STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR ef PMEMGS HEALTH CARE ADMINISTRATION, Petitioner, O cor O72 AHCA NO: 2002048939 vs. MANOR CARE OF BOYNTON BEACH, INC., d/b/a MANOR CARE HEALTH SERVICES, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against MANOR CARE OF BOYNTON BEACH, INC., d/b/a MANOR CARE HEALTH SERVICES (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose a conditional licensure status effective October 17, 2002, pursuant to Sections 400.23(7) (b) and 400.23(8) (b). The original conditional license is attached hereto as Exhibit “A”. 2. The Respondent was cited for the deficiency during the annual survey conducted on or about October 14-17, 2002. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 13881 Eagle Ridge Drive, Fort Myers, Florida 33912. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I EFFECTIVE OCTOBER 17, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO THE RESPONDENT BASED UPON THE DETERMINATION THAT THE RESPONDENT WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) CLASS II DEFICIENCY AT THE MOST RECENT SURVEY OF OCTOBER 14-17, 2002. §400.23(7), Fl. Stat. (2002) FIRST CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about October 14-17, 2002 an annual survey was conducted at the facility. 9. On that date, based on based on record review, observations, and interviews with family member and facility staff, the facility failed to provide necessary care and services for Resident #7, (1 of 20 active, sampled residents), who is severely cognitively impaired. The findings include: 9.1 Resident #7 was admitted to the facility on 7/29/02 with diagnoses including S$/P (Status Post) Hip Fracture, Alzheimer's disease, (UTI) Urinary Tract Infection, Atrial Fibrillation, and Interstitial Lung Disease. The History and Physical of 7/31/02 lists current meds to be Lanoxin, Aricept, Zyprexia, and Nitropaste. The report stated that the resident had no lower extremity edema. The report further confirmed that this resident was upper "edentulous, lower few remaining teeth and with oral mucosa pink, moist." Admission weight of this resident was recorded to be 109 pounds. A physician's order of 8/04/02 specified the diet to be changed from Regular Consistency to Ground Enhanced with House Supplement TID (three times daily). During the months of August and September the resident suffered from UTIs. Lab tests confirm these infections on 8/14/02, 9/04/02, and 9/23/02. Appropriate ABT (antibiotic therapy) was administered with each infection. 9.2 After admission to the facility the resident encountered a severe weight loss of 14.7% of body weight (from 109 Pounds on 8/5 to 93 pounds on 10/09/02). Nursing notes during this time frame describe the resident as resistive to care with frequent refusals of medications, meals, fluids, and showers. The resident's weight had increased to 98.8 pounds on the third day of the survey when the surveyor requested a current weight. Facility staff during interview on 10/16 attributed the weight gain to the resolution of the UTIs. 9.3 Laboratory values of 8/26/02 report a BUN elevated at 22 (desirable range 7 to 17), Creatinine within normal range at 0.8, a BUN/Creatinine Ratio of 27.5 (values above 25 indicate possible dehydration), and a decreased moderately depleted visceral protein status indicated by an Albumin of 3.1 (desirable 3.5 to 5.0). Additional lab values of 9/17/02 documented an increased BUN of 31, a normal Creatinine of 0.9, a BUN/Creatinine Ratio of 34.4 indicating possible dehydration, and a still depleted Albumin of 3.0. At this time a physician's order was obtained to encourage fluids: 600 cc every 8 hours. Also on this date a problem of "At Risk for Dehydration and UTI was added to the care plan. At an undeterminable date the problem of At Risk for Dehydration had been discontinued on the care plan when it was reviewed by the surveyor and copied on 10/15/02. When the surveyor on 10/16/02 once again reviewed the care plan, the problem of "At Risk for Dehydration" again appeared on the care plan with no indication as to when this problem had again become a concern. In addition the care plan, which was apparently updated, on 10/16/02 reflected the approach of "Provide assistance with reposition & for comfort." 