Te eee ee eee ae NT NONE MIN PiVewoaged meg FP UUE/Ulg Pre Cy oramnoprronpa AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 00-2965 Petitioner, AHCA NO: 01-00-0532NH vs. DESTIN HEALTH CARE & REHAB CENTER, LE-ONY 02 Jnr 00 Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (‘Agency’) intends to impose an administrative fine in the amount of $4,000.00 upon Destin Health Care & Rehab Center. As grounds for the imposition of this administrative fine, the Agency alleges as follows: l. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part II, Florida Statutes. . 2. Respondent, Destin Health Care & Rehab Center, is licensed by the Agency to operate a nursing home at 195 Mattie M. Kelly Boulevard, Destin, Florida 32541 and is obligated to operate the nursing home in compliance with Chapter 400 Part I], Florida Statutes, and Rule 594-4, Florida Administrative Code. 4 TE ET EERE ERR EE ENSE TENE SAMIR GATES OT Me ENE REY GEENA MD (EUsVIITe! eThhs F.UUS/YLS s. ou D4 2$, 1999 @ suncy team tron’ the Agency’s Area 1 Office conducted a survey and the following Class III deficiencies were cited. 3A. Pursuant to 42 CFR 483.15/e)(1), a resident has the right to reside) and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. This requirement was not met as evidenced by the following observations: (1) Record review revealed resident #9 had significant change assessments (RAI's} on January 8, 1999 and June 25, 1999. Comparison of the RAI's indicated the resident had declined in transfers, ambulation, positioning and eating. Range of motion limits had also deteriorated from arm, hand and other (shoulder) to neck, arm, hand, leg, foot. The resident's diagnosis was osteoporosis, pathological bone fractures and mild compression of L5,4,3, and 2. (a) The resident received physical and occupational therapy January 27, 1999 through February 3, 1999 for wheelchair position and range of motion to left hand and wrist. “Documentation Notes” of June 25, 1999 by interdisciplinary team, "Resident has become more dependent on staff for mobility, transfer, and positioning. It now takes 2 people to transfer her from wheelchair to toilet. etc. (b) Therapy recommendations included a new seat cushion to wheelchair, side cushion for lean to left side, upright posture for 2 hours, patient needs to lie down mid moming and afternoon.” nw Porat erie nee Fame k te PTR EVE TENGEN ING MINTY FINE INE TEMSUIIIET meg P.UUa/UTY Frr4 / Ye, Onpservations on July 271999 at 12:45 and 1:55 p.m. revealed the resident sitting in a wheelchair in the dining room, leaning to the left side. Interview with staff at 10:40 on July 29, 1999, "She refuses positioning devices, rest periods, and range of motion exercises.” Observations on July 27, 1999 at 3:20 p.m. revealed the resident to be leaning to the left in her lounge chair with no attempts by staff to position resident upright. (d) Record review revealed the MDS of June 25," 1999 assessed the resident 2/2 Section G, h (eating} one person assist with limited assistance. Interdisciplinary progress notes on June 21, 1999 “resident still able to feed self." Interview with resident on July 27, 1999 revealed "my food is cold.” (e) Observations on July 27, 1999 at 12:45 to 1:55 p.m. revealed the resident attempting to eat lunch seated in wheelchair, leaning to the left side, with overbed table in front of her with tray. Resident had difficulty scooping food from plate, and bringing it to her mouth. Food dropped on her lég. The resident dropped her spoon onto floor and attempted to use fork. Staff member picked up the spoon and wiped it with a napkin and returned it to the resident. Resident ate 25% of meal. (6 The facility did not pursue alternative interventions, when the resident refused OT, PT recommendations, to position the resident or maintain range of motion. The facility did not provide assisting devices or assistance with eating. (2) Based on record review, observations and interviews with staff and residents, it was determined that the facility violated Rule 59A-1.288, F.A.C., for failing to ensure that residents received services with reasonable accommodations of individual needs and preferences for 1 of 23 sampled residents. EE EERE EE NCE EE Nee OME NTENSATEEY OR Meant ret SHEN ELEM ODE WohiQ PF UYA/UTY Fs 4] ap. rusia to 42 Crk 4535.20(K), the Sauty must develop a comprehensive care plan for each resident that includes measurable objectives and tmetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This requirement was not met as evidenced by the following observations: (1) Through record review it was revealed that resident #4 had a history of pressure sores that had healed. The only measure to be found in the care plans regarding the prevention of pressure sores involved the use of the foley catheter, During the