- 26- 16 and ongoing. 34 nurses
Pictures updated and placed in MAR. 10- 15- 16
and audited on 02- 25- 16.
Monitoring:
Re- education of nurses on medication
administration. 2- 19- 16 ongoing. 34 nurses
DHS or RN Supervisor to complete daily review
of MAR' s for completion.
94-
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
monthly during change over to ensure pictures

are in place.
Completed 2- 1- 16

Issue: F329- J: related to unnecessary medications. Action Taken to ensure no residents will be affected in
of assessment and the future:
Having an expectation
monitoring of resident that was needed with

Nurses were educated to monitor for pain
allegation that it was not done.
prior to administering controlled substance
pain medications. 02- 26- 19 ongoing. . 34
nurses completed the education by 2/ 29/ 16.

adverse reactions related to controlled
substance pain medications. 02- 26- 16 ongoing.
34 nurses completed the education by
2/ 29/ 16..
Monitoring:
DHS or RN Supervisor will review MAR' s weekly
to ensure that level of pain is being monitored.
Issue: F282- J: related to care plan by qualified
Care Medication Action Taken to assure no other residents will be
professional. plan reads: as
ordered- allegation that one resident received
Nurses were inserviced related to medication
administration. 02- 19- 16 ongoing. . 34 nurses

Monitoring:
Completed 2- 1- 16.
Issue: F514- J: Allegation that pain medication was not

signed when administered Action Taken to ensure no other residents will be
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151

beginning. 02- 26- 16 and ongoing. . 34 nurses

Monitoring:
completion.

completion.
CIA committee will meet and discuss monthly

Issue: F281- J: related to professional standards. Action Taken to ensure no other residents will be
Allegation that nurse failed to monitor the pain affected in the future:
level of one resident when giving routine pain

medication. Nurses were educated related to observation
and documentation of pain prior to
administering controlled substance pain
medication. 02- 16- 16 on going. . 34 nurses

adverse reactions related to Controlled
substance pain medications. 02- 26- 16 on
going. . 34 nurses completed the education by
2/ 29/ 16.
Monitoring:
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
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Medication discrepancy form

Will be completed as identified
and scanned to pharmacy consultant
For review.
Pharmacy consultant will sign and fax back

To facility administrator or DHS
Monitoring:


during her visit.

Monthly
Issue: F520- J: related to QAA committee members, Action Taken to ensure no residents will be affected in
meetings and meeting the future:


beginning. 2- 26- 16 and ongoing. 34 nurses
Monitoring:


800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151


Monthly
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638-4151
February 26, 2016
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
Observation of patient for change of

condition
MD notification for change of condition

Res.# 1 sent to ER and was admitted— did not
return to facility
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

Education was provided to 34 nurses by

Clinical Competency Coordinator and RN
Supervisor related to medication
administration for nurses 02- 19- 16 and
ongoing. Education review included
medication administration general guidelines,
including but not limited to, following
physicians' orders, medication pass times,
consistent and accurate documentation of
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151

medications, medication discrepancies,
Newly hired nurses will be inserviced by
Clinical Competency Coordinator and mentor
nurse on medication administration general
guidelines, including but not limited to,
following physicians' orders, medication pass
times, consistent and accurate
acceptance/ refusal of medications,
medication discrepancies, adverse medication
medication orders, and identification of
patients. Newly hired nurses will be required
to complete the Orientation Skills Checklist,
Medication Administration Video with post-
test, and Medication Cart Orientation. Med
Pass Observation will also be completed with
each newly hired nurse, with successful
completion.
Education was provided to 34 nurses from 2-

19- 16 to 2- 29- 16 by Clinical Competency
Coordinator, Senior Nurse Consultant and RN
administration video from American Society
of Consultant Pharmacists, which included
oral medications, Eye Meds/ inhalers/ Patches,
and Meds via G tube administration of
medication with successful completion of
posttest beginning 2- 26- 16- 2- 29- 16 and on-
going.
Pictures of residents updated and placed in

MAR. 10- 15- 15 and audited on 02- 25- 16 and
will review monthly and updated as needed
Clinical Competency Coordinator provided
education to nurses regarding utilization of
other staff members to assist with the
identification process of patients as needed
800 PATTERSON ROAD
LAFA YETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Nurses were inserviced by Clinical

Competency Coordinator and RN supervisor
on 2/ 26/ 16 and ongoing related to pain,
including observation and documentation of
pain with routine pain medication
administration. Nurses were also inserviced
by Clinical Competency Coordinator regarding

administration.
Education provided by Clinical Competency

Coordinator for nurses included observation 1
for sedation prior to administering controlled
substance pain medication.
Nurses educated by Clinical Competency

Coordinator and RN Supervisor regarding
Errors, Omissions and late entries, and Pruitt
University class for Medication Administration
and Avoiding Common Errors begun 2- 29- 16
and ongoing.
Monitoring:
Re- education of nurses by Clinical
Competency Coordinator and RN Supervisor
on medication administration. 2- 19- 16
ongoing included. 34 nurses completed the

education by 2/ 29/ 16.
DHS or RN Supervisor to complete daily
review of MAR' s for omissions.
monthly during change over to ensure
pictures of residents are in place.
med pass for 10%
of nurses weekly x 1 month,
Completed 2- 1- 16

Committee for action as needed
Issue: F329- J: related to unnecessary Immediate Action Taken for Residents:
medications.
Having an expectation of
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
assessment and monitoring of resident that was Observation of patient for change of
needed with allegation that it was not done. condition

return to facility




completion.

form and documentation
regarding any
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151

oral medications, Eye Meds/ Inhalers/ Patches,
going.

administration.

Coordinator for nurses included observation

and ongoing.
Monitoring:
DHS or RN Supervisor will review MAR' s
weekly to ensure that level of pain is being
monitored.

Issue: F282- J: related Immediate Action Taken for Residents:

to care plan by qualified
professional. Care plan reads: Medication as
ordered- allegation that one resident received Observation of patient for change of
condition
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151

resides in facility





800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151


completion.


going.

MAR. 10- 15- 15 and audited on 02- 25- 16 and i

and ongoing.
Monitoring:
Completed 2- 1- 16.

800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Issue: F514- J: Allegation that pain medication was Immediate Action Taken for Residents:
not signed when administered, failed to accurately

document medications Observation of patient for change of
condition

return to facility
Resident# 3— no harm, patient no longer
resides in facility— Nurse was counseled
related to failure to document on MAR






completion.
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151

34 Nurses reviewed. Medication

going.


administration.


and ongoing.
Monitoring:
completion.

completion.

800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
Issue: F281- J: related to

professional standards. Immediate Action Taken for Residents:
Allegation that nurse failed to monitor the pain

level of one resident when giving routine pain Observation of patient for change of
condition
medication and allegation that one resident
received MD notification for change of condition

another resident' s routine medication
in error
return to facility
resides in facility




800 PATTERSON ROAD
LAFAYETTE. GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 41S1



completion.



going.


administration.

800 PATTERSON ROAD
LAFAYETTE. GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151


and ongoing.
Monitoring:
Issue: F425- J: related to pharmaceutical services Immediate Action Taken for Residents:
Allegation that facility failed to provide

pharmaceutical services to review, track and trend Observation of patient for change of
medication errors, and determine the need for condition
intervention MD notification for change of condition

return to facility
resides in facility


800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151


completion.



going.
800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151

administration.


and ongoing.
Monitoring:


during her visit.

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

resides in facility


Action Taken to ensure no residents will be affected
in the future:
Education related to medication



identification of patients. 34 nurses
completed the education by 2/ 29/ 16
Newly hired nurses will be inserviced on

800 PATTERSON ROAD
LAFAYETTE, GA 30728
PHONE: 7061638- 4112 FAX: 7061638- 4151
identification of patients. Newly hired nurses

will be required to complete the Orientation
Skills Checklist, Medication Administration
Video with posttest, and Medication Cart
Orientation. Med Pass Observation will also
be completed with each newly hired nurse,
with successful completion.


going.
Pictures updated and placed in MAR. 10- 15-

15 and audited on 02- 25- 16 and monthly
Nurses were educated that they can also
verify patients with other staff to assist with
identification.
Nurses educated on Errors, Omissions and

late entries 2- 29- 16 and ongoing.
Monitoring:



PRINTED: 03/ 17/ 2016
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT
C
115452 B. WING
02126/ 2016
800 PATTERSON RD
PRIJITTHEALTH - SHEPHERD HILLS
SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

X4) ID
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
DATE
TAG
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
A complaint survey was conducted from

February 18, 2016 through February 26, 2016, to
investigate complaint numbers GA 00156430, GA
00158124, and GA 00159480. The facility was not
in substantial compliance with Medicare/ Medicaid
regulations at 42 Code of Federal Regulations
C. F. R.) Part 483, Subpart B- Requirements for
Long Term Care Facilities. The following
deficiencies resulted from the facility' s
noncompliance related to the complaint numbers
GA 00158124 and GA 00156430. The facility' s
census was 107.
to residents. The facility' s Administrator,
Services ( DHS) and Nursing Supervisor TE"
Registered Nurse ( RN) were informed of the J
5: 00 p. m. The Immediate Jeopardy continued
through the end of the complaint survey, February''
26, 2016 and remains ongoing.
The Immediate Jeopardy is outlined as follows:
The noncompliance related to the Immediate

Jeopardy was identified to have existed as of
October 14, 2015, the date Resident# 2
experienced a significant medication error, when
he was administered two anti hypertensive
medications ordered for a different resident, and
was emergently transferred to the hospital and
admitted to the Intensive Care Unit with a
diagnosis of Severe latrogenic Hypotension, and
LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE X6) DATE
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
PRINTED: 03/ 17/ 2016
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,
STATEMENT
C
115452 B. WING
02/ 26/ 2016
800 PA N RD
LAFAYETTEETTE,
LA GA 30728

X4) ID
DATE
TAG
DEFICIENCY)
F 000 Continued From page 1 F 000'
Demand Ischemia. The diagnosis of Demand

Ischemia indicated myocardial damage and had
occurred resulting from the Severe Hypotension.
On October 15, 2015 a Physician Progress note
NSTEMI).
Resident# 1 experienced a significant medication

error on December 20, 2015 when, due to failure
of the off going shift nurse to sign or initial the
Morphine administered on the Medication
Administration Record or Controlled Drug Record, '
R# 1 was administered the narcotic Morphine
twice within thirty minutes, at 7: 00 a. m. by the
night shift nurse and and 7: 30 a. m. by the day
shift nurse. During the night of December 20,
2015, and early morning hours of December 21,
2015, he continued to receive doses of Morphine
at two ( 2) hour intervals without assessment of
pain level or respiratory status. A Nurses Note
did identify an ongoing assessment indicating
sedation was present throughout the 7: 00 p. m. to
7: 00 a. m. shift on December 20, 2015. He was
discovered on the morning of December 21, 2015
in respiratory distress, with an oxygen saturation
of 55% and transferred emergently to a hospital
where he required mechanical ventilation. The
resident was
Failure and required mechanical ventilation

intermittently until discharge to a Longterm Acute
Care facility on February 4, 2016.
On October 12, 2015, October 13, 2015, October',

29, 2015 and October 30, 2015 at 9: 00 p. m.
Resident( R)# 3 received medications without the
correct documentation on the Medication
Administration Record. On October 12, 2015,
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CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 _

A. BUILDING
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GA

X4) ID
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PREFIX PREFIX
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i

October 29, 2015 and October 30, 2015 at 9: 00
p. m., and on October 30, 2015 at 9: 00 a. m., R# 3
received Levemir Insulin Injection 70 units without ',
documentation on the Medication Administration
Record. R# 3 also received Advair Diskus
inhalation at 9: 00 p. m., on October 13, 2015 and
Fluval 0. 5 milliliter( ml) Injection on the 3- 11 shift
on October 25, 2015 without the correct
documentation on the Medication Administration
Records. The facility investigated the failure to
document the Levemir Insulin administrations.
An interview with the Administrator on February
19, 2016 at 2: 30 p. m., revealed the Levemir
insulin administration without correct
documentation was investigated because insulin
administration was identified as an issue being
worked on for Quality Assurance. The Fluval and
Advair Diskus administered to Resident# 3
without correct documentation were not
investigated or identified as Quality Assurance
issues.
The Quality Assurance Committee had identified

on October 14, 2015, an issue with nurses
unfamiliar with the residents having difficulty
identifying them for medication administration and
identified an intervention of ensuring pictures of
each resident were available on the Medication
Administration Record. Observations of each
residents Medication Administration Record on
February 19, 2015 at 2: 10 p. m. and February
25, 2016 at 10: 45 a. m. revealed six( 6) residents
whose pictures were not on the Medication
An interview with the facility Corporate Clinical

Consultant on February 24, 2016 at 2: 45 p. m.,
revealed the Medication Discrepancy/ Adverse
Reaction Report forms required by the Medication '
Discrepancy and Adverse Reaction Policy had not',
been completed for an unknown length of time
i
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because the nurses did not know to complete the

form. The Administrator reported errors verbally
but there was no record of what errors were
reported or the Consultant Pharmacists' review
of the occurrences.
The Immediate Jeopardy was related to the
facility' s noncompliance with the program
requirements at:
42 C. F. R. 483. 20 ( k)( 3)( i), Services Provided
Meet Professional Standards ( F281,
Scope/ Severity: J);
42 C. F. R 483. 20 ( k)( 3)( ii), Services By Qualified
Persons/ Per Care Plan ( F282, S/ S: J);
42 C. F. R. 483. 25( 1) Unnecessary Drugs ( F329,
S/ S: J);
42 C. F. R 483. 25( m)( 2), Residents Free of
Significant Medication Errors ( F333, S/ S: J);
42 C. F. R 483. 60 Pharmaceutical Services ( F425,
S/ S: J);
42 C. F. R 483. 75( 1) Clinical Record Contents
F514, S/ S: J) and
42 C. F. R 483. 75( o)( 1), Quality Assessment and
Assurance Committee Members/ Meet
Quarterly/ Plans( F520, S/ S: J.).
F 281 483. 20( k)( 3)( i) SERVICES PROVIDED MEET F 281
SS= J PROFESSIONAL STANDARDS

must meet professional standards of quality.

by:
Based on observations, record review and
interview the facility failed to ensure that services
were provided in accordance with professional
standards of quality, regarding medication
administration and monitoring for one ( 1) resident
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X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES
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X4) ID
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R# 1), who incorrectly received two( 2) doses of

Morphine within a thirty( 30) minute period and
continued to receive Morphine routinely every two
2) hours for pain without monitoring or
assessment for adverse effects and regarding
accurate resident identification prior to medication
administration for one ( 1) resident( R# 2), who
received another resident' s medications in error,
from a total sample size of twenty- one( 21)
residents.
Findings include:
1. Reveiw of the facility' s Medication

Administration General Guidelines policy included
information on identifying residents. The
procedure section documented residents are
identified before medication is administered. A
list of methods of identification to use, when in
doubt about the resident' s identity, included to
check for an identification band, check for
photograph attached to the medical record, call
the resident by name and if necessary verify the
resident's identify with other healthcare staff.
Record review for R# 2 revealed an Annual
Minimum Data Set assessment dated December
11, 2015 that documented R 2 as admitted to the
facility on February 5, 2013 with the diagnoses
that included Hypertension, Dementia with
behaviors, Alzheimer' s disease, and Psychotic
Disorder. A record review for R# 2 revealed
nursing notes dated October 14, 2015
documenting that the resident was given 30 mg of
Procardia and 100 mg Hydralazine in error by
newly hired) Licensed Practical Nurse( LPN)
BB" during the 6: 00 a. m. medication pass. A
further review of the 10/ 14/ 15 nurses notes
revealed that, after the medications were
administered in error, the resident' s blood
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STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA
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AND PLAN OF CORRECTION IDENTIFICATION
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pressure ( B/ P) began to drop and the resident

