STATE OF FLORIDA FIL ph AGENCY FOR HEALTH CARE ADMINISTRATION 05 JAN -5 pM 4:32 STATE OF FLORIDA AGENCY FOR HEALTH CARE Aone UH ADMINISTRATION, HEAR Ais UIVE Petitioner, vs. Case Nos. 2004000163 2004009575 CLEWISTON INVESTMENTS & ASSOCIATES, 2004009633 LLC, d/b/a GRACE HEALTHCARE OF CLEWISTON, 2004009458 2004009459 Respondent. ‘Z) S- 6 O U7 ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against Clewiston Investments & Associates, LLC, d/b/a Grace Healthcare of Clewiston, (hereinafter Grace Healthcare), pursuant to §§ 120.569, and 120.57, Fla. Stat., (2003), and alleges: NATURE OF THE ACTION This is an action to impose administrative fines in the amount of $45,000, a survey fee of $6,000 and assign a conditional licensure status commencing 09/15/04 and extending through November 4, 2004, based upon Grace Healthcare being cited for three uncorrected State Class III deficiencies, two State Class II deficiencies, and one State Class I deficiency, as defined by §400.23(8)(a), (b) and (c) Fla. Stat. (2003). The Respondent was cited for the deficiencies as a result of a recertification survey conducted on or about 11/06/03, follow-up surveys conducted on or about 12/16/03 and 09/23/04 and complaint investigation surveys conducted on or about 08/04/04 and 09/15/04. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2003). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Grace Healthcare operates a 155-bed nursing home located at 301 S. Gloria Street, Clewiston, Florida 33440, and is licensed as a skilled nursing facility, license number 1092096. 5. Grace Healthcare was at all times material hereto, a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.25(m)(1), Grace Healthcare must ensure that it is free of medication error rates of five percent or greater. 8. On, or about, 11/06/03, the Agency conducted an annual survey of Grace Healthcare. 9. Based on observation during medication pass on 11/04/03 and clinical record review, the facility's nursing staff failed to accurately administer medications to residents as evidenced by a 6.57% medication error rate, 5 errors out of 76 opportunities. 10. On11/04/03 a facility staff nurse was observed preparing medications for a resident. The resident was receiving multiple medications including Protonix 40 milligram (mg.) tablets. 11. The nurse told the surveyor that the resident liked his/her medications crushed to make it easier to swallow. She/he then proceeded to crush the medications, mix them with pudding and administer them to the resident. 12. Review of the Medication Administration Record (MAR) revealed that the order for Protonix stated, "Do not crush." 13. Review of the Pharmacist recommendations for Protonix for this resident, dated 09/08/03, stated, "Please be sure this medication is not crushed (per manufacturer).” 14. On 11/04/03 a facility staff nurse was observed preparing medications for another resident. The resident received multiple medications including Phenytoin 125mg/Sml oral suspension. The staff nurse administrated 4 ccs (100 mg.) to the resident. 15. Review of the physician order revealed the order stated, Phenytoin 125mg/Sml, 12 ccs (300 mg.) every morning for seizures and 4 ccs (100 mg.) at bedtime. 16. The staff nurse had administered the evening dose instead of the morning dose. After surveyor intervention, she/he administered the remainder of the dose. 17. Observations during medication pass were conducted on 11/04/03 beginning at 7:30 a.m. 18. A review of Resident # 18's MAR revealed an order for Milk of Magnesia (MOM) 30 cc by mouth every morning with breakfast and a Multivitamin tablet by mouth daily with breakfast. 19. The Licensed Practical Nurse (LPN) administered a Multivitamin with iron following the resident’s breakfast meal. There was no MOM administered to Resident #18 with the breakfast meal. 20. A review of the MAR for Resident #28 revealed an order for Novolin N (long acting) Insulin 15 units every AM (morning) at 7:00 A.M. 21. Anobservation at 9:20 A.M., revealed the LPN giving Resident #28 15 units of Novolin N, 2 % hours late. 22. The Agency determined that Grace Healthcare potentially compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as a State Class III deficiency. 23. | The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 12/06/03. 24. — On, or about, 12/16/03, the Agency conducted a follow-up survey of Grace Healthcare. 25. Based on observation, clinical record review and review of the facility's policies and procedures, the facility failed to accurately administer medication as evidenced by a 13.64% medication error rate on this follow-up survey. 26. There were forty-four opportunities observed with six errors. The mediation pass included observation of four different facility nurses on both the North and South Wings of the facility. Each nurse was responsible for at least one error. Residents affected by these errors were Residents #17, #43, #44 and #45. 27. On 12/15/03, Nurse #1 was observed preparing and administering medications to Resident # 43. Medications included Combivent inhaler 2 inhalations. 28. The nurse was observed administering one puff of the medication and immediately administering another puff. 29. Per manufacturers recommendations and facility policy and procedure, at least one minute must lapse between puffs of this inhalant. 