Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 013429 (X3) Date Survey Completed 12/10/2025
Name of Provider or Supplier Grove Hill Primary Care Street Address, City, State 297 South Jackson Street, Grove Hill, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
J0125 PROVISION OF SERVICES

491.9(b) Patient care policies. (3) The policies include: (iii) Rules for the storage, handling, and administration of drugs and biologicals.


This STANDARD is not met as evidenced by:
Based on observations, clinic policy, medical record (MR) review, and interviews with staff, it was determined the clinic failed to ensure the medical provider's order for medication administration was followed. This deficient practice affected one of two patients in observations of medication administration including MR # 1 and had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy: Storage, Handling & Administration of Drugs, Biologicals, and Pharmaceuticals Policy Number: 220.0 Revised: 3/10/25 ...Policy Purpose: The purpose of this policy is to outline the procedures related to the storage and handling of drugs, biological and pharmaceuticals... 3. Administration of Drugs: a. Use of Patient Identifiers: The clinic shall use acceptable patient identifiers to confirm that the patient name, the order, and the selected drug are in agreement prior to administration... b. The Six Rights: All staff who are responsible for medication administration shall follow the "Six Rights" to ensure accurate administration of drugs... 1. MR # 1 presented to the clinic on 12/9/25 at 8:22 AM with complaints of nausea and diarrhea. Review of the Clinic Provider Note, Ordered Medications, dated 12/9/25 at 9:33 AM revealed medication orders for Ondansetron Hydrochloride (HCL) 2 milligrams (mg) to be administered intramuscular (IM). An observation of medication administration by Employee Identifier (EI) # 4, Medical Assistant, was conducted on 12/9/25 at 9:35 AM. EI # 4 removed one vial of Ondansetron HCL 2 mg/milliters (ml), 2 ml vial from the medicine cabinet. EI # 4 withdrew 2 ml from the Ondansetron vial, entered MR # 1's room, and administered the Ondansetron HCL 2 ml (4 mg) IM to MR # 1. EI # 4 failed to follow the provider's order for the dosage of the medication. An interview was conducted on 12/9/25 at 1:50 PM with EI # 4. EI # 4 was asked what was the dosage of the Ondansetron withdrawn and administered to PI # 1. EI # 4 responded, "The whole vial, 2 ml." An interview was conducted on 12/10/25 at 12:15 PM with EI # 1, Nurse Manager, who confirmed the staff failed to confirm the medication dosage and administer the correct medication dosage as ordered.