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. Resident# 2
was transferred to the hospital and admitted to
the Intensive Care Unit( ICU) with diagnosis of
Hypotension and Medication Poisoning. There
was no evidence of how LPN " BB" verified R2' s
idenity prior to administering him the incorrect
medications.
Review of the facility incident report for the

medication error that occurred on October 14,
2015 revealed the medication error was identified
after resident' s roommate reported to the
Certified Nursing Assistant( CNA) that R 2 had
been incorrectly given 6: 00 a, m. medications that
were meant for him ( the roommate).
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.
In an Interview on February 22, 2016 at 9: 30 a. m.

the Administrator acknowledged the supervising
licensed nurse" HH" had left licensed nurse" BB"
unattended and licensed nurse" BB" did not know
the residents. She further acknowledged that
pictures of the residents were always on the
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Random observations conducted on February 22,

2016 of the Medication Administration Record' s
MAR' s) located on the medication carts revealed
pictures were not on the MAR' s. On February 24,
2016 six( 6) resident pictures remained missing
on the South Wing MAR' s.
During An interview on February 23, 2016 at

10: 00 a. m. LPN " HH", the nurse who was
supervising newly hired licensed nurse" BB" on
October 14, 2015 when R# 2 received the wrong
medications, stated that she thought licensed
nurse" BB" had been working with the residents
long enough to know who they were. LPN " HH"
cart when the medications were prepared and
also acknowledged there were no pictures of
these two residents on the MARS.
Review of the National Council of State Boards of

Nursing Model Nursing Practice Act and Model
Nursing Administrative Rules revealed that the
Model Nursing Administrative Rules, Chapter 2 -
Standards of Nursing Practice, Section 2. 3. 2( c),
specified that the nurse demonstrate
attentiveness and provide resident surveillance
and monitoring.
2. Review of the clinical record for Resident# 1

revealed he was admitted to the facility on
12/ 18/ 15 after a six( 6) month hospitalization. He
was brought to the facility to be closer to his
family and was chronically ill, debilitated and
underweight, paralyzed in three extremities and
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had minimal movement in his right upper

extremity, allowing him to use a communication
board of numbers and letters because he was
unable to speak. He had a Percutaneous
Endoscopic Gastrostomy( PEG) tube, a
Peripherally Inserted Central Catheter( PICC
line), a Foley Catheter, a Tracheostomy and
multiple pressure ulcers. The resident' s
diagnoses included Chronic Respiratory Failure,
Chronic Deep Vein Thrombosis( DVT),
Transverse Myelitis and Behcet' s Syndrome with
Neurological Involvement.
Review of the admission orders revealed an order
for 20mg/ ml of Morphine-give 0. 5ml sl q4h. On
12/ 19/ 15 at 8 a. m. the order was changed to
morphine 20mg/ ml one ml sl q3h. However, on
12/ 19/ 15 at 3: 30 pm, the order was again
changed to morphine 20mg/ ml give one ml sl q2h
for continued pain.
However a review of the Controlled Drug Record

for 12/ 20/ 15 revealed the following:
At 4: 30 a. m. Resident# 1 received a one( 1) ml
dose of Morphine 20 mg/ ml.
At 7: 00 a. m. Resident# 1 received a one ( 1) ml
At 7: 30 a. m. Resident# 1 received a one ( 1) ml
A continued review of the Controlled Drug Record

for 12/ 20/ 15 revealed Resident# 1 did not receive
the Morphine scheduled for 5: 30 p. m. and 7: 30
p. m. These doses were recorded as refused.
However R# 1 did receive a dose of Morphine, as
ordered, at 9: 30 p. m., 11: 30 p. m. and on 12/ 21/ 15
at 1: 30 a. m., 3: 30 a. m. and 5: 30 a. m.
A review of the back of the Medication

Administration Record ( MAR) revealed that on
FORM CMS- 2567( 02- 99) Previous Versions Obsolete Event ID: Z2SU11 Facility ID: LTC11461: 209 If continuation sheet Page 8 of 67
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CENTERS FOR MEDICARE &
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA
COMPLETED
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115452 B. WING 0212612016

800 PATTERSON RD
PROVIDER' S PLAN OF CORRECTION x5)
SUMMARY STATEMENT OF DEFICIENCIES ID
X4) ID BE COMDP ION
ACTION SHOULD
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE
LEE
DEFICIENCY)
F 281 Continued From page 8 F 281 '',
12/ 20/ 15 at 5: 30 p. m. and 7: 30 p. m. the Morphine

was held. The 7: 30 p. m. dose was documented
by Nurse" BB" as held due to being unable to
arouse( the resident).
Review of the Nurses Notes for 12/ 20/ 15

revealed that at 8: 00 p.m. it was discovered that
due to Nurse " BB " not documenting
administrations of Morphine at 4: 30 a. m. and 7: 00
a. m., an administration of Morphine scheduled for '
7: 30 a. m. was given by Nurse " AA" , thirty
minutes after the previous dose that was

scheduled for 5: 30 a.m., but given at 7: 00 a. m.
There was no indication of assessment of oxygen
saturation, pain level or level of sedation for 7: 00
a. m. to 7: 00 p. m.
Review of Nurses Notes for 12/ 20/ 15 by the 7: 00

p. m. to 7: 00 a. m. Nurse " BB" gave no indication
of oxygen saturation after 2: 00 a. m. when it was
90%, no indication of level of pain or sedation.
In an interview with Nurse " AA" on 2/ 19/ 16 at

10: 35 a. m. revealed she had not known the
correct way to transcribe the orders for Morphine
20 mg/ ml give 1 ml q 3 hours and Morphine 20
mg/ ml give 1 ml q 2 hours, to the MAR or how to
schedule the Morphine every 3 hours, then
changed to every 2 hours. She had realized the
documentation' s on the front of the MAR could
not be deciphered with administrations
documented on the wrong dates, some before
the order had been taken, and administrations
circled and crossed out. Nurse " AA" revealed
she had asked someone, she could not
remember who, for assistance, but they could not
help her. She stated she arrived on 12/ 20/ 15 at
7: 00 a. m. and counted narcotics with Nurse " BB
and the count for the Morphine had seemed to
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MEDICAID SERVICES OMB NO. 0938- 0391 .

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TAG
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come out correct, but it was difficult to see

because the liquid was clear and the count must
not have been correct because Nurse " BB " had
failed to document administration of Morphine
scheduled at 3:30 a. m. and 5: 30 a. m. She left
two( 2) lines and gave the dose scheduled for
7: 30 a. m. She learned when Nurse " BB
returned at 7: 00 p. m. that the 5: 30 a. m. dose
had been administered ninety( 90) minutes late,
at 7: 00 a. m., and Nurse " AA" had administered
Morphine just 30 minutes later. She had informed

the Physician and had been told that since 12
hours had passed since the error there would not
be any problem because Morphine was
metabolized rapidly and if the resident were going
to have a problem it would have been within one
hour. She acknowledged she had recorded the
residents lungs were congested, but had not
recorded checking an oxygen saturation for the
entire 12 hours shift, and was unable to
remember if she had checked this. She
acknowledged recording Morphine held at 5: 30
p. m. as refused, but she had actually requested
the assistance of the North Hall Supervisor Nurse
EE" Registered Nurse( RN) to advise her of
whether Morphine should be administered at this
time because the resident was sedated. Nurse "
EE " assessed the resident with her and they
decided to use Nursing Judgement and hold the
medication. She acknowledged she should not
have recorded the dose held as refused. She
revealed she had checked on Resident# 1 when
Nurse " BB" arrived at 7: 00 p. m. and Nurse "
EE " RN was requested to assist again with
assessment. The Morphine scheduled for 7: 30
p. m. on 12/ 20/ 15 was also held for sedation and
Nurse " EE " gave education regarding using
nursing judgement when administering scheduled
or as needed ( prn) medication and this was
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COMPLETED
A. BUILDING
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115452 B. WING 0212612016
OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NAME OF PROVIDER
800 PATTERSON RD
STATEMENT OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

X4) ID SUMMARY
PREFIX
TAG
DEFICIENCY)
especially important in the case of opioid

medication that could suppress respiration.
Nurse " EE " educated both Nurse " AA" and
Nurse " BB " at this time.
In an interview on 2/ 19/ 16 at 11: 55 a. m. with

Nurse" BB " revealed she had failed to document
administration of Morphine on 12/ 20/ 15 at 4: 30
a. m. and 7: 00 a. m. She could not remember why
she gave the 5: 30 a. m. scheduled Morphine at
7: 00 a. m., or why she failed to document, why
she failed to mention this in report, or why she did
not note this on the back of the MAR or flag the
MAR to communicate this information. Nurse"
BB " could not explain why she had charted on
the Controlled Drug Administration Record that
Resident# 1 had refused Morphine on 12/ 20/ 15 at
7: 30 p. m., when she and Nurse " AA" and
Nurse " had witnessed the resident had
EE"
been too sedated to receive the medication.
Nurse " BB " remembered Resident# 1 was
sedated and less comprehending throughout the
entire shift that night. Nurse " BB"
acknowledged she had not assessed a pain
scale, or charted a level of sedation during the
12/ 20/ 15 7: 00 p. m. through 12/ 21/ 15 7: 00 a. m.
shift. She was not able to remember if the
resident had actually indicated refusal of
suctioning at 10: 00 p. m. and 2: 00 a. m., or just did
not answer her, as when she charted refusal of
the Morphine at 7: 30 p. m. Nurse " BB"
confirmed she should have checked an oxygen
saturation after 2: 00 a. m. when it was 90%, and
pain level to know if the resident could answer

and comprehend, every 2 hours with each of the
five( 5) times Morphine was administered.
Nurse " BB" revealed she gave the medication
every two ( 2) hours because it was ordered
every two ( 2) hours. Nurse " BB revealed she
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TAG
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had discovered Resident# 1 in respiratory

distress about fifteen ( 15) minutes after her last
administration of Morphine at 5: 30 a. m, and
requested assistance and Resident# 1 was
transferred to the hospital
In an interview on 2/ 22116 at 2: 50 p. m. with

Emergency Medical Service ( EMS) Paramedic
transferring Resident# 1 to the hospital on
12/ 21/ 15 at 6: 30 a. m. revealed he had assessed
the resident as over sedated due to the facility
staff reporting he had been administered
Morphine and he had noted the resident had
pinpoint pupils, which is a sign of Morphine
overdose. He had administered Narcan to
reverse the Morphine as soon as possible and
the residents condition improved, with increased
level of consciousness, respiratory rate and effort, '
pulse oximetry and a decrease of pupil size.
Review of the EMS Patient Care Report, date

12/ 21/ 15 at 6: 41 a. m. revealed an administration
of Narcan 0. 5 mg to Resident# 1 with respirations
increasing from 8 and shallow, with oxygen
saturation of 85 % on high flow oxygen at 10 liters
per minute on first assessment, to respiratory rate:
of 16, normal depth and 98 % oxygen saturation
after Narcan and suctioning at 7: 15 a. m.
In an interview on 2/ 23/ 16 at 1: 30 p. m. with the

attending Physician of Resident# 1 revealed he
had been informed of the resident being
administered Morphine 20 mg/ ml 1 ml at 7: 00
a. m. and 7: 30 a. m. when the situation had been
discovered twelve ( 12) hours later but did not
consider this as causing his respiratory distress
the following morning at 5: 55 a. m. The Physician
revealed he would expect the nurses to hold a
medication like Morphine for sedation and check
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F 281 Continued From page 12 F 281 :
for mentation and respiratory status with every

administration because this is a nursing standard.
Review of Corporate policy entitled Pain

Management, Lippincott Procedures, indicated
that when administering strong opiod
medications, pain level, and adverse reactions
timely manner, according to the onset of the

F 282 483. 20( k)( 3)( ii) SERVICES BY QUALIFIED F 282
SS= J PERSONS/ PER CARE PLAN

must be provided by qualified persons in
accordance with each resident' s written plan of
care.

by:
Based on record review, and staff interviews, the
facility failed to provide care, related to
medication administration as per physician' s
orders and in a manner to avoid adverse
medication effects, as specified by the Care Plan
of one( 1) resident( R 2) on the total survey
sample of twenty- one( 21) residents.
This failure of the facility to administer to Resident

2 only those medications which were ordered, to
avoid adverse effects from medications as
specified by the Care Plan, resulted in a situation
in which the facility' s noncompliance with the
requirements of participation caused, or had the
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CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/
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PREFIX EACH DEFICIENCY DATE
TAG
DEFICIENCY)
likelihood to cause, serious harm, injury,

impairment, or death to residents. The census
was 107 residents.
Findings include:
Record review for R# 2 revealed an Annual

Minimum Data Set assessment of 12/ 11/ 2015
which documented, in Section I- Active
Diagnoses, that the resident had diagnoses which
included Alzheimer' s Disease, Dementia with
behaviors, Hypertension, and Psychotic Disorder.
Further review of R 2' s clinical record revealed
that the October Physician Orders form specified
the administration of Namenda XR 28 milligram
mg) daily at 9: 00 a. m. forAlzheimer' s, Vitamin
D3 2000units daily at 9: 00 a. m. for bone health,
Propranolol 20 mg every 12 hours at 9: 00 a. m.
and 9: 00 p. m., Hold for heart rate less than 50,
for Hypertension, ( listed as a Beta blocker),
Donepezil 10 mg every evening at 5: 00 p. m. for
Alzheimer' s/ Dementia. Additional record review
for R# 2, to include review of this October
Physician Orders form, revealed no evidence of a
current or past Physician' s order for the
administration of the Anti hypertensives Procardia
30 mg ( listed as Calcium Channel blocker) or
Hydralazine 100mg.
Review of the Care Plan for R# 2 revealed

multiple identified Problems involving the
administration of drug therapy, and specifying as
Approaches that drug therapy be administered in
accordance with Physician' s orders. The Care
Plan identified, as a Problem that R# 2 had a
diagnosis of Hypertension with the specified
Approach to Administer medications as ordered
and updated October 17, 2016 as return from
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hospital- continue plan of care, another Problem

identified was R# 2 had a diagnosis of Dementia
with behaviors and Psychotic disorder and
specified as an Approach to administer
medications as needed as ordered, another
Problem identified was the risk for constipation
and impactions, as specified as an Approach to
administer laxatives/ stool softeners as ordered by
physician. Document effectiveness. Problem
identified as risk for pain, specified as an
Approach administer medications as ordered as
needed., Problem identified as risk for
Respiratory infections and Pneumonia specified
as an Approach Antibiotics/ medications as
ordered, Problem identified as risk for Urinary
Tract Infections, specified as an Approach
Administer antibiotics/ medications as ordered,
and Problem identified as history of inappropriate
behaviors, specified as Approach Medications as
needed/ as ordered. The Care Plan of R# 2
specifically directed to give medications as
ordered as needed by the physician.
Recored review of Nurses Note ( NN) for October

14, 2015 with no time listed; entry for R# 2
documented that the resident was in bed this a. m.
and was given medications by trainee, that were
for another resident . R# 2 was given Procardia
30 mg and Hydralazine 100 mg, vitals were B/ P
136/ 58, Pulse 57, Temperature 96. 8 and no signs
of acute distress. MD made aware.
Review of NN for October 14, 2015 at 7: 10 a. m.

documented R# 2 now starting to fall in blood
pressure ( BP) and becoming unresponsive,
called 911, placed in bed in Trendelenburg; BP
now 64/ 38. Resident fading in and out of
staff. Placed on 02 at 2LPM via mask. Eyes are
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STATEMENT
A. BUILDING
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115452 B. WING
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LYETTE, A 30728
GA

X4) ID
DATE
TAG
DEFICIENCY)
open 68/ 50 manual BP. Awaiting ambulance.

