12/01/2003 12:56 ~~ 6506265983 "SANDY RIDGE =<) PAGE . 82 AYCURE. _ STATE OFFLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Case No.: 2002007400 SANDY RIDGE INVESTORS, INC. d/b/a SANDY RIDGE CARE CENTER, ‘ Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION “hereinafter , “Agency”), by-and through its undersigned counsel, and files this Adminisvrative Complaint oo against SANDY RIDGE INVESTORS, INC. d/via SANDY RIDGE CARE 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 impose an adninistrative fine on SRCC in the amount of Two Thousand Five Hundred and No/100s Dollars ($2,500.00) pursuant to Sections 400.102(1}(d) and 400.23(8)(b), Florida Statutes (2003), based on one (1) class I deficiency sited «t a survey performed on or about September 9, 2003, and (b) to assess costs related to the investigation and prosecution of the case pursuant to Section 400.121(10), Florida Statutes (2003). 12/01/2083 12:56 8586265983 SANDY RIDGE PAGE JURISDICTION AND VENUE 1. This Court bas jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 2. The Agency has jurisdiction pursuant to Chapter 400, Pert H. Flori ja Statvtes (2003). 3. Venue shall be determined pursuant to Rule 28-106.207, Florida Adrninistrative Code (2003). PARTIES 4. The Agency is the regulatory authority responsible for licensure and ¢ xforcement of all applicable statutes and rules governing skilled rursing facilities pursuant to Chapter 400, Part I, Florida Statutes (2003), and Chapter 59.4-4, Florida Administrative Cod: (200:'). 5. Sandy Ridge Investors, nc. is a Florida for profit corporation with a principal address of 2851 Remington Green Circle, Suite D, Tallahassee, Florida 32208. 6. SRCC is licensed by the Agency to operate a 60-bed nursing home loca:ed at 5260 Glover Lane, Milton, Florida 32570, having been issued license number SNF 1490096. 7. SRCC is and was at all times material hereto a licensed facility wider the licens‘ng authority of the Agency, and is and was required to comply with all applicadle niles an statutes, 83 12/81/2083 12:56 8585265983 SANDY RIDGE COUNT I PAGE 04 SRCC FAILED TO ENSURE, BASED ON A COMPREHENSIVE ASSESSMENT OF A RESIDENT, THAT: (A) A RESIDENT WHO ENTERS THE FACILITY WITHOUT PRESSURE SORES DOES NOT DEVELOP PRESSURE SORES UNLESS THE INDIVIDUAL’S CLINICAL CONDITION DEMONSTRATES THAT THEY WERE UNAVOIDABLE; OR (B) A RESIDENT HAVING PRESSURE SORES RECEIVES NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION AND PREVENT NEW SORES FROM DEVELOPING, 8. 42 CER. § 483.25(c)(1) or (2) Rule 59A-4.1288, Fla. Admin. Code (2003) CLASS It DEFICIENCY The Agency realleges and incorporates by reference paragraph’: one « 1) through seven (7) above as if fully set forth herein. 9. On or about September 9, 2003, the Agency conducted a survey at SRCC. An isolated class If deficiency was cited against SRCC based on the findings below involving Resident #1 or Resident #2. Based on observation, record review and interview the facility failed to prevent the development of pressure sores after admission and “o provide necessary treatment and services to promote healing for 2 of 22 sampled residents (#1,2). The findings are: Record review for resident #1 indicated the resident is alert and oriente i to person, place, and time and is own responsible person to make decisions. The record indicates the resident has a diagnosis of Neurogenic Blac der and Multiple Sclerosis (MS). The Minimum Data Set @MIDS) dated 9/2/03 indicates the resident requires extensive assistance with ADLs, inclucing bed mobility. The resident has a foley catheter due to Neurcgeni: Blad jer. 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 catheter since November 21, 2000. Review of the nurses notes dated 8/16/03 indicé ted extremely excoriated and bloody buttocks. The note also indicates the resident is scheduled to see a paysician 8/28/03. A telephone order -vas written on 7/18/03 indicating a urology consult for "incontinenze around catheter". Another nurses note dated 8/19/03 indicates excoriated beefy red buttocks with deep imprints from the Foley catheter. The reccrd lacced evidence that the physician was notified of the severity of the wounds uatil 12/81/2863 12:56 8585265983 SANDY RIDGE the resident saw the urologist on 8/28/03. Nurses’ votes indicate the resident saw the urologist on 3/28/03 and was referred to the Wound Center the following day. Review of the Wound Center notes dited 8/29/03 state the resident was diagnosed with a yeast infection and the yeast rash is potentiated by the wetness he/she experiences from his her leaking foley catheter. The center also indicates the resident has several pressure sores related to pressure from his/her Foley Catheter. The MDS dated 9/3/03 is coded for 4 stege 2 ulcers on the buttocks, coccyx and thigh. Review of the 8/03 medication record indicates the resident i3 to receive Nystatin ointment to the buttocks twice daily. The following dates lack signatures noting Nystatin ointment. as given on the 7-3 shift: 3/2, 8/3, 8/8, 8/11, 8/16, 8/27, 8/18, 8/20, 8/21, 8/22, and 8/25 and fer the :-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, &/6, 8/8, 8/9, 8/10, 8/12, &/15, 8'22, 8/23, 8/24, 8/27, 8/28. The medication record also lacked signatures no ing for Criticaid to the buttocks bid (twice a day) on the following dates: 7-3 shift: 8/27 and 8/28. Calmoseptine ointment. to be applied to areas 2-4 times a day, the medication record lecked signatures