STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003005926 AHCA No.: 2003005236 v. Return Receipt Requested: 7002 2410 0001 4236 9090 HEBREW HOME SINAI, INC., d/b/a 7002 2410 0001 4236 9106 SINAI PLAZA NURSING & REHAB CENTER, 7002 2410 0001 4236 9113 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Hebrew Home Sinai, Inc., d/b/a Sinai Plaza Nursing & Rehab Center (hereinafter “Sinai Plaza Nursing & Rehab Center” or the “facility”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2002) (hereinafter “Fla. Stat.”), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose and maintain the Agency’s administrative fine of $5,000.00 pursuant to Section 400.23(8), Fla. Stat., for the protection of the public health, safety and welfare. 2. This is an action to impose and maintain the Agency’s assignment of a Conditional Licensure status to Sinai Plaza Nursing & Rehab Center, pursuant to Section 400.23(7) (b), Fla. Stat. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 4. Venue lies in Miami-Dade County, pursuant to Section 400.121(1)(e), Fla. Stat., and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Fla. Stat., and Chapter 59A-4 Florida Administrative Code. 6. Sinai Plaza Nursing & Rehab Center is a 150-bed skilled nursing facility located at 201 N.E. 112°" Street, Miami, Florida 33161. Sinai Plaza Nursing & Rehab Center is licensed as a skilled nursing facility; license number SNF15190961; certificate number 10445, effective 07/15/2003 through 06/06/2004. Sinai Plaza Nursing & Rehab Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. 7. Because Sinai Plaza Nursing & Rehab Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, F.A.C. COUNT I SINAI PLAZA NURSING & REHAB CENTER FAILED TO INTERACT WITH RESIDENTS COURTEOUSLY, WITH THE FULLEST MEASURE OF DIGNITY, IN A MANNER THAT ENHANCES EACH RESIDENT’S DIGNITY AND RESPECT. TITLE 42, SECTION 483.15(a), CODE OF FEDERAL REGULATIONS, as INCORPORATED by RULE 59A-4.1288, F.A.C. and SECTION 400.022(1)(n), Fla. Stat. (QUALITY OF LIFE) UNCORRECTED CLASS III DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During the Licensure and Re-Certification survey conducted by the Agency on 6/9-12/2003 and based on observation, interview, and record review, the Agency found that Sinai Plaza Nursing & Rehab Center failed to interact with residents courteously, with the fullest measure of dignity, in a manner that enhances each resident’s dignity and respect, for two (residents #2, #14) of 21 sampled residents. Findings include the following, to wit: (a) Review of sample resident #2's medical record revealed that the resident was assessed in the minimum data set (MDS) as being independent in cognition. In addition, the resident was assessed as being independent with eating but needing assistance with set-up. Observation in resident #2's room, at approximately 8:00 am on 6/11/03, revealed the resident sitting in bed with a breakfast tray on a table across the bed. The resident was holding a juice container that the resident was drinking. A Certified Nurse's Aide (C.N.A.) entered the room and inquired why the resident did not complete eating breakfast. The resident responded, "I can't eat without my teeth". The resident then looked at the surveyor and said, in an angry voice, "She's new, she doesn't know anything". The C.N.A. then retrieved the dentures from the resident's night table, which was beyond his/her reach, and attempted to put the resident's dentures in his mouth. The C.N.A,. was able to put the upper dentures in the resident's mouth, but after unsuccessfully attempting to insert the lowers, the C.N.A. told the resident that, "You lost weight, your mouth shrunk, I'll feed you". The resident looked at the C.N.A. with an angry facial expression. At this point, the surveyor enlisted the assistance of the Assistant Director of Nursing, who put the lower denture plate in the resident's mouth without a problem. There was no attempt by the CNA to summon a licensed nursing staff to check on the resident’s dentures and to ensure that the resident was eating independently. (b) Interview with the Restorative Coordinator at approximately 9:35 am on 6/11/03, revealed that the dentures should be cleaned and returned to the resident as part of routine morning care. (c) Review of Policy and Procedure provided by the Restorative Coordinator, titled "Resident Personal Care Oral Hygiene (Dental Care)" revealed that direct care staff was instructed to offer oral hygiene before breakfast, after each meal and at bedtime. (d) Review of sample resident #14's medical record revealed that he/she was assessed in the Minimum Data Set (MDS) dated 4/23/03 as needing total assistance with all activities of daily living (ADLs). In addition, the MDS assessment coded the resident a "2" for cognition, indicating that his/her cognition was moderately impaired. On 6/12/03 at 12:50 pm, resident #14 was observed in a recliner with family members present. The resident had been transferred from his/her original room to a new room. The family members stated that the resident was not wearing his/her own clothes, but