Presbyterian Village - Athens

F-F760 Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 115775 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 115775 B. Wing 07/22/2024

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

Presbyterian Village - Athens 1400 Live Oak LN Bldg 100 Athens, GA 30606

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997

Residents Affected - Few Based on record review, staff interviews, review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers, and review of employee job descriptions, the facility failed to ensure one of 20 sampled residents (R) (Resident R77) was free from a significant medication error related to not administering medications according to the physician orders. Specifically, Resident R77 was ordered lamotrigine (a medication used to treat seizures) 250 milligrams (mg) extended release (ER) daily, but was only administered 25 mg per day, due to

a pharmacy dispensing error. Actual harm was identified to have occurred on [DATE REDACTED] when Resident R77 suffered a grand mal seizure, as a result of a subtherapeutic dose of lamotrigine for 13 days.

Findings include:

Review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers with a review date of [DATE REDACTED] documented Purpose, Objective, and Goals. Purpose: Number 1. To strive to protect the safety and welfare of patients receiving medications while residing in a nursing center. Number 3. To strive to provide medical care team members with written guidelines, for instructional, as well as standardizing purposes, which govern all aspects of medication handling, storage, documentation, and administration. These guidelines are consistent with all State and Federal laws and generally accepted principles of pharmacy and nursing practices. Objective: Number 2. To strive to educate all concerned personnel about medications and their proper administration to patients in a nursing center. Number 3. To strive to promote the rational, safe and economic dispensing of medications to nursing center patients. Goal: Number 1. To strive to provide patients with the needed medications, in a timely manner (as ordered by the patient's prescriber) and in a manner consistent with high professional standards. General Guidelines for Medication Administration Intent: Medications are administered as prescribed, in accordance with good nursing principles. Procedural Guidelines: The joint responsibility of the nursing center and the pharmacy is to ensure accurate medication administration. The RIGHT medication must be given to the RIGHT patient in the RIGHT dose at the RIGHT time, using the RIGHT method of administration and the RIGHT method of documentation.

Review of the undated Director of Nursing job description documented the Job Summary: The Director of Nursing is a registered Nurse who is responsible for the organization and implementation of nursing care in

the Health Services Center. She initiates implements and evaluates nursing care to assure holistic, restorative and rehabilitative care in accordance with accepted standards. Responsibilities/Duties: Number 3. Provides direct supervision to all HSC Registered Nurse Supervisors, Nurse Managers, as well as Team Leaders, Certified Nursing Assistants and the Activity Program Coordinator on the Special Care Unit. Implements and enforces all nursing policies and procedures. Number 12. Assess residents' response to medication and make appropriate recommendations for nursing action to be implemented. Number 26. Responsible for knowledge regarding Federal, State and local nursing home rules and regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 115775 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 115775 B. Wing 07/22/2024

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

Presbyterian Village - Athens 1400 Live Oak LN Bldg 100 Athens, GA 30606

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of the undated Staff Nurse/Team Leader job description revealed the Job Summary: The Charge Nurse is a registered nurse or a licensed practical nurse that is responsible for the organization and Level of Harm - Actual harm implementation of nursing and program care on a specified unit. She/ he initiates, implements, and evaluates nursing care to assure holistic, restorative and rehabilitative care in accordance with accepted standards. Residents Affected - Few Responsibilities/Duties: Number 4. Administers medications and treatments according to established policies and procedures.

Observation on [DATE REDACTED] at 9:06 am, Resident R77 was in the sitting area neatly dressed in street clothes and wearing

a Thoracic Lumbar Sacral Orthosis (TLSO) and a right arm brace.

Review of the Admission Record revealed Resident R77 was admitted to the facility on [DATE REDACTED] with diagnoses including seizures, displaced comminuted fracture of right radius, wedge compression fracture of fourth lumbar vertebra, and of unspecified thoracic vertebra.

Review of the Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the assessment was in progress.

Review of the care plan initiated [DATE REDACTED] revealed resident is at risk for seizure activity related to diagnosis of seizure disorder. Interventions to be implemented included administer medications as ordered and implement seizure precautions per facility guidelines.

Review of the hospital discharge order dated [DATE REDACTED], revealed an order for lamotrigine 250 mg Tr24 (time release 24 hours) one tablet in the morning.

Review of the Order Summary Report dated [DATE REDACTED] revealed Lamotrigine ER 250 mg. Give one tablet by mouth in the morning related to other seizures, with start date of [DATE REDACTED].

Review of the Order Summary Report dated [DATE REDACTED] revealed Lamotrigine ER 250 mg Give one tablet by mouth in the morning related to other seizures, with a start date of [DATE REDACTED].

Review of the Order Summary Report dated [DATE REDACTED] revealed lamotrigine ER 250 mg give one tablet by mouth in the morning related to other seizures with a start date of [DATE REDACTED].