On October 14, 2015 at 7: 20 a. m. R# 2 out by
ambulance to Hutcheson Medical Center ( HMC).
Responsible Party( RP) aware. MD made aware
of resident being sent out.
Reveiw of the hospital' s History and Physical

H& P) report documented a Cardiology Consult
requested due to increase in Troponin level which
revealed Demand Ischemia with minimal Left
Ventricle damage and diagnosis of Non ST
Segment Elevated Myocardial Infarction.
Medications given Procardia ( Calcium Channel
blocker) and Hydralazine. The resident was
given the medications of another resident by
accident, resulting in accidental overdose. The
resident was given 100 mg of Hydralazine and 30
mg of Procardia by mistake and his blood
pressure went down into the 50s and 60s systolic.
On presentation to the Intensive Care Unit( ICU)
the residents' B/ P was 90/ 64 and he was alert
and responsive. The H& P further documented
the medication error occurred about 6: 00 a. m.
and his medicines were given by a nurse who
was new to the facility and undergoing
orientation. The hospital Discharge Summary for
R# 2 documented diagnoses which included
latrogenic Hypotension secondary to medications
mistake at the nursing home, Demand Ischemia,
Dementia, Cardiac Hypotension, History of
Coronary Artery Disease, and History of
Hypertension.
I
Reveiw of the facility Investigation Report( IR) for

R# 2 October 14, 2015 at 6: 15 a. m. documented
that Blood Pressure medication had been given in
error during 6: 00 a. m. medpass. The room mate
of R# 2 reported the error to a Certified Nursing
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A. BUILDING
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LAFAYETTEETTE
LA A 30728
GA

X4) ID
DATE
TAG
DEFICIENCY)

Assistant( CNA) and the CNA reported it to the
Charge Nurse.

p. m. with the Administrator revealed the
supervising nurse had left nurse" BB", who did
not know the residents, unattended and" BB"
administered the 6 a. m. medications for another
resident to R 2. The administrator further
revealed that when she was made aware of the
medication error she had both the trainee and the
nurse training her in the office and verbally
reprimanded both nurses. Pictures of residents
were placed on the Medication Administration
Records and an in service was completed on
supervision of new employees during medications'
administration on October 14, 2015.

p. m. with Licensed Practical Nurse ( LPN) " HH"
revealed that she was the nurse training LPN
BB" on the morning of October 14, 2015 when
the wrong medication was given to R 2. She
further acknowledged that she did not go into the
room with " BB" when the medications were
administered and that she should have went with
her. " HH" also acknowledged that there were no
pictures on the MARS at the time of the error but
the next day pictures were placed on the MARS
identifying the residents.
Cross reference to F 333

F 329 483. 25( I) DRUG REGIMEN IS FREE FROM F 329
SS= J UNNECESSARY DRUGS
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OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER
800 PATTERSON RD
OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION X5)

DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE
PREFIX EACH
TAG
DEFICIENCY)
Each resident' s drug regimen must be free from

unnecessary drugs. An unnecessary drug is any
drug when used in excessive dose( including
duplicate therapy); or for excessive duration; or
without adequate monitoring; or without adequate
indications for its use; or in the presence of
adverse consequences which indicate the dose
should be reduced or discontinued; or any
combinations of the reasons above.
Based on a comprehensive assessment of a

resident, the facility must ensure that residents
who have not used antipsychotic drugs are not
given these drugs unless antipsychotic drug
therapy is necessary to treat a specific condition
as diagnosed and documented in the clinical
record; and residents who use antipsychotic
drugs receive gradual dose reductions, and
behavioral interventions, unless clinically
contraindicated, in an effort to discontinue these
drugs.

by:
Based on record review, staff, Physician, family
and Emergency Medical Services interview, the
facility failed to ensure monitoring of respiratory
status and pain level to ensure the safe
administration of Morphine twenty( 20) milligrams
mg) sublingual ( SL) every( q) two ( 2) hours in
accordance with Physician orders, for one ( 1)
resident(# 1) from a total survey sample of
twenty-one ( 21) residents. The facility census was',
107.
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X4) ID CO
PREFIX EACH DEFICIENCY MUST BE PRECEDED BY FULL
INFORMATION)
PREFIX
TAG CROSS- REFERENCED TO THE APPROPRIATE
DATEION
DEFICIENCY)

Findings include:
Record review for Resident# 1 revealed that he

was admitted to the facility on 12/ 18/ 15 with
diagnoses including Chronic Respiratory Failure
and Behcets' Syndrome with Neurological
Involvement. He was chronically ill with a
tracheostomy, foley catheter, percutaneous
endoscopic gastrostomy( PEG) tube, peripherally
inserted central catheter( PICC) line, and
pressure ulcers. He was completely paralyzed in
three extremities and had minimal movement in
the right upper extremity. He was unable to speak
and used a communication board to point to
letters. He weighed one hundred ten ( 110)
pounds ( lbs). He required humidified oxygen at 5
Liters by trach mask, nebulized breathing
treatments and
oxygen saturation was ninety six percent( 96%).

Review of transferring hospital records revealed
an order for Morphine 2 mg IV q 4 hours while
awake. Additional review of transfer records
revealed Resident# 1 had completed a course of
Vancomycin for Methicillin Resistant
Staphylococcus Aureus and Pseudomonas
Pneumonia.
Review of facility admission orders revealed an
order for Morphine 20 mg/ ml give 0. 5 ml SL q 4
hours.
Reveiw of Admission Nurses Notes, date
12/ 18/ 15 at 10: 30 p. m., revealed Resident# 1 had
been transferred from out of state by a Medivac
flight and had required the administration of
Fentanyl 100 mg Intravenously( IV) for pain and a
nebulized respiratory treatment enroute. Nurse' s
notes on 12/ 19/ 15 at 8: 20 a. m., written by the
night shift nurse, indicated the resident did not
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LA YETTE,
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GA

X4) ID
DATE
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DEFICIENCY)
experience sufficient pain relief with the

admission order of Morphine 10 mg SL q 4 hours,
the physician was notified on 12/ 19/ 15 at 8: 00
a. m., and the order was changed to Morphine 20
mg/ 1 ml give 1 ml SL every three ( 3) hours.
Resident# 1 continued to experience pain after
administrations of Morphine 20 mg every 3 hours
and the physician increased the frequency of
routine scheduled Morphine 20 mg SL to every
two ( 2) hours on 12/ 19/ 15 at 3: 30 p. m. There was
one pulse oximeter oxygen saturation of 93%,
recorded at 3: 30 p. m. on 12/ 19/ 15 and one
recorded pain level of eight( 8). He had allowed
suctioning four times.
Review of the Nurses Note on 12/ 20/ 15 at 1: 30
a. m. revealed resident denied pain and allowed
suctioning and tracheostomy care as ordered.
The next entry at 8: 05 p. m. by the day shift Nurse
AA" LPN revealed the resident had
experienced fever of 102, was congested, and
had received Morphine 20 mg SL at 7: 00 a. m.
and again at 7:30 a. m. due to a documentation
omission by the prior shift. He had allowed
suctioning and tracheostomy care as ordered.
The physician had been notified of the fever and
gave orders for lab work. The fever had lowered
to 99. 9 at 6: 00 p. m. No vital signs except for
temperature were recorded for the 7 a. m. to 7
p. m. shift and no pain scale or oxygen saturation
were recorded. The facility had not assessed pain
level, blood pressure, pulse, or oxygen saturation.
The physician was notified of the medication error
on 12/ 20/ 15 at 8: 00 p. m. and gave orders for vital
signs to be checked every hour until midnight.
Review of the Controlled Drug Record revealed
Resident# 1 received Morphine 20 mg SL 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
PRINTED: 03/ 17/ 2016
FORM APPROVED
STATEMENT OF DEFICIENCIES ( X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
A. BUILDING
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DEFICIENCY)
12/ 20/ 15 at 5: 30 p. m. and 7: 30 p. m. The

Controlled Drug Record has these doses listed as ::
refused. The reverse side of the Medication
Administration Recored ( MAR) indicated the 5: 30
p. m. dose was refused and this was signed by
Nurse " AA" . Continued review of the reverse
side of the MAR indicated an entry by Nurse " BB '
had not been able to administer the 7: 30 p. m.
dose of Morphine because she could not arouse
Resident# 1. Nurse " BB" also recorded on the
MAR that Resident# 1 had refused suctioning on
12/ 20/ 15 at 10: 00 p. m. and on 12/ 21/ 15 at 2: 00
a. m.
The Nurses Notes for 12/ 21/ 15 at 2: 00 a. m.

records the following vital signs in the date and
time margin:
10: 00 p. m. - 11: 00 p. m. : 60, 18, 90/ 50
11: 00 p. m. - 12: 00 p. m. : 61, 16, 92/ 60, 93%
The Nurses Note, by Nurse " BB " , for 12/ 21/ 15
at 2: 00 a. m. records vital signs at 2: 00 a. m. as
97. 1, 75, 17, 91/ 53 and oxygen saturation of 90%. '
This Nurses Note indicated the resident had
refused suctioning twice during the shift, but had
been suctioned orally via Yankauer suction. No
assessments were recorded for level of pain,
congestion or general respiratory status, or level
of sedation for the shift, or oxygen saturation after
2: 00 a. m.
The Controlled Drug Record indicated the
resident was administered Morphine 20 mg SL on
12/ 20/ 15 at 9: 30 p. m., and 11: 30 p. m. and on
12/ 21/ 15 at 1: 30 a. m., 3: 30 a. m. and 5: 30 a. m.
Review of Nurses Progress Notes date 12/ 21/ 15
on the Situation Background Assessment
Request( SBAR), with no time recorded, Nurse "
CC " recorded being called to the residents room
due to low oxygen level of 55%. The physician
had been notified at 5: 55 a. m., ordered transfer to
hospital and the EMS system arrived for transport
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DEFICIENCY)

at 6: 30 a. m. The resident had responded to
suctioning, breathing treatment and an increase
in the oxygen setting, with an oxygen saturation
of 63%.
Review of EMS Patient Care Report 12/ 21/ 15 at
6:25 a. m. revealed the following: Upon initial
arrival he seemed very sleepy and had pinpoint
pupils. The report revealed once in the
ambulance he was deep suctioned and large
amounts of mucous and emesis resulted.
Respiratory rate was eight( 8) and shallow, and
15 liters of oxygen was applied by mask over
trach. Narcan 0. 5 mg was administered after IV
access was obtained and the resident responded
with an increase in respirations to an acceptable
rate and volume and his pupils became less
constricted. The transport was upgraded to
urgent after airway findings and arrived at
destination hospital at 7: 32 a. m.
Review of Emergency Department clinical record
12/ 21/ 15 from 7: 43 a. m. through 11: 15 a. m.
revealed on arrival was alert, with emesis and
mucous on gown, skin and dressings on arrival.
His level of consciousness diminished and at 9: 30
a. m. was placed on mechanical ventilation. The
emergency Department Physician charted greater,
than 35 minutes critical care. ICU admission
diagnosis was Acute Respiratory Failure,
Hypotension and Leukocytosis.
In an interview 2/ 18/ 16 at 5: 15 p. m. with the

Corporate Clinical Consultant revealed the facility
did not administer Morphine by IV route, so the
attending physician had changed the order to a 1
corresponding Oral dosage. The facility did not
consider the administration of Morphine 20 mg SL j
on 12/ 20/ 15 at 7: 00 by Nurse " BB" and at
a. m.
7: 30 a. m. by Nurse" AA" due to the omission of

documentation by Nurse " BB" , an error
I
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STATEMENT
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X4) ID
DATE
TAG
DEFICIENCY)
F 329 Continued From page 22 F 329,
because after pouring the medication out and

measuring what remained, there was no
Morphine missing. The Consultant then
acknowledged there was a dose unaccounted for
on 12/ 19/ 15 between 6: 00 a. m. and 8: 00 a. m.
and said this was not an error either. She
revealed the 2 administrations within 30 minutes
had been reported to the physician twelve hours
later, when discovered, and the physician said the
resident would have had a problem within an
hour, by 8: 30 a. m. and so this was not considered
to have caused a problem the next day when he
was found in respiratory distress. The Consultant
acknowledged there were no assessments of
pain on the Nurses Notes, or anywhere on the
chart for twenty four( 24) hours prior to being
discovered in respiratory distress. She also
acknowledged the Morphine had been held at
7: 30 p. m. on 12/ 20/ 15, because he could not be
aroused, but no mention of his level of
consciousness except refusal of suctioning at
10: 00 p. m. and 2: 00 a. m. can be found in the
nurses notes for that shift. Nurse " BB" had
charted on the Controlled Drug Record the
resident had refused Morphine at 7:30 p. m. on
12/ 20/ 15 and, on the back of the MAR, had
charted for the same time that he could not be
aroused. The Consultant explained he had
refused suctioning twice during the night of
12/ 20/ 15 through the a. m., but was unable to
explain that since, with the Morphine at 7: 30 pm
being held because he could not be aroused, but
was charted as a refusal on the Controlled Drug
Record by Nurse " BB" , if this could have been
the reason the suctioning was charted as refused, ',
when the resident may have not responded to the
request to suction due to sedation. The
Consultant acknowledged that asking a resident
for a level of pain would be an appropriate
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FORM APPROVED
A. BUILDING
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800 PATTERSON RD
DEFICIENCY)

method to determine level of sedation and
mentation, as well as pain.
Interview 2/ 19/ 16 at 10: 35 a. m. with Nurse " AA"
revealed she works every weekend from 7: 00
a. m. to 7: 00 p. m. She remembered this resident.
She acknowledged she had called the physician
on 12/ 19/ 15 at 8: 00 am, for the residents '
complaints of no pain relief form Morphine
20mg/ ml 0. 5 ml q 4 hours, and received an order
to increase the dose to Morphine 20mg/ ml give 1
ml q 3 hours. Then she called the physician again
at 3: 30 p. m. because the resident still complained
of pain and the physician increased the frequency
to Morphine 20mg/ ml give 1 ml q 2 hours. She
acknowledged the next morning on 12/ 20/ 15 at
7: 30 a. m. she administered a dose of Morphine in
accordance with the physicians order at the
scheduled time of 7: 30 a. m. and the nurse
working the prior shift, Nurse " BB " had not
documented her last 2 scheduled administrations
of the Morphine due at 3: 30 a. m. and 5: 30 a. m.
and she left her spaces to document. Nurse " AA
discovered at 7: 30 p. m. when Nurse " BB "
returned and filled in the missing documentation
that Nurse " BB" had administered Morphine 20
mg/ ml 1 mi at 7: 00 p. m. and knew this was an
error to give this Morphine with only 30 minutes
between doses and called the physician and
family. Nurse " AA" acknowledged the narcotic
count was performed on 12/ 20/ 15 at 7: 00 a. m.
but the liquid was clear and difficult to see and
she and Nurse " BB " had both signed the count
was correct, but with 2 doses not accounted for it
could not have been correct. The physician had
told her since this had happened twelve hours
previously the effects would have caused a
problem within an hour after the administrations
and she conveyed this information to the family
when she notified them. She indicated she should
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X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX DATE
OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
TAG REGULATORY
DEFICIENCY)
F 329 Continued From page 24 F 329',
have called the supervisor prior to administering

the Morphine at 7: 30 a. m. and reported the
missing documentation. She revealed on the
controlled drug record at 5: 30 p. m. she had
indicated the resident had refused Morphine but
he was actually sedated and she had not
indicated this on the back of the MAR as she
should have or in the Nurses Notes. She revealed '
she had not recorded a pain level or mental
status, level of sedation, and blood pressure,
pulse or respitarory rate or oxygen saturation at
all and could not remember what she had
assessed except the congestion in his lungs and
temperature. She acknowledged these
assessments were of importance when a
debilitated resident with Respiratory Failure was
receiving Morphine every 2 hours. Nurse " AA"
had requested the assistance of the 7: 00 am to 7
p. m. Registered Nurse " EE" supervisor from
the North Hall to assist her in determining
whether it was safe to administer Morphine to
Resident# 1 at 5: 30 p. m. and it was determined
the scheduled Morphine should be held due to
sedation. Nurse " AA" revealed she should have
indicated holding this Morphine on the reverse
side of the MAR but did not record this anywhere
except as refused on the Controlled Drug Record.
Nurse " AA" then revealed at 7: 30 p. m. she
requested further assistance when she entered
the room of Resident# 1 with the oncoming Nurse '.
BB" when the next Morphine was due, and
discovered Resident# 1 was still sedated. Nurse
EE " , Nurse " AA" and Nurse " BB " decided
to hold this dose of Morphine as well. Nurse " EE
then gave education to the nursing staff

regarding the importance of using nursing
judgement when administering medication. and
assessing oxygenation with opiates like
Morphine.
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FORM APPROVED
COMPLETED
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800 PATTERSON RD