9.4 The RAI (Resident Assessment Instrument) completed on 8/09/02 as an Admission Assessment coded the resident to be severely cognitively impaired, resistive to care, and requiring moderate to total physical assistance with ADLS (Activities of Daily Living). The most current RAI completed as a significant change on 10/07/02 coded the resident as severely cognitively impaired, resistive to care, and requiring moderate to total care with ADLs with the exception of eating which is coded as Independent with Set-Up help only required. However, the October charting by the CNAs (Certified Nursing Assistants) document that with eating, this resident requires, “hands on limited assistance with one person physical assist at the evening meal for the days of October 1 through October 14 while being independent requiring set-up help only for breakfast and lunch on the same dates. The offerings of food and hydration are documented as "y" instead of number of offerings approximately 50% of the time. Meal intake is recorded as varying between 0 and 25%. A Diet Communication Form dated 8/12/02 specified that the resident would eat in the Colony Dining Room at the second seating as a part of the Restorative Dining Program. An undated Diet Communication Form designates that the resident is to have lunch and dinner meals in the Edison Dining Room. The staff serving residents in this dining room related to the surveyor on 10/15/02 that Resident #7 was still on Restorative Dining even though she was now designated to eat in the Edison Dining Room. 9.5 The Monthly Nursing Summary dated 10/13/02 states that oral intake is 25 to 50% that she needs encouragement and verbal cues when eating, and eats in the dining room. Dietary notes of 10/08 and 10/10/02 document that the resident eats all meals in her room because it is "her preference." 9.6 On 10/15/02, the surveyor observed this resident's meal to be delivered to her room at approximately 8:10 A.M. The tray was left on the sleeping resident's over bed table with the meal still covered, milk cartons (2) unopened, no syrup or butter on the pancake, super cereals (2) remained covered, orange juice unopened. At 8:25 A.M., the resident remained sleeping with tray untouched. The roommate who was eating her breakfast stated that the resident liked to sleep late, that her tray was always left while she was sleeping in the mornings, no care was rendered before Breakfast to either resident, and that Resident #7 always has to wait for assistance to be rendered - if ever rendered. At 9:10 A.M., no staff had returned to the room to assist the resident with tray set-up or with AM care. The resident was observed to have opened a carton of chocolate milk and was drinking directly from the carton as no straw was on the tray. The food was cold and remained untouched. At 10:15 A.M., the resident was again sleeping, still in hospital gown stained with chocolate with no apparent AM care given. A peanut butter and jelly sandwich was observed to be wrapped and on the over bed table along with a banana and chocolate milk. The breakfast tray had been removed. At 11:15 A.M., the resident was observed to be eating the banana while the sandwich remained wrapped. At 11:45 A.M., the resident was sleeping, the sandwich was still wrapped, and * of the chocolate milk had been drunk. At 12:20 P.M., on the same day the resident's lunch tray was delivered to her room. Staff left the tray with no interaction with the resident and with no set-up. The resident was eating a slice of bread she had removed from the sandwich. She remained in a soiled hospital gown. Her hands were soiled with food debris and her fingernails were long and encrusted with debris. Lunch consisted of 2 containers of chocolate milk and a peanut butter and jelly sandwich. At 12:50 P.M., a staff member was observed to enter the room and take the roommate to the dining room for the noon meal. The staff member did not acknowledge Resident #7 in any fashion. The resident was eating the sandwich and drinking from a carton on chocolate milk without the benefit of a straw. This resident remained in a soiled hospital gown and was eating with dirty fingers and dirty hands. At 1:10 P.M., the resident's hands were soiled with peanut butter and jelly, as was the hospital gown. The resident had eaten the sandwich and consumed 1 carton of the milk. The other carton remained unopened on the over bed table. 9.7 While reviewing the resident's clinical record the surveyor noted that the resident was on a Restorative Ambulation Program and had a physician order dated 9/30/02 for ambulation 3 times a week for 12 weeks. Review of the form for Restorative Ambulation revealed that the resident had been ambulated on 4 occasions in October with 1 refusal. At 2:10 P.M. on 10/15/02, the Restorative Aide was interviewed. This Aide stated that the resident was not usually combative and enjoyed walking. At 2:30 P.M., the resident was observed to be ambulating with the Aide. This resident was smiling, waving to, and joking with staff members in the hallway. 