STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 93 Av? ! PH R - . Pak STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Or%r- Het AHCA NO: 2002049119 vs. ' NINTH STREET HEALTH CARE ASSOCIATES, LLC, d/b/a HERITAGE HEALTHCARE & REHABILITATION CENTER, 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 NINTH STREET HEALTH CARE ASSOCIATES, LLC, d/b/a HERITAGE HEALTHCARE & REHABILITATION CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the total amount of nine thousand dollars ($9,000) pursuant: to Sections 400.102(1) (a) and (d), 400.022(3), and 400.23 (8) ( Florida Statutes. 2. The Respondent was cited for the deficiencies set forth below as a result of a revisit survey conducted on or about November 26, 2002, as a follow-up to the annual heaith licensure and recertification survey conducted on or about October 21-24, 2002. JURISDICTION AND VENUE ' 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Collier County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 F.A.C. PARTIES | j 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 777 - 9% Street North, Naples, Florida 34102. The facility is licensed under Chapter 400, Part II, plorida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO ENSURE THAT NONFLAMMABLE MEDICAL GAS SYSTEMS AND EQUIPMENT USED FOR THE ADMINISTRATION OF INHALATION THERAPY AND FOR RESUSCITIVE PURPOSES COMPLY WITH NFPA STANDARDS, VIOLATING RULE 59A-4.130(1), FLORIDA ADMINISTRATIVE CODE. ' CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Based on observations, the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99, 13-5.1, 7-1.2, and NFPA 70. 9. Specifically: (a) One unsecured E-tank oxygen cylinders was observed in the oxygen storage room on the second floor. (b) The facility Plan of Correction stated that an in-service of all facility employees on the handling and storage on non-flammable medical gas would be completed before the correction date of November 22, 2002. (c) Interviews with the Administrator, Risk Manager, Assistant Director of Nursing, and the Maintenance Director revealed that the “in-service” was not performed as required. 10. Based on the foregoing, HERITAGE HEALTHCARE & REHABILITATION CENTER violated Rule 59A-4.130(1), Florida Administrative Code that requires the facility to comply with all life safety code requirements and building code standards. 11. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of three thousand dollars ($3,000) is authorized pursuant to Section 400.23(8)(c), Florida Statutes. COUNT IT RESPONDENT FAILED TO ENSURE THAT RESIDENTS CHOICES WERE HONORED FOR TWO (2) RESIDENTS WHO WERE CARE PLANNED FOR FOOD PREFERENCES, VIOLATING RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE, INCORPORATING BY REFERENCE 42 CFR 483.15(b), FLORIDA STATUTES, AND SECTION 400.022(1) (L), FLORIDA STATUTES. ' UNCORRECTED CLASS III DEFICIENCY 12. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 13. Based upon observation, record review and interviews, it was determined that the facility failed to assure that resident choices were honored for two residents (residents #9 and #11) who were care planned for food preferences, including but not limited to portion size choices. The facility also failed to honor portion sizes for six residents (residents #21, #48, #49, #51, #52 and #53) as indicated on the lunch meal tray preference tickets. 14. Specifically, # (a) Resident #9 had a significant change Minimum Data Set (MDS) completed on 8/27/02. The Resident Assessment Protocol (RAP) for Nutritional Status revealed, "Name Omitted is receiving a NCS-NAS (No Concentrated Sweets-No Added Salt) Diet. In addition she is getting a small portion per her request. Her food intake is poor, she receives dietetic snacks wit meals." The resident's Care Plan for Nutrition dated 9/3/02 under approaches states, "Provide NCS-NAS Diet with small portions per her request. Provide mashed potato with Lunch and Dinner." (bo) On 11/26/02 at approximately 12:49 P.M., a surveyor spoke with the resident in her room and observed the meal. The meal consisted of Fish, Butter Beans, Hush Puppies, Apple Juice, Cheese Cake, and Cole Slaw. The meal was observed to be a regular portion meal and not a small portion per resident ‘request and care plan. Additionally the resident was not served mashed potatoes. The resident's preference card from Dietary stated the resident "liked" and "disliked" mashed potatoes. The surveyor asked the resident whether she liked mashed potatoes or not. The resident stated she liked mashed potatoes. (c) In an interview with the Director of Nurses (DON), Assistant Director of Nurses (ADON), and Registered Dietitian (RD) on 11/26/02 at approximately 4:00 P.M., the DON acknowledged the resident should have received masked potatoes with her lunch. The RD stated she had spoken with