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
EACH CORRECTIVE ACTION SHOULD BE CO PLETION
PREFIX DATE
TAG
DEFICIENCY)
Interview 2119/ 16 at 11: 55 a. m. with Nurse " BB"

LPN revealed she remembered not signing on the',
MAR or Controlled Drug Record for Morphine
20mg/ ml one ml to be administered to Resident
1 on 12/ 20/ 15 at 3: 30 a. m. and 5: 30 a. m., but
actually administered at 4: 30 a.m. and 7:00 a. m.
Nurse " BB" was unable to remember why
these doses were administered late. She
acknowledged that omitting this documentation
had resulted in 2 doses of Morphine being
administered within 30 minutes and this was an
error and could have caused Resident# 1
oversedation and respiratory depression. She
acknowledged she had not assessed the resident
s pain level throughout the 12/ 20/ 15 7 p. m. to
7: 00 a. m. shift and had administered the
Morphine at 9: 30 p. m., 11: 30 p. m., 1: 30 a. m.,
3: 30 a. m. and 5: 30 a. m. because it was ordered
to be given on that schedule. Nurse " BB"
revealed she could not remember if the resident
actually responded to her request to suction him
or just did not answer her at 10: 00 p. m. and 2: 00
a. m. Nurse " BB" confirmed she had not
obtained an oxygen saturation after 2: 00 a. m.
when it was 90% and she did not know why she
did not check the oxygen level after a low

reading. Nurse " BB" remembered the resident
had been sedated and less comprehending
throughout the entire shift. She could not explain
why she had recorded on the Controlled Drug
Record that Resident# 1 had refused the 7: 30
p. m. dose of Morphine and then charted on the
back of the MAR that he could not be aroused
when she and 2 other nurses had not been able
to awaken him. Nurse " BB" acknowledged
receiving education from Nurse " EE" RN
regarding using nursing judgement even when a

medication was scheduled and the need to use
objective data such as vital signs and subjective
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X4) ID
SHOULD BE COMPLETION
EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION
PREFIX DATE
TAG
DEFICIENCY)
data such as the resident' s ability to use a pain

scale to determine whether it was safe to
administer a prescribed medication. Nurse " BB "
remembered signing an education roster for this

discussion but could not remember why she did
not apply this education to administering
Morphine to Resident# 1. Nurse " BB" revealed
she had been told to document her medications
after she gave them and not to wait until the end
of the shift to chart.
In an interview with a family member of Resident
1 on 2/ 19/ 16 at 2: 00 p. m. revealed the resident
had been in and out of the Intensive Care Unit for
about two months, needing mechanical
ventilation most of the time and multiple IV
medications. The Resident had communicated to
the family member, who was unable to give an
exact date, by using his letter board that at some
point during the night before he was transferred
from the facility to the hospital he had awakened
to medication being administered in his mouth,
without any one speaking to him, and did not
remember anything after that.
In an interview on 2/ 22/ 16 at 150 p. m. with EMS
Paramedic that transfered Resident# 1 to the
hospital on 12/ 21/ 15 at 6: 30 a. m. stated he
remembered the resident was very sedated with
pinpoint pupils that are classic in a Morphine
overdose. His respiratory rate was 6 to 8 per
minute and shallow and the resident was
lethargic. The Paramedic revealed he attended to
clearing the residents ' airway, administering high
flow 02 and suctioning. He applied the cardiac
monitor, started an IV and gave Narcan 0. 5 mg IV
as soon as he possibly could because he was
sure this would improve the residents' condition.
The residents ' condition did improve with

increased respiratory rate and depth and pupil
size, but he had to suction copious amounts of
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X4) ID
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DEFICIENCY)
secretions constantly and the resident was

vomiting as well so the transfer was upgraded to
urgent and the resident reached the Emergency
Department at 7: 30 a. m.
Interview 2/ 23/ 16 at 1: 30 p. m. with the attending
Physician of Resident# 1 revealed he had
changed the original transfer order for Morphine
from intravenous( IV) to sublingual ( SL)
administration because the facility did not
administer IV Morphine. He revealed this required
an increased dose because Morphine is
metabolized very differently when administered
SL. The Physician revealed he had been called
twice after his original order because Resident# 1
had complained of no pain relief. He had, on the
morning of 12/ 19/ 15, first increased the 10 mg
Morphine dose to 20 mg and decreased the
schedule from every 4 hours to every 3 hours,
and on the second call the afternoon of 12/ 19/ 15
had again decreased the scheduling from every 3
hours to every 2 hours. He had been made aware '.
of the resident receiving 2 doses of Morphine 20
mg SL within 30 minutes on the morning of
12/ 20/ 15, but indicated due to the rapid
metabolism of Morphine this would not have
caused the Resident a problem with respiratory
depression the next day. The Physician indicated
he would expect a nurse to hold a scheduled
dose of Morphine for sedation and to evaluate a
resident' s respiratory status prior to
administration of Morphine, whether it is
scheduled or as needed.
Clinical Competency Coordinator( CCC) revealed
there was no Clinical Competency Coordinator
during the orientation of Nurse " BB" LPN, who
was hired on 10/ 1/ 15. The orientation program
consisted of 2 checklists, a medication test,
computer learning modules and learning
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OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION x5)

SHOULD BE CO PLETION
MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION
PREFIX EACH DEFICIENCY DATE
TAG
DEFICIENCY)
medication pass with another nurse supervising.

The Nurse in charge of completing Minimum Data',
Set Assessments was given the extra duty of
being responsible for orienting new nurses. She
resigned in December 2015. The Clinical
Competency Coordinator was hired for this
position on December 16, 2015. She revealed
she teaches orienting nurses that an actual pain
level may not be needed for each dose of a
scheduled pain medication but for a narcotic
being administered every 2 hours an in- depth
assessment of respiratory status and level of
consciousness should be assessed with each
dose. She acknowledged Nurse " BB" had not
returned the checklist entitled Skills Competency
Checklist Form: RN/ LPN.
For Resident# 1, the facility increased the dosage
and scheduling of Morphine as ordered by the
Physician, but failed to assess the residents pain
level and respiratory status, and administered the
Morphine without regard to the level of sedation
for the doses administered on December 20,
2015 at 9: 30 p. m., 11: 30 p. m. and on December
21, 2015 at 1: 30 a. m., 3: 30 a. m. and 5: 30 a. m.
R# 1 was discovered in respiratory distress on
December 21, 2015 at 5: 50 a. m. and was
transferred to the hospital, admitted to the
Intensive Care Unit, and remained hospitalized
until February 4, 2016. The facility' s failure to
monitor the resident' s level of consciousness,
respiratory status and pain level resulted in a
situation which the facility' s noncompliance with
the requirements of participation caused, or had
the likelihood to cause, serious harm, injury,
Based on the above R# 1 was admitted to the ICU
with a diagnoses of Severe latrogenic
Hypotension and the next day Intenstive Care
Unit( ICU) Physician Progress notes indicated he
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FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391 ,

CENTERS
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X4) ID COMPLETION
BY FULL EACH CORRECTIVE ACTION SHOULD BE
PREFIX EACH DEFICIENCY MUST BE PRECEDED PREFIX
DATE
INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)
was diagnosed with Demand Ischemia and Non

ST Segment Elevation Myocardial Infarction
NSTEMI). The Immediate Jeopardy continued
through December 20, 2015, the date Resident
2 received, due to an omission of
documentation, receeved two ( 2) doses of
Morphine 20 mg SL within 30 minutes, one dose
at 7: 00 a. m. and another dose at 7: 30 a. m. The
night of 12/ 20/ 15 and the morning of 12/ 21/ 15,
from 9: 30 p. m. through 5: 30 a. m. Resident# 1
received Morphine 20 mg SL every 2 hours
without assessment of respiratory status, pain
level and without regard to sedation level and
education provided by a Nursing Supervisor
advising the use of nursing judgement, the
residents ability to use a pain scale to assess
sedation, and the possibility of respiratory
depression with the use of opioid medication.
F 333 483. 25( m)( 2) RESIDENTS FREE OF F 333
SS= J SIGNIFICANT MED ERRORS
The facility must ensure that residents are free of

any significant medication errors.

by:
Based on random observations, facility and
clinical record review, and staff interviews, the
facility failed to ensure that two ( 2) residents i
R# 1, and R# 2) were free of significant

medication errors, regarding the failure of signing
off or initialing when a medication was given on
the Medication Administration record or
Controlled Drug Record resulting in R# 1 received
the narcotic Morphine two ( 2) times within thirty
30) minutes, and failure to ensure nurses
administering Morphine assessed R# 1 for pain
PRINTED: 03/ 17/ 2016
FORM APPROVED
A. BUILDING
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DEFICIENCY)
level and/ or respiratory status prior to continued

administration of the narcotic which resulted in
R# 1 found in respiratory distress on 12/ 21/ 15
with an oxygen saturation of 55% and was
transferred emergently to a hospital where he
required mechanical ventilation And the
administration of Antihypertensive medications
prescribed for another resident, that R# 2, who
did not have a Physician' s order for the
administration of Procardia or Hydralazine,
received both medications in error, from a sample j
size of twenty- one ( 21) residents.
Findings include:
1. Review of the clinical record for Resident# 1

revealed he was flown to a landing strip in the
area of the facility on 12/ 18/ 15 by Medivac
Helicopter, then transferred to the facility by
ambulance. He had been hospitalized for six( 6)
months. He was thirty-four( 34) years old and
weighed one hundred ten ( 110) pounds ( lbs.). His
diagnoses on admission to the facility was
Chronic Respiratory Failure, Decubitus Ulcer of
Right Knee, Behcet' s Syndrome with Neurological
Involvement, Chronic Deep Vein Thrombosis
DVT), Transverse Myelitis and Major Depressive
Disorder. He arrived with a Peripherally Inserted
Central Catheter( PICC Line), a Percutaneous
Endoscopic Gastrostomy( PEG) tube, a Foley
Catheter, multiple pressure ulcers, a
tracheostomy, paralysis in three extremities and
minimal movement in the right upper extremity
and could not speak. He used a communication
board with numbers and letters to communicate.
Continued review of the transfer record from the
hospital revealed he had been diagnosed with
Meningitis two ( 2) years ago, then eighteen
months ago returned to the hospital with severe
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weakness in all extremities, incontinence, visual
disturbances and ulcerations of his mucous
membranes and was subsequently diagnosed
with Behcet' s Syndrome. He did not seek medical
treatment for approximately one year due to poor
personal care while he was in the process of
divorce. Then he was admitted to the transferring
medical center in June, 2015 due to increasing
respiratory failure, aspiration pneumonia and
severe sepsis.
Review of Physician orders for Resident# 1

revealed he had an admission order, date
12/ 18/ 15 at 9: 00 p. m., for Morphine 20 milligrams
mg) per milliliter( ml) sublingual ( SL) give 0. 5 ml
every four( 4) hours. Another Physician order
was received by the facility on 12/ 19/ 15 at 8: 00
a. m. indicating that due to continued pain
Morphine 20 mg/ ml give 1 ml every 3 hours was to
be administered. On 12/ 19/ 15 at 3: 30 p. m. an
order to increase the Morphine to 20mg/ ml give
1 ml every 2 hours was received due to pain level
eight of ten ( 8/ 10).
Review of the Controlled Drug Record revealed

the Morphine 20mg/ ml 1 ml SL was administered
on 12/ 29/ 15 at 3: 30 p. m., 5: 30 p. m. by Nurse
AA" LPN. The next administrations were by
Nurse" BB" and took place on 12/ 19/ 15 at 8: 00
p. m., 10: 00 p. m., on 12/ 20/ 15 at 12: 00 a. m., 2: 00
a. m., 4: 30 a. m. and 7: 00 a. m. Nurse" AA"
returned and administered the next dose at 7: 30
a. m. Further review of the Controlled Drug
Record revealed on 12/ 20/ 15 at 5: 30 p. m. and
7: 30 p. m. Morphine 20mg/ ml, 1 ml q 2 hours was
not administered, indicated by" refused" on the
corresponding line. Morphine was administered
as scheduled on 12/ 20/ 15 at 9: 30 p. m., 11: 30
p. m., on 12/ 21/ 15 at 1: 30 a. m., 3: 30 p. m., and
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j PREFIX
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5: 30 a. m.
Review of the reverse side of the Medication

Administration Record ( MAR) for 12/ 20/ 15
revealed Nurse" BB" had recorded Resident# 1
could not be aroused at 7: 30 p. m. and the
Morphine was held. There is no other
documentation on the reverse side of the MAR
for subsequent doses.
Review of the Nurses Notes for Resident# 1 for

12/ 20/ 15 revealed no indication of an assessed
pain level, blood pressure, pulse, oxygen
saturation or efforts to provide tracheal suctioning
for the 12/ 20/ 15 7: 00 a. m. to 7: 00 p. m. shift by
Nurse" AX. The Nurses notes for that time
period did reveal that due to omission of
documentation of Morphine administration by
Nurse"" BB" for 4: 30 a. m. and 7: 00 a. m., a dose of
Morphine had been administered at 7: 30 a. m.
The Nurses Notes for 12/ 20/ 15 7: 00 p. m. through
12/ 21/ 15 at 7: 00 a. m. indicated R# 1 had refused
suctioning at 10: 00 p. m. and 2: 00 a. m. There was
no mention of his sedation level, pain level, for
the twelve( 12) hour night shift or R# 1 respiratory
status after 2: 00 a. m. A pulse oximeter reading
was recorded at 2: 00 a. m. revealing an oxygen
saturation of 90 %. At 5: 55 a. m. the residents'
physician was notified that he had been found in
respiratory distress with an oxygen saturation of
55 %, had been suctioned, oxygen setting
increased, a nebulized breathing treatment
administered, and the oxygen saturation was
63%. EMS was called, and transported R# 1 to
the hospital where he was emergently placed on
mechanical ventilation and admitted to Intensive
Care Unit.
Review of the EMS Patient Care Report 12/ 21/ 15
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X4) ID SUMMARY
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revealed Resident# 1 had been administered

