ae F a STATE OF FLORIDA . AGENCY FOR HEALTH CARE ADMINISTRATION 204 DEC 27 PP 2:93 AGENCY FOR HEALTH CARE ae ADMINISTRATION, nnn Petitioner, AHCA No.: 2004009455 AHCA No.: 2004009454 v. Return Receipt Requested: 7004 1350 000 5650 1258 WOOD LAKE HEALTH CARE 7004 1350 000 5650 1265 ASSOCIATES, LLC d/b/a WOOD 7004 1350 000 5650 1272 LAKE NURSING AND . REHABILITATION CENTER \ { “> Respondent. a L TY. | ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against Wood Lake Health Care Associates, LLC d/b/a Wood Lake Nursing and Rehabilitation Center (hereinafter “Wood Lake Nursing and Rehabilitation Center”) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2004) hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $12,500.00 pursuant to Sections 400.23(8) (b), Florida Statutes [AHCA No.: 2004009454]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7)(b), Florida Statutes [AHCA No. 2004009455]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Palm Beach County pursuant to Section 400.121 Florida Statutes and Chapter 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Wood Lake Nursing and Rehabilitation Center is a skilled nursing facility located at 6414 13th Road South, West Palm Beach, Florida 33415 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter S9A-4, Florida Administrative Code. COUNT I WOOD LAKE NURSING AND REHABILITATION CENTER FAILED TO ENSURE THAT THE RESIDENT WAS FREE FROM VERBAL AND PHYSICAL ABUSE. 42 SECTION 483.13(b) and (c), CODE OF FEDERAL REGULATIONS SECTION 415.102, FLORIDA STATUTES (ABUSE) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Wood Lake Nursing and Rehabilitation Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. A recertification survey was conducted from 8/16/04 through 8/19/04. Based upon documentation review and interview, the residents were not free from verbal and physical abuse for 2 (Residents #13 and 26) of 18 sampled residents and 5 (Residents #25, 32, 33, 37 and 39) of 28 random residents. The findings include the following: 10. During an interview with resident # 25, who was alert and oriented times three, on 8/18/04 in the afternoon, the following situation was revealed: Approximately one month ago, during the a.m. the resident was using the bed pan. A CNA came in with her breakfast tray and put it on the over-bed table. The resident said that she had a bowel movement in the bed pan and for the aide to please take it away. The resident said that the CNA said in a loud harsh voice, "That's disgusting" and walked out of the room. The CNA came back with a plastic bag and put the entire bedpan in the bag. The resident said that she told the CNA that she doesn't like being in her position, but that she can not get to the bathroom. She told the CNA that she was hurt and felt very badly by the CNA's reaction. The resident did not get the CNA's name (the resident said that many of the CNA's have their badges turned around so the residents or others can't identify them) nor has she seen her since. 11. Review of the facility Grievance Log, 8/17/04, at 2:00pm, revealed that resident #25 was treated disrespectfully by a CNA. Interview with resident #25 on 8-18-04 revealed the following: The resident asked the CNA to give her a bed bath. According to the documented evidence and resident interview evidence, the CNA said that the resident would have to wait. The CNA came back into the room at 2:50pm with 2 other CNA's and the resident felt that they were rough with her. The resident also said that the one CNA was playing a mean game with her. The CNA would say her name and the resident would answer and the CNA would say nothing. According to the resident, this went on several times. Then the CNA and the 2 other CNA's started speaking in Creole and laughing. The resident said that she felt terrible while this was going on, but that she felt that she was at their mercy because she needed her bath. She said that for a good while after they left, she still felt emotionally terrible. The resident said that she is still bothered by it today even though this happened in June. 12. During a group confidential interview, on 8/17/04, at 10:30am, a resident reported that a certified nursing assistant "Put her face in my face and said do you want me to take it outside." This resident said that this certified nursing assistant was hired by a unit manager to steal a kitten in the middle of the night. The resident reported this, and a grievance report filed within the facility Grievance Log, corroborated this. This CNA remains on duty and is assigned to the resident's unit. 13. Based on review of the facility Grievance Log on 8/17/04, at 2:00pm, revealed that on 8/9/04 resident # 32 "asked to be toileted and waited an hour and was told that she could go to the bathroom herself when she needs assistance.” 