9.8 The following day, 10/16/02, at the breakfast meal at 8:35 A.M., the resident's tray was placed on the over bed table. The resident was awakened and told that her breakfast was here. The resident stated to the CNA that she was still sleepy and wanted to eat later. The CNA stated that she would come back in 10 minutes to assist with eating. The resident stated, "Make that 15 minutes." The CNA said she would return later and exited the room. However, she immediately came back into the room and proceeded to set-up the tray and talk to the resident. The resident was now asleep. The tray consisted of scrambled eggs, 2 super cereals, a Danish, orange juice, 1 container of chocolate milk and a Nu Basic milkshake. The tray card stated that the resident was to receive 2 containers of chocolate milk and the Nu Basic had been discontinued by physician order on 10/10/02 due to "poor intake. Too sweet." Even though the supplement had been discontinued, it appeared as an approach on the current care plan in the entries of chocolate Nu Basic Plus with meals and Nu Basic three times daily. The resident was observed to be sleeping at 8:45 A.M., at 8:55 A.M. and at 9:20 A.M. At 9:20 A.M., the tray had been removed from the room. 9.9 At 9:25 A.M., the CNA who had delivered the meal was asked if she assisted the resident to eat. The CNA stated that the resident had eaten a few bites. The tray was found on a lateral cart in the hallway. The orange juice was unopened, no chocolate milk had been drunk, and only a few bites of the Danish were gone. 9.10 At 11:35 A.M., the resident was observed to be in bed, but dressed. An unwrapped uneaten sandwich was present on the over bed table along with a container of Nu Basic witha straw, and a half-eaten banana. Upon seeing the surveyor, the resident exclaimed, "I am ready to get up." When asked if she would like to go to the dining room to eat her meal the resident replied, "Yes, that would be nice. Would you take me?" 9.11 At 2:45 P.M., a sandwich, banana, and Nu Basic were present on the resident's over bed table. The sandwich was untouched and still wrapped. At 3:20 P.M., the snack remained untouched. Also enumerated on the care plan as approaches for the problem of weight loss were: Super foods at each meal, house supplements three times daily (which were discontinued on 10/10/02), assist with meals, encourage intake, peanut butter and jelly sandwich three times daily, chocolate milk at 10 A.M., 2 P.M., and 8 P.M., peanut butter and jelly sandwich for lunch and dinner, and banana at 10 A.M., 2 P.M., and HS (Hours of Sleep). The physician on 9/24/02 as a family request three times daily had ordered the peanut butter and jelly sandwich. The peanut butter and jelly sandwiches with soup for lunch and dinner per resident request were added to the care plan on 10/01/02. The resident did not receive the enhanced soup for lunch on the second day of the survey, only the sandwich. 9.12 At 12:15 P.M., Resident #7 was observed to be up in her wheelchair, dressed and ready to go to the dining room. She stated, "I am as hungry as a sick kitten." She asked the surveyor: "Do you have something to eat and drink?" No combativeness was displayed and the resident appeared anxious to go to lunch in the dining room. She remained in the hallway outside the dining room until 12:30 P.M. At that time she complained that her feet hurt. No footrests were present on her wheelchair and her feet were dangling in the air. She proceeded to place her feet on the wheels of the wheelchair in front of her and stated, "That's better." She stated that she was tired of waiting but continued to converse with passers-by. At 12:35 P.M., the doors to the dining room were opened and she pulled herself by using the handrail to the doorway. At that point, an aide came and ambulated her to a table. The place card on the table was for another resident and no place card for Resident #7 was present in the room. After surveyor intervention, a place card was placed in front of her and she stated to her tablemate, "That's my name, look." At 12:41 P.M., an aide delivered two containers of chocolate milk to her and poured them both into 2 glasses. She immediately started to drink the milk. When asked what she wanted for lunch, her answer was, "I want it all." At 12:45 P.M., she was offered and accepted a clothing protector. At 12:46 P.M., an aide was taking the order from her tablemate. The Aide then looked at Resident #7 and pointed to the resident while asking a nurse, "Is she new?" The nurse called out the resident's name. The aide left without taking the resident's lunch order. 