initial tour on July 26, 1999, the staff stated the resident had no pressure sores. v (a) Interview with family on July 27, 1999 revealed the resident did have a pressure sore on the Coccyx. Record review of Hospice notes on June 28, 1999 indicated a Stage II pressure sore on the coccyx. (b) | Observation of dressing change on July 29, 1999 at 9:30 a.m. revealed a Stage II pressure sore on the coccyx. Interview with care plan coordinator indicated neither staff nor Hospice had informed her of the pressure sore. (2) Resident #5 was assessed on the May 28, 1999 Minimum Data Set (MDS) to be at risk for falls having fallen during the past 31-180 days. The care plan had as an approach to place the resident on the "Red Dor Program". Interview with staff revealed that the "Red Dot Program" consisted of the placement of a red dot (made of construction paper and visible) on the back of a resident's wheelchair and on the resident's bed in order to alert staff thar the resident was at high risk for falls. (a) | Observations on all days of the survey revealed that there was no red dot on the back of the resident’s wheelchair or on the resident’s bed. The facility did not follow their own care plan for this resident and placed the resident at a higher risk for falls. St esr BONE ENE TMV TINTING Me MY FEMA WU fF FUGUE I-1f3) PUUB/OIS = Fe? 4] ed (3) Resident #3 was admitted to the faciliry on March 20, 1995. The resident's diagnosis was arthritis, depression, glaucoma and peripheral vascular disease. The most recent care plan dated May 21, 1999 stated problem #514, at risk for dehydration. The approaches included, "Encourage fluids and stay with him/her when he/she drinks; input & output (I & O) each shift; and monitor for UTI - encourage at least 2000cc fluids /24 hours." (a) Review of the resident's treatment record for, June and July, 1999 revealed that staff had signed off that the intake and output had been completed, bur, review of the intake and output records revealed that the intake and output on this resident had not been done since March 18, 1999. The facility failed to follow the resident's plan of care. (4) Based on observation, record review and interview, it was determined that the facility violated Rule S9A-4.106(2), F.A.C., for failing to develop a comprehensive care plan for each resident and to follow through to meet measurable objectives and timetables for 3 of 23 residents sampled. 3C. Pursuant to 42 CFR 483.25(c}, based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent any new sores from developing. This requirement was not met as evidenced by the following observations: (1) Record review of resident #2 revealed the resident was re-admitred to the facility on February 20, 1999 following a hip fracture, RAI of February 20, 1999 stated “no skin breakdown", RAI on July 14, 1999 revealed "Stage IT - blisters on both heels." MDS of July 14, 1999 assessed the blisters on the heel as pressure areas. (2) Teese en a! {a) Care Plan interventions on July 13, 1999 included “follow MD protocol for decub.” Turn and reposition using pillows and heelbo’s.” Nursing notes on July 14, 1999 stated "Blisters to both heels- Stage 1 Granulax", July 18, 1999 stated "coccyx applors red," and July 23, 1999 stated “dressing to right buttock ICM. Stage II pink, healed." (b) Observations on July 27, 1999 from 8:30 a.m. until 11 a.m. indicated the resident was sitting in his, wheelchair wearing socks and slippers, his heel in contact with the floor. At 11:10 a.m. observation revealed the resident in bed, laying on back, moved to left side by staff, left and right heels had 2 cm black areas. Right buttock was healed but coccyx area bright red with open areas, larger on left side with small open area on right side of inside buttocks. (c) Interview with staff during observation, "We use only socks and soft slippers for PT." Observations on July 28, 1999 at 8:30, 9:30, 9:45, 10:45, and 11 a.m. revealed the resident to be sitting in his wheelchair with heels in contact with the floor. At 9:45 a.m. until 10:45 a.m. resident was in therapy room sitting in wheelchair except for short period of ambulation. (a) Observation at 2 p.m. revealed resident sitting in his wheelchair and staff in his room stated, "I think I'll put him to bed, he's been up a good while." (e) The facility did not coordinate care with therapists and did not protect the resident's heels, buttocks and coccyx from the development of pressure sores, Through record review it was revealed that resident #4 had a history of pressure sores that had healed. The only measure to be found in the care plans regarding the prevention of pressure sores involved the use of the foley catheter. During the initial tour on July 26, 1999, the staff stated the resident had no pressure sores. (3) PNT