"12/01/2083 9:18 9506265983 | SANDY RIDGE PAGE 92 a 0 OF OR STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Ji) -5 Pil 4: 00 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Case No.: 20(3007€56 SANDY RIDGE INVESTORS, INC. d/b/a SANDY RIDGE CARE CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Sd 'files this Administrativ: Complaint cpus :. Agency”), by-aiid-through its undersigned counsel: against SANDY RIDGE INVESTORS, INC. dib/a SANDY RIDGE CARJi CENTER (hereinafter “SRCC”), pursuant Sections 120.569 and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTION This is an action: (a) to assign a conditional licensure status to SRCC pursuait to Section 400.23(7), Florida Statutes (2003), due to the presence of at least one class It deviciency at a survey performed on or about September 9, 2002; and (b) to assess ccsts re.ated to the investigation and prosecution of the case pursuant to Section 400.121(10), Florida Statutes (2003). The original conditional license is attached hereto as Exhibit “A”. 12/81/2883 89:18 8586265983 SANDY RIDGE PAGE @3 JURISDICTION AND VENUE 1. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 2. The Agency has jurisdiction pursuant to Chapter 400, Part iJ, Flo: ‘ida Statutes (2003). 3. Venue shall be determined pursuant to Rule 28-106.207, Florida Acministrative Code (2003). PARTIES 4. ‘The Agency is the regulatory zuthority responsible for licenswe and enforcement of all applicable statutes and rules governing skilled nursing facilities pursuznt to Chapter 400, Part Il, Florida Statutes (2003), and Chapter 59A-4, Florida Administrative Co Je (20')3). 5, Sandy Ridge Investors, Inc. is a Florida for profit corperation with a principal address of 2851 Remington Green Circle, Suite D, Ta lahassee, Florida 32308. 6. SRCC is licensed by the Agency to operate a 60-bed nursing ho:ne located at 5360 Glover Lane, Milton, Florida 32570, having been issued license number SNF119009¢. 7. SRCC is and was at all times material hereto a licensed facility under the licensing authority of the Agency, and is and was required to comply with all applicable ules aad statutes. 12/01/2803 99:18 8506265983 SANDY RIDGE COUNT I PAGE EFFECTIVE SEPTEMBER 9, 2003, THE AGENCY ASSIGNED A CONDITIONAL LICENSURE STATUS TO SRCC BASED UPON THE DETERMINATION F-JAT SRCC WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF 8. A LEAST ONE CLASS II DEFICIENCY AT THE MOST RECENT SURVEY OF SEPTEMBER 9, 2003. § 400.23(7), Fla. Stat. (2003) 42 C.E.R. § 483,25(c)(1) or (2) Rule 59A-4.1288, Fla. Admin. Code (2003) CLASS If DEFICIENCY The Agency realleges and incorporates by reference paragrapiis one (1) through seven (7) above as if fully set forth herein. 9. II deficiency was cited against SRCC based on the findings below involviig Resident #1 or Resident #2. On or about September 9, 2003, the Agency conducted a survey at SRIC. A class Based on observation, record review and interview the facility failed to prevent the development of pressure sores after admissior. and to pre vide necessary treatment and services to promote healing for 2 of 2 sampled residents (#1,2). The findings are: Record review for resident #1 indicated the resident is alert and oriented to person, place, and time and is own responsible person to make decis: ons. The record indicates the resident has a diagnosis of Neurogenic Blaider and Multiple Sclerosis (MS). The Minimum Data Set (MDS) dated 9/3/03 indicates the resident requires extensive assistance with ADLs, including bed mobility. The resident has a foley catheter due to Neurogenic Blac der. Review of the medication record indicates the resident is receiving medications for bladder spasms. Review of the nurses’ notes and care plan indicate the resident has been leaking urine around the catieter since November 21, 2000. Review of the nurses notes dated 8/16/05 indicated extremely excoriated and bloody buttocks. The note also indicates the resident is scheduled to see a physician 8/28/03. A telephone order was written on 7/18/03 indicating a urology consult for "incontinerce