Narcan 0. 5 mg IV at 6: 41 a. m. with rapid
response of increased level of consciousness,
increased level of oxygenation, increased rate of
respirations and increased pupil size.
Review of corporate policy entitled Medication

Administration: General Guidelines, Procedure,
revealed the following:
10, Medications are to be administered within
sixty( 60) minutes before or after scheduled time.
11, After medication administration the residents
MAR is initialed by the person administering the
medication.
19, Signal stickers that denote important

information regarding the medications are used to
assist in accurate medication administration
2. Record review for R 2 revealed an Annual

Minimum Data Set( MDS) assessment having an
Assessment Reference Date of 12/ 11/ 15 which
documented that the residents' race was white
and the resident's year of birth was 1936, thus

indicating the resident was 79 years of age.
Section I- Active Diagnoses of this MDS
documented that Resident# 2 had diagnoses
which included Alzheimer' s disease, Psychotic
Disorder Order, Dementia, and Hypertension and
Section C - Cognitive Patterns documented that
the resident had both short- term and longterm
memory problems with a Brief Interview Mental
Status Score of 05. Section G - Functional Status'
documented that Resident# 2 was extensive
assist of one ( 1) person with Activities of Daily
Living ( ADLs).
In comparison, review of the medical record for

the roommate of R 2 revealed a Quarterly MDS
assessment having an Assessment Reference
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Date of 12/ 21/ 15 which documented that the
residents ' race was black or African American
and the residents ' year of birth was 1954, thus
indicating the resident was 61 years of age.
Section I- Active Diagnoses of the MDS
assessment documented the resident as having
Congestive Heart Failure, Hypertension, Cerebral
Vascular Disease, and Depression and Section
C- Cognitive Patterns documented the resident as
having a BIMS of 15, Section G- Functional Status '
documented that the resident was independent to
supervision ( set up help only) with ADLs.
A Nurse' s Notes ( NN) entry of 10/ 14/ 15 with no

time listed for R 2 documented that the resident
was in bed this a. m. and was given meds that
were for another resident by trainee. Resident
was given Procardia 30mg and Hydralazine
100mg. Vitals are 136/ 58, 57, 96. 8 and no signs
of acute distress. Doctor made aware.
A NN entry of 10/ 14/ 15 at 7: 10 a. m. documented

Resident now starting to fall in Blood Pressure
B/ P) and becoming unresponsive. Called 911,
placed in bed in Trendelenburg. B/ P now 64/ 38.
Resident fading in and out of responsiveness.
Very drowsy and not answering staff. Placed on
oxygen ( 02) at 2 liters ( L) per minute via mask.
Eyes are open. 68/50 manual B/ P. Awaiting
ambulance.
A NN entry of 10/ 14/ 15 at 7: 20 a. m. documented

Resident out by ambulance to Hutcheson Medical
Center. Responsible party( RP) aware. MID
made aware of resident being sent out.
The facility presented an Investigation Report( IR)
related to the facility's investigation into Resident
2's significant medication error involving the
antihypertensive medications given to the wrong
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DEFICIENCY)
resident. In this IR, the facility documented that,

based on its investigation, it was found that on
10/ 14/ 15 Resident# 2 had received
antihypertensive medications during the 6: 00 a. m. '
med pass that were prescribed for the roommate.
The residents' roommate reported the
medication error to a Certified Nursing Assistant
CNA) who reported it to the Charge
Nurse. 12/ 25/ 2013, The Residents' B/ P began to
drop and he became lethargic. Eyes remained
open, placed in Trendelenburg position and put
on 02 at 2/ L. EMS notified and transported to
Hutcheson Medical Center.
A hospital History and Physical ( H& P) report for R

2 documented the resident' s 10/ 14/ 15 admission
to the hospital. This H& P documented, in the
History of Present Illness section, R 2 presented
to the hospital with complaints of hypotension.
The patient is currently a resident of Shepherd
Hill Nursing Home and was given the medications
of another resident by accident, resulting in
accidental overdose. The patient was given
100mg of Hydralazine and 30mg of Procardia by
mistake and his blood pressure went down into
the 50x and 60s systolic. The patient was
transferred to the emergency department where
Poison Control was called and they
recommended IV fluid resuscitation with close
monitoring of blood pressure in ICU. There is no
antidote required or recommended by Poison
Control and he was transferred up the ICU for
further monitoring, on presentation to the ICU his
blood pressure is 90/64 and he is alert and
responsive without any focal neurologic deficits.
The medication error occurred about 6: 00 a. m.
and his medicines were given by a nurse who
was new to the facility and undergoing
orientation. Past Medical History documented
I
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Dementia, Hypertension and History of Coronary

Artery Disease. Assessment documented
Accidental overdose with anti hypertensive
medications including Hydralazine and Procardia,
Severe Hypotension, Dementia, and History of
Hypertension and Coronary Artery Disease.
Review of the Cardiologist progress noted dated

10/ 15/ 15 documented Demand Ischemia with
minimal Left Ventricle damage.
The hospital Discharge Summary for R 2

documented a hospital discharge date of
10/ 17/ 2015. The Discharge Diagnoses section
of this Discharge Summary listed diagnoses for
R2 which included, among others, latrogenic
Hypotension secondary to medication mistake at
the nursing home, Demand Ischemia, Dementia,
Cardiac Hypotension, History of Coronary Artery
Disease, and History of Hypertension.
Review of the incident report for the medication

error that occurred on October 14, 2015 revealed
the roommate reported to the Certified Nursing
Assistant( CNA) that R 2 had been given 6: 00
a. m. medications that were meant for him.
Interview with the Administrator on February 19,

2016 at 6: 30 p. m. revealed that an in service was
conducted when this medication error was
discovered and she had both nurses in her office
and wrote up the nurse that was training the new
nurse because she was sitting at the nurse' s
station lettering her give meds alone.
Interview with the Administrator on February 22,
2016 acknowledged the supervising nurse had
left Nurse BB unattended and she did not know
the residents. She further acknowledged that
pictures of the residents were always on the
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Review of the facility policy: Medication

Administration: General Guidelines, revised
01/ 23/ 2015 and reviewed 01/ 26/ 2016, revealed:
Policy Statement: Medications are administered
as prescribed, in accordance with good nursing
principles and practices and only by persons
legally authorized to do so. Personnel authorized
to administer medications do so only after they
have familiarized themselves with the medication.
Procedure: ( 2) Medications are administered in
accordance with written orders of the attending
physician. If a dose seems excessive
considering the patient/ resident' s current
diagnosis or condition, the physician is contacted j
for clarification prior to the administration of the
medication. This interaction with the physician is
documented in the nursing notes and elsewhere
in the medical record as appropriate. ( 7)
Patients/ residents are identified before

medication is administered. When in doubt: ( a)
Check identification band ( b) Check photograph
attached to medical record. ( c) Call
patient/resident by name. ( d) If necessary, verify
patient/ resident identification with other
healthcare center personnel. ( 14) Medications
supplied for one patient/ resident are never
administered to another patient/ resident.
Review of the Lexi- Comp' s Drug Reference

Handbook 12th Edition, revealed pg. 1100
Procardia, a Calcium Channel Blocker, used for
treatment of angina ( vasospastic, chronic stable),
Hypertrophic Cardiomyopathy, Hypertension
sustained release only), Pulmonary
Hypertension. Contraindications; Serious
adverse events ( cerebrovascular ischemia,
syncope, heart block, stroke, sinus arrest, severe
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DEFICIENCY)

hypotension, acute myocardial infarction, and
EKG changes) have been reported in relation to
each use. Blood pressure lowering should be
done at a rate appropriate for the patient's
condition. Rapid drops in blood pressure can
lead to arterial insufficiency. Increased angina
and/ or MI has occurred with initiation or dosage
titration of calcium channel blockers.
Hypersensitivities to Nifedipine or any component
of the formulation, immediate release preparation
for treatment of urgent or emergent hypertension,
acute MI. Warnings/ Precautions: The use of
sublingual short- acting nifedipine in hypertensive
emergencies and pseudoemergencies is neither
safe nor effective and should be abandoned!
Severe hypotension may occur in patients taking
immediate release nifepine concurrently with beta
blockers when undergoing CABG with high dose
fentanyl anesthesia. pg. 1311 Propranolol, a
Beta- Blocker, used for management of
Hypertension, Angina Pectoris, essential tremors,
arrhythmias, and prevention of Myocardial
Infarction. Contraindications: Hypersensitivity to
Propranolol, beta- blockers, or any component of i
the formulation; uncompensated Congestive
Heart Failure. Warnings/ Precautions: Administer
cautiously in compensated heart failure, and
monitor for worsening of the condition ( U. S.
Boxed Warning): Beta- block therapy should not
be withdrawn abruptly( particularly in patients with

CAD), but gradually tapered ( over 2 weeks) to
avoid acute tachycardia, hypertension, and/ or
ischemia, pgs 739- 740 Hydralazine, Vasodilator,
Used for management of moderate to severe
Hypertension, Congestive Heart Failure,
Warning/ Precautions: Use with caution in
Myocardial Oxygen Demand), Use in caution with
Pulmonary Hypertension ( may cause
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Hypotension) and , pgs 739- 740 Hydralazine,

Vasodilator, Used for management of moderate
to severe Hypertension, Congestive Heart
Failure, Warning/ Precautions: Use with caution in
Myocardial Oxygen Demand), Use in caution with
Pulmonary Hypertension ( may cause
Hypotension)..

2016 of the MARS located on the medication
carts revealed pictures were not on the MARS.
On February 24, 2016 six( 6) resident pictures
remained missing on the South Wing MARS.
Interview conducted on 2/ 23/ 16 at 10: 00 a. m. with

LPN " HH " , who was the nurse supervising "
BB " on October 14, 2015 when R 2 received the
wrong medications revealed that she thought "
BB " had been working with the residents long
enough to know who
they were. " HH " further
revealed that she was at the medication cart
when the medications were prepared and also
acknowledged there were no pictures of these
two residents on the MARS.
Interview with administrator on 2/ 22/ 16 at 2: 30
p. m. revealed the supervising nurse had left
Nurse" BB" unattended and she did not know the
residents and gave the 6: 00 a. m. doses
belonging to the roommate to R 2 by accident.
She further revealed pictures of the residents are
s to identify the residents.
In an Interview conducted on 2/ 24/ 16 with the

Administrator revealed that the next day when
she was made aware of the medication error she
had both the trainee and the nurse training her in
the office and verbally reprimanded both of them,
she further acknowledged that the Medical
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Director was made aware and recommended
pictures identifying residents placed on all MARS,
and a revamp of the orientation process for
nurses required to administer medications.
2016 at 2: 10 p. m. revealed four( 4) residents on
the North Hall and two ( 2) residents on the South
Hall did not have pictures identifying the
residents. Subsequent observations conducted
on February 25, 2016 at 10: 40 a. m. of the books
containing the MARS revealed six( 6) residents
did not have pictures of residents.
Interview on 2/ 18/ 16 at 5: 15 p. m. with the

Corporate Clinical Consultant revealed on
12/ 20/ 15 Resident# 1 received 2 doses of
Morphine 30 minutes apart, at 7: 00 a. m. and 7: 30
a. m., resulting from an omission of
documentation for the 7: 00 a. m. administration.
The Consultant indicated this was investigated by
pouring out the Morphine and measuring it and
determining after Nurse" BB" had signed out the
previously undocumented doses that no
Morphine was missing and no extra
administrations had occurred. The Consultant
acknowledged that this concluded the
investigation and that despite the low level of
tolerance for a timing discrepancy with Morphine,
with the resulting administration 30 minutes
beyond what the corporate policy allowed, with
the resident history of Chronic Respiratory
Failure, and with the weight of 110 lbs. and
general debility placing the resident at higher risk
of adverse reaction, this was not considered a
medication error. The five ( 5) doses of Morphine
that occurred on 12/ 20/ 15 at 9: 30 p. m. li
beginning
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through 12/ 21/ 15 at 5: 30 a. m., without
assessment of pain level for 24 hours, no record
of oxygen saturation after 2: 00 a. m. and with 2
doses at 5: 30 p. m. and 7: 30 p. m. held due to
sedation witnessed by 2 additional nurses, that
were charted as refused, and the residents
subsequent respiratory depression less than 30
minutes after the last dose, were also not
identified as an error.
Interview on 2/ 19/ 16 at 10: 35 a. m. with Nurse

AA" revealed she had administered scheduled
Morphine 20 mg 1 ml SL at 7: 30 a. m. and left 2
spaces for the 7: 00 p. m. to 7 a. m. Nurse" BB" to
fill in. She acknowledged the MAR was not
decipherable, due to her errors in scheduling and
recording doses on the wrong time and date,
circling doses that had actually been
administered and crossing out her initials to
attempt to correct errors. She acknowledged she
had not questioned Nurse" BB" until 7: 00 p. m.
about the missing documentation on the MAR
and Controlled Drug Record and she should have
reported this to the supervisor immediately before
administering the 7: 30 a. m. dose. Nurse" AA"
revealed she had received no mention in report of',
Nurse" BB" s administration of Morphine at 7: 00
a. m. when it was scheduled for 5: 30 a. m., 30
minutes outside the one hour allowed by policy,
and there was no flag on the MAR or any other
indication this had been administered late. Nurse
AA" revealed at 5: 30 p. m. when it was time to
administer a scheduled dose of Morphine she
had indicated on the back of the Controlled Drug
record that the resident had refused Morphine.
She had called the supervisor, Nurse"" EE"
Registered Nurse ( RN) from the North Hall and
the resident had been evaluated as too sedated
to receive the Morphine and the resident had not
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actually not responded to her when she asked if

he was going to take his pain medication or the
level of his pain. She acknowledged she should
have recorded an oxygen saturation, blood
pressure, pulse, pain level and level of sedation
for this 12 hour shift. She acknowledged she
should have recorded the Morphine was held for
sedation and not recorded it was refused.
Interview 2/ 19/ 16 at 11: 55 a. m. with Nurse" BB"

revealed she had not signed the MAR or
Controlled Drug Record for two administrations of
Morphine to Resident# 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 had not communicated this to
Nurse" AA" and she should have signed and
initialed the medication as well as reporting this
and flagging the MAR with the information. She
acknowledged this failure resulted in Resident# 1
receiving 2 administrations of Morphine within 30
minutes and for a Resident with Chronic
Respiratory Failure, this resulted in a high
likelihood of an adverse reaction. Nurse" BB"
revealed she had recorded holding Morphine at
7: 30 p. m. as refused on the Controlled Drug
Record and on the back of the MAR as held
because she and Nurse" AA" and Nurse" EE" had
not been able to arouse the resident. She
revealed she could not remember why she wrote
refused, and could not remember if the resident
had actually responded to refuse the suctioning at
10: 00 p. m. or 2: 00 a. m. or if he just did not
respond at all. She did remember Resident# 1
had been sedated and less comprehending
throughout the shift. Nurse" BB" acknowledged
she had not assessed pain level throughout the
12/ 20/ 15 7: 00 p. m. to 12/ 21/ 15 7: 00 a. m. shift, or
assessed respiratory status throughout the shift,
or checked oxygen saturation after 2: 00 a. m.
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DEFICIENCY)
F 333 Continued From page 43 F 333'',

when it was 90%. She revealed she should have
evaluated this resident for respiratory depression
and she had not performed these assessments.
She acknowledged she gave the Morphine every
2 hours because it was ordered to be given every
2 hours.
Interview with the parent and responsible party for