PENPEVEN NS AMMA INSAEFY be ENE EY MINE PeUsusases IT1f9 F.UUB/UIY bf 4) j / ta) Tnatcrvicw with family on Say 27, 1999 revealed the resident did have a pressure sore on the coccyx. Record review of Hospice notes on June 28, 1999 indicated a Stage Il pressure sore on the coccyx. Observation of dressing change on July 29, 1999 at 9:30 AM revealed a Stage Il pressure sore on the coccyx. (b) Interview with staff at that time as to why staff was not measuring nor documenting the pressure sore until July 26, 1999, staff replied, "I honestly can't say”.” Interview with care plan coordinator indicated neither staff nor Hospice had informed her of the pressure sore. {c) Observation of the residents positioning on July 26, 1999 at 2:45 p.m., July 27, 1999 at 2:45 p.m., July 28, 1999 at 9:30 a.m., 12:00 p.m., 3:20 p.m., and on July 29, 1999 at 10:10 a.m., 11:00 a.m. and 12:00 p.m. revealed that even through the resident may have been repositioned, the caccyx continued to have pressure. Record review of resident #8 revealed a diagnosis of muluple sclerosis and quadraplegia. The MDS of October 15, 1998 and June 18, 1999 revealed Stage I] pressure sore of right heel. Care plan indicated October 15, 1998 Stage II right heel; January 12, 1999 4.0 x 2.2 x 0.3 depth, night heel; March 31, 1999 1.0 x 1.0 x 0.2 depth, right heel; June 15, 1999 Stage II right heel-headed. (a) Care plan interventions included pressure reducing mattress, pad add bony prominences, but care plan did not address heels. Physician order of June 29, 1999 - "Keep heels off bed at all times,” Observation on July 27, 1999 at 10:15 a.m. revealed staff doing treatment and dressing to right heel. Stage ll dark area, 2.0 cm, no open area at present. (b) Observations on July 28, 1999 at 8:20 am., 10:10 am., 12:10 p.m., 1:40 p.m., revealed the resident to be lying on his back with a pillow under his heels and his heels in contact with the pillow. On July 27, 1999 at 10:15 a.m., staff stated "we bought him a special mattress.” Information provided by the manufacturer and interview with staff revealed “not an ae ee ee ee Vee ere er Ne TUU4UIIIEl mite F.UUS/UIY r-(4t alternating air mattress. It inflates with less air at the foot end of the mattress." Heels are in direct contact on the mattress or pillow. (c) The facility did not follow care plan nor provide heel protectors, repositioning to prevent the development of pressure sores, (4) Resident #17 was re-admitted to the facility on May 3, 1999 following a right cerebral hemorrhage. She was assessed and had a care plan written identifying her as being at risk for pressure sore development due to her decreased mobility, bowel incontinence, peripheral vascular disease, and her inability to use or increased wealmess in both her upper and lower extremities. She also was assessed as having a decline in activities of daily living secondary to the cerebral bleed with various approaches planned to help prevent further decline. These approaches however, did not include measures and care specific to the resident's ability to feed herself. (a) By May 17, 1999, the resident had experienced a 6.9% weight loss and by July 12, 1999 had lost an additional 8.1% of her body weight. Further review of facility records reveals that on June 18, 1999, the resident developed a stage II pressure sore (blister) on her left heel, (b) At the time of the survey, the resident's weekly skin assessment indicated that the Stage II pressure sore measured 2 cm. Observation on July 29, 1999 at 9:30 a.m. revealed a Stage II pressure sore with black center and pink to red edges. Staff stated, "That's a pressure sore." (c} Lab data reported on June 22, 1999 revealed that the resident had a serum albumin of 2.3 g/dl. A high calorie supplement was added to the resident's diet on June 2, 1999, however, she continued to lose weight. On July 27, 1999, additional protein supplements were added to the resident's diet. 3D. Teese ee eee footw et Mutha PF UIUsSUTY Pee ‘wa, On July 28, 1999, a plan 8 care was written for this resident identifying her as being at nutritional risk. A plan of care specific to the resident's development of the pressure area was also written on July 28, 1999. The facility failed to appropriately assess and plan care specific to this resident's unique tisk factors which could have avoided the development of the pressure sore. (5} Based on record review, observations and interviews, it was determined that the facility violated Rule 59A-4.1283,~ F.A.C., for failing to ensure that residents received services to prevent the development of pressure sores for 4 of 23 sampled residents. Pursuant to 42 CFR 483.25(i)(1), based on a resident’s comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible. This requirement was not met as evidenced by the following