30. On 12/16/03, Nurse #2 was observed preparing and administering medications to Resident # 44. Medications given to the resident included 5 cc of Ferrous Sulfate liquid - 44 mg/lml. This administered dose equals 220 mg. of Ferrous Sulfate. 31. Review of the physician orders revealed the order to read Ferrous Sulfate 5 grains is to be administered. Five (5) grains is equal to 300 mg. The resident was given 80 mg. less of the ordered dose. 32. On 12/16/03, Nurse #3 was observed preparing and administering medications to Resident # 45. Medication administered to the resident included a Multiple Vitamin with Iron. 33. Review of the physician orders revealed the resident should have been given a regular Multivitamin without iron. 34. On 12/16/03, Nurse #4 was observed preparing and administering medications to Resident # 17. Morning medications included: Cortisporin eye drops 2 drops in each eye, Flonase 1 spray in each nostril and Combivent inhaler 2 puffs. 35. | The resident keeps inhalants and sprays locked at the bedside. 36. | The nurse and surveyor observed the resident administer 2 sprays of Flonase to each nostril. 37. | The nurse and surveyor then observed the resident with the Combivent inhaler. The resident administered 2 puffs, one immediately after the other. 38. Atno time did the nurse stop the resident from administering the incorrect dose of Flonase, nor did the nurse stop the resident from using the Combivent inhaler inaccurately. 39. The nurse then administered the Cortisporin eye drops. The nurse touched the sclera of the left eye with the tip of the bottle. 40. The nurse administered 2 drops to the left eye and 2 two drops the right eye. No time elapsed between separately administered drops. 41. Per manufacturer recommendation and per facility policy and procedure at least 3 - 5 1 minutes must lapse between each individual drop. A total of 3 medication errors were observed for this resident. 42. The Agency determined that Grace Healthcare had potentially compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as an uncorrected State Class Ill deficiency. 43. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 01/16/04. 44. _ A State Class III uncorrected deficiency subjects Grace Healthcare to an administrative fine in the amount of $1,000.00. 45. A Default Final Order was issued on 04/26/04 citing Grace Healthcare for a Class II deficiency resulting from an annual survey conducted on 11/06/03. Pursuant to § 400.23(8)(c), Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT II 46. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 47. _ Pursuant to 42 CFR § 483.75(1)(1), Grace Healthcare must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. 48. On, or about, 11/06/03, the Agency conducted an annual survey of Grace Healthcare. 49. _ Based on record review, the facility did not ensure that accurate medication records were maintained for one active sampled resident (Resident # 7) of 21 active sampled residents and for one (Resident # 24) of three closed records. 50. Resident # 7 was re-admitted to the facility on 10/02/03. Pertinent diagnoses include but were not limited to Pelvic Fracture, Urinary Tract Infection, Esophageal Reflux, Abdominal Pain and Insomnia. 51. The resident's Minimum Data Set (MDS), signed as completed on 10/14/03, revealed in section J2 a and b (Pain Symptoms) the resident is assessed as having moderate pain daily (J2 a and J2b =2). The pain site in J3d is "hip pain.” 52. The surveyor spoke to the Unit Manager (UM) and asked to see the resident's Percocet from the medication cart and narcotic control sheet. 53. The UM checked with the nurse responsible for Resident # 7 and was informed the resident did not have any Percocet. 54. A review of the MAR and physician's order sheet revealed the resident is to receive Percocet 7.5 mg/500 mg every 6 hours as needed. 55. Areview of the MAR revealed the resident last received Percocet on 11/02/03 (Sunday) at 10:15 A.M. 56. The surveyor observed that the front and back of the MAR are not completely filled out documenting when the resident received Percocet and its effectiveness. 57. On 11/04/03, the surveyor discussed the Percocet and documentation issues with the Director of Nurses (DON) and requests an audit be performed. 58. The DON informed the surveyor that the narcotics records and MARs for controlled medications for Resident # 7 did not match. 59. On 11/05/03, the DON stated that the Percocet count was off for not only Resident # 7, but also for other residents receiving as needed pain medications (PRN). 60. On 11/06/03, the DON reviewed with the surveyor the results of the facility audit on Resident # 7's Percocet. 61. The DON stated that the facility could not account for eleven doses of Percocet removed from the drug packet. 62. | The DON further stated there were sixteen other instances where either the front (noting date administered) or the back (noting effectiveness) of the MAR is not filled out for this resident. 63. Review of the closed medical record for Resident # 24 revealed the resident was admitted to the facility on 08/04/03 with Diagnoses that include Spinal Spondylosis, Diabetes, Gastroesophageal Reflux Disease (GERD), Hypertension and Congestive Heart Failure (CHF). 64. Review of the initial MDS, signed as complete on 08/11/03, revealed in section J2 a and b (Pain Symptoms) the resident is assessed as having moderate pain daily (J2 a and J2b=2). 