Resident# 1 on 2/ 19/ 16 at 2: 00 p. m. revealed his
son had communicated to him using his letter
board, during his most recent hospitalization, he
had awakened during his last night at the facility,
with medication being administered in his mouth,
with no one explaining what they were doing or
what the medication was. He did not remember
anything after that.
Interview 2/ 22/ 16 at 1: 00 p. m. with the

Administrator revealed she had discussed with
the medical director, who was also Resident# 1' s
Physician, the order changes for Morphine, the
administration of two doses within 30 minutes,
and the hospitalization of Resident# 1 for
respiratory distress and the Medical Director
responded by saying the only thing he could have
done differently would have been to add to the
Morphine order to hold for sedation, but he
thought that was standard nursing practice.
Interview 2/ 23/ 16 at 1: 30 p. m. with the Physician

of Resident# 1, revealed he had changed the
order for Morphine twice because the resident
continued to complain of pain. He had been made
aware of the administration of two doses of
Morphine within 30 minutes on 12/ 20/ 15, but this
was not discovered until 12 hours after the
administrations and because Morphine is
metabolized so rapidly this would not have
caused the residents respiratory distress 24
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hours later. The Medical Director acknowledged
he expected any nurse administering Morphine to
assess the resident' s respiratory status and to
check for any adverse reactions with every
administration whether it was scheduled or as
needed ( prn).
Review of corporate policy entitled Pain

Management, Lippincott Procedures, indicated
that safe medication practices should be followed
when administering strong opioid medications
such as Morphine. Pain and adverse reactions
timely manner according to the onset of the
Review of Nursing Drug Guide, Nursing 2014,

Drug Handbook, by Lippincott, Williams and
Wilkins, 34th edition, Copyright 2014, page 953,
Morphine Sulfate, Adverse reactions include
Apnea, Respiratory Arrest and Respiratory
Depression. The onset of Morphine administered
by oral route is takes place in 30 minutes, peak
action in 1- 2 hours and duration of action is 4- 12
hours.
Based on the above findings the facility failed to

administer Morphine, a drug capable of producing
Respiratory Depression, with in the scheduled
with a diagnosis of Chronic Respiratory Failure,
and monitor respiratory status, pain level and
adverse reactions.
i
Cross reference to F 281, F 329, F 425, and F

514 for additional information regarding Resident
1.
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F 425 483. 60( a),( b) PHARMACEUTICAL SVC- F 425
SS= j ACCURATE PROCEDURES, RPH
The facility must provide routine and emergency

drugs and biologicals to its residents, or obtain
them under an agreement described in
483. 75( h) of this part. The facility may permit
unlicensed personnel to administer drugs if State
law permits, but only under the general
supervision of a licensed nurse.
A facility must provide pharmaceutical services

including procedures that assure the accurate
acquiring, receiving, dispensing, and
administering of all drugs and biologicals) to meet
the needs of each resident.
The facility must employ or obtain the services of

a licensed pharmacist who provides consultation
on all aspects of the provision of pharmacy
services in the facility.

by:
Based on record review, review of Medication
Discrepancy/ Adverse Reaction Report policy, and
staff interview the facility failed to provide
pharmaceutical services to review, track and
trend medication errors, and determine the need
for interventions such as staff education, for two
2) residents (# 1 and# 2) from a sample of
twenty- one ( 21) residents.
Findings include:
Record review for Resident# 1 revealed that he

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DEFICIENCY)
was admitted to the facility on 12/ 18/ 15 with

diagnoses including Chronic Respiratory Failure
and Behcet' s Syndrome. He was chronically ill
with a tracheostomy and required humidified
oxygen at 5 Liters by trach mask. Review of
Physician orders for Resident# 1 revealed an
order was received for Morphine 20 mg/ ml one
ml SL every 2 hours on 12/ 19/ 15 at 3: 30 p. m.
Review of Nurses ' notes dated 12/ 20/ 15 at 8: 05
p. m. revealed at 7: 00 a. m. Resident# 1 had
received Morphine 20 mg SL that had been
scheduled for 5: 30 a. m. and had not been
documented on the Medication Administration
Record or the Controlled Drug Record by Nurse
BB"
Review of the Controlled Drug Record confirmed j

Nurse " BB" had administered the 4: 30 a. m.
scheduled Morphine 20 mg SL at 7: 00 a. m. and
Nurse " AA" had administered the next dose on
schedule at 7: 30 a. m. Continued review revealed
Resident# 1 had received Morphine 20 mg SL as
scheduled on 12/ 20/ 15 at 9: 30 p. m., 11: 30 p. m.,
and 12/ 21/ 15 at 1: 30 a. m., 3: 30 a. m. and 5: 30

a. m. None of these administrations were
recorded as wasted in the area provided.

Nurse " AA" stated she had assumed on
12/ 20/ 15 that the scheduled Morphine had been
administered on time at 5: 30 a. m. and left spaces
for Nurse " BB " to sign on the MAR and narcotic
sign out form, and had administered the next
scheduled Morphine 20 mg SL as ordered at 7: 30
a. m. Nurse " AA" acknowledged she should
have contacted the Nursing Supervisor who
would have contacted Nurse " BB " before
administering the Morphine.
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A. BUILDING
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800 PATTERSON
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DEFICIENCY)

Review of the Situation Background Assessment
Recommendation ( SBAR), 12/ 21/ 15 at 5: 55 a. m.
revealed R# 1 had been found at some time prior
to 5: 55 a. m., no time recorded- in respiratory
distress with an oxygen saturation of 55%.
Review of the Patient Care Report received from

the Emergency Medical Service transporting
Resident# 1 on 12/ 21/ 15 at 6: 25 a. m., revealed
he had been transferred emergently to a hospital,
requiring continuous tracheal and oropharyngeal
suction, administration of the opiod reversal agent'
Narcan, and high flow oxygenation.
Review of Nursing Drug Guide, Nursing 2014

Drug Handbook by Lippincott, Williams and
Wilkins, 34th Edition, Copyright 2014, Page 953,
Morphine Sulfate, Adverse Reactions include
apnea, respiratory arrest, and respiratory
depression. Half- life occurs in 2 to 3 hours.
Review of the clinical record for Resident# 2

revealed diagnoses including Hypertension,
Congestive Heart Failure ( CHF), Alzheimer' s '
Dementia, Anxiety, and Psychotic Disorder.
Review of the Quarterly Minimum Data Set
MDS) Assessment, date 8/ 18/ 15, Section C,
revealed a Brief Interview for Mental Status
BIMS) Score could not be obtained. Continued
review of past MDS revealed the last BIMS
scoring Resident# 2 was able to complete was
dated 7/ 3/ 13 and the resident scored 3, indicating li
severe cognitive impairment.
Review of Physician orders revealed Resident# 2

has an order for and receives Propranolol 20 mg
1 tab by mouth every 12 hours. Nurses Notes
indicated on 10/ 14/ 15 this resident was
administered 2 medications for hypertension,
PRINTED: 03/ 17/ 2016
FORM APPROVED
A. BUILDING
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115452 B. WING
02/ 26/ 2016
800 PATTERSON RD
DEFICIENCY)
Procardia 30 mg and Hydralazine 100 mg, at 6: 00 '

a. m. medication pass, that were ordered for
another resident, and at 7: 05 a. m. was fading in
and out of consciousness with a blood pressure
of 64/ 38. He was emergently transferred to the
closest hospital.
Review of clinical records received from the

hospital revealed in the Emergency Department
Resident# 2 required fluid resuscitation and
admission to the ICU. The diagnoses on
admission was latrogenic( medically induced)
Hypotension. The following day a Physician
Progress note included diagnoses of Demand
Ischemia and Non ST Segment Elevation
Myocardial Infarction ( NSTEMI), indicating
cardiac damage had occurred from lack of
oxygenation to the myocardium, a result of the
severe hypotension.
Review of Nursing Drug Guide, Nursing 2014

Drug Handbook by Lippincott, Williams and
Wilkins, 34th Edition, Copyright 2014, Page 988,
Nifedipine ( Procardia), Adverse Reactions include '
dizziness, light- headedness, weakness,
hypotension, somnolence and shortness of
breath. Drug- Drug interactions with Propranolol,
included on the Physician orders for Resident# 2,
include hypotension and heart failure. Use
together cautiously. Continued review of the
above Nursing Drug Guide, Page 690,
Hydralazine, revealed the following adverse
reactions: dizziness, angina pectoris, palpitations,
tachycardia, and orthostatic hypotension.
Drug- Drug interactions include with Propranolol:
may increase levels and effects of the
beta- blockers. Monitor patient closely. Nursing
considerations reveal elderly patients may be
more sensitive to drugs hypotensive effects.
PRINTED: 03/ 17/ 2016
FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938- 0391

CENTERS
PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION X3) DATE SURVEY
STATEMENT OF DEFICIENCIES ( X1)
COMPLETED
A. BUILDING
C
115452 B. WING 0212612016
800 PATTERSON RD

X4) ID CO ION
BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX EACH DEFICIENCY MUST BE PRECEDED
DATE
TAG
DEFICIENCY)
Review of the corporate policy entitled Medication

Discrepancies and Adverse Reactions revealed
medication discrepancies and adverse reactions
are to be reported to the patient/ resident' s
attending physician, the consultant and provider
pharmacists, and the Pharmaceutical Services
Subcommittee and or/the Quality Assurance
Committee. Review of Procedure, Section 5
indicated a Medication Discrepancy/ Adverse Drug
Reaction Report is to be completed. Section 8
revealed the report is to be reviewed by the
consultant pharmacist and on a quarterly basis by
the Pharmaceutical Services Subcommittee
and/ or the Quality Assurance Committee and
acted upon as appropriate.

Administrator, after requesting completed
Medication Discrepancy and Adverse Reaction
Reports for Resident# 1 and Resident# 2
regarding the incidents outlined above, revealed
that the forms had not been completed.

Corporate Clinical Consultant revealed the
Report Forms, required by Corporate Policy, have li
not been completed for any medication related
incidents for an unknown length of time. The
Consultant confirmed errors are reported verbally
to the Pharmacy Consultant, but there is no
record of what errors get reported, or the review
of these errors with recommendations or no
recommendations. The Corporate consultant
revealed the staff involved with Resident# 1 being
administered 2 doses of Morphine within 30
minutes, and Resident# 2 being administered
PRINTED: 03/ 17/ 2016
FORM APPROVED
C
115452 B. WING
02/ 26/ 2016
800 PATTERSON RD
DEFICIENCY)

another residents medications had not been
reported to the State Board of Nursing because
these incidents did not meet the criteria of what
must be reported.

Consultant Pharmacist revealed she remembered ',
the Administrator telling her about Resident# 2
receiving another residents blood pressure
medications and offering to observe Nurse " BB"
administer medications but since Nurse " BB "
was only in the building on weekend nights this
was not possible. She had no additional
recommendations, no documentation of
reviewing this incident and had not received a
Form. Continued interview on 2/ 26/ 16 at 11: 25
a. m. with the Consultant Pharmacist revealed the
Administrator had verbally advised her of
Resident# 1 being administered 2 doses of
Morphine 20 mg SL within 30 minutes when she
made her monthly visit on 1/ 8/ 16 and she stated
that she did not review the incident or anything
related to this resident because he had only been
in the facility for 2 days and was in the hospital
currently. The Consultant Pharmacist revealed
she did not receive a Medication Discrepancy and
Adverse Reaction Report Forms from the facility.
In an additional interview with the Consultant
Pharmacist conducted during a monitoring visit
on 3/ 2/ 16 at 11: 10 a. m., she revealed the
Report Forms should be completed for any
adverse reaction or possibility of an adverse
reaction. The forms should also be completed for
any deviation from the five rights of medication
administration, including right resident, right
medication, right route, right time and right dose.
PRINTED: 03/ 17/ 2016
FORM APPROVED
SERVICES OMB NO. 0938- 0391 ,
CENTERS FOR MEDICARE & MEDICAID
X3) SURVEY
EY
CONSTRUCTION
IDENTIFICATION NUMBER:
X2) MULTIPLE
CATE
C
115462 B. WING 02/ 2612016

OR SUPPLIER
NAME OF PROVIDER
800 PATTERSON RD
PRUITTHEALTH - SHEPHERD HILLS LA FAYETTE, GA 30728
X4) ID COMPLETION
MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE
PREFIX EACH DEFICIENCY
TAG DEFICIENCY)
The Consultant Pharmacist acknowledged she

has consulted for the facility since 2007 and has
never received a Medication Discrepancy/
Adverse Reaction Report Form.
Based on the above findings, two residents(# 1

and# 2) experienced Adverse Reactions to
medication administered by the facility without
completion and forwarding of the Medication
Discrepancy/ Adverse Reaction Report Form as
required by corporate policy. For Resident# 1,
the facility failed to administer Morphine twenty
20) milligrams ( mg) as scheduled at two ( 2) hour !,
intervals and due to the failure to document an
administered dose the resident received 2 doses
within thirty( 30) minutes. The following day
Resident# 1, after receiving Morphine 20 mg
every 2 hours from 9: 30 p.m. through 5: 30 a. m.,
experienced respiratory distress, required
emergent transport to a hospital, mechanical
ventilation and admission to Intensive Care Unit
ICU). This error was not reported on a
Medication Discrepancy/ Adverse Reaction Report
Form.
Resident# 2 received two ( 2) antihypertensive
medications with no order for these medications
and experienced severe hypotension, and altered
level of consciousness. Resident# 2 was then
transferred to the hospital and admitted to the 1
ICU. This error was not reported on the
Report. This resulted in a situation in which the
facility' s noncompliance with the requirements
of participation caused, or had the likelihood to
cause, serious harm, injury, impairment or death
to residents.
F 514 483. 75( I)( 1) RES F 514'
Obsolete Event ID: Z2SU11 Facility ID: LTC11461209 If continuation sheet Page 52 of 67
FORM CMS- 2567( 02- 99) Previous Versions
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800 PATTERSON RD
REGULATORY OR LSC IDENTIFYING DATE

TAG INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)

SS= J RECORDS- COMPLETE/ ACCURATE/ ACCESSIB
LE
The facility must maintain clinical records on each

resident in accordance with accepted professional
standards and practices that are complete;
accurately documented; readily accessible; and
systematically organized.
The clinical record must contain sufficient

information to identify the resident; a record of the
resident's assessments; the plan of care and
services provided; the results of any
preadmission screening conducted by the State;
and progress notes.