had his/her new roommate’s clothes on. Interview with the family member at that time disclosed that the resident has his/her own clothes, but staff does not know where they are. Mandated Correction Date: 7/12/03 10. During the follow-up survey conducted on 7/16/2003 and based on observation, interview and policy review, the Agency again found that Sinai Plaza Nursing & Rehab Center failed to interact with residents courteously, with the fullest measure of dignity, in a manner that enhances each resident’s dignity and respect; the facility failed to promote care for residents in a manner and environment to maintain and enhance dignity and respect for individuality for multiple residents, in 3 of 4 dining areas. The findings include the following, to wit: 11. At approximately 12 noon on 7/15/03, in the area designated the dayroom adjacent to nursing station "A", five residents were observed with their lunch trays. At that time there was one staff member and one department head present. Three of the residents were in wheel chairs with their trays on over-bed tables. One resident was eating independently, one was being fed by a staff member and three were seated in front of their uncovered trays, waiting. When a staff member was asked if they were usually so short on staff for the mealtime, she stated no, not usually, but that help had been pulled to the main dining room. 12. At approximately 12:15pm on 7/15/03 in the area designated the dayroom adjacent to nursing station "B", 13 residents were observed with their lunch trays. Four staff members were present. Five residents were seated around the only table in the room. One staff member was feeding two residents, sitting on either side of her, at the same time. The remaining eight residents were seated in their wheelchairs with their trays on over-bed tables, lined up along the wall and facing outward. Another resident was brought in and set up with his/her wheelchair and tray on over-bed table but had to be interrupted and moved several times during the course of the meal to allow staff members to reach and assist other residents. 13. At approximately 11:45am on 7/15/03 in the area designated the dayroom adjacent to nursing station "C", six residents were observed with their lunch trays. Two staff members were present. Two residents and two staff members were seated at the table and the remaining four residents were seated in wheel chairs with their trays on over-bed tables. One staff member was observed feeding two residents on either side of her and cuing another resident across the room to eat. One resident was observed to be trying to drink ice cream that was frozen, with the rest of his/her meal untouched. A staff member responded to this by leaving the resident she was feeding on the other side of the room and giving the resident a spoonful of ice cream. The staff member then returned to the resident she had been feeding and resumed the meal. 14. During an interview with the Director of Nursing (DON) a copy of the facility's policy on feeding residents was requested. The policy titled "Nourishment Feeding the Resident" states, "Never make resident feel that the meal must be hurried, but that the procedure is pleasant. Give him or her your complete attention." 15. Based on the foregoing, Sinai Plaza Nursing & Rehab Center violated Title 42, Section 483.15(a), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, and/or 400.022(1)(n), Fla. Statutes, herein classified as an uncorrected Class II! deficiency pursuant to Section 400.23(8)(c), Fla. Stat., which carries an assessed fine of $2,000.00 This uncorrected deficiency also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). COUNT IT SINAI PLAZA NURSING & REHAB CENTER FAILED TO STORE, PREPARE, DISTRIBUTE, AND SERVE FOOD UNDER SANITARY CONDITIONS, TO PREVENT THE SPREAD OF FOOD BORNE ILLNESS, WHICH MAY RESULT IN FOOD CONTAMINATION AND COMPROMISED FOOD SAFETY FOR RESIDENTS. Title 42 483.35(h) (2), CODE OF FEDERAL REGULATIONS AS INCORPORATED BY 59A-4.1288, Florida Administrative Code (DIETARY SERVICES) UNCORRECTED CLASS III DEFICIENCY 16. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 17. During the licensure and re-certification survey conducted by the Agency on 6/09-12/2003 and based on observation and interview, the Agency found that Sinai Plaza Nursing & Rehab Center failed to store, prepare, distribute, and serve food under sanitary conditions, to prevent the spread of food borne illness, which may result in food contamination and compromised food safety for residents. The findings include the following, to wit: 18. The following was observed during meal service on 6/10/03, beginning at 11:00 am: (a) Temperatures were taken on the only two 8- ounce container of whole milk (a potentially hazardous food) that was on the resident trays prior to leaving the kitchen. The temperatures taken by a calibrated thermometer disclosed one of the milks was reading 45 degrees Fahrenheit (F), which is above the required 41 degrees F or below temperature to prevent food-borne iliness. (b) During the meal service, a staff member was