65. Review of the physician orders revealed the resident could receive one Darvocet N 100 every 4 hours as needed for pain. 66. Review of the MARs, for August and September 2003, reveal they are not completely filled out with documentation as to when the resident received Darvocet N 100 and the effectiveness of the medication. 67. | The MARs do not consistently match each entry on the Controlled Medication Utilization Records as to the date and time of administration of Darvocet N 100. 68. During an interview on 11/06/03, the DON stated, "I'll guess we'll have to monitor all the PRN pain meds." 69. | The Agency determined that Grace Healthcare had potentially compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as a State Class III deficiency. 70. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 12/06/03. 71. On, or about, 12/16/03, the Agency conducted a follow-up survey of Grace Healthcare. 72. Based upon record review and interview it was determined the facility failed to accurately document the MARS and Controlled Medication Utilization Sheets for two of fifteen (Resident # 17 and Resident # 35) sampled residents. 73. Resident # 17 was admitted on 09/13/02. Pertinent diagnoses include but are not limited to pain in the limb and marked obesity. The resident was alert and oriented and was capable of making his/her needs known. The resident had a prescription for Oxycodone (Percocet) 5 mg/325mg. 1 tablet by mouth every 4 hours as needed for pain or 2 tablets by mouth every 4 hours as needed for pain. TA, During record review on 12/15/03, a surveyor observed the MAR, Pain Management Flowsheet (PMF), and Controlled Medication Sheet (CMS) did not match. 75. The surveyor reviewed these documents with the UM on the South Unit and discussed 1 the fact that these documents did not match. 76. The CMS showed 43 Percocet had been given. 77. The back of the MAR showed 24 Percocet as being administered at 12 different times from 12/01/03 through 12/14/03. 78. The front of the MAR showed 13 times Percocet had been administered from 12/01/03 through 12/14/03 but no quantities are shown on the front of the MAR. 79. The CMS showed 43 Percocet were removed for this resident on 23 different occasions from 12/01/03 through 12/15/03. 80. The PMF showed the resident was administered at least 22 Percocet from 12/05/03 when the PMF was implemented through 12/15/03. 81. The UM advised she was not sure what was occurring with the documentation of the Percocet. 82. On 12/15/03, the surveyor met with the Administrator, DON and UM to discuss the documentation issue. 83. The DON was asked to reconcile the PMF, MAR, and CMS. 84. Based upon the three documents it was determined that one nurse was responsible for most of the documentation errors. 85. When the three documents were viewed side by side it was determined that one dose of Percocet could not be accounted for on 12/14/03. 86. | The DON acknowledged the documentation of controlled substances was in need of improvement. 87. Review of the CMS further revealed that a nurse on 12/09/03, at 8:00 p.m., documented taking 2 Percocet out of the Medication Packet. However, the nurse only subtracted 1 Percocet 10 from the count. The count prior to removal was 37 and after removal of 2 Percocet the balance was shown as 36. 88. | In an interview with the surveyor, the DON acknowledged this error. The DON noted the shifts change at 7:00 a.m. and 7:00 p.m. The count discrepancy should have been noted at 7:00 a.m. on 12/10/03. 89. The nurse working the shift from 7:00 a.m. to 7:p.m. then documents on the CMS, at 4:30 p.m., that one Percocet was taken, but subtracted two from the total to make the count 31 instead of 32. Thus the count was corrected through another subtraction error. 90. On 12/15/03, the DON and surveyor met with the night nurse responsible for most of the errors as determined by the DON. 91. After reviewing the medication records the nurse acknowledged she had subtracted in error. The nurse indicated she could not explain the other documentation errors. 92. On 12/16/03, the surveyor and the DON met to discuss the correction of the CMS by multiple subtraction errors. 93. | The DON acknowledged the facility did not have any medication error reports documenting the narcotic count being off on 12/10/03 at 7:00 a.m. 94. The surveyor showed the DON how the count had been corrected on 12/10/03 by another subtraction error at 4:30 p.m. The DON acknowledged this was not the proper method to correct medication error counts. 95. Resident # 2 was admitted on 12/04/01. Pertinent diagnoses include Muscle Disease Atrophy and Arthropathy. The resident was generally able to make his/her needs known and had a physicians order for Hydrocodone/APAP (Vicodin) 5-500 mg. 1 tablet by mouth every four hours as needed for pain. i 96. During record review on 12/15/03, the surveyor observed that the front of the MAR from 12/04/03 through 12/15/03, details the resident to have been administered 10 doses of Vicodin. 97. The back of the MAR only reveals 2 entries for the effectiveness of the Vicodin through the same time period. 98. The surveyor asks the UM to obtain the resident's Vicodin and CMS. 99. The packet reveals there are 11 doses of Vicodin shown as removed from 12/04/03 through 12/15/03. 100. The PMF reveals 9 doses of Vicodin are documented as being administered from 12/4/03 through 12/15/03. 