observations: {1) Review of facility records revealed that resident #17 suffered a Right Basal Ganglia Hematoma on May 2, 1999. Following her return to the facility on May 3, 1999, she experienced a decline in her activities of daily living including her ability to feed herself. Interview with facility staff revealed that the resident was completely dependent on staff for meals. (a) Observations of the resident during the breakfast meal on July 28, 1999 revealed that staff was feeding the resident and providing verbal encouragement throughout the meal. Interventions addressing the resident's decline in her independence with eating were never developed. Weight records indicate that the resident had a 6.9% weight loss between April and May 1999 (5/19/99), and an additional 8.2% weight loss from May to July 1999, 4 BV bs CUUU VIP ouUaE PUMP OCYERE) NEALTAGARC YCURMIA TLURIVA URUUP FI UGUISSCI Im1fd P.UTIZUES Fm , 7 (b) Lab values recorded on June 22, 1999 revealed a serum albumin of 2.3 g/dl. High calorie supplements were ordered on June 2, 1999, however, the resident continued to lose weight between June and July. A nutritional assessment was completed on June 20, 1999 acknowledging the resident's significant weight loss and nutritional risk, however, a care plan Was not written to provide interventions to prevent further decline in nutritional status until July 28, 1999. On July 27, 1999, additional protein was ordered as part of the resident's medication regimen. {c} The facility failed to provide timely, necessary interventions in order to avoid the resident's continued nutritional decline. (2) Based on observation, interview, and record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for failing ta ensure that 1 of 23 sampled residents maintained acceptable parameters of nutrition. 4. On April 6, 2000 a survey team from the Agency’s Area 1 Office conducted a survey and the following uncorrected Class I deficiencies were cited. 4A, Pursuant to 42 CFR 483.15(e)(1}, a resident has the right to reside and receive services in’ the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. This requirement was not met as evidenced by the following observations: (1) Resident #17, was admitted on March 27, 2000 with a medical diagnosis of spastic quadraparesis secondary to brain injury. During the initial tour of the facility on April 3, 2000 at approximately 10:15 a.m., and on many occasions throughout the survey, the resident was observed sitting in bed, rails up and a pneumatic call bell attached to the bed linens beside the resident's left shoulder. The resident was 10 (4d 4B, 7 veer ™TPQ OP ULEAUIS oboe noved%o be wearing hand splints on upper extremities on April 3, 2000 and April 4, 2000. (a) Interview with staff during the tour revealed the resident had no voluntary movement of extremities and was dependent on the room-mate to call for assistance when attention was needed. The resident's roommate was identified by staff as being confused at times. Review of the resident's clinical record revealed no alternative methods for communicating needs to staff from the resident's room had been provided. . {b) After discussion with administrative staff on April 6, 2000, an alternative call bell which can be activated by the resident was ordered. (2) Based on observation, interview and record review, it was determined that the facility violated Rule 59A-4.1288 F.A.C., for again failing to provide services with reasonable accommodations of individual needs for 1 of 24 sampled residents. Pursuant to 42 CFR 483.20(k), the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This requirement was not met as evidenced by the following observations: (1) Resident #16, was admitted to the facility January 3, 2000 with multiple medical diagnoses including hypertension, ischemic heart disease, and progressive supernuclear palsey. Review of the resident's clinical record revealed that the resident was found to be impacted on March 21, 2000, partially disimpacted, and subsequently hospitalized for rectal bleeding following the disimpaction. The resident returned to the facility on March 27, 2000 and a comprehensive assessment was completed April 3, 2000, assessing the resident's bowel status as having constipation, not fecal impaction. YW 4l VUES ENN US cram PURI DO VERLT AEALIALARE WEURLIA FLUKIVA URUUP = //U4U9992) T-175) -P.O13/019 F-741 \w \/ (a) Review of the resident's plan of care which was reviewed and revised on March 30, 2000 revealed no evidence of assessment, goals or interventions addressing either constipation or fecal impaction. (2) | Resident #10 was admitted to the hospital January 6, 2000-January 13, 2000 with a diagnosis of pacemaker malfunction and dehydration, having a BUN of 34 (normal range is 7-18). Facility weight records