STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2002049278 2002049277 A“ O%-O 140 SEMINOLE MERIDIAN LIMITED PARTNERSHIP, d.b.a. ISLAND LAKE CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against SEMINOLE MERIDIAN LIMITED PARTNERSHIP, d.b.a. ISLAND LAKE CENTER (hereinafter Island Lake), pursuant to §§ 120.569, and 120.57, Fla. Stat., (2002), and alleges: NATURE OF THE ACTION This is an action to change Island Lake’s licensure status from Standard to Conditional, commencing 7/11/02 and ending 8/27/02, and to impose an administrative fine in the amount of $5,000.00 based upon its two cited State Class II deficiencies requiring Island Lake to provide timely care services and to monitor and provide supervision to each resident. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory agency responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Island Lake operates a 120-bed nursing home located at 155 Landover Place, Longwood, Florida, 32750, and is licensed as a skilled nursing facility, license number SNF13460963. 5. Island Lake was at all times material hereto, a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to 42 C.F.R. § 483.13(c), Island Lake must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 8. On or about July 7-11, 2002, the Agency conducted an annual recertification survey of Island Lake. 9. Based upon observation, interview and record review, Island Lake failed to ensure that two residents, Resident # 1 and Resident # 12, of 24 sampled residents, received adequate care and services in a timely and professional manner after the residents had been identified with constipation problems. 10. Clinical record review revealed that Resident # 1 was admitted to Island Lake on 2/21/01 with diagnoses of spina bifida, osteomyelitis, major depressive disorder, paraplegia due to ischemic insufficiency, anemia, exogenous obesity, splenectomy and decubitus ulcer. 11. Interview with Resident # 1, on 7/09/02, revealed that the resident was having problems with constipation. The resident indicated that bowel movement was not regular and needs laxative or other rectal stimulation at times to make bowels move and due to the decubitus ulcer to the sacral area, has been ordered to be on bed rest. Record review, on 7/08/02, revealed that the resident was sent to a wound care center at a local hospital for treatment of the ulcer. The wound care center nurse performed a manual fecal disimpaction that day as the resident was having small amounts of bowel movement and had complained of abdominal discomfort. Resident # 1 was returned to [sland Lake with a recommendation from the wound care center to initiate a bowel program to prevent future problems of fecal impaction. Further record review revealed that the resident had no bowel movement from 6/25/02 to 6/30/02. The resident's physician had ordered milk of magnesia to be administered daily, as needed, and prune juice two times daily. The medication administration record revealed that the milk of magnesia was administered but once, on 6/02/02, during the month of June, and prune juice was not recorded as given. Interview with the staff nurse on 7/12/02, indicated that the resident is supposed to have bowel movements every two days. However, the bowel movements were irregular and the record was not accurate. Review of the resident's care plan, dated 10/17/01, revealed that the constipation problem was to be addressed as an altered pain and comfort approach. The bowel program recommended by the wound care center was never initiated, acknowledged, or addressed. 12. During that survey, observation, interview and record review of Resident # 12, revealed that he/she was uncomfortable and had some back pain on 7/08/02. On 7/09/02, the resident was again observed to be in bed. During an interview with resident, he/she stated that he/she was not feeling well and had eaten breakfast in the room. Interview with the Certified Nursing Assistant (CNA) working with resident, revealed that he/she was assisting the resident with toileting and the resident had not had a bowel movement after a number of attempts. During the interview with the resident, he/she was observed grabbing his/her side and drawing his/her legs in. The resident stated "I'm having a bad cramp quite a bit". Nursing staff was informed of the resident's pain. Shortly thereafter, the resident vomited. On 7/10/02, the resident was sent to the Hospital via Ambulance. 13. Review of Minimum Data Set (MDS) quarterly assessment, dated 5/12/02, coded Resident # 12 as continent of Bowel. Review of the Nutrition Assessment, dated 2/ 15/02, documented the resident as incontinent of bowel and bladder, with constipation, with a level of Significant. No further information was documented in regards to bowel incontinence or constipation on the Nutrition Progress notes, dated 2/18/02, 2/21/02, 3/11/02, 5/20/02, or 6/19/02. 14. During an interview with a Nurse Practitioner (ARNP), he/she stated there was no written protocol for use of laxatives for constipation. However, review of the Facility's protocol for Constipation defined constipation "as passing two or fewer bowel movements per week, or straining more than one out of four times when having a bowel movement." The facility did not have this protocol readily available for review. When the policy was received for review the second page of the protocol was missing and again had to be located for review. 15. The facility had not implemented the written facility protocol for Resident # 12, thereby neglecting to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness for the resident. 16. These observations were cited as an isolated, State Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Island Lake, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8) and 400.102, Fla. Stat., and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. COUNT II 17. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 18. Pursuant to 42 C.F.R. § 483.25(h)(2), Island Lake must ensure that each resident receives adequate supervision and assistance devises to prevent accidents. 