101. After review of the 3 documents the UM acknowledges that the 3 documents do not match. 102. On 12/15/03 the surveyor met with the Administrator, DON and UM to discuss the documentation issue. 103. The DON was asked to reconcile the PMF, MAR, and CMS. 104. The DON indicated she could not determine what happened with a dose of Vicodin shown as removed from the CMS on 12/14/03. 105. On 12/15/03, the DON and surveyor met with the night nurse responsible for most of the errors as determined by the DON. After reviewing the Vicodin medication documents the nurse stated, "I just messed up." 106. The Agency determined that Grace Healthcare had potentially compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as an uncorrected State Class 12 IE deficiency. 107. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 01/16/04. 108. A State Class III uncorrected deficiency subjects Grace Healthcare to an administrative fine in the amount of $1,000.00. 109. A Default Final Order was issued on 04/26/04 citing Grace Healthcare for a Class II deficiency resulting from an annual survey conducted on 11/06/03. Pursuant to § 400.23(8)(c), Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT HI 110. The Agency re-alleges and incorporates paragraphs (1) through (5), as if fully set forth herein. 111. Pursuant to 42 CFR § 483.35(h)(2), Grace Healthcare must store, prepare, distribute, and serve food under sanitary conditions. 112. On or about 08/04/04, the Agency conducted a complaint investigation of Grace Healthcare. 113. Based on observations, the facility failed to store food under sanitary conditions. The facility also did not ensure surfaces in the kitchen were clean when storing clean kitchenware. 13 114. Observation of the kitchen on 08/04/04, revealed the following: a. eight boxes were stored on the floor of the dry storage room, b. in the large refrigerator, there was one cup of cut tomatoes with no date and label, a container of bologna with no date and label, and one container of some type of meat with no date and no label, c. there was a bucket of dirty water with bleach stored on top of a sink counter with clean utensils next to it, d. the blender had hard-crusted food on it, e. the toaster had crumbs on the tray, f. there were dirty water pitchers and utensils stored on a counter, and g. clean trays were stored on a tray holder. Both the trays and holder had crumbs on the trays and on the slots of the tray holder. 115. Observation in the two-door refrigerator revealed: a. one tray stored in the refrigerator with 15 cups of fruit with no date and label, b. a second tray showed one cup of fruit and three glasses of juice not labeled and dated. c. 1/2 of a sandwich uncovered and liquid from one of the glasses poured onto the tray covering the bottom of the tray, the uncovered sandwich was being soiled by this liquid, d. a third tray had a container of cottage cheese with no label and date, e. a fourth tray had five cups of pudding, two cups of fruit, and four glasses of liquid with no label and no date. > 116. The Agency determined that Grace Healthcare had potentially compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services, and cited these deficient practices as a widespread State Class III deficiency. 117. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 09/03/04. 118. On or about 09/15/04, the Agency conducted a follow-up survey of Grace Healthcare. 119. Based on observations, staff interviews and review of facility policies and procedures the facility failed to distribute food in a safe sanitary manner as evidenced by outdated and unlabeled food in pantry refrigerators and dirty pantry refrigerators, floors and cupboards. 120. Observation of the 100 Hall Pantry, on 09/13/04, revealed: 1. The floor in front of the refrigerator in the pantry had dried food spills that had dust and hairs in them. 2. The refrigerator's freezer had food spills inside. 3. The refrigerator had multiple dried food spills and debris on the shelves and in the drawers and contained, but was not limited to: me Bop mR Doe . an opened 12-ounce can of fruit punch with no date or name, a Styrofoam cup of water with a straw in it that had no name or date, a Styrofoam cup of soda with a straw in it that had no name or date, five cartons of chocolate milk that were outdated (09/10/04), . apitcher of orange juice with no date, . ahalf of a bologna and cheese sandwich dated 09/07/04, one dated 09/11/04, and a whole sandwich dated 09/12/04, . bag containing Chinese food with no name or date, . abag from Sonny's Bar-BQ with food with no name or date, a large yellow Tupperware container with no name or date, and a large plastic bag with foil wrapped items that was unmarked and had no date. . the ice chest had the scoop inside, the microwave had food spills inside, m. the counter had food spills and there was a box of % eaten Popeye's Chicken in front of the microwave, and n. dirt and food spills in the drawers and cupboards. 