May-31-2002 10:12am — From-ADMIN{ STRATION 986-446-8039 T-901 P.002/014 — F-780 6 50 - 5 2 ( - (V4a STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No. 2002007651 VB. OAK 'TERRACE HEALTH CARE ASSOCIATES, LLC D/B/A ) G > : o2-¢ GOVERNOR’ S CREEK HEALTH AND REHABILITATION, Respondent, ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“ABCA”), by and through the undérgigned counesal, and files this Administrative Complaint against OAK TERRACE HEALTH CARS ASSOCIATES, L.L.C, D/B/A GOVERNOR'S CREEK RRALTH AND REHABILITATION hereinafter roterred to GOVERNOR'S CREEK or as Respondent, pursuant bo Section 120.564, and 120.57, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 2. This a8 an action to impose an administrative fine against GOVERNOR’S CRRRK, pursuant to Section 400.102, Florida Ssatutes, (2001) and assess costs related to the investigation and prosecution ¢f this case, puxauant to Section 200,122(10), Fla. Stat. (2901), May-31-2002 (0:12am — From-ADMINISTRATION 986-448-6033 T-901 P.003/014 — F-790 SURISDICTION AND VENUE 2. This trikunal hao jurisdiaczon pursuant to Sections 120.569 and 129.57, Plorida Statutes, (2001). 3. Vanue shall be devermined pursuant to Rule 28- 106.27, Florida Administrative Code. PARTIES 4. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutea and rules governing skillea nuxysing facilities pursuenc to the omnibus Reconciliation Act sf 1967,Tirle Iv, Subtitle C (as amended); Chapler 409, Part II, Florida Statutes, (2001), and; Chapter $9A-4 Fla. Admin. Code, respeecively. 5. COVERNOR’S CREEK is a nursing facility whose 120- ord nursing home is logated at 802 Oak Siceat, Green Cove Springs, Florida. COVERNOR'’S CREEK 1s licensed to operate a nursing facility license #1181096 é. At ali xvelevant times, GOVERNOR'S CREEK wags & licensed facility vaquired to corply with ail applicable regulations, statutes and rules under the sicensing authority of ARCA. May~31-2002 10:12am From-ADMINISTRATION 586-446-6033 T-901 -P.0N4/014 — F-790 COUNT I GOVERNOR’ S CREEK FATLED TO INSURE THE RESIDENT Was FREE FROM UNNECESSARY DRUGS. 42 CFR 483.28(1) (1) Rule 592-4.1288, Fla. Admin. Coda (2001) 7, AHCA se-allegas and incecrporatey paragraphs (1) through (6) as if fulty set forth herein, 8. AHCA conducted survey of GOVERNCR'S CREEK on or about January 24, 2002, Investigation revealed 4 Class IIL deficiency. Based upen surveyor observations, start interview and record review it was revealed the facility failed to comply with Florida law. The findings are Gelineactes as follows: 9, Based on review of the facility plan ef correction, review of 1 of 11 sampled resident records and scaff interviews, tha facility did not ensure thar a reassessment of Resident #2's Asnormal Involuntary Movement Scaie (AIMS) form was conducted as stated in the facility plan of correation. Therefore, the facility did net consistently ensure that residents had itonicoring done for adverse consequences, The findings include: a. Review of Resident #2's medical record on the morning of the revisit survey revealed that “he ATMS form that was in the vecerd during the eurvey on 12/21/91 was 3 May-31-2002 19:13am © From-AOMINISTRATION still in the residents record, the scale for abnormal movements had not been done gince February 2001. Interview with staff indicated that the resident was not due ta ke aacessod until March 2002, go no new asseasment tad been done. Staff also indicated that Lhe resident nad ner had any changes since September 2001 when a note Nad been writcen and the medication documented, when first raviewed the scale for September 2001 was not complete. b) Review of the facility's plan of correction state than Resident #2 was to have beer veassessed using the AIMS form. During the review of the record in the morning of che revisit, the Facility had noc reassess Residenc #2. 10. MICA provided to GOVERNOR’S CREEK a written mandated correction date ef January 21, 2002, in accardance with Section 400.23(8) ic), Florida Statutes, GOVERNOR'S CREEK, however, failed te correct the class iIt deficiency by the mandated correction date and the same defticienoy was discovered at the survey conducted an or about January 24, 2002. Based on rhe foregoing GOVERNOR'S CREEK was olited for an uncorreered class Iit deficiency. 