14. Documentation within the facility Grievance Log, reviewed 8/17/04, at 2:00pm. revealed that on 8/5/04 that the mother of resident # 33 reported that her daughter is being treated roughly and asked that staff be more gentle since the resident is in a lot of pain. The documentation said that the mother was cutting the resident's nails and staff came into the room and to the mother to "Get Out." The documentation went on to read that staff said, "We have to hurry, we have more people to do. You get out." The complainant said, "don't tell us what to do, we know what to do, now you go out." This all happened in the presence of the resident. The CNA who was mentioned has had substantiated infractions with other residents according to the documentation. It was also noted that no investigation into this alleged verbal abuse transpired until surveyor’s intervention during the survey. 15. Documentation within the facility Grievance Log, reviewed 8/17/04, at 2:00pm, revealed that on 7/21/04, resident # 37 complained that the CNA was rough during transfer causing her right hand and arm to be painful. According to the documentation, this resident is to be transferred with a 2- person assist and was not. The resolution stated, "Call and spoke to CNA involved via phone and follow up when return to work." Interview with the Social Services/Risk Management Designee, and the Risk Manager employed by another facility, managed by the same company, on 8/17/04, at 2:30pm, noted that the Designee was not able to elaborate as to the conversation, nor any follow-up which had taken place. Review of the personnel record for the CNA involved in the incident, 8/17/04, at 2:45pm, revealed no conclusive documentation regarding this incident. Further interview with the Risk Manager employed by another facility, that is managed by the same company, noted that "all issues will have to be investigated and In-services conducted". 16. Documentation within the facility Grievance Log, reviewed 8/17/04, at 2:00pm, revealed that on 7/3/04 resident # 39 complained that "CNA is very disrespectful. When call light is put on the CNA states 'What do you want / or don't start with me today.'" The resolution states, "CNA was counseled on customer service issues." Interview with the Social Service/Risk Management Designee, 8/17/04, at 2:30pm, the Designee was asked if he/she thought that this scenario was abusive. He did not respond. 17. Further interview with the Social Service/Risk Management Designee and the Risk Manager employed by another facility, managed by the same company, on 8/17, 8/18, and 8/19/04, in the afternoon, revealed that there were no written policies and procedures regarding Abuse or the Investigation of Abuse located in the facility. 18. Interview with Random resident #22, on 8/17/04 at approximately 9am, revealed that on the 3-11 shift prior to 8/17/04, that Resident #22 had requested Tylenol on 3 - 4 occasions, had not received it, and further stated that "staff were so mad at us and were banging doors last night". Review of the Minimum Data Set, dated 8/1/04, revealed that the resident was alert with short-term memory loss and had some difficulty in new situations only relating to decision making. The resident was readmitted to the facility on 8/6/04. 19. Based on the foregoing facts, Wood Lake Nursing and Rehab: litation Center violated 483.13(b) and (c), Code of Federal Regulation, and Section 415.102, Florida Statutes (2003), herein classified as a Class II violation pursuant to Section 400.23(8), Plorida Statutes, which carries an assessed fine of $5,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. COUNT II WOOD LAKE NURSING AND REHABILITATION CENTER FAILED TO COMPLETE A NUTRITIONAL ASSESSMENT. 483.20(b), CODE OF FEDERAL REGULATION 59A-4.109(1) (c), FLORIDA ADMINISTRATIVE CODE (RESIDENT ASSESSMENT) CLASS II 20. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 21. A recertification survey was conducted from 8/16/04 through 8/19/04. Based on record review and interview, the facility failed to complete a nutritional assessment for 1 of 18 sampled residents, (resident #1), following admission and following a significant weight loss. The findings include the following: 22. Resident #1 was admitted to the facility on 8/23/03, was hospitalized from 6/25/04 through 7/2/04, and readmitted to the facility on 7/2/04. On 6/21/04, prior to leaving the facility, the resident weighed 177 pounds (#), on return to the facility on 7/2/04, the resident weighed 160 pounds and on 8/16/04, the resident weighed 149.2 pounds. The last dated Nutrition Assessment was dated 6/21/04 (prior to hospitalization). The initial admission weight loss (17#) and the continual weight loss (additional 10.8#) for this resident were not identified or addressed by nursing or dietary. The facility policy states: "To document the nutritional status of a resident able to take food/fluids orally WHEN ‘within 2-5 days of admission for the resident with: - greater than (>) 5% weight loss in 30 days; > 7.5% weight loss in 60 days; > 10% weight loss in 90 days. Interview with the Licensed Dietitian revealed that she had "missed this resident". There was no nutritional assessment following admission on 7/2/04 and no assessment after the continual weight loss (a total of 27.8 pounds). 23. Based on the foregoing facts, Wood Lake Nursing and Rehabilitation Center Nursing violated 483.20(b), Code of Federal Regulation, and 59A-4.109(1) (c),Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries, in this case an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b) Florida Statute. COUNT III WOOD LAKE NURSING AND REHABILITATION CENTER FAILED TO REVIEW AND REVISE THE CARE PLAN RELATED TO HYDRATION AND ACTUAL WEIGHT Loss. 483.20(k), CODE OF FEDERAL REGULATION RULE 59A-4.109, FLORIDA ADMINISTRATIVE CODE (RESIDENT ASSESSMENT) CLASS IT 24. BDHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. A recertification survey was conducted from 8/16/04 through 8/19/04. Based on observation, record review and interview, it was determined that the facility did not periodically review and revised the care plan, for 1 of 18 sampled residents (resident #1), related to hydration and actual weight loss. The findings include the following: 26. Resident #1 was admitted to the facility on 8/23/03, readmitted on 6/18/04, hospitalized from 6/25/04 through 7/2/04, and readmitted to the facility on 7/2/04. The resident had diagnoses that included chronic renal failure with an episode of acute renal failure, diabetes, hypertension, anemia, and chronic obstructive pulmonary disease (COPD) . 27. Review of the care plan for resident #1 revealed that on the initial care plan, dated 7/2/04, (date of readmission to 10 the facility) revealed that the section related to Nutrition/Hydration was blank and not addressed by the nurse completing the form. This section was also noted to be blank on the admission (6/18/04) for the initial care plan, dated 6/21/04. 28. There was no documentation of a comprehensive care plan following the 7/2/04 re-admission. 29. Review of the comprehensive care plan, dated 6/21/04, revealed that the resident’s "problems/issues" were documented as "Resident is at risk for weight changes, hypo/hyperglycemia and fluid imbalance related to diagnosis of anemia, renal failure, diabetes, hypertension. On therapeutic diet low hemoglobin. Has stage ITI buttocks..." The goal was: "1. Resident weight will remain stable +/- 5 lbs (pounds) till next review...2. Maintain blood sugar level...3. Resident will have no s/s (signs or symptoms) of dehydration till next review date 9/21/04". The approaches included: "1. Provide diet as ordered; 2. Honor food preferences within dietary restrictions; 3. Monitor po (oral) intake, encourage 75% of meal consumption; 4. Provide verbal encouragement & assistance while feeding; 5. ACC check as ordered; 6. Monitor signs & symptoms of hypo/hyperglycemia i.e.. cold clammy skin, increase lethargy, increase confusion; 7. Monitor weights Refer to Dr (doctor) if with any gradual or significant weight loss of 5% in 1 month or 11 10% in 6 months; 8. Monitor for s/s of dehydration i.e.. short of breath, edema, poor skin turgor, dry lips; 9. Vitamin C, Zinc Sulfate as ordered; 10. Procrit as ordered." 