9.12 At 12:55 P.M., no staff had returned to take Resident #7's lunch order. The surveyor then asked the Dietary Aide who previously had not known the name of the resident if she was going to take the resident's order. The aide stated, "She gets a peanut butter and jelly sandwich and soup for lunch." The Surveyor requested that lasagna be offered to the resident along with the sandwich. At 1:03 P.M., the lasagna and Soup were served to the resident. She took a few bites of the lasagna, garlic bread, and soup. She proceeded to dip crackers into the soup and eat them. A sandwich was brought to her and she proceeded to eat the entire sandwich and to drink 1 glass of chocolate milk and 1 cup of coffee with cream and sugar. She requested and ate a few bites of ice cream, 9.13 At 8:05 A.M. on 10/17/02, the surveyor contacted a family member via telephone. The interview revealed that the family had various concerns regarding the care and services rendered to the resident. The member stated that enormous resident. The family members had tried to communicate to staff on numerous occasions that the resident must be approached in a friendly, funny way, not with a demanding attitude. A demanding attitude would result in resistance by the resident. The resident should be coaxed rather than told she must do something. The family member stated, "They either don't know how to approach her or don't care." The family member related, "She is always ina dirty hospital gown and frequently needs showers. When I press the call bell it is always at least 15 minutes before someone comes to assist. I have gone over and over with the aides how to get her to drink and eat. For a while she drank nothing because they did not spend time trying to coax her to drink. JI put a sign in her bathroom to remind trying to get her medications in gel-form because she refuses to swallow many of her meds. A nurse who works here told us the gel-form might work better for her. I was hoping that Hope Hospice could get the gel-form meds for us, but we had a consult yesterday and she is not eligible for Hospice. I overheard one aide, " ", making negative comments about the resident and laughing and joking with other staff members about her. I didn't appreciate that but I didn't say anything.” 9.14 During the afternoon of 10/16/02 at approximately 3:15 P.M., a conference was held with the DON (Director of Nursing), the Administrator, and the Consultant RD (Registered Dietitian) during which the concerns regarding the care of this resident were communicated. One concern that was shared was why this resident with Alzheimer's Disease was not living in Thalia (Secured Unit). No answer was given except that the resident's condition had not stabilized. 9.15 At noon on the last day of the survey the resident was observed to be sitting in her wheelchair complete with foot rests in the hallway across from the nurses' station. She appeared to be enjoying watching the activity occurring and smiled at the surveyor while eating a chocolate Magic Cup. She was dressed in street clothes, stated she was ready to go to the dining room for lunch, and told the surveyor, "Good-bye. Be good, but if you can't be good, be careful." 10. The above actions or inactions constitute a violation of 59A-4.106(4) (aa) and 59A-4.1288 Florida Administrative Code incorporating by reference 42 CFR 483.25 Fl. Stat. (2002) which defines a Class II as a situation that has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 11. The Agency seeks to impose a Conditional Licensure Status effective October 17, 2002, based on one Class II deficiency Sections 400.23(7) (b), 400.23(8) (b) and 400.022(3), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; Recommend that the change of licensure status effective October 17, 2002, from Standard to Conditional be upheld; and Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (10) Fl. Stat. (2002) All other general and equitable relief allowed by law. DISPLAY OF LICENSE Pursuant to Section 400.062(5) and Section 400.23(7) (e), Florida Statutes, MANOR CARE OF BOYNTON BEACH, INC., d/b/a MANOR CARE HEALTH SERVICES shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE MANOR CARE OF BOYNTON BEACH, INC., d/b/a MANOR CARE HEALTH SERVICES is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 330D, St. Petersburg, Florida 33701. 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. Cobrece tut isGbmitted, HO. iA < Aktle/ Eileen O'Hara Garcia, Esquire AHCA ~- Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to C T Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324, by U.S. Mail and to Administrator, Manor Care Health Services, 13881 Eagle Ridge Drive, Fort Myers, Florida 33912 by U.S. Certified Mail Return Receipt No.7002 2030 0007 8499 5785, on January [eroos. Copies furnished to: C T Corporation System Registered Agent for Manor Care health Services 1200 South Pine Island Road Plantation, Florida 33324 (U.S. Mail) Administrator Manor Care Health Services 13881 Eagle Ridge Drive Fort Myers, Florida 33912 (U.S. Certified Mail) Eileen O'Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 A | fa A\ | / - J Ol Ye MWD §fL- ahua Eileen O’Ha¥a Garcia, Esquire d

Docket for Case No: 03-000936