11. Pursuant to Section 400,23(8), Florida Stetutes, the foregoing is an “isolated” class TIT deficiency because it afiected one or a very limited number of residents, involved one or a very limited mumber of staff, or occurred only accasionally or in a very limited number of locations, 4 386-446-6093 7-901 P.005/014 F-790 May-31-2002 10:13am From-ADMINISTRATION 386-448-6039 T-901 P.006/014 12. GCVERNOR’S CREEK failed to ensure menicoring was completed for adverss consequences. such tailure constitutes inaction that materially affects the residents’ health and violates the statutes and rules governing nursing hames and furtasr constitutes grounds for the administracive fine under Sections 400.162.1) (a) &{2) (a), Pla. Stat, (2002) and Rule S59A-4.1288, vla. admin. Code, vespectively. The Agency’s assessment of costs related to the investigat.on and proseeuricn of this case is proper, pursuant to Section 400,121(10), Fla, Stat, (2001). CLAIM FOR RELIEF WHEREFORE, AHCA requests the following reliar: a) Enter actual and legal findings in favor of AHCA 2) Impose & $1000 civil penalry against. GOVERNOR’ S CREEK. c) Assess coete related to the investigation and prosecution of this case pursuant to Section 400.122(10), Florida Statutes (2001); and a) Grant any ocher general and equitable relief as appropriate, F-790 May~31-2002 16:13am © From-ADMINSSTRATION 388-446-6033 T-901 = P.007/014 = F790 COUNT TT GOVERNOR'S CREEK FAILED TO ENSURE THAT IT IS FREE OF MEDICATIONS RATES OF FIVE PERCENT OR GREATER 42 CFR 493.25 Rule 598-4.1238, Fla. Admin. Code (2001) 13. AHCA re-alleges and ineorporatea paragraphs (1) through (4) as if fully set forth herein, 14, AHCA conducted survey of GOVERNOR’S CREEK on or abour January 24, 2002, Investigation revealed a Class TIT deficiency. Based? cpou surveyor observacions, staff interview and record review it was révealed the facility failed ro develop and implement policies and procedures to protect tne health and safety of the residents. The findings are delineased as follows; 15. Based on observations of the medication pass and recerd review conducted on 1/24/02 at 8:15 A.M., the facility failed to ensure that the medication error rate was 5% or lewa. It was determined during the medication pass that a total of 45 observations oceuxred, with three Medication exvor's, therefore the facility received a 6.7% medication arrar rate. The findings include: During the medication pass on the West Wing on 1/24/02 the following errors occurred: May-31-2002 10:13am From-ADMINISTRATION 386-446-6033 a. Vitamin Daily Laquid l0ce's was given to an unganpled resident. The physician order revealed the following Theragran Vit 1 tab via G-tube. The Surveyor compared ingredients and tound thar the ingredients were not the same and there was no order that the medication given could be substituted for Theragrar. b. Ferrous Sulfate 220 mg/Sec was given to an ungampicd resident. The physician order revealed thac Ferrous Sulfacre 325 mg/Scc was ordered. CG. Observacion of the wrapper for Tegretol being given tO a Yegident revealed chat the wrapper conmained an expiration dace of 1/12/02. Staff was informed, and a new box of the medication was checked. The new box of the medication indicated the same expiration date, 16. GOVERNOR'S CREEK’S failure to ensure the medication error rate was 5% or less contravenes Seecion 47 CFR 423.25 and conscitutes a denial cco the residents’ of the right to receive adequate and appropriate health care Wunder Section 409.022(1) (1), Fla. Stat. (2001). Such constitutes action that materially affeces the residenrs’ health and violates tha etacutes and rules governing nursing homes and further constitutes grounds fer the administrative fine under Sections 400.102.1) (a) & (4) (a), Fha, Stag. (2001) and Rule 59A-4,1228, Fla, Admin. Code, respectively. Uhe Agcney’s agsezsment of costs calated to T-901 -P.008/014 F790 May-31-2002 10: {4am © From-ADMINISTRATION 396-446-6093 T-901 - P.OOS/OI4 = F+790 the investigation aad prosecution of this case is proper, pureuant to Section 100.121(10), Fla. Star, (2001). 