19. On or about July 7-11, 2002, the Agency conducted an annual recertification survey of Island Lake. 20. During that survey, based on observations, staff interviews, and record review, the facility failed to monitor, provide adequate supervision to prevent falls with injuries and to develop interventions to ensure the safety of two (2) of 22 sampled residents (#2, #7). 21. Resident # 2, was admitted to the facility on 9/15/00, with diagnoses of osteoporosis, Parkinson's disease, dementia, depression, hypertension and a past medical history of falls, and a fracture of the right femoral neck, for which the resident underwent a unipolar prosthetic arthroplasty. 22. Review of Island Lake's interdisciplinary notes, dated 9/15/00, indicated that Resident # 2 had multiple bruises to the body sustained from a fall. The facility assessed and identified the resident as being high risk for falls at admission, but the facility did not develop a falls care plan with measurable goals interventions and a monitoring system in place to meet the resident's needs to prevent further injuries from falls. Review of the clinical record and interview with the Unit Manager, revealed that documentation provided in the falls care plan was not developed until 10/2/00. The interdisciplinary team reviewed the care plan on 12/29/00, 3/15/01, 4/21/01, 5/11/01 and 7/13/01. On the care plan, dated 7/30/01, it was noted that the resident had sustained an injury to the head. On 8/10/01, the interdisciplinary team reviewed the resident's care plan, but did not revise the care plan approaches of 5/11/01. On 11/5/01 the resident fell at the facility and was transferred to local Emergency room because of a fall, where it was discovered that the resident had sustained a fracture of the left hip. Resident #2 was readmitted to the Island Lake on 11/13/01, however, the facility failed to up-date the falls care plan until 11/28/01, fifteen (15) days later. Documentation revealed that during the period from 12/04/01 through 7/07/02, the resident continued to sustain multiple falls, many with injury. 23. An Interdisciplinary Therapy Screen, dated 7/8/02, indicated a Velcro belt physical was to be used, on a trial basis. The interdisciplinary team care plan indicated that a Velcro belt was to be used when the resident was in a wheelchair. Island Lake staff failed to follow the falls care plan for physical restraint. Surveyor observation of Resident # 2, on 7/10/02, revealed that the resident was in a Velcro belt physical restraint, but was wandering in the wheelchair without staff's observance of the care plan. 24. Based on interview with the Unit Manager and record review on 7/10/02, Island Lake failed to develop an effective falls care plan and a maintain a monitoring system in place to meet the resident's needs to prevent further injuries from falls. 25. Resident # 7 was admitted to the facility on 4/16/02, with diagnoses of fracture of the pelvis, transient ischemic attack, dementia and hypertension. The MDS current assessment, dated 5/14/02, coded the resident's cognitive status as moderately impaired, decision poor; cues/supervision required. Based on interview with the Unit Manager and record review, the facility failed to develop a care plan with measurable goals, interventions, or a monitoring system in place to meet the resident's needs to prevent further injuries from falls until 5/15/02. On 7/02/02, Resident # 7 fell, but no injury was noted. On 7/3/02, the resident fell and sustained a small scrape and bruise to right forearm. Again, on 7/03/02, the resident was found on the floor along side of the bed in another room. On 7/5/02, the resident climbed out of bed and fell. The facility interdisciplinary team failed to update the falls care plan with approaches or system to monitor falls to prevent further falls with injury. 26. These observations were cited as an isolated, State Class IT deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Island Lake, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8) and 400.102, Fla. Stat., and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. COUNT IL 27. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth 28. Based upon Island Lake's two cited Class II deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400 or the rules adopted by the Agency and is a violation subject to assignment of a conditional licensure status under § 400.23(7)(b), Fla. Stat. WHEREFORE, the Agency intends to assign a conditional licensure status to Island Lake, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(7) commencing 7/11/02 and ending 8/27/02. Respectfully submitted this __ 4.5 : day of January, 2003. fi Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330 L St. Petersburg, FL 33701 727.552.1526 (office) 727.552.1440 (fax) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat., Island Lake shall post the most current 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. Respondent 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Sebring Bldg., 330L, 525 Mirror Lake Drive, St. Petersburg, FL 33701, Attention: Gerald L. Pickett, Senior Attorney. 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, CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the > foregoing has been served by certified mail return receipt Jeez xo3e goo7 LYTG 5SV22ON_ faut. aay 1S, , 2003 to: Administrator, Island Lake Center, 115 Landover Place, Longwood, Florida 32750 and US. Mail to C T Corporation System, Registered Agent for Island Lake Center, 1200 South Pine Island Road, Plantation, Florida 33324. yy, i Lah Yad Straid L. Pickett Copies furnished: Administrator, CT Corporation System — Gerald L. Pickett Island Lake Center Registered Agent for Agency for Health Care 115 Landover Place Island Lake Center Administration Longwood, Florida 32750 1200 South Pine Island 525 Mirror Lake Drive, 330 L (U.S. Certified Mail) Road St. Petersburg, FL 33701 Plantation, Florida 33324. (U.S. Mail)

Docket for Case No: 03-000940