30. On re-admission 7/2/04, there was no documentation that the facility addressed the initial hospital weight loss with the physician. Review of the weight sheet in the record revealed that on 6/21/04, the resident's weight was 177 pounds (#); on 7/2/04 (readmission), the weight was 160#; on 7/14, weight was 160#; on 7/29, weight was 163.7#; on 8/4/04, weight was 163.7#, on 8/11, weight was 152.2; and on 8/16/04, weight was 149.2#. Interview by two surveyors with the Acting Director of Nurses (DON), the licensed dietitian, the food “service manager (also a certified dietitian), and the unit nurse on 8/17/04, at approximately noontime, revealed that they were unaware of the weight loss sustained by this resident. 31. Interview with the unit nurse & Acting DON on 8/16/04 in the afternoon revealed that the resident had received intravenous fluids (IV) for 24 hours on 8/12/04. Review of the record for 8/12/04 revealed that after faxing lab work to the physician, the physician ordered IV fluids for the resident. 32. The care plan, initiated on the prior admission (6/21/04), was not updated or revised to reflect this resident's needs related to the weight loss or potential for dehydration. This was the most recent care plan related to weight and hydration needs. 33. Based on the foregoing facts, Wood Lake Nursing and Rehabilitation Center Nursing violated 483.20(k), Code of Federal Regulation and Rule 59A-4.109, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries in this case an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b) Florida Statutes. COUNT IV WOOD LAKE NURSING AND REHABILITATION CENTER FAILED TO ENSURE THAT A RESIDENT MAINTAINED ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS. 483.25(i), CODE OF FEDERAL REGULATION, AS INCORPORATED BY RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS IT 34. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 35. A recertification survey was conducted from 8/16/04 through 8/19/04. Based on record review and interview, the facility did not ensure that one of the 18 sampled residents (resident #1) met acceptable parameters of nutritional status in identifying and preventing weight loss. On re-admission (7/2/04) 13 to the facility, the resident had lost 17 pounds and within 6 weeks had lost an additional 10.8 pounds, a total of 27.8 pounds from 6/21/04 to 8/16/04. The findings include the following: 26. Resident #1 was admitted to the facility on 8/23/03, readmitted on 9/5/03, on 3/1/04 and on 6/18/04, hospitalized from 6/25/04 through 7/2/04, and readmitted to the facility on 7/2/04. The resident had diagnoses that include chronic renal failure with an episode of acute renal failure, diabetes, hypertension, anemia, and chronic obstructive pulmonary disease (COPD) . 37. The facility policy for Nutrition Assessment under Nutrition Services includes: Purpose: "To document the nutritional status of a resident able to take food/fluids orally"; WHEN ‘within 2-5 days of admission for the resident with: greater than (>) 5% weight loss in 30 days; > 7.5% weight loss in 60 days; > 10% weight loss in 90 days". 38. Resident #1 was hospitalized from 6/25/04 through 7/2/04 (7-8 days), and readmitted to the facility on 7/2/04. On 6/21/04, prior to leaving the facility for a doctor's appointment (sent to hospital from doctor's office per interview with the nurse and review of the nurses notes), the resident weighed 177 pounds (#). When the resident returned to the facility on 7/2/04, the resident weighed 160#. This weight was documented on the same weight sheet as the 170 pounds (6/21/04). 14 Interview with the Restorative nurse responsible for ensuring weights are done revealed that this documented weight on the weight sheet included the resident wearing his/her prosthesis. Review of the weight sheet in the record revealed that on 6/21/04, the resident's weight was 177 pounds (#); on 7/2/04 (readmission), the weight was 160#; on 7/14, weight was 160#; on 7/29, weight was 163.7#; on 8/4/04, weight was 163.7#, on 8/11, weight was 152.2; and on 8/16/04, weight was 149.2#. 