the resident last Friday (November 22, 2002) and the resident indicated she likes mashed potatoes. The RD stated to the surveyor the facility failed to correct the resident's preference card. (d) Review of Resident #11's Care Plan on 11/26/02 at approximately 4:00 P.M., addressing "Weight Fluctuation", revealed the resident was to be "provided small portion, NAS (No Added Salt) diet per request." Observation of Resident #11's meal ticket during lunch on 11/26/02 at approximately 12:20 P.M. revealed that the resident was to receive "small portions." The resident received regular size portions on her plate. (e) During observation of the lunch meal tray line on 11/26/02 at 11:30 A.M., it was observed that there were no serving utensils on the tray line for serving small portions. Review of the facility's printed menu revealed that it did not list the amount of food to give for small portions. (£) During the meal service, small portions was noted to be listed on the meal tickets as a resident preference/choice for Residents #9 and #11 and RS Residents #21, #48, #49, #51, #52 and #53. The cook was observed serving regular size portions or larger to these residents. The cook served approximately 3-4 ounces of fish (menu listed 2 ounces for regular portion), #* cup of butter beans, 4% cup of coleslaw, 2 hush puppies and a regular portion of cheesecake for residents on regular small portion diets. The pureed small portion diets were served a #16 scoop (1/4 cup) of pureed fish, #8 (1/2 cup) pureed butter beans, #8 (1/2 cup) of pureed hush puppies (menu listed #16 scoop or % cup for regular portion) and 4 ounces of pureed fruit. The Mechanical Soft small portion diets were served 4 ounces of chopped fish, * cup of butter beans, 2 hush puppies and a regular serving of cheesecake. (g) Interview with the Dietary Manager on 11/26/C2 at 12:40 P.M., revealed that there was no written policy regarding small portions. He stated that the staff serves portions that are "a little smaller than regular." (h) Interview with the cook on 11/26/02 at 1:00 P.M., revealed that she had no written guidelines to follow for small portions. She stated that she gave "one small piece of fish, a'‘little less of the vegetables and 2 hush puppies because the regular serving was small to begin with." She confirmed that she did not have smaller serving utensils on the tray line to measure out a smaller portion. Observation of the cook throughout the meal service from 11:30 A.M. to 1:00 P.M. revealed that she did not serve small portions as she had indicated. 15. Based on the foregoing, HERITAGE HEALTHCARE & REHARILITATION CENTER violated Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR 483.15(b), and Section 400.022(1) (1), Florida Statutes, which requires the facility to give residents adequate and appropriate health care and protective and support services consistent with the resident’s care plan, and to provide residents with the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care. 16. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of one thousand dollars ($1, 000) is authorized pursuant to Section 400.23(8) (c), Florida Statutes. COUNT III RESPONDENT FAILED TO ENSURE THAT CARE PLANS FOR TWO RESIDENTS WERE IMPLMENTED BY STAFF, VIOLATING RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE, INCORPORATING BY REFERENCE 42 CFR 483.20(k) (3) (ii), AND SECTION 400.022(1)(L), FLORIDA STATUTES. UNCORRECTED CLASS III DEFICIENCY 17. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 18. Based on the observation, record review and staff interview, the facility did not ensure that care plans for two residents, (residents #46 and #9), were implemented by staff, as evidenced by the following: (a) Allowing a resident who needed assistance with mobility to sit in a dining room for a duration of 3 hours without providing assistance for repositioning and pressure reduction; (b) Failing to assist a resident who is dependerit on staff for toileting needs; and (c) Failing to provide a resident mashed potatoes based on the resident’s request and devised plan of care. 19. Specifically, the findings include: (a) Resident #46 was admitted to the facility on 10/25/01 with multiple diagnoses including, not limited to Organic Brain Syndrome, Osteoporosis, and History of Hip Fracture. (b) Review of Resident #46's nurses notes revealed that on 11/01/02 at 2:00 P.M., it was indicated the resident needed, "..limited to extensive assist..with transfers and toileting..." On 11/11/02, nurses notes document that the resident is "toileted by staff" and ' on 11/17/02 at 8:00 P.M., nurses notes revealed, "requires assist times 1 (of one person) with transfers and ADL's (Activities of Daily Living) ." (c) Resident's Quarterly MDS (Minimum Data Set) dated 11/19/02 assessed the resident to.have both