indicated that he experienced a 24.2 pound weight loss from January 3, 2000 to January 17, 2000. Upon his retum to the facility, a’ comprehensive significant change assessment was completed on January 25, 2000 reflecting the significant weight loss and the resident's use of a diuretic daily. There was no other indication of the resident's previous state of dehydration. (a) Summary notes for the Resident Assessment Protocol regarding his nutritional status indicated that the resident "has had a significant weight loss and that his intake had been fluctuating," however, notes regarding dehydration/fluid maintenance revealed that in spite of his “potential for dehydration due to daily diuretic use", the decision was made "not to care plan" for this since "at this point resident is eating and drinking anything that is handed to him." There was conflicting information regarding the adequacy of the resident's oral intake and no care plan was established for aiding in the maintenance of adequate hydration for this resident. (b) Subsequent lab data on March 17, 2000 revealed a BUN of 28, indicating that the resident continued to be poorly hydrated. Interview with facility staff and observations made on April 4, 2000 at lunch and dinner meals as well as review of the facility meal intake log revealed that the resident had a very sporadic fluid intake. (3) | Observation of resident #12 on all days of the survey revealed a resident spending most of the day in her room in bed. The only observed times out of the room occurred when family came in to visit and take the resident around the facility in her wheelchair. The resident had a-care plan to have a contracture tree placed between her knees for four hours every shift. All days of the survey, the device was observed sitting on a chair by the bathroom door. 12 TREE EISPENEN GO MERNSZINMET EY TINT WY MINI PURI S| T-175 P.O14/019 — F=74] Y {a} The resident was also to have “cool, clean water at bedside all the time." Observations on all days revealed the resident had no water at bedside. This Tesident was also assessed as having fecal impactions but no care plan was developed to address the services that would be provided to prevent further impactions, (b} Interview with staff on April S, 2000 at 9:20 a.m. revealed the resident hasn't worn the contracture tree in a very long time and they did not keep water at the bedside due to the resident frequently throwing things.” Staff was not aware of the fecal impactions, (c) Based on clinical record review, this resident, in addition to the fecal impactions, also suffered from UTI's almost monthly. : (4) Based on observation, interview and record review, it was determined that the facility violated Rule 59A-4.106(2), F.A.C., for again failing to develop a comprehensive care plan to include measurable objectives to meet the resident's medical and nursing needs for 3 of 24 sampled residents, resulting in actual harm to Resident #10 and #12. 4C. Pursuant to 42 CFR 483.25(c), based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent any new sores from developing. This requirement was not met as evidenced by the following observations: (1) During the initial tour of the facility, resident # 4 was identified by facility staff as having terminal cancer, a "Stage IV plus (unstageable)” pressure sore on her coccyx and was currently under the care of hospice. vosee TMI REYE RET GAL IAMARE UCURUEA FLURIVA URUUF ff USUYIU?) T-175) -P.O15/019 Fe 74] 4D. (2) (a) Review of the resident's clinical record revealed that the resident received antibiotic rreatment for infection related to decubims from February 21, 2000 - March 3, 2000. Assessment by facility staff and observations during the survey revealed that the resident generally left 25% or more of her meal uneaten. (b) Further review of the resident's clinical record revealed a nutritional assessment and note by the facility's registered dietitian on December 8, 1999° which read “open area to coccyx" and recommended adding a multi-vitamin/mineral supplement, 500 mg. of Vitamin C twice a day, and 2 ounces of 2Cal HN with medication pass four times a day for the purpose of improving the resident's nutritional status and promoting wound healing. There was no evidence that any of these recommendations had been implemented at the time of the survey. {c) Interview with facility staff revealed that the recommendations were never made to the resident's hospice treatment team or physician and on April 4, 2000, the recommendations were made and orders were received to begin the nutritional supplements in order to aid in the treatment of the pressure sore. Based on record review and interview, it was determined that the facility violated Rule 59A-4. 