121. Observation of the 200 Hall Pantry, on 09/13/04, revealed: f. a. the floor had dried food spills, b. the ice chest had the scoop inside, c. d e the cart the ice chest was on had dirt and food spills, . the microwave had food spills, . there were dirt and food spills in the drawers and cupboards and on the counter, the refrigerator's freezer had food spills, a cup of ice cream with the side broken out of it, a bottle of Sprite and two bottles of water with no names on them inside, and . there was food build-up and what looked like mildew or mold on the refrigerator between the freezer and refrigerator doors. . the refrigerator contained, but was not limited to: 1. three outdated cartons of chocolate milk, 2. acontainer of orange juice with no date, 3. % of a peanut butter and jelly sandwich dated 08/29, 4. a container of grapes with no date or name, 5. seven half bologna and cheese sandwiches dated 09/12/04, two whole sandwiches dated 09/11/04, and two sandwiches with no date, 6. an open bottle of water with no name, 15 122. 123. 124. 7. a plate of food from KFC with no name or date, and 8. two Wal-Mart bags that had food inside with no name or date. Observation of the 300 Hall Pantry, on 09/13 04, revealed: a. 1. The freezer had food spills, two- gallon containers of ice cream with no date when they were opened, 2. aMcDonald's milkshake, and 3. an open package of croissant pockets with no name or date. The refrigerator contained, but was not limited to: . five outdated cartons of chocolate milk, . a bag containing a carton of chip dip with no date or name, . sandwich dated 09/11/03 and one dated 09/12/03, . there were food spills on the shelves and in the drawers, and . the cabinets and drawers had food spills in them. MWRhWH Observation of the 100 Hall Pantry on 09/14/04, revealed: a. 1. The freezer still had food spills. There was a half-gallon carton of ice cream with no name or date. 2. An open container of thickened apple juice with no date when it was opened was found on the shelf on the cart that holds the ice chest. 3. There were multiple food spills and debris in the drawers and cabinets including a large plastic bag and a plastic cup with food waste and trash in it under the sink. b. The refrigerator contained, but was not limited to: 1. a bottle of water with no name, 2. a Tupperware container and the bag of foil wrapped items with no name and date, 3. a Styrofoam cup of water with a straw in it with no name, 4. a Styrofoam container of food with no date or name, and 5. food spills and debris on the shelves and in the drawers. Observation of the 200 Hall Pantry on 09/14/04, revealed: 1. The freezer still had food spills. 2. There were two bottles of water with no name or date. 3. The refrigerator still contained the container of grapes and the sandwich dated 08/29/04 located in the "snack drawer". 16 4. There were food spills and debris in the drawers and on the shelves. 5. The drawers and cupboards had food spills and debris in them. 125. Observation of the 300 Hall Pantry on 09/14/04, revealed: 1. There were still the two gallon containers of ice cream with no date when they were opened. 2. The refrigerator had food spills and the cupboards and drawers had food spills and debris. 126. An interview with the Food Service Manager on 09/14/04 revealed that the CNA's are responsible for keeping the refrigerators and pantries clean. 127. Review of the facility policy on cleaning the pantries revealed that the CNA's are to clean out the refrigerators of outdated foods. 128. An interview with the ADON on 09/15/04 revealed that if the policy said the CNA was to clean out the refrigerator in the pantry that meant to also clean it. 129. The Agency determined that Grace Healthcare had potentially compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services, and cited these deficient practices as a widespread uncorrected State Class III deficiency. 130. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 10/15/04. 131. A State Class III widespread deficiency subjects Grace Healthcare to an administrative fine in the amount of $3,000.00. 132. A Default Final Order was issued on 04/26/04 citing Grace Healthcare for a Class II deficiency resulting from an annual survey conducted on 11/06/03. Pursuant to § 400.23(8)(c), Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more 17 Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $6,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT IV 133. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 134. Pursuant to 42 CFR § 483.25(i)(1), Grace Healthcare must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible. 135. On or about 09/15/04, the Agency conducted a complaint survey of Grace Healthcare. 136. Based on observation, clinical record review and interview with the DON and the UM, the facility failed to ensure one resident, Resident # 7, was provided care and services to avoid weight loss. This is evidenced by the resident having lost 29 pounds in 21 days for a severe weight loss of 14.3%. 137. Resident # 7 was admitted to the facility on 08/24/04 with a diagnosis of Cerebral Vascular Accident, Hypertension, Diabetes, and Dysphagia. 138. Review of the resident's nursing assessment indicated the resident’s weight as 203.5 pounds. 139. Review of the facility's dietician initial notes reveals the dietician used this weight for her assessment. 18 140. The initial dietary note, dated 08/28/04, states, “the resident is on a puree diet with honey thick liquids. The resident's albumin is low but may be secondary from Diabetes.” The dietician concludes with, "Resident would benefit from progressive wt (weight) loss to at least 190 pounds. Will monitor.” 