short and long term memory problems. He/She was also assessed as being non-ambulatory and requiring the physical support of 1 person to assist him/her with transfers. (d) Review of the resident's ADL Care Plan dated 11/26/02 revealed, "Assistance required in performance of ADL tasks secondary to Mobility Limitations and Vision Loss." Another Care Plan problem identified by the facility on 11/26/02 stated, "Increased Risk of Skin Breakdown Related to History of Pressure Area, assistance required in bed mobility...” Approaches listed for this plan of care: included, "Assist to turn and reposition q (every) 2 hours for comfort and pressure reduction" and "Check every two hours and prn y(as needed) for toileting need." (e) Observation of the resident on 11/26/02 at 9:20 A.M., revealed the resident sitting toward the back of the dining room, in his/her wheelchair with head down, eyes closed. The resident was leaning on his/her left side with his/her left arm pressing against the arm of the wheelchair. The resident remained in this position through 12:15 P.M., a duration of 3 hours. Two activity events had occurred while the resident sat in the back of the room in this position without receiving any assistance or intervention. At 12:20 P.M., a CNA (Certified Nursing Assistant) pushed the resident, who remained in this position, to the lunch table, with 2 other tablemates. The resident was sitting at the table, head bent forward, eyes closed, leaning to the left side. The resident was served lunch and remained unassisted for 10 minutes until ‘surveyor intervention. At 12:30 P.M., the CNA walkec over to the resident and shook the resident's right shoulder to arouse the resident. Observation by the surveyor revealed that from 9:20 A.M. through 1:00 P.M., the resident did not receive any assistance in turning or repositioning for comfort and pressure reduction, nor was the resident checked for toileting needs, based on the devised plan of care. (f) Resident #9 had a significant change,Minimum Data Set (MDS) completed on 8/27/02. The Resident Assessment Protocol (RAP) for Nutritional Status revealed, "Name Omitted is receiving a NCS-NAS (No Concentrated Sweets-No Added Salt) Diet. In addition she is getting a small portion per her request. Her food intake is poor, she receives dietetic snacks wit meals." The resident Care Plan dated 9/3/02, under approaches states, "Provide NCS-NAS Diet with small portions per her request. Provide Mashed Potato with j Lunch and Dinner." (g) On 11/26/02 at approximately 12:49 P.M., a surveyor spoke with the resident in her room and observed the meal. The meal consisted of Fish, Butter Beans, Hush Puppy, Apple Juice, Cheese Cake, and Cole Slaw. The meal was observed to be a regular portion and not a small portion per resident request and Care Plan. Additionally the resident was not served mashed potatoes. The resident's preference card from Dietary stated the resident "liked" and "disliked" mashed potatoes. The surveyor asked the resident whether she liked mashed potatoes or not. The resident stated she like mashed potatoes. (h) In an interview with the Director of Nurses (DON), Assistant Director of Nurses (ADON), and Registered Dietitian (RD) on 11/26/02 at approximately 4:00 P.M., the DON acknowledged the resident should have received masked potatoes. The RD stated she had spoken with the resident last Friday (November 22, 2002) and the resident indicated she likes mashed potatoes. The RD stated to the surveyor the facility failed to correct the resident's preference card. 20. Based on the foregoing, HERITAGE HEALTHCARE & REHABILITATION CENTER violated Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR 483.20 (k) (3) (11), and Section 400.022(1) (1), Florida Statutes, which requires the facility to provide residents with adequate and appropriate health care and protective and support services consistent with the resident’s care plan. 21. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of one thousand dollars ($1,000) is authorized pursuant to Section 400.23(8) (c), Florida Statutes. ' COUNT IV RESPONDENT FAILED TO ENSURE MENUS MET THE NUTRITIONAL NEEDS OF RESIDENTS IN ACCORDANCE WITH THE RECOMMENDED DIETARY ALLOWANCES OF THE FOOD AND NUTRITION BOARD OF THE NATIONAL RESEARCH COUNCIL, NATIONAL ACADEMY OF SCIENCES; BE PREPARED IN ADVANCE; AND BE FOLLOWED, VIOLATING RULE 59A~-4.1288, FLORIDA ADMINISTRATIVE CODE, INCORPORATING BY REFERENCE 42 CFR 483.35(c¢) (1)-(3), AND SECTION 400.022(1) (L), FLORIDA STATUTES. # UNCORRECTED CLASS III DEFICIENCY 22. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 23. Based on observation of the tray line and meal service in the dining room, review of the facility’s printed menu and alternate menu and dietary staff interviews, the facility failed to follow their cycle and alternate menus for three (3) residents, (residents #9, #50 and #51), and for those resicents who were prescribed pureed, mechanical soft, low cholesterol, no concentrated sweets and finger food diets. This was evidericed by: (a) Food was not prepared with correct portion sizes and for each resident’s diets in accordance’ with the menu; (b) Food was not prepared in accordance with the pre- planned alternate menu; and (c) Adequate amounts of food to follow the menu for all residents needing to be served the meal were not provided. 24. Specifically, the findings include: (a) During observation of the lunch meal tray line on 11/26/02 at 11:20 A.M., the cook was observed preparing grilled cheese sandwiches. Tomato soup and stewed tomatoes were observed on the steam table. Interview with the cook revealed that these items were the alternate menu items for the meal. (b) Review of the facility's pre-planned alternate menu revealed that the grilled cheese and tomato soup was planned for Monday and the Tuesday alternate lunch meal was veal patty with gravy, mashed potatoes and carrots. None of these menu items were observed on the tray line. (c) Further interview with the cook at 11:35 A.M., revealed that there were no veal patties in stock to prepare. She stated that she had not prepared the carrots because there were no canned carrots in the stock room so she prepared stewed tomatoes instead. The cook also stated that she had not checked if there were any frozen carrots. She confirmed that she had prepared the same alternate meal on Monday because the residents "always ask for grilled cheese sandwiches." (d) Interview with the Dietary Manager on 11/26/02 at 11:45 A.M., revealed the veal was in the freezer and he instructed the cook to prepare the veal for the lunch meal. The cook checked the freezer and stated that there was no veal. The Dietary Manager checked 11 the freezer and told the cook to prepare hotdogs and frozen carrots. (e) Review of the facility's approved printed menu for Week III, Day 2, Tuesday (Fall and Winter 2002- 2003), xvevealed that residents on pureed diets were to be servéd 1 T of lemon butter sauce with their pureed fish, a second #8 (1/2 cup) serving of pureed vegetables to replace the coleslaw, a #16 (1/4 cup) serving of pureed Hushpuppies and slurried cheesecake with garnish. (£) Observation of the lunch meal tray line on 11/26/02 at 11:30 A.M. revealed that the cook was serving plain pureed fish without the sauce, a #8 serving of pureed butterbeans without a second vegetable serving, a #8 serving of the pureed Hushpuppies instead of a #16, and: pureed peaches instead of the slurried cheesecake. (g) Interview with the dietary aides at noon revealed that they had not made a slurried cheesecake for the meal and they had decided to serve the pureed fruit in its place. Interview with the Dietary Manager revealed he was not aware that the staff had not made the slurried cheesecake. They also confirmed that they had not made the #8 serving of pureed vegetable as listed on the menu to substitute for the coleslaw. The cook was observed serving only one vegetable serving, a #8 scoop of pureed butterbeans. (h) Further review of the facility's approved menu yvevealed that residents on mechanical soft diets were to receive a #16 (1/4) cup of chopped fish with 1 T of lemon butter sauce and a second #8 serving of a soft vegetable to replace the coleslaw. Observation of the lunch rinOimeal tray line on 11/26/02 at 11:30 A.M. revealed that the cook was serving a plain chopped fish without the additional sauce and a #8 serving of butterbeans. There was. no second soft vegetable on the steam table to replace the serving of coleslaw as listed on the menu. The lemon butter sauce was on the stove, but the cook never put it on the line to use or. the pureed and mechanical soft fish. At 12:45 P.M., the cook ran out of chopped fish, so she began taking a whole fillet of fish and chopping it up on the resident's plate. She did not measure it after it was chopped and served the 4-ounce fillet. ‘(i) Interview with the dietary aides and cook revealed that they were not aware that a second vegetable was listed on the menu for the residents or. the pureed and mechanical soft diets. They stated that they had not prepared a second vegetable for either of the diets. The staff did not correct the error once it was identified and continued to serve the residents only one vegétable serving. (j) Review of the menu revealed that residents on a Low Cholesterol diet ‘were to follow the low fat menu extension. Review of.the extension revealed that residents on this diet were to receive plain baked fish without the lemon butter sauce and a roll instead of the Hushpuppies. Observation of the tray line revealed that there were no rolls to serve on this diet and no plain fish