as given for the following dates and times: 8/29 the 1-7 shift, 8/30 the 7-3 end 11-7 sh fis, 8/31 the 7-3 sbift. Interview with the resident on 9/9/03 at 4:00 PM indicated her/his butte cks is painful and has been for sometime. The resident states he/she is uniuble to reposition self in bed or in the wheelchair. He/she also states he: she has had a catheter for a long time and that he/she has bladder spasms ‘hat causes her/him to leak urine around the catheter. The resident states the urine leaking onto the skin as caused irritation and pain. The resiclent states he/she is put to bed around 7:00 PM and is gotten up around £:00 AM. The resident states the staff does not reposition me at least every wo hours and does not check to see if I am wet, I lay in the same positior 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 a histor)’ of skin breakdown related to MS with immobility and incoritinence. This plan of care related to skin breakdown was last reviewed on 9/3/03 vith the following interventions: administer treatments as ordered, monitor site daily, keep skin clean and dry, check resident every 1-2 hours for cath:ter leakage. The record lacked evicence the treatments were done us ordered and the site was monitored daily. Per interview with the resident the resident was not checked for wetness throughout the night, nor was the resident assisted with turning while in bed at least every 2 hours. Per interview with the resident the resident was not tumed every two hours. PAGE 85 12/81/2883 12:56 8585265983 SANDY RIDGE PAGE 86 This pressure area was avoidable and treatment and services were not provided based on the lack of evidence that treatments were adininistered as ordered, notifying the physician of change in condition from 8 16- 28/03, delay in treatment urologist consult ordered 7/18/03 and saw urologist 8/28/03, interview of resident stating he/she is not checked for wetness every 2 hours and nct repositioned every two hours and not following the plan of care. Review of #2 record indicates a diagrosis 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 ‘o the coccyx (Clean coccyx with nor nal saline, pat dry and apply Sorbsan and cover with dressing daily) was given for the following dates: 8/22, 8/23, 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 for 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 ordeved by the physician which was daily. This pressure area was avoidale and treatment and services were not provided based on not following the plan of care and treament not administered as ordered. 10. Based on all of the foregoing, SRCC violated Rule 59A- 4.1288, Florida Administrative Code, which incovporetes 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 pressurs sores does not develop pressure sores unless the individua:’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. 12/81/2883 12:56 8586265983 SANDY RIDGE PAGE 11. Pursuant to Section 460.23(8), Florida Statutes (2003), the foregoing is an “isolated” class II deficiency because it affected one or a very limited number of residents, involved cne or a very limited number of staff, or occurred only occasionally or in a very limited number of locations. 12. Pursuant to Section 400.23(8) (b), Florida Statites, an isolated class II deficiency warrants a fine of $2,505.00. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make factual and legal findings in favor of the Agency or. Coun: I; 2) Impose a fine against SRCC in the amount of $2,500.00; and 3) Assess costs related to the investigation and prosecution of this vase pursuant to Section 400.121(10), Florida Statutes (2003). NOTICE SRCC hereby is notified that it bas a right to request an administrative hearir g pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). Specific options for adriinistrative action are set out in the attached Election of Rights form (two pages) and explained in the attached Explanation of Rights form (one page). All requests for hearing shall be niade to the Agency, and delivered to Leeland McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tailakassee, Florida 32308. a7 12/81/2803 12:56 8596265983 SANDY RIDGE PAGE 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 OFA FINAL ORDER BY THE AGENCY. THE REQUEST FOR HEARING IMUST BE RECEIVED BY THE AGENCY WITHIN TWENTY-ONE (21) DAYS FOLLOWING RECEIPT OF THE ADMINISTRATIVE COMPLAINT BY SRCC. Respectfully submitted, dre Co Daswer Lori C. Desnick, Esquire Assistant General Counsel Florida Bar No. 129542 Agency for Health Care Administration 2727 Matan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: (850) 922-8854 Fex: (850) 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that one original Administrative Complaint, Election of Rights form, and Explanation of Rights form, has been sent via U.S. Certified Mail, Retum Receipt Requested, (return receipt # /Jo/ 6 360 (Y03 3i0¢ Ob. 4) to Mark 4. Daniels, Administrator, Sandy Ridge Investors, Inc. d/b/a Sandy Ridge Care Center, 5360 G over Line, Milton, Florida 32570, and that one original Administrative Complaint, Eecticn of Rights form, and Explanation of Rights form, has been sent via U.S. Certified Mail, Return Receip! Requested etum receipt ¢_ W2 QA Wb VY 359 SHV) to Michael J. Bittman, 301 East Pine Street, Suite 1400, Orlando, Florida 3280, Registered Agent for Sandy Ridge Investors, Inc, on this By day of November 2003. LORI C. DESNICK, ESQUIRE ©

Docket for Case No: 04-000028