arcund catheter". Another nurses note dated 8/19/03 indicates excoriated beefy red buttocks with deep imprints from the Foley catheter. The record lacked evidence that the physician was notified of the severity of the wounds i ntil 84 12/91/2883 @9:18 8506265983 SANDY RIDGE the resident saw the urologist on 8/28/03. Nurses’ notes indicat: the resident saw the urologist on 8/28/03 and was referred to the Wound Center the following day. Review of the Wound Center aotes lated 8/29/03 state the resident was diagnosed with a yeast infect.on ani the yeast rash is potentiated by the wetness he/she experiences from hr s/her leaking foley catheter. The center also indicates the resident has several pressure sores related to pressure from his/her Foley Catheter. The MIDS dated 9/3/03 is coded for 4 stage 2 ulcers on the buttocks, coccy?. and thigh. Review of the 8/03 medication record indicates the resident is to receive Nystatin ointment. to the buttocks twice daily. Th follc wing dates lack signatures noting Nystatin ointment. as given on the 7-3 shift: 8/2, 8/3, 8/8, 8/11, 8/16, 8/17, 8/18, 8/20, 8/21, 8/22, and 3/25 and for the 3-11 shift: 8/4, 8/5, 8/6, 8/8, 8/10, 8/12, 8/21, 8/22, 8/23, and 8/24. Also the medication record lacked signatures noting foley cath. care at HS hour of sleep) on the following dates: 8/4, 8/5, 8/6, 8/8, 8/9, 8/10, 8/12, 8/15, 8/22, 8/23, 8/24, 8/27, 8/28. The medication record also lacked signe tures noting for Criticaid to the buttocks bid (twice a day) cn the following dates: 7-3 shift: 8/27 and 8/28. Calmoseptine ointment to be appli2d to areas 2-4 times a day, the medication record lacked signatures as given for the following dates and times: 8/29 the 1-7 shift, 8/30 the 7-3 and 11-7 shifts, 8/31 the 7-3 shift. Interview with the resident on 9/9/03 a? 4:00 PM indicated her/his but ocks is painful and has been for sometime. The resident states he/she is unable to reposition self in bed or in the wheelchair. He/she aiso siates h/she has had a catheter for a long time and that he/she has bladder spasm:. that causes her/him to leak urine around the catheter. The residert states the urine leaking onto the skin as caused irritation and pain. The res dent states he/she is put to bed around 7:00 PM and is gotten up round 9:00 AM. The resident states the staff does not reposition me at least every two hours and does not check to see if I arn wet, I lay in the same positicn all night. The resident also states he/she thinks the staff thinks he/she: can take care of self because he/she used to be an aide. Record review of the plan of care dated 11/21/00 indicates ¢. histo:y of skin breakdown related to MS with immobility and incentinence, This plan of care related to skin breakdown was last reviewed on 9/3/03 with the following interventions: administer treatments as ordered, rionitor’ site daily, keep skin clean and dry, check resident every 1-2 hours vor catheter leakage. The record lacked evidence the treatments were done as orc ered and the site was monitored daily. Per interview with the residen: the resident was not checked for vetness throughout the night, nor wa: the resident assisted with turning while in bed at least every 2 hours. Per interview with the resident the resident was not turned every two hours. PAGE @5 12/91/2003 99:18 8586265983 SANDY RIDGE PAGE &@6 This pressure area was avoidable and treatment and services wer: not provided based on the lack of evidence that treatments were administered as ordered, notifying the physician of change in condition from 3/16- 28/03, delay in treatment urologist consult ordered 7/18/03 and saw urologist 8/28/03, interview of resident stating he/sbe is not checked for wetness every 2 hours and not repositioned every two hours anc: not following the plan of care. Review of #2 record indicates a diagnosis of Organic Brain Syndrome. According to the MDS dated 7/03 indicates the resident has 2 stage 2 pressure areas on the coccyx. Review of the August medication record lacks signatures that treatment to the coccyx (Clean coceyx with normal saline, pat dry and apply Sorbsen and cover with dressing daily) was given for the following dates: 8/22, &/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29 and 8/30. ; Interview with staff on 9/9/03 at 4:30 PM stated the order was fos the treatment to be done every 7th day and that was what the nurse signed for. Review of the plan of care dated 7/03 indicates to treat as ordered by: the physician which was daily. This pressure area was avoidable and. treatment and services were not provided based on not following the plan of care and treetment not administered as ordered. 