fillets. One resident who was prescribed this diet received a regular diet with fish that was coated with the butter sauce and breaded , Hushpuppies. (k) Review of the menu for the extension for the Finger Food diet revealed that residents on this diet were to receive 2 ounces of fish strips, lemon butter sauce for dipping, a #8 scoop of butterbeans, cucumber sticks, 2 Hushpuppies and a #8 (1/2 cup) serving of fruit instead of the cheesecake with the strawberry glaze. Observation of the tray line at 12:45 P.M. revealed that RS Resident #51 was served a chopped hotdog on a bun, diced cooked carrots, cucumber sticks and a square of strawberry cheesecake. Review of the resident's meal ticket revealed that the resident did not have dislike of fish. The resident was not served the fish strips, butterbeans, Hushpuppies or fruit as listed on the menu. The menu also stated that sandwiches for the Finger Foods diet should be cut up into 2 to 4 parts. The staff served the chopped hotdog on a whole bun. The cook was not observed checking the menu to determine what other foods should be served on this diet. (1) Interview with the dietary aide at 12:45 P.M., revealed that the fish strips had not been prepared for the meal so they had to give hotdogs. 13 (m) Observation of the resident in the first floor dining room at 1:10 P.M. revealed that she was having a difficult time eating the chopped hotdog on the bun. The meat was falling off of the bun as the resident ‘ was eating it. The staff had not cut up the cheesecake into bite-size pieces that the resident could pick up with her fingers. (n) Interview with the RD at 2:00 P.M., confirmed that the chopped hotdog was not an appropriate substitute for the residents on the finger food diet. (0) Further review of the tray line at 12:45 P.M. revealed that RS Resident #50 was prescribed a High Calorie Full Liquid diet. The staff was observed serving her mashed potatoes with gravy. Review of the resident's meal ticket revealed that mashed potatoes were not listed on the menu for this resident. (p) Interview with the dietary aide revealed that he thought the mashed potatoes were allowed on this diet since one other resident on this diet received them. (q) Resident #9 was prescribed a No Concentrated Sweets, 'No Added Salt diet with small portions. Review of the resident's tray ticket for lunch on 11/26/02 revealed that she had a food preference for mashed potatoes. Mashed potatoes were also listed under the dislikes. The dietary staff setting up the resident's tray were observed to be confused regarding whether to serve rinOithe resident mashed potatoes or ynot. The staff did not check with the Dietary Manager and decided among themselves to serve the resident Hushpuppies instead of the potatoes. Review of the NCS menu extension revealed that the residents on this diet were to be served 2 ounces of baked fish and a diet version of the cheesecake that had a fruit garnish. Observation of the steam table revealed that the cook was serving various size fillets of fish from 3 to 4 ounces. She did not weigh a portion of the fish prior to starting the tray line to determine the correct portion size. The diet cheesecake on the tray line was plain without a fruit garnish. These incorrect items were served to Resident #9. (rv) Interview with the RD at 2:00 P.M., revealed that there were many errors on the meal tickets and she would have to check the computer entries for each resident to verify that they were receiving the correct food items. (s) At 12:55 P.M., the staff ran out of cheesecake for the regular and No Concentrated Sweets diets. The aide stated, "I'm three desserts short." The aides did not check with the Dietary Manager and began serving sliced oranges. The surveyor notified the Dietary Manager who questioned the staff regarding the lack of cheesecake. The aide stated that,they "made what we had." The manager instructed the staff to served diced peaches. (t) Review of the Production Sheets for the Week III (Day 2 - Tuesday) menu revealed that the fish strips were listed as an item that needed to be prepared for the lunch meal. The pureed and soft vegetables were also listed under the coleslaw as the items to make for the pureed and mechanical soft diets. The ; slurried cheesecake, fruit and diet cheesecake with fruit garnish were listed as items that needed to be prepared for dessert. 