1288, F.A.C., for again failing to provide the necessary treatment and services to prevent the development of pressure sores and promote healing and prevent infection for residents with pressure sores for 1 of 24 sampled residents. Pursuant to 42 CFR 483.25(i)(1), based on a resident’s comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional statis, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible. This requirement was not met as evidenced by the following observations: ri PUMHETOGVERKT AGALTMVARE GEURLIA FLORIDA GROUP 7704099921 T-175 P.O16/O19 F741 \/ ~ (1) Resident #1 was admitted to the facility on March 7, 2000 with a diagnosis of anoxic brain damage following an acute myocardial infarct. At the time of admission, the resident was determined to be 71 inches tall and weighed 137 pounds. He was noted to have a stage IJ pressure sore on his coccyx and an unstageable pressure sore on his right heel. On the day of admission, the facility registered dietitian completed a nutritional assessment and determined that the resident's caloric needs were estimated to be 1783- 1961 calories per day for weight maintenance, 62-70 grams” of protein, and 1860-2170ce fluid. The resident was receiving bolus tube feedings of Pulmocare 140cc every 3 hours as his sole source of nutrition along with 100cc water flushes every six hours, which Provided him with 1680 calories, 70 grams of protein, and 1520 ce fluid per day. (a) On March 15, 2000, the resident's tube feeding was changed to continuous feedings with a gradual increase to Pulmocare at 80cc per hour for 20 hours per day. The next weight recorded on the resident was on April 2, 2000, at which time he weighed 131.6 pounds, a 5.4 pound weight loss in less than 30 days. {b) On April 3, 2000, the facility dietitian recommended an increase in the tube feeding to 85cc per hour for 22 hours per day secondary to weight loss, increasing his daily intake to 2805 calories, 117 grams protein, and 2207cc fluid. The resident experienced avoidable weight loss due to the facility's failure to provide adequate tube feeding. and the necessary calories to maintain body weight. (2) Based on observation, interview and record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for again failing to ensure that 2 of 24 sampled residents maintained acceptable parameters of nutritional status. TT STEEN OEM SPENT TY MESON PEMA IIIE | P1739 P.O7/019 F744 3. wase on the foregoing, Destin Health Care and Rehab Center has violated the following: a) Tag F246 incorporates 42 CFR 483.15(e){1) and Rule 59A-4.1288, F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. b) Tag F279 incorporates 42 CFR 483.20(k) and Rule S9A-4,106(2), F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. . c) Tag F314 incorporates 42 CFR 483.25(c} and Rule S9A-4.1288, F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. ad) Tag F325 incorporates 42 CFR 483.25(i)(1) and Rule S9A-4.1288, F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. 6. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.23(9)(c), Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of a Nursing Home. NOTICE Respondent is notified that it has a Tight to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense}, to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecim issued, and to present written evidence or argument if it requests a hearing. Yores~ cuuy US. cod PFOMMBEVERLY HEALIRUARE GEUKGIA FLORIDA GROUP 7704099921 T-175)-P.018/019 «F-74} \w Ww In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for’ Health Care Administration, Attention: Sam Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. All payment of fines should be made by check, cashier’s check, or - moriey order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. All payrnent of fines should be sent to the Agency for Health Care Administration, Attention: Christine T. Messana, 2727 Mahan Drive, Mai] Stop #3, Tallahassee, Florida 32308-5403. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. “eee RS vores PUSH BEVERLE RBEALIAGLARE GEURKUIA FLURIVA URUUP = 7704099921 T-175 P.019/019 = F-741 Oe ae oom [Issued this day of é , 2000. Do Heiberg Field Office Manger, Area #1 Agency for Health Care Administration Health Quality Assurance 2639 N. Monroe Street, Suite 208 Tallahassee, Florida 32303 . CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrator, Destin Health Care & Rehab Center, 195 Mattie M. Kelly Boulevard, Destin, Florida 32541 on this L3ktday of _\ wren, 2000, Christine T. Messana, Esquire Office of the General Counsel Copies furnished to: Christine T. Messana Area 1 Office Attomey Agency for Health Care Gloria Collins, Finance & Accounting Administration 2727 Mahan Drive Mail Stop #3 Tallahassee, Florida 32308 Pete J. Buigas, Deputy Director Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403 ree

Docket for Case No: 00-002965