17. AHCA proviaed to GOVERNOR'S CRETE a written mandated correction date of January 21, 2002, in ancerdance Wilh Section 400.23(8) (c), Florida Statuces. GOVERNOR’ S CREEK, however, failed to correct the Glass III deficiency by the mandated correction date and the same deficiency was discovered at the survey conducted on or about January 24, 2002. Based on the Toregoing GOVERNOR’S CREEK was cited for an uncorracted class II1 ceficiency, 18. Pursuant tc Section 400.23(8), Florida Statutes, the foregoing is a “pattern” class IIT deficiency because wore than a very limiced number of residents were affected, move than a very limited number of araff were involved, the situation occurred in several locations, or the same resident or residents were affected by repeated oceurrences of the same deficsent practice but the avfect of the defitetenc practice was not pervasive throughour the facilicy. 19. GOVERNOR'S CREEK’S failure =o ensure the medication error rate was 5% or less contravenes Section 42 CFR 433.25 and constitutes a denial to che vasidents’ of the right to receive adequate and apprograats health care under Section 4€0.022(1){1), Pla. Stat. (2001), Such constitutes action that materially affects the residents’ & May-31-2002 {0:14am From-ADMINISTRATION 386-446-6033 T-901 P.O10/014 = F790 health and violates the statutes and rules governing tuursing homes and further consticuces grounds for | he adminigtrative fine under Sections 400.192.1) (a) &{1) (a), Fla. Stat. (2002) and Rule 59A-4.1288, Fla. Admin. Code, respectively. The Agency’s assessmeit of costs related to the investigation and prosecution of this case is proper, Ppursiant to Section 400,121(10), Fla. Snart. (2001). CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following reliof: a) Enter actual and legal findings in favor of AHO. b) Impose a $2000 civis penalcry against GOVERNOR'S CREEK. c) Assess costs related to the investigation ang prosecution of this case pursuant to Section 400.121(20), Plorida Statutes (2001); and da) Grant any other general and equitable relief as appropriate, Agency for Health Care Administration z 2 b é Cg ghryfreee Richard “Joseph: Saliba, Esquire, Senior Attorney Fla. Bar, No. 0240389 Counsel for Petitioner Agency for Health Care Adminiscration Building 3, Mail Stop #2 2727 Mahan Drive Tallahassee, Florida 32303 (850) 921-0071 (affice) (850) 921-0158 (fax) May~31-2002 10:14am From-ADMINISTRATION 388-445-6039 T-901 P.O1I/014 NOTICE OAK TERRACE HNALTH CARE ASSOOIATES, LLC D/B/A GOVERNOR'S CREEK HEALTH AND REARABILITATION, hereby is notified that it has a right to request an administrative hearing pursuant cto Seecrion 120.569, Flocida Statures,. Specific options for administrarive aetion are S@t out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page}, All raquests for hearing shall be made to the Agency for Health Care Administration, and delivered to Rachard Joseph Saliba, Esquire, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 43, Tallahassee, Florida, 32398. OAK TERRACE HEAWTH CARE ASSOCIATES, tic D/B/A GOVERNOR’ S CREEK HEALTH AND REHABILITATION 13 FURTHER NCTIFIED THAT THE FAILURE To REQUEST A HEARLNG WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION GF THE PACTS ALLEGED IN THE ADMINISTRAYIVE COMPLAINT AND TEE INTRY OF A PINAL ORDER SY ACHA. Agency for Health Care Administration . a freely ar ds Joseph Saliha, Esquire, _ Senior Attorney Fla. Bar. No. 0240339 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop 43 2727 Mahan Drive Tallahassee, Florida 32308 (859) 921-0071 (offices) (850) 921-0158 (Fax) F~790 May-31-2002 10:15am — From-ADKINISTRATION 386-446-6033 T-a0! P.ot2/ot4 = F-790 CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing Administrative Complaint has been sent by U.S. Certified Mail Return Receipt Requested (return receipt 4 TAO& 4395 1294 2049 7631) to OAK TERRACE HEALTH CARE ASSOCIATES, L.L.C.0/8/A GOVERNOR'S CREEK HEALTH AND REHABILITATION MS, Celia Garland-Tomlinaon, Administrator Oak Terrace Spaclalty/ Governor's Creek Nursing Home, 803 Oak Street, Green Cove Springs, Plorida. 32943, chia GY day of May, 2002. Agency for Health Care Administration heed oe Saliba, Eogquire, Senior Attorney Pla. Bar. No. 0240389 Counsel for Petilioner Agency for Health Cara Administration Building 3, Mail Stop #5 2727 Mahan Drive Tallahassee, Florida 22398 (850) S21-0071 (office: (880) 921-0158 (fax) 11

Docket for Case No: 02-002497