25. Based on the foregoing, HERITAGE HEALTHCARE & REHABILITATION CENTER violated Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR 483.35(c)(1)-(3), and Section 400.022 (1) (1), Florida Statutes, which requires that facility menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences; be prepared in advance; and be followed, and to provide residents with adequate and appropriate health care and protective and support services consistent with the resident’s care plan. 26. The above referenced violation constitutes the crounds for the imposed uncorrected Class III deficiency and for which a fine of one thousand dollars ($1,000) is authorized pursuant to Section 400.23(8) (c), Florida Statutes. COUNT V RESPONDENT FAILED TO STORE, PREPARE, DISTRIBUTE, AND SERVE FOOD UNDER SANITARY CONDITIONS, VIOLATING RULE 59A-4.1288, INCORPORATING BY REFERENCE 42 CFR 483.35(h) (2), RULE 59A-4.122, FLORIDA ADMINISTRATIVE CODE, AND SECTION 400.022(1) (L), FLORIDA STATUTES. ; _ UNCORRECTED CLASS III DEFICIENCY 27. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. | 28. Based on observations and interviews with dietary staff, the facility failed to prepare, hold and serve food under sanitary conditions to prevent the development of harmful micr@organisms that can cause food borne illness and failed to maintain the kitchen in a clean and sanitary manner to prevent the spread of harmful microorganisms, as evidenced by: (a) Cold food not held proper temperature below 41 degrees F.; (b) Hot food not cooked to proper holding temperature prior to serving to residents; (c) Unsanitary food handling practices and use of contaminated gloves for handling resident food and plates; (da) Freezer gasket and air vents covered with black mildew and dust; 16 (e) Improper food thawing practices; (£) Unsanitary handling of sanitized dishes; and (g) The kitchen had dirty air vents and freezer gaskets and there was no cleaning schedule for the kitchen. 29. Specifically, the findings include: (a) During the initial tour of the kitchen on 11/26/02 at 9:15 A.M., the mixer blade on the large ‘mixer was coated with a white substance; 2 large packages of frozen fish were in the sink in a bowl partially covered with water. The water was not running. Most of the fish was not in the water. A pan labeled "cheesecake", dated 11/25/02, was observed on a rack next to the steam table. (b) During observation of the food preparation for the lunch meal at 11:20 A.M., the second cook was observed making sandwiches for the lunch meal. A ham and cheese sandwich and 2 plates of sliced cheese were observed on the counter next to the tray line. ‘The sandwiches and cheese were not refrigerated and had no means to maintain a cold temperature. A package of frozen Hushpuppies was observed sitting on the counter next to the steam table. The label on the package stated, "Keep frozen until ready to use." The package sat on the counter throughout the entire meal service. Temperature check of the Hushpuppies at 12:40 P.M. revealed that they were 55 degrees F. and completely thawed. The Hushpuppies remained on the counter at the end of the tray line at 1:00 P.M. (c) During the observation of the meal service at 11:30 A.M., the cook took the temperature of some of the hot foods and did not check the temperature of the cold foods. The staff put out 2 trays of cheesecake and a tray of coleslaw at 11:40 A.M. onto a rack without means of refrigeration to keep the cheesecake or coleslaw cold. Temperature check of the regular and diet cheesecake and the coleslaw revealed they were 60 degrees F. at the beginning of the tray line. Temperature check of the diet cheesecake at 12:30 P.M. revealed it was 70 degrees F. and at 12:40 P.M. the diet cheesecake was 80 degrees F. The staff continued to serve the diet cheesecake to the residents 17 ‘ throughout the entire meal without monitoring the temperature. (d) The staff also placed out two pans on the tray line that contained yogurt, ice cream, magic cups and shakes. Ice was put around the items. The staff did not check the temperature of these cold food items before beginning the tray line. The yogurt was stacked three deep in the pans and was not covered by the ice. Temperature check of the yogurt at the end of the tray line at 1:00 P.M. revealed it was 48 degrees F. The aide asked what the temperature was and put the yogurt back into the walk-in refrigerator. (e) The pan of cheesecake dated 11/25 observed at 9:15 A.M. was still on the rack at 11:55 A.M. Temperature check of the cheesecake revealed it was 80 degrees F. (£) Interview with the Dietary Manager revealed that he did not know why the cheesecake had not been refrigerated and remained un-refrigerated all morning on the rack. (g) At 11:55 A.M., the cook was observed opening the steamer to check the temperature of the carrots. She was observed placing her gloved finger in the carrots, putting the gloved finger in her mouth and returning to the steam table. The carrots were left in the steamer and later served to the residents. The cook did not change her gloves or wash her hands and continued to handle resident plates, food and serving Yutensils. The cook did not change her gloves throughout the entire meal service even though she was touching