by:
Based on clinical record review, staff interview,
Controlled Drug Record review, and Medication
Administration Record ( MAR) review, the facility
failed to accurately document medications
administered for two ( 2) residents (# 1 and# 3),
from a sample of twenty- one ( 21) residents.
Specifically for Resident# 1, who had diagnoses

including Chronic Respiratory Failure,
Neurological Behcet' s Syndrome, Chronic Deep
Vein Thrombosis ( DVT) and Transverse Myelitis,
the resident received Morphine twenty( 20)
milligrams ( mg) by mouth ( po) at 7: 00 a. m. and
again received Morphine 20 mg po at 7: 30 a. m.
related to failure to document the 7: 00 a. m. dose
on the resident' s MAR or Controlled Drug
Record after administration. Resident# 1 had
been admitted with an order for Morphine ten ( 10)
mg po every ( q) four( 4) hours routinely for pain
and had failed to achieve pain control with this
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DEFICIENCY)

dose. The Physician was contacted two ( 2) times
with the complaints of ongoing pain
residents'
and the facility received 2 additional physician

orders for increases to the Morphine dosage and
frequency. The facility failed to record the
subsequent physician orders on the physician
order form or the MAR in conformance with the
corporate policy to include the time of the order,
the strength of the Morphine liquid, and the actual
dose to be administered. Additionally, Resident
3 received Levemir Insulin seventy( 70) units
subcutaneously ( sq) four( 4) times, administration
ofAdvair Diskus one ( 1) inhalation 1 time and
Fluvall 0. 5 ml intramuscular( IM) 1 time, during
the month of October, without the accompanying
documentation on the MAR. This resulted in a
situation in which the facility' s noncompliance
with the requirements of participation caused, or
had the likelihood to cause, serious harm, injury,
The facility' s Administrator, Director of Health
Services ( DHS), Corporate Clinical Consultant,
and Nursing Supervisor" EE" Registered Nurse
on February 25, 2016 at 5: 00 p. m. The
Jeopardy was identified to have existed on
October 14, 2015, the date another resident(# 2)
received two ( 2) antihypertensive medications
with no order for these medications and was
transferred emergently to the hospital, according
to Nurses notes, fading in and out of
consciousness with a blood pressure of 64/ 38. He',
was subsequently admitted to the ICU with a
diagnoses of Severe latrogenic Hypotension and
the next day ICU Physician Progress notes
indicated he was diagnosed with Demand
Ischemia and Non ST Segment Elevation
Myocardial Infarction ( NSTEMI). The Immediate
PRINTED: 03/ 17/ 2016

COMPLETED
A. BUILDING
115452 B. WING 0212612016
OR SUPPLIER
NAME OF PROVIDER
800 PATTERSON RD
OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION 5)

SHOULD BE CO PLETION
BY FULL PREFIX EACH CORRECTIVE ACTION
EACH DEFICIENCY MUST BE PRECEDED DATE
PREFIX
TAG
DEFICIENCY)
Jeopardy continued through December 20, 2015,

the date Resident# 1 received, due to an
omission of documentation, two( 2) doses of
Morphine 20 mg SL within 30 minutes, at 7: 00
a. m. and 7: 30 a. m. The night of 12/ 20/ 15 and the
morning of 12/21/ 15, from 9: 30 p.m. through 5: 30
a. m. Resident# 1 received Morphine 20 mg SL
every 2 hours without assessment of respiratory
status, pain level and without regard to sedation
level and education provided by a Nursing
Supervisor advising the use of nursing
judgement, the residents ability to use a pain
scale to assess sedation, and the possibility of
respiratory depression with the use of opioid
medication. An interview with the Corporate
Clinical Consultant on 2/ 18/ 16 at 5: 00 p.m.
revealed the investigation of these events had not
resulted in identifying a problem with narcotic
administration and monitoring or medication
administration and documentation. The
Immediate Jeopardy remains on going, pending
the acceptance of a final Credible Allegation of
Jeopardy Removal. Observations were made of
medication administration to assess staff' s
conformance with accurate documentation of
medication administration. Record reviews were
conducted to assess staffs conformance with
correct scheduling of medications when
transcribing orders to the Medication
Findings include
1. Record review for Resident# 1 revealed an
admission date of 12/ 18/ 15. Physician orders
included on admission to the facility, on 12/ 18/ 15
at 10: 30 p. m., Morphine 10 mg po q 4 hours
routinely for pain, Review of Physician orders
dated 12/ 19/ 15 at 8: 00 a. m. revealed a telephone
order to increase Morphine to 1 milliliter( ml) q 3
hours( hrs) due to ( d/ t) unrelieved pain. This order'
PRINTED: 03/ 6
FORM APPROVEROVE D
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DEFICIENCY)
F 514 Continued From page 55 F 514'.
did not specify the concentration or mg to be

given. The next telephone order on the Physician
order form was timed at 11: 30 a. m. and was to
increase Morphine 1 ml q 2 hrs d/ t unrelieved
pain. This order does not specify concentration of
the liquid, route of administration or number of
mg to be given.
Review of the MAR for Resident# 1 revealed the
admission order for Morphine had been
transcribed with the concentration of 20 mg per
ml, give 0. 5 ml q 4 hours routinely. No time for the
order appeared on the MAR and the times
administered were recorded correctly. The next
order transcribed to the MAR had no time when
the order was received and was transcribed as
Morphine Sulfate 1 ml q 3 hrs, with no
concentration, mg, route or date. Two doses were
signed as given on 12/ 19/ 15 at 8: 00 a. m. and
11: 00 a. m. The next order was written on the
MAR as Morphine 1 ml SL q 2 hrs routine
12/ 19/ 15. No time of the order, concentration or
mg was included. The order was initialed as given '
at 1: 00 PM. This order was marked as changed
and rewritten with a concentration and no date or
time and was initialed as given on 12/ 19/ 15 at
1: 30 a. m., 3: 30 a. m., 5: 30 a. m., 7: 30 a. m., and
9: 30 a. m. These doses were recorded as
administered before the order existed. The next
four doses on 12/ 19/ 15 at 11: 30 a. m., 1: 30 p. m.,
3: 30 p. m. and 5: 30 p. m. were correctly recorded
on the MAR then at 7: 30 p. m. and 9: 30 p. m.
initials were crossed out. The 11: 30 p. m. dose
was initialed as given. Continued review of the
MAR for 12/ 20/ 15 revealed Morphine 20 mg/ ml 1
ml was initialed as administered every 2 hours
until the initials were circled at 3: 30 p. m., 5: 30
p. m., 7: 30 p. m. and 9: 30 p. m., indicating these
doses were not administered. At 11: 30 p. m. the
Morphine was initialed as administered. On
PRINTED: 03/ 17/ 2016
FORM APPROVED
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800 PATTERSON
FAYETTE, GA R 30728

DEFICIENCY)

12/ 21/ 15 at 1: 30 a. m., 3: 30 a. m. and 5: 30 a. m.
the Morphine was initialed as administered.
Review of the Controlled Drug Record for
Resident# 1 revealed Morphine was correctly
signed as given on 12/ 19/ 16 at 2: 00 a. m. and
6: 00 a. m. Then a 0. 5 ml/ 10 mg dose had been
signed out without a time. The next dose on
12/ 19/ 15 at 8: 00 a. m. is a 1 ml 20 mg dose in
conformance with the order. According to review
of the Controlled Drug Record the next doses of
Morphine were administered as ordered until a 20
mg Morphine dose was given on 12/ 20/ 15 at 7: 00
a. m. and another was administered at 7: 30 a. m.
Review of corporate policy entitled Physician
Orders indicated as follows: A physician order for
medication or treatment must include the
following information: Date and time of order,
name of medication, strength of medication
where indicated, dosage, route of administration
and frequency of administration.
Review of corporate policy entitled Medication
Administration: General Guidelines revealed if a
dose of regularly scheduled medication is
withheld, refused or given at other than the
scheduled time the space provided on the front of
the MAR is initialed and circled and an
explanatory note is entered on the reverse side of
the record. Continued review revealed after
medication administration the MAR is initialed by
the person administering the medication.
Record review of Nurses Notes dated 12/ 20/ 15 at
1: 30 a. m. by Nurse BB Licensed Practical Nurse
LPN " revealed no indication that medication
was not given at the scheduled times. Review of
the reverse side of the MAR revealed no note
regarding a variation in the time Morphine was
administered.
The following note written by the 7: 00 a. m. to 7: 00

p. m. Nurse " AA" LPN on 12/ 20/ 15 at 8: 05 p. m.
PRINTED: 03/ 17/ 2016

X3) DATE SURVEY
OF DEFICIENCIES X1) PROVIDER/ SUPPLIER/ CLIA X2) MULTIPLE CONSTRUCTION
STATEMENT
COMPLETED
A. BUILDING
115452 B. WING 02126/ 2016

800 PATTERSON RD
OF DEFICIENCIES ID PROVIDER' S PLAN OF CORRECTION x5)

ACTION SHOULD BE COM PLLE ION
MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE
PREFIX EACH DEFICIENCY
TAG
DEFICIENCY)
revealed that upon checking narcotic count at

7:00 p. m. a medication error was found. The 7:00
p. m. to 7: 00 a. m. Nurse " BB" LPN had not
signed out the doses of Morphine administered at
4: 30 a. m. or 7: 00 a. m. and the day shift nurse "
AA" had assumed the Morphine had been
administered at the correct time, which would
have been 5: 30 a. m. and administered a dose of
20 mg Morphine thirty ( 30) minutes later at 7: 30
a. m. " AA" documented notification of the
physician and family, and an assessment of the
residents respiratory status. " AA" noted the
physician had responded that since the two doses

within 30 minutes had occurred twelve hours
previously any adverse reaction would have
already occurred.
Interview 2/ 18/ 16 at 5: 15 p. m. with Corporate
Clinical Consultant revealed this incident had
been investigated and since there were no doses
of Morphine missing and it had measured out
correctly this was not considered to be an error.
The Corporate Clinical Consultant revealed that
the policy for medication administration allows for
a one hour variation before or after the
medication is due, the administration of a dose of
Morphine due at 4: 30 p. m. and given ninety( 90)
minutes later at 7: 00 a. m., even though it was
thirty ( 30) minutes past the allotted hour, was not
considered an error. The Corporate Clinical
Consultant acknowledged that the omission of
documentation for the doses administered at 4: 30
a. m. and 7: 00 a. m. had resulted in 2 doses being
administered within 30 minutes and the resident,
already with a diagnoses of Chronic Respiratory
Failure and very debilitated, could have a high
likelihood of experiencing an increased degree of
Respiratory Failure as an adverse reaction to the
Morphine. The Clinical Consultant indicated the
unaccounted for dose of Morphine recorded on
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DEFICIENCY)
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 Nurse "
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 Resident# 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 2/ 19/ 16 at 10: 35 a. m. with Nurse " AA"
LPN revealed when writing the orders for the
increased doses of Morphine she did not know
she needed to include the concentration and
milligrams. Nurse " AA" indicated she also had
not known the time of the order, concentration,
and 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 and she rewrote the order with the
concentration and mg at that time. Nurse " AA"
revealed she had difficulty writing the scheduled
times and this resulted in doses being initialed
that were not given, before the order was written,
and the MAR really could not be deciphered due
to crossed out initials, circled doses, missing
documentation on the back of the MAR, as well
as doses initialed that were not actually given.
Nurse " AA" revealed she had asked another
nurse on duty on 12/ 19/ 15 how to correct the
MAR and they did not have any suggestions.
Nurse " AA" was asked about the extra dose
signed on the Controlled Drug Report on
12/ 19/ 15 between 6: 00 a. m. and 8: 00 a. m. and
she was unable to account for this. Nurse " AA"
LPN revealed when she arrived for work on
12/ 20/ 15 at 7: 00 a. m. she discovered two doses
of Morphine for Resident# 1, scheduled for 3: 30
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DEFICIENCY)
a. m. and 5: 30 a. m. were not initialed as given on

the MAR or signed on the Controlled Drug
Report. She reported she assumed they had
been administered as scheduled and the next
dose due at 7: 30 a. m. was administered as
scheduled. LPN " AA" revealed she should have
called LPN " BB" but did not. She
acknowledged the narcotic count had been
performed that morning before LPN " BB " left
and it had looked correct but it was difficult to see
the liquid because it was clear and it must not
have been counted correctly. She left 2 spaces
on the Controlled Drug Report and asked LPN "
BB"
to fill in the spaces as well as the empty
spaces on the MAR, when she returned on
12/ 20/ 15 at 7: 00 p. m. When LPN " BB" filled in
the time for her administration due at 5: 30 a. m.
as 7: 00 a. m. Nurse " AA" reported to the
physician,family and facility. LPN ' AA" revealed
she should not have left empty spaces on the
Controlled Drug Record.
Interview with Nurse " BB " LPN 2/ 19/ 16 at 11: 55
a. m. revealed she remembers not signing the
MAR and Controlled Drug Record on 12/ 20/ 15 for
the 3: 30 a. m. and 5: 30 a. m. doses she had
administered late at 4: 30 a. m. and 7: 00 a. m. She
was unable to remember why she had
administered these doses late or why she had not
reported this to Nurse " AA" , or why she had not
signed as having administered the Morphine. She
acknowledged leaving the spaces blank on the
MAR and not documenting them on the
Controlled Drug Report, and not reporting giving
the last dose 90 minutes late to the oncoming
Nurse had resulted in 2 doses of Morphine being
administered 30 minutes apart and this could
have caused the resident to have a serious
adverse reaction. Nurse " BB" revealed there
was no disciplinary action regarding the missing
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YETTE,
LAFAYET
LA GA
A 30728
DATE
DEFICIENCY)

documentation, but someone had told her to be
sure to document medication administration.
2. Record review for Resident# 3 revealed a

re- entry date of 6/ 29/ 15, with an admission
diagnosis including Congestive Heart Failure
CHF), Hypertension, and Diabetes. Review of
the October Physician orders for Resident# 3
included orders for Advair 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
p. m., on 10/ 29/ 15 at 9: 00 p. m., on 10/ 30/ 15 at
9: 00 a. m. and 9: 00 p. m. Advair Diskus 250/ 50
one puff q 12 hours had not been initialed on
10/ 13/ 15 at 9: 00 p. m. and Fluvall 0. 5 ml IM to left
deltoid was to be administered on 10/ 25/ 15 and
was not initialed.
Continued review of the clinical record revealed
Resident# 3 had been in the facility on the dates
the above medications were to be administered
and there was no clinical indication not to
administer the medications. The back of the MAR
for the month of October does not indicate the
Levemir Insulin, Advair Diskus and Fluvall were
held for any reason. The Nurses Notes for the
month of October were reviewed and no
indication of holding these medication on the
above dates could be found.
2: 30 p. m. revealed the documentation omissions
for Levemir Insulin 70 units sq a. m. and hs had
been investigated by the facility as a follow up to
a Quality Assurance Intervention that was
considered resolved in August, 2015. The facility
had determined the insulin had been
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02/ 26/ 2016
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LAFAYET
LA YETTE, A 30728
GA

X4) ID
DATE
TAG
DEFICIENCY)
administered and the nurses had received written

disciplinary action for not documenting according
to policy. The MAR ' s are supposed to be
checked by the unit manager at the end of each
shift but there was no unit manager on the South
Hall for the month of October and the MAR' s did
not get checked. The administration of Fluvall
was documented in the Nurses' notes but never
was documented on the MAR and the missing
initials were not addressed and the administration
of the Advair Diskus on 10/ 13/ 15 at 9: 00 p. m. was
never investigated. The administrator confirmed
Nurses are expected to initial the MAR according
to policy, as soon as a medication has been
administered.
Interview 2/ 25/ 16 at 1: 35 p. m. with Nurse " LL"
LPN revealed she received counselling regarding
missing documentation of Levemir Insulin on
10/ 12/ 15 at 9: 00 p. m. and 10/ 30/ 15 at 9: 00 a. m.
and remembered she had administered the
insulin but had not documented. Nurse " LL"
acknowledged also giving the Advair Discus
250/ 50 one puff q 12 hours on 10/ 13/ 15 at 9: 00
p. m. but failed to document. LPN " LL"
confirmed she was aware that not documenting
the administration of medications could lead to
serious harm to the residents.
Interview 2/ 25/ 16 at 1: 30 p. m. with Nurse " FF"
revealed she had administered Levemir Insulin 70'
units to Resident# 3 on 10/ 29/ 15 and 10/ 30/ 15 at
9: 00 p. m. and had not initialed the MAR. She
indicated she received counselling and was
aware that missing documentation could have
serious consequences for the resident.
Based on the above findings omission of
documentation on the MAR immediately following
medication administration had a high likelihood of
causing harm to two residents, Resident# 3 with
undocumented insulin administration, and
PRINTED: 03/ 17/ 2016
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
ATTERSON RD
LAA FAYETYETTE,
L GA 30728
DATE
DEFICIENCY)