141. The next dietary note, dated 08/30/04, states, "Met with ST (Speech Therapy) to discuss resident case. ..... resident is talking very little. Nutrition Risk assessment reviewed and res (resident) at increased risk with serum alb (albumin) reflecting moderate visceral protein depletion and anemia..... _ ...poor po (oral) intake and labs indication of poor nutrition that supplements are warranted. ....suggest Boost Pudding one can tid (three times per day) 240 kcal/7 grams of protein and ProMod 2 scoops po bid (twice per day) 112 kcal and 20 grams of protein. ..." 142. Review of the clinical record reveals the Boost and ProMod were ordered by the physician. However, review of the resident's medication and treatment administration records reveal the Boost was never added to these forms, only the ProMod powder. 143. The resident never received any Boost supplement. This was confirmed by the RN Unit Manager. 144. Review of the resident's admission MDS, dated 09/07/04, reveals the resident is totally dependent on staff for eating. 145. The RAP (Resident Assessment Protocol) worksheet, dated 09/06/04, states, "Resident is at a nutrition's risk due to leaving 25% uneaten at meals, he/she is on a therapeutic diet and is fed by staff, he/she has dysphasia and speech is working with him/her. Proceed with care plan and goal will be that resident does not have any significant weight loss....” 146. The care plan for nutrition was established 08/28/04. The care plan includes notifying the physician of any significant change. 147. The surveyor noted the resident was taken to the emergency room twice with diagnoses of hypoglycemia. 148. A report, dated 09/10/04, included an albumin of 2.0, normal 3.4 - 5.0 and total protein of 5.9 normal 6.4 through 8.3. These values are indicative of severe protein depletion. 149. The care plan was updated on 09/10/04, stating, "cont with poc (continue with plan of care)." The care plan does not reflect any changes to weight change, low albumin and protein stores or changes in oral intake. 150. Review of the resident's ADL (Activities of Daily Living) record dating from 09/01/04 through 09/14/04, completed by a CNA, indicates the resident was averaging only 25% to 75% of food intake daily, except for 09/11/04, during which the resident consumed 100% of daily intake. 151. The nurse's notes do not reflect a diminished appetite for this resident nor does it reflect the poor percentage of food intake. 152. Review of the facility's "Weekly Weight Monitoring Sheet" indicated that Resident # 7’s admission weight of 187 pounds, and dated 09/06/04, even though the resident was admitted on 08/24/04 with a weight of 203.5. The next weight is dated 09/12/04 at 187 pounds. 153. Review of the nurse's notes for these days do not reflect the resident has lost 15.5 lbs. in 13 days. There is no change to the care plan. 154. Neither the physician nor the dietician were made aware of the weight change. There are no physician or dietary notes on these dates. There is no documentation the physician was made aware of the weight change. 155. On 09/14/04, the surveyor asked a weight to be performed on Resident #7. The 20 resident's weight was now 174.5 pounds, a loss of 29 pounds in 21 days. This is a severe weight loss of 14.3%. 156. Due to the facility's lack of observation, re-assessment, communication among staff and failure to follow the physician's plan of care and failure to notify the physician of weight changes, this resident suffered actual harm as indicated by severe weight loss. 157. The Agency determined that Grace Healthcare has compromised the resident's ability to maintain or reach his/her highest practicable physical, mental and psychosocial well being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited this deficient practice as a State Class II deficiency. 158. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 10/15/04. 159. A State Class II deficiency subjects Grace Healthcare to an administrative fine in the amount of $2,500.00. 160. A Default Final Order was issued on 04/26/04 citing Grace Healthcare for a Class [I deficiency resulting from an annual survey conducted on 11/06/03. Pursuant to § 400.23(8)(b), Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). 21 COUNT V 161. The Agency re-alleges and incorporates paragraphs (1) through (5), as if fully set forth herein. 162. Pursuant to 42 CFR § 483.25(c), Grace Healthcare must ensure that 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; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 163. On or about 09/15/04, the Agency conducted a complaint survey of Grace Healthcare. 164, Based upon observation, clinical record review, review of the comprehensive assessment and care plan, and interviews with the DON and the UM, the facility failed to ensure one resident, Resident # 7, was provided care and services to avoid pressure sores. 165. Resident # 7 developed a pressure sore within the first 21 days of stay. 166. Resident # 7 lost 29 pounds in 21 days indicating a severe weight loss of 14.3% and contributing to the pressure sore development. 167. Resident # 7 was admitted to the facility on 08/24/04 with a diagnosis of Cerebral Vascular Accident, Hypertension, Diabetes, and Dysphagia. 168. Review of the initial nursing assessment dated 08/24/04 indicates the resident was free from pressure sores and skin lesions. 