39. On 8/16/04 (approximately 6 weeks from 7/2/04), the resident weighed 149.2 pounds. The last dated Nutrition Assessment was dated 6/21/04 (prior to hospitalization). The initial admission weight loss (17#) and the continual weight loss (additional 11#) for this resident were not identified or addressed by nursing or dietary. There was no documented nutritional assessment, no current plan of care for the actual weight loss, and no documented notification to the physician of any weight issues, including the weight loss on readmission on 7/2/04 and the continual weight loss through 8/16/04 (a total of 27.8 pounds). This was reviewed with the Acting Director of Nurses (DON), Licensed Dietitian, Food Service Manager and Unit Manager on 8/17/04. 40. Review of the Minimum Data Set (MDS) revealed that the S-day MDS dated 7/2/04 documented weight of 177 pounds (#) (the documented admission weight on the weight sheet was 160# and 15 confirmed on interview with the Restorative Nurse). The 14-day MDS dated 7/14/04, section K2, documented 160#, with no significant weight change identified in section K3 41. Interview with the resident conducted during the orientation tour the morning of 8/16/04 and periodically during the next three days revealed that he/she stated that he/she had lost weight, was not sure how much, and wished to gain it back to his/her original weight of about 170 pounds. The resident also stated that the food was so-so and was usually okay, but didn't always eat everything. 42. During interview with the Acting DON, food service manager, the unit manager and Licensed Dietitian revealed that the Dietitian stated that she had "missed this resident", and the assessment had not been completed since readmission. Interview by two surveyors with the Acting Director of Nurses (DON), the licensed dietitian, the food service manager (also a certified dietitian), and the unit manager on 8/17/04, at approximately noontime, revealed that they were unaware of the weight loss sustained by this resident. 43. Although, the resident had not been in the facility following re-admission for more than 60 days (approximately 6 weeks), the resident's weight loss at the time of the survey was greater than 5%. The assessment completed by the facility dietitian on 8/17/04, from weights of 160 pounds to weight of 16 150 pounds (done on 8/17/04), was calculated to be 6.25%. This weight loss, from 160 pounds to 149.2 pounds, was calculated by the survey dietitian to be 6.8%. The total weight loss calculation, by the surveyor dietitian, from 177 pounds to 149.2 pounds, was 9.6%. 44 Based on the foregoing facts, Wood Lake Nursing and Rehabilitation Center Nursing violated 483.25(i), Code of Federal Regulation, as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Wood Lake Nursing and Rehabilitation Center shall post the license in a prominent place that is 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 “A” EXHIBIT “A” Conditional License License # SNF 13390962; Certificate No.: 11840 Effective date: 08/19/2004 Expiration date: 06/30/2005 Standard License License # SNF 13390962; Certificate No.: 11841 Effective date: 10/07/2004 Expiration date: 06/30/2005 18 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Counts I, II, III, and IV. 2. Assess against Wood Lake Nursing and Rehabilitation Center an administrative fine of $12,500.00 for the violations cited above. 3. Assess against Wood Lake Nursing and Rehabilitation Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if applicable. 5. Grant such other relief as the 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 (2003). 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 Clerk, Agency for 19 Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Lourdes A. Naranjo, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6801 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive - Suite 101 West Palm Beach, Florida 33407 (Interoffice Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florica 32308 (Interoffice Mail) 20 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Glen Anthony Miller, Administrator, Wood Lake Nursing and Rehabilitation Center, 6414 13 Road South, West Palm 3each, Florida 33415; Wood Lake Health Care Associates, LLC, 10210 Highland Manor Drive - Suite 250, Tampa, Florida 33610; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this 2 4 day of Nav bm bE , 2004. ourdes A. Naranjo, Esq. 21

Docket for Case No: 04-004631