un-sanitized items throughout the kitchen while she was serving the meal. (h) At 11:55 A.M., a pan of pureed squash was observed uncovered on the counter in front of the steamer. The squash had been taken off of the tray line due to lack of space. Temperature check of the squash revealed it was. 120 degrees F. The pan sat on the counter and was later put in the steamer and served to the residents. The pans on the steam table were not properly placed so that all of the pans were placed down into the hot water to maintain the temperature. The temperature of the pureed alternate meat was checked at 12:05 P.M. and found to be 115 degrees F. The staff continued to serve it to the residents. (1) At 11:55 P.M., the cook removed 2 hotdogs from the steamer and served them to a resident without first verifying that they were fully heated and at proper serving temperature. . Temperature check of the’ hotdogs with the Dietary Manager revealed that they were 115 degrees F. (j) At 12:10 P.M., the second cook was observed rinsing the blender in the food preparation sink. She did not wash or sanitize the blender before preparing the next pureed food, item. (k) Observation at 12:25 P.M., revealed an aide washing dishes in the three-compartment sink. ‘The aide put the dishes on the side of the sink after they were removed from the sanitizer solution. She then wiped them with a towel before putting them on the rack. Interview with the Dietary Manager and the aide at 12:30 P.M., revealed that she was not aware that the pans needed to be air dried and not wiped with a cloth. (1) Observation of the ceiling vents in the food preparation area at 12:40 P.M. revealed that they were covered with a black substance that was extended out onto the ceiling from the corners of the vent. Observation of the air vents in the remainder of the kitchen at 4:35 P.M. revealed that the vents were dusty and dirty with a black substance covering the vents. The gasket and rim of the walk-in freezer was coated with black mildew. (m) Interview with the Dietary Manager revealed that the vents had not been cleaned. He stated that the mildew was "hard to keep it off" on the rubber gaskets and sides of the freezer door and rim. Earlier interview with the Dietary Manager at 9:15 A.M. revealed that there was no pre-planned cleaning schedule for the kitchen. He stated that he had told the staff to "clean as you go." 30. Based on the foregoing, HERITAGE HEALTHCARE & REHABILITATION CENTER violated Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR ' 483.35(h) (2), Rule 59A-4.122, and Section 400.022(1) (1), Florida Statutes, which requires the facility to prepare, store, distribute and serve food under sanitary conditions, provide a safe, clean, and sanitary environment, and to provide residents with adequate and appropriate health care and protective and support services. 31. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of three thousand dollars ($3,000) is authorized pursuant to Section 400.23(8) (c), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: HA. Make factual and legal findings in favor of the Agency on Counts I, II, III, IV and Vv; B. Impose a fine of nine thousand dollars ($9,000) for the violations cited in Counts I, II, III, IV and Vv against: the respondent as authorized under Sections 400.102(1) (a,d), and 400.23(8)(c), Florida Statutes; c. Attorney’s fees and costs and D. All other general and equitable relief allowed by law. NOTICE The 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 Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to, the attention of Michael P. Sasso, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., Suite 330K, St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, che [_Xfeee— Michael P. Sasso, Esquire AHCA ~- Senior Attorney Fla. Bar No. 0167363 525 Mirror Lake Drive North St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint has been furnished via U.S. Certified Mail Return Receipt No. 21 7002 2030 0002 7109 5776 to CT Corporation System, Registered Agent for Heritage Healthcare, 1200 South Pine Island Road, Plantation, Florida 33324 and a copy of the foregoing has been furnished via U.S. Certified Mail, Return Receipt No. 7002 2030 0002 7109 5783, to Laurence Reed, Administrator, Heritage Healthcare, 777 - 9° street North, Naples, Florida 34102, on January 3/7, 2003. qwckill Pr. schecor Michael P. Sasso, Esquire COPIES TO: CT 'Corporation System Registered Agent for : Heritage Healthcare & Rehabilitation Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Laurence Reed, Administrator Heritage Healthcare & Rehahilitation Center 777 - 9° Street North Naples, FL 34102 (U.S. Certified Mail) Michael P. Sasso, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330K St. Petersburg, Florida 33701 22

Docket for Case No: 03-001167