observed towel drying a gasket belonging to the Robot Coupe (food processor). The staff member was observed further as she went back to the food preparation sink area where she was washing the main section of the food processor and blade. The staff member was using a towel with bleach at the food preparation sink to wash. Interview with the staff member acknowledged that she had washed (with bleach) and dried the Robot Coupe with a towel. (c) During the observation of the food preparation sink, a bleach-soaked towel was hanging on the sink and that food that was in the oven was next to the sink. (d) Food service equipment must be allowed to air dry to prevent contamination. Secondly, food service equipment must be washed first, then rinsed and finally sanitized to prevent bio-growth. Finally, the food preparation sink is designated for washing, peeling, thawing of food and not for cleaning equipment. (e) Temperatures were taken using a correctly calibrated thermometer for 2 of the kosher (TV style) dinners after they had been microwaved and placed on the resident trays. The first dinner consisted of pot roast, mashed potato (140 degrees F), and green beans (138 degrees 10 F). The second kosher dinner was filet of sole (138 degrees F), mashed potato (80 degrees F) and string beans (140 degrees F). Cooked food should be reheated to 165 degrees F. Mandated Correction date: 7/12/03. 19. During the follow-up survey conducted 7/16/2003 and based on observation and interview, the Agency again found that Sinai Plaza Nursing & Rehab Center failed to store, prepare, distribute, and serve food under sanitary conditions, to prevent the spread of food borne illness, which may result in food contamination and compromised food safety for residents. The findings include the following, to wit: 20. The following was observed during the kitchen observation on 7/15/03, between 10:30am and 12:45pm: (a) A dietary staff member was preparing an omelet on the range top when she was asked to assist with moving a drying rack. The staff member left the omelet, picked up the drying rack and took it to the dirty side of the dish machine. She then removed her gloves, picked two gloves out of the box of gloves on the wall and put them on without washing her hands, thus contaminating them. She then returned to the omelet and continued to prepare it. This was called to the attention of the Food Service Director at that time. The omelet was served. ll (b) When preparing for the tray-line, the staff member serving the food was seen setting up the service scoops and ladles by picking them up by the food contact surfaces. Review of the "General Information Safety and Sanitation For Dietary Personnel" provided by the facility states, "Pick up serving and eating utensils by their bases or handles." (c) An undated quarter pan of cooked shredded chicken, a potentially hazardous food, was noted in the refrigerator at approximately 10:30am. It was removed and later served for lunch as the alternative. (d) At 10:50am, a dietary staff member was noted to be mixing mashed potatoes on the stovetop, stirring the potatoes while wearing an oven mitt that was torn with the stuffing protruding from I, over the food. (e) At approximately 12:45pm, the food preparation sink was noted to contain a dirty knife and spatula used during the tray-line to serve meat loaf. This sink is designated for food preparation and not for cleaning food service utensils. They were removed immediately after it was brought to the Food Service Director's attention. Uncorrected from annual survey with correction date of 7/12/03. 12 21. Based on the foregoing, Sinai Plaza Nursing & Rehab Center violated Title 42, Section 483.35(h) (2), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as an uncorrected Class III deficiency pursuant to Section 400.23(8) (c), Fla. Stat., which carries an assessed fine of $3,000.00. This uncorrected deficiency also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Sinai Plaza Nursing & Rehab Center 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. The Conditional License is attached hereto as Exhibit NAY CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and II. B. Assess and maintain the Agency's administrative fine totaling $5,000.00 against Sinai Plaza Nursing & Rehab Center on Counts I and II. Cc. Assess and maintain the Agency’s assignment of a conditional license status to Sinai Plaza Nursing «& Rehab Center, in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308, attention Lealand McCharen, Agency Clerk. Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED M4 IN THE COMPLAINT AND THE AGENCY. ENTRY OF A FINAL ORDER BY THE Respectfully submitted, Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 N. W. 53 Street Miami, (305) Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration 8355 N.W. 53™ Street Miami, Florida 33166 U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Florida 33166 EXHIBIT “A” de Conditional License License No. SNF15190961 Certificate No. Effective date: 07/15/2003 Expiration date: 06/06/2004 16

Docket for Case No: 03-003867