169. On 8/24/04, a Braden score of "14" was established, meaning a moderate risk for pressure sore, 170. Review of the RAP, dated 09/06/04, indicated the resident was at risk for pressure sores due to decreased bed mobility and total care by the staff. 22 171. A physical therapy evaluation was performed on 08/25/04 indicating the resident has totally dependent on staff for bed mobility. 172. On 08/25/04, a nursing care plan for, "At risk for skin breakdown" was established. A second date of 09/10/04 is on this form but it is not clear if any new interventions were initiated. 173. The care plan approaches include, inspect skin daily during bathing, encourage adequate nutrition and hydration, keep clean and dry, cream to bony prominences, out of bed and reposition frequently. 174. Review of the ADL sheet indicated a "T" for total on all three shifts, for how resident moves between locations and surfaces. However, there is no indication if the resident has been up in the chair or how many times he/she was repositioned during the day. 175. Observation by the surveyor on 09/14/04, from 8:00 a.m. until 2:00 p.m., the resident remained in bed, flat on his/her back. 176. Again, on 09/15/04, from 7:30 a.m. until 10:00 a.m., the resident was observed in bed lying on his/her back. 177. Review of the ADL book did not include any instructions for the CNA's regarding repositioning or offloading for this resident. 178. Review of the MAR and TAR did not reveal that any "cream" had been ordered for this resident. 179. On 09/15/04 the surveyor was made aware that the resident had developed a Stage II pressure sore. 180. With the resident's permission, the surveyor observed the nurse's evaluation of the pressure sore. The pressure sore was located over the middle and left upper gluteal folds. The pressure sore measured 5 x 2 cm and is oval in shape. 23 181. The surveyor asked the UM if daily or weekly skin checks were being performed by nursing for this resident. The UM advised that weekly care summaries are performed for each resident, which includes a skin check. However, when the surveyor asked for copies of the weekly summaries because the forms were not on the clinical record, the UM stated the summaries had not been performed. 182. Interview with the DON revealed that a weekly skin summary was not facility protocol at that time. 183. During an interview, the UM explained that a CNA had noticed a "skin tear” to the area on Sunday, 09/12/04, but forgot to tell anyone. 184. Due to progressive severe weight loss that was not addressed by nursing staff, failure of nursing staff to re-assess resident for skin condition, failure to follow the established plan of care for preventing pressure sores, and failure to ensure the CNA staff were following the plan of care, including repositioning and getting the resident up out of bed, this resident suffered actual harm in the form of an avoidable Stage II pressure sore. 185. The Agency determined that Grace Healthcare has compromised the resident's ability to maintain or reach his/her highest practicable physical, mental and psychosocial well being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited this deficient practice as a State Class II deficiency. 186. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 10/15/04. 187. A State Class II deficiency subjects Grace Healthcare to an administrative fine in the amount of $2,500.00. 188. A Default Final Order was issued on 04/26/04 citing Grace Healthcare for a Class II 24 deficiency resulting from an annual survey conducted on 11/06/03. Pursuant to § 400.23(8)(b), Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT VI 189. The Agency re-alleges and incorporates paragraphs (1) through (5), as if fully set forth herein. 190. Pursuant to 42 CFR § 483.75(m)(2)-(4), Grace Healthcare must train all employees in emergency procedures when they begin work in the facility; periodically review procedures with existing staff; and carry out unannounced staff drills using those procedures. 191. On or about 09/23/04, the Agency conducted a recertification survey of Grace Healthcare. 192. Based on observations, interviews with staff and review of employee education files, the facility failed to ensure that 17 residents in the Alzheimer's unit were protected against the threat of a fire. 193. The facility failed to assure that four staff members who were responsible for the lives of sixteen Alzheimer's residents provided a timely response in following the facility's Fire Procedures thereby endangering the residents. 194. The facility failed to assure that three of the four staff members who were tesponsible for 25 those residents attended unannounced fire drills. 195. The facility failed to adequately train the licensed staff in Fire Procedures which resulted in a nurse's panic and the announcement over the facility's intercom system that the fire alarms were malfunctioning before there was confirmation that a fire was not in the facility. 196. The facility failed to adequately train the licensed staff to read the Fire Panels in the South and Deep South Nurse's station, which resulted in the inability of the nurse to determine the location of a fire within the facility. This failure contributed to the threat and endangerment of the lives of the residents within the facility. 197. Observation during the evening medication pass on 09/21/04, at approximately 8:30 p.m., on the "North" unit of the facility, revealed the onset of intermittent bright flashing lights and the sounds of alarms. 