10. Based on all of the foregoing, SRCC violated Rule 52A- 4.1288, Florida Administrative Code, which incoporetes by reference Title 42 C.F.R. § 483.25(c)(1) or (2), by failing to ensure, based on a resident’s comprehensive assessment, that: (a) a resident who enters the facility without pressure sores does not develop pressure sores unless the individuai’s clinical condition demonstrates that they were unavoidable; or (b) a resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 12/01/2083 99:18 8595265983 SANDY RIDGE PAGE 87 11. Pursuant to Section 400.23(8)(b), Florida Statutes (2003), the foregoiag is a class II deficiency because it compromised Resident #1’s or Resident #2’s ability to mainiain or reach his or her highest practicable physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 12. Pursuant to Section 400.23(7), Florida Statutes (2003), the presence of one class I deficiency warrants the assignment of a conditional licensure status to SRCC. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make factual and legal findings in favor of the Agency on Court I; 2) Uphold the assignment of a conditional licensure status to SF.CC for the time period commencing September 9, 2093, and ending The license was upgraded to standard effective ; and 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2003). DISPLAY OF LICENSE PURSUANT TO SECTION 400.23(7)(e), FLORIDA STATUTES, SRCC SHALL POST THE LICENSE IN A PROMINENT PLACE THAT IS IN CLEAR AND UNOBS7RUCTED PUBLIC VIEW AT OR NEAR THE PLACE WHERE RESIDENTS ARE BEING A))MITTED TO THE FACILITY. 12/01/2883 69:18 8585265983 SANDY RIDGE PAGE NOTICE SRCC hereby is notified that it has a rigit to request an administrative hear ng pursuant to Sections 120.569 and 120.57, Florida Statues (2003), Specific options for administrative action are set out in the attached Election of )tights form (two pages) anc. expleined in the attached Explanation of Rights form (one page). All requests for hearing shall be ‘nade to the Agency, and delivered to Lealand McChare.t, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32303. SRCC IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. TH}! REQUEST FOR HEARING IMUST BE RECEIVED BY THE AGENCY WITHIN 1 WENTY-ONE (21) DAYS FOLLOWING RECEIPT OF THE ADMINISTRATIVE COMPLAINT BY SRCC. Resp: xtfully submitted, hr C. L ri ©. Desnick, Esquire Assis ant General Counsel Flerica Bar No. 129542 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3. Tallahassee, Florida 32308 Telephone: (850) 922-8854 Fax: (850) 413-9313 88 12/81/2883 99:18 8586265983 SANDY RIDGE PAGE CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that one original Administrative Complaint, Electio: of Rights form, Explanation of eee form, and the original conditional license has been sent via U.S. Certified Mail, Receipt Requested, (return rex cipt # 60) 034 lb V4 . “S04 4B) ‘o Mark H. Daniels, Administrator, Sandy Ridge Investors, Inc. d/b/a Sandy Ridge Care Center, 5360 Glover Lane, Milton, Flonda 32570, and that one origina] Administrative Complaint, Election of Rights fonn, Explanation of Fights form, and a true and correct copy of the conditional license has been sent via U.S. Cerified Mail, Retum Receipt Requested (retum receipt # 7001 0360 0002 354 20/l ) to Michael J. Bittman, 301 East Pine Street, Suite 1400, Orlando, Florida 3280} Regist ered Agent for Sandy Ridge Investors, Inc, on this BAH day of November 2003. QenrwreAd LORIC. ssi ESQUIRE a3

Docket for Case No: 04-000027