Resident# 1, with undocumented Morphine
administration resulting in 2 doses being
administered in thirty minutes.
F 520 483. 75( o)( 1) QAA F 520
SS= J COMMITTEE- MEMBERS/ MEET
QUARTERLY/ PLANS
A facilitymust maintain a qqualityY assessment and

assurance committee consisting of the director of
nursing services; a physician designated by the
facility; and at least 3 other members of the
facility' s staff.
The quality assessment and assurance

committee meets at least quarterly to identify
issues with respect to which quality assessment
and assurance activities are necessary; and
develops and implements appropriate plans of
action to correct identified quality deficiencies.
A State or the Secretary may not require

disclosure of the records of such committee
except insofar as such disclosure is related to the
compliance of such committee with the
requirements of this section.
Good faith attempts by the committee to identify

and correct quality deficiencies will not be used as',
a basis for sanctions.

by:
Based on record review and staff interview the
facility failed to have an effective Quality
Assessment and Assurance ( QAA) Committee
that developed and implemented a process to
PRINTED: 03/ 17/ 2016
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
PATTERSON RD
LA
PREFIX PREFIX
DATE
DEFICIENCY)
ensure medication administration in accordance

with Physicians' orders, and ensured the
ongoing monitoring of plans of action
implemented to correct an identified problem with !,
resident identification by staff nurses during
orientation.
This had resulted in a significant medication error

involving the administration of two ( 2)
antihypertensive medications to the wrong
resident(# 2) on 10/ 14/ 15, when a photograph
was not available on the Medication
Administration Record ( MAR) for an
unsupervised orienting nurse to use for
identification. Photographs were not available for
six( 6) residents (# 16, # 17, # 18, # 19, # 20, and
21) residing in the facility when MAR books were
reviewed on 2/ 19/ 16 at 2: 10 p. m. and on 2/ 25/ 16
at 10: 40 a. m.. The total survey sample was
twenty- one ( 21) residents. The facility' s
Administrator was informed of the Immediate
Jeopardy on 2/ 25/ 16 at 5: 00 p. m. The
Jeopardy was identified to have existed as of
October 14, 2015, the date Resident# 2 was
administered another residents antihypertensive
medications and remains ongoing.
Findings include:
An interview with the Corporate Clinical

Consultant on 2/ 18/ 16 at 5: 00 p. m. revealed the
investigation of these events had not resulted in
identifying a problem with narcotic administration
and monitoring or medication administration and
documentation.
Review of the clinical record for Resident# 2
revealed he was administered Procardia 30 mg
and Hydralazine 100 mg by mouth on 10/ 14/ 15 at
PRINTED: 03/ 17/ 2016
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
800 PATTERSON RD
REGULATORY OR LSC IDENTIFYING DATE

TAG INFORMATION) TAG CROSS- REFERENCED TO THE APPROPRIATE
DEFICIENCY)

6: 00 a. m., and did not have orders for these
medications. He was discovered to be severely
hypotensive at 7: 10 a. m., and transferred
emergently to the closest hospital and admitted to
the Intensive Care Unit( ICU) with a diagnosis of
latrogenic Hypotension.
Observation of the MAR books conducted on
2/ 19/ 16 at 2: 10 p. m. and on 2/ 25/ 16 at 10: 40 a. m.
revealed six ( 6) resident pictures missing.
In an interview conducted with Nurse " HH "

Licensed Practical Nurse ( LPN) on 2/ 24/ 16 at
3: 00 p. m. she revealed she had oriented Nurse "
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/ 15.
She remembered observing Nurse " BB"
preparing two ( 2) antihypertensive medications at
the cart for Resident# 4 to be given at 6: 00 a. m.,
she did not enter the room with Nurse " BB " .
She revealed there were no pictures of Resident
2 or Resident# 4 on the Medication
Admnistration Record' s ( MARS) because the
pictures had not been changed on October 1,
2015 from the previous months MAR book, in the
medication room. Nurse " HH " acknowledged
she had thought Nurse " BB " had been on
orientation long enough to remember who the two
2) residents in that room were and which one
received medication at 6: 00 a. m., but should not
have left her to give any medication unattended.
Nurse " HH " revealed she had been notified by
a Certified Nursing Assistant( CNA) that Resident
4 said he did not get his usual 6: 00 a. m.
medication and his roommate, Resident# 2 might
have received it.
Interview conducted on 2/ 25/ 16 at 10: 40 a. m. with
Nursing Supervisor " EE" Registered Nurse
RN) revealed the six( 6) missing resident
pictures had either fallen out of the sleeves they
PRINTED: 03/ 17/ 2016

AND PLAN OF CORRECTION
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
800 PA RD
LAFAYETTEETTE
LA A 30728
GA

X4) ID
DATE
TAG
DEFICIENCY)
are kept in or left in the last months MAR books

kept in the medication rooms on both the North
and South Halls. " EE" acknowledged each
book should have a picture of each resident.
In an interview on 2/ 25/ 16 at 3: 30 p. m. the

Administrator revealed the QAA Committee had
identified the issue involving identification of
residents by photographs on 10/ 14/ 15, and this
was considered to be resolved on 10/ 14/ 15, after
Resident# 2 had been transferred to the hospital
and all MAR' s had been equipped with pictures.
The Administrator then acknowledged there were
six ( 6) residents whose pictures were missing on
2/ 25/ 16 at 10: 40 a. m. and additional monitoring
and auditing of the MAR ' s was necessary.
MARS were monitored for pictures of residents
and staff interview were conducted. Continues
interivew with the Administrator on 2/ 25/ 16 at 3: 30
p. m. related to the facility' s QAA Committee, the
Administrator was asked about the QAA
Committee' s oversight of the facility' s
compliance with the corporate policy entitled
Medication Administration: General Guidelines,
revised on 1/ 23/ 15. The policy indicated
Patients/ Residents are to be identified before
medication is administered. When in doubt:
Check photograph attached to the medical
record. The Administrator acknowledged the
pictures were to be on all MAR ' s according to
her decision following the administration of
anti hypertensive medication to the wrong resident
on 10/ 14/ 15. The pictures had been moved from
the previous months MAR books on 10/ 14/ 15 to
the current MAR books and the QAA committee
and Medical Director had recommended two ( 2)
sets of pictures be available for each resident,
one on each MAR book. The Administrator
revealed the committee had not continued the
PRINTED: 03/
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED D
CENTERS FOR MEDICARE & MEDICAID SERVICES .,, OMB NO. 0938- 0391
A. BUILDING
C
115452 B. WING
02/ 26/ 2016
800 PATTERSON
FAYETTE, GAR 30728

DEFICIENCY)
F 520 Continued From page 66 F 5201I

process of monitoring this identified problem and
acknowledged there were six ( 6) residents who
did not have pictures available in the current MAR
book. The Administrator revealed there had not
been any errors resulting from lack of
identification for these six( 6) residents, and
acknowledged if there had been any new nurses i
orienting and they were left unsupervised, this
may have been a problem. The Administrator
revealed the QAA committee with the Medical
Director also recommended hiring a Clinical
Competency Coordinator( CCC) as soon as
possible and the position was filled on December
16, 2015.
Based on the above, the facility' s QAA

Committee failed to ensure the necessary
monitoring of a plan of action, developed by the
facility in response to an identified problem with
the identification of residents by staff who are
unfamiliar with them, when passing medication, to
ensure the implementation of the newly
developed intervention. This failure had caused,
or had the likelihood to cause, serious harm,
impairment or death to these residents.
Cross Reference to F333.
Sanders, Andrea
From: Keesler, Jeanne
Sent: Saturday, April 09, 2016 9:08 PM

To: 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
From: Weeks, Kathy

Sent: Friday, April 08, 2016 4:23 PM
To: Sanders, Andrea; Keesler, Jeanne
Subject: PruittHealth Shepherd Hills
Attachments: PHShepherdHill_Abuse_a. pdf, PHShep herd HIlls_Abuse_b.pdf; Shepherd Hills CMS- 20059
Abuse Prohibition. doc
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
From: Allen, Marsha J.
Sent: Thursday, March 31, 2016 10:50 AM

To: achandler@pruitthealth. com
Cc: Sanders, Andrea

Subject: 2567 & letter
Attachments: 2567. pdf; letter. pdf, N tag letter. pdf; N tags - . pdf
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
From: Keesler, Jeanne
Sent: Sunday, March 20, 2016 7: 58 PM

To: Meyer, William; Weeks, Kathy; Sanders, Andrea; Davis, Cathy
Subject: FW: U at PH Shepherd Hills PLEASE READ
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.
Cathy Davis RN, Nurse Surveyor

State of Georgia, Department mfCommunity Health
2 PeaohtneeSt Suite 447
AUanba. Ga 30303
CeU: 4O4' 37G' 84G8
Fax: 4O4- 857- 8934
cdaviu7( c)doh. qa. qov
Follow unun Twitter sdhttp: 0tm/ ifter. mmmn6madoh and Fanebook

athttp: 0bit'| y/ b1GoX|
Reader Advisory Notice: E- mail to and from a Georgia state agency is generally public record, except for content that is confidential under specific laws.
Security by encryption is applied to all confidential information sent by e- mail from the Georgia Department of Community Health.
From: Simon, Melanie
Sent: Friday, March 1O, ZOl610: 21AM

To: Davis, Cathy
Subject: Pwd: UatPH Shepherd Hills
Please pass along to surveyors going to Shepherd Hi|| s-' thanks.
Sent from nnyiPad
Begin forwarded message:
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,
William" < wmeverCa) dch. ga. gov>
Subject: RE: IJ at PH Shepherd Hills
Hi Melanie & Bill:
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 inservice 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,
Chief, LTC Certification & Enforcement Branch

Centers for Medicare & Medicaid Services
Sam Nunn Atlanta Federal Center
61 Forsyth Street, S, W., Suite 4T20
Atlanta, GA 30303- 8909
PH- ( 404) 562- 7471
FX: ( 404) 562- 7478
E- mail: Ster) hanie. Davisacms. hhs. qov
00,1,07070.........-
ANN*
CENTERS KA MEVICARF, MWWAID SUVIC16
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BYLAW:

This information has not been publicly disclosed and maybe privileged and confidential. It is for internal government use only and must riot be
disseminated, distributed, or copied to persons not authorized to receive the informotion. Unauthorized disclosure may result in prosecution to
the full extent of the low. if you are the unintended recipient of this information please notify the sender.
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
Subject: IJ at PH Shepherd Hills

Importance: High
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.
Pruitt+ 1ealth- Shepherd tills- 1. 15452 -- -- --- _ - -

800 Patterson Road
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
Division Chief, Healthcare Facility Regulation

Georgia Department of Community Health
2 Peachtree Street, N. W., Suite 31- 403
Atlanta, GA 30303
404) 657- 3990
msimonPdch. Ra. Rov
Follow us on Twitter at http:// twitter. com/ gadch and Facebook at

https:// www. facebook. com/ gadeot/ communitvhealth.
Reader Advisory Notice: Email to and from a Georgia state agency is generally public record, except for content that is
confidential under specific laws. Security by encryption is applied to all confidential information sent by email from the Georgia
Department of Community Health.
4
GEORGIA DEPARTMENT
OF COMMUNITY HEALTH
2 Peachtree Street, NW I Atlanta, GA 30303- 3159 1 404- 656-4507 1 www.dch. georgia.gov
VIA e- mail
March 31, 2016

800 Patterson Rd
Dear Ms. Chandler:
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).
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
Enclosures
cc: Facility File
Page 2

2016 DCH Reports Involving Sherpherd Hill Nursing Home

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2016 DCH Reports Involving Sherpherd Hill Nursing Home

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Department of Health& Human Services

Centers for Medicare& Medicaid Services

Refer to: 5452. comp. 06. 08. 16

IMPORTANT NOTICE— PLEASE READ CAREFULLY

Ms. Anggie Chandler, Administrator

Re: Compliance Notice

Dear Ms. Chandler:

Nathan Deal, Governor Clyde L. Reese III, Esq., Commissioner

IMPORTANT NOTICE - PLEASE READ CAREFULLY

Ms. Anggie Chandler, Administrator

Dear Ms. Chandler:

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

Nathan Deal, Governor Clyde L. Reese III, Esq., Commissioner

IMPORTANT NOTICE - PLEASE READ CAREFULLY

May 12, 2016

Ms. Anggie Chandler, Administrator

Dear Ms. Chandler:

Refer to: 5452. IJ. ab. 04. 22. 16

IMPORTANT NOTICE— PLEASE READ CAREFULLY

April 22, 2016

Ms. Anggie Chandler, Administrator

Re: Imposition Notice

Dear Ms. Chandler:

II. DISCRETIONARY REMEDIES

Civil Monev Penalty ( CMP)

substantial compliance is achieved or your facility' s Medicare participation is terminated. We

NOTICE OF INTENT TO HOLD YOUR FACILITY' S CMP IN ESCROW

Brittany N. Jones, Legal Officer

Georgia Department of Community Health

NOTICE OF RIGHT TO REOUEST HEARING OR WAIVE HEARING RIGHTS

CMPWaiversATL@cros. hhs. gov

Discretionary Denial of Pavment for New Admissions ( DPNA)

Substandard Quality of Care ( SQC)

determined to constitute substandard quality of care ( SQC) as defined at 42 C. F. R. 488. 301.

implementing regulations at 42 C. F. R. 488. 325( h),

Please note that, in accordance federal law at 42 C. F. R. 488. 325( g),

Loss of Nurse Aide Training Program ( NATCEP)

Department of Health& Human Services

Region4_ DAB_HearingRequest@cros.hhs. gov

Nathan Deal, Governor Clyde L. Reese III, Esq., Commissioner

IMPORTANT NOTICE - PLEASE READ CAREFULLY

April 13, 2016

Ms. Anggie Chandler, Administrator

Dear Ms. Chandler:

a revisit to the survey conducted on at which one or more

F0282 -- S/ S: J -- 483. 20( k)( 3)( ii) --

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

F0490 -- S/ S: J -- 483. 75 -- Effective Administration/ resident Well- Being.

F0514 -- S/ S: J -- 483. 75( 1)( 1) -- Res Records- Complete/ accurate/ accessible

Substandard Qualitv of Care

Loss of Nurse Aide Traininq Program

A denial of payment for new admissions will be imposed immediately.

Immediate Jeoaardv Removed

including dates will be included on the CMS 2567.

Plan of Correction ( PoC)

An acceptable PoC must:

Informal Disaute Resolutions ( IDRR

Disclosure of Survev Results

Healthcare Facility Regulation Division

cc: Melanie Simon

Nathan Deal, Governor

IMPORTANT NOTICE - PLEASE READ CAREFULLY