Review of a photographic image of Resident R77's medication card (bubble pack) revealed the prescription for lamotrigine 25 mg tablets was filled by the facility's pharmacy on [DATE REDACTED]. Further review revealed instructions on the card were to administer per the instructions on the MAR (medication administration record).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 115775 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 115775 B. Wing 07/22/2024

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

Presbyterian Village - Athens 1400 Live Oak LN Bldg 100 Athens, GA 30606

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of a Nursing Alert Note dated [DATE REDACTED] at 11:00 am documented this writer was in [sic] assisting Certified Nursing Assistant (CNA) in getting resident up and readied [sic] for lunch. The resident at baseline Level of Harm - Actual harm for behavior and expression (verbal and facial). She was smiling and responding well with markedly less resistance to cares than other times. After getting resident into wheelchair, she suddenly scream out with Residents Affected - Few hands wide and proceeded to have what this writer would assess, as a grand mal seizure. He [sic] back arched, feet turned downward, and eyes rolled upwards. Clenched her jaw, head was extended back and exhibited difficulty in breathing due to airway issue. This writer and a CNA placed resident on her side in bed, which alleviated enough distress to return to baseline oxygen saturation (O2 sat) and skin color pink. Seizure lasted from ,d+[DATE REDACTED] mins with postictal state at ,d+[DATE REDACTED] mins. Blood Pressure ,d+[DATE REDACTED], pulse106, and O2 sat 95 precent room air. Nurse practitioner present during postictal time. Physician arrive to assess shortly thereafter. Pupils at 2 millimeters (mm), unreactive, returning to ,d+[DATE REDACTED] mm and reactive after postictal state resolved.

Interview on [DATE REDACTED] at 1:50 pm, the Director of Nursing (DON) stated Resident R77 was admitted to the facility on [DATE REDACTED] from [name] Hospital. She confirmed Resident R77's discharge medications included lamotrigine 250 mgER

on ce a day for a diagnosis of seizures. During further interview, she stated the pharmacy dispensed lamotrigine 25 mg tablets, instead of the 250 mg tablets, reflecting that Resident R77 received the lamotrigine 25 mg for 13 days, instead of the prescribed 250 mg ER. She stated the medication error was identified after the resident had a grand mal seizure on [DATE REDACTED]. She stated the nursing staff has been in serviced on medication administration - five rights, and the medications must be checked before placing them on the cart.

Interview on [DATE REDACTED] at 7:59 am, Registered Nurse (RN) DD stated that she was working on [DATE REDACTED] when Resident R77 had the grand mal seizure. She stated after the seizure, she herself, the Physician, and the Nurse Practitioner checked the hospital discharge orders against the order put in the residents' EMR and confirmed that both orders were for lamotrigine ER 250 mg. RN DD stated she then checked the bubble pack of lamotrigine medication, which revealed the bubble pack was filled with lamotrigine 25 mg tablets. RN DD stated that residents are often times given low dosages of lamotrigine to treat behaviors, and because Resident R77 did exhibit behaviors at times, she didn't think anything about her taking 25 mg instead of 250 mg. The RN DD confirmed that she did not follow the five rights of medication administration. During further interview, RN DD stated that she received education on medication administration and reading the MAR and the bubble pack to make sure they match. She stated discrepancies should be reported to the charge nurse before administering the medication.

Interview on [DATE REDACTED] at 8:40 am, the Director of Nursing (DON) revealed the policy Medication Management-Certified Medication Assistant was the only policy the facility had on medication administration.

She stated she is aware that the policy references Certified Medication Aides, but stated only license nurses are allowed to pass medications to the residents.

Interview on [DATE REDACTED] at 8:43 am, Pharmacy Director BB stated the nursing staff should be following the policy for medication administration found in the Pharmacy Policy & Procedure Guide for Care Centers. She stated

the manual should be at each nursing station.

Interview on [DATE REDACTED] at 9:30 am, Licensed Practical Nurse (LPN) FF stated she is aware of the incident regarding Resident R77's medication. LPN FF stated she has not been provided any education on medication administration and stated no one in the facility has observed medication pass with her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 115775 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 115775 B. Wing 07/22/2024

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

Presbyterian Village - Athens 1400 Live Oak LN Bldg 100 Athens, GA 30606

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Interview on [DATE REDACTED] at 11:30 am, LPN EE stated she is familiar with the care that Resident R77 required. She revealed on the days she administered Resident R77 her medications, she did not check the bubble pack with the Level of Harm - Actual harm MAR to ensure she was administering the correct dose of medication. She stated the Nurse Educator provided education on medication administration, reading the MAR, and the bubble pack to make sure Residents Affected - Few everything matched.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 115775 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 115775 B. Wing 07/22/2024

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

Presbyterian Village - Athens 1400 Live Oak LN Bldg 100 Athens, GA 30606

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 44960

Residents Affected - Many Based on record review, review of the Certifying Board of Dietary Managers and interviews, the facility failed to ensure that the dietary department had a designated staff as director of food and nutrition services, was a certified dietary or food service manager, or had a similar food service management or degree to provide the daily functions/duties of a Dietary Manager. This deficient practice had the potential to affect 25 of 25 residents who received meals in the facility.

Findings include:

Review of the document titled Certifying Board of Dietary Managers dated 4/2023 revealed States Recognizing the CDM, CFPP Credential reads all 50 states must follow the CMS federal guidelines as outlined in rule $483.60 Food and Nutrition Services and have adopted state-level regulations that meet or exceed the federal standards.

Review of the employee file for the Dietary Manager (DM) revealed a hire date of 1/29/2021. The DM employee file revealed no certification or education degree in culinary art or any other food service management degree.

Interview on 7/22/2024 at 10:27 am, during the initial tour of the kitchen, the DM was asked to provide her certification as the DM. She stated that she did not have the certification yet, but would soon be enrolling in a course, to become certified. She stated she had been employed in her position since April 2024. She stated that the Registered Dietitian was not full-time and came to the facility on ce a week.

Interview on 7/22/2024 at 3:55 pm, the Executive Director stated that he was aware the DM was not certified.

He stated that the DM did not need to be certified now, according to the Certified Board for Dietary Managers. He also stated that the Director of Dining Services was working on getting his CDM, but he had not completed his coursework.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 115775