198. The Charge Nurse locked the medication cart and proceeded to the "North" Unit Nurse's Station. The Charge Nurse informed two CNA's and a Nurse that were nearby the Nurse's Station, that the "Fire Alarms were going off.” The CNAs and the Nurse began assisting residents to nearby rooms while the Charge Nurse headed toward the "South" Unit of the facility. 199. Observation of the corridor leading down from the North to the South Unit of the building revealed intermittent bright flashing lights and the sounding of alarms. 200. Observation of the "short" and "long" corridors of the "South Unit" of the facility revealed the continuance of intermittent bright flashing lights and alarms. 201. Staff on the South Unit were observed assisting residents to nearby rooms, removing items from hallways and closing doors. 202. The Charge Nurse walked up to a panel behind the South Unit Nurse's Station and stated, "There's nothing there." The panel was blank. 26 203. At 8:31 p.m., the Charge Nurse proceded toward the "Deep South” section of the facility, the location of the Alzheimer's Unit. 204. She proceeded through the unlocked double doors to a black, flashing panel across from the Nurse's Station. 205. Observation of the Alzheimer’s Unit revealed the absence of intermittent bri ght flashing lights and no audible evidence of fire alarms. 206. Residents were not being assisted to their rooms. Staff were observed looking up at the Charge Nurse who remained at the flashing panel. 207. The Charge Nurse began pressing areas on the panel and would look continuously to the left and right of the panel to attempt to decipher the code that the panel was displaying. 208. The panel displayed the code, "CKT:2 Device 98." 209. Additional staff members with fire extinguishers ran into the Alzheimer's Unit and asked, "Where is it coming from, where is the fire?” The nurse began to panic and stated, "I don't know, I can't understand what this is saying, there is no CKT on this map, can anyone see where this is?" 210. As staff from the other units congregated around the panel and attempted to read where the location of the fire was, the staff from the Alzheimer's Unit was observed approaching the Nurse's Station. 211. Between 8:31 p.m. and 8:35 p.m. (4 minutes), the Charge Nurse was observed running back and forth from the telephone at the Deep South Nurse's Station to the flashing panel on the wall. She indicated she was "trying to silence the alarm." 212. A nurse who came from the North Unit Nurse's Station and still holding a fire extinguisher stated she would "go back again and look" on the North Unit for evidence of a fire. 27 213. A nurse from the South Unit Nurse's Station stood in the middle of the Alzheimer's Unit Nursing Station (Deep South) and stated, "If this was a fire we would all be in a bad situation." 214. At approximately 8:35 p.m., a staff member, who was observed down the long hall of the Alzheimer's Unit, walked up to the Charge Nurse while she was on the phone and asked, "What was going on?" The Charge Nurse stated, "The fire alarms are going off! Make sure that door is closed (and pointed to the unlocked exit door of the facility).” 215. None of the other staff that were present on the Alzheimer's Unit responded to the Charge Nurse's response of fire alarms going off. A staff member who was working on the Alzheimer's Unit was observed putting her purse on her shoulder and leaving the unit. 216. Multiple residents from the Alzheimer's Unit were observed ambulating in the activity room (door open), two residents were observed ambulating in the corridor. The doors to occupied resident rooms # 317, 316 and 315, remained open. Observation revealed there was no staff intervention to ensure resident safety. 217. At approximately 8:37 p.m. staff members of the Alzheimer's Unit were observed standing in the center of the Nurse's Station. A full seven minutes after the initiation of the fire alarms, multiple staff members were observed running into the Alzheimer's Unit, some with fire extinguishers, following the announcement of the Charge Nurse informing a staff member inside the Alzheimer’s Unit that “fire alarms” were going off. 218. Not one staff member was observed responding to secure the safety of the Alzheimer’s residents during the threat of a fire. 219. At approximately 8:38 p.m., the Charge Nurse indicated she was calling the Maintenance Director to help her "read what the panel was saying" and to "help her locate where the fire was.” 220. Questioning of the staff standing in the center of the Deep South Nurse's Station, 28 confirmed that the staff could not indicate that they knew what to do in the event of a fire in accordance with the facility's Fire Procedure. 221 — Staff could not indicate whether there were alarms that go off or what tri ggers the response of fire alarms. . 222 A CNA who returned to the unit confirmed she had never attended a fire drill. The CNA stated that she had been working in the unit since July. 223“ From 8:31 p.m. through 8:40 p.m., there was no response by the staff to assure the Alzheimer’s residents were secured from the threat of a fire in the Alzheimer's Unit. 224. At 8:44 p.m., the Charge Nurse proceeded toward the South Unit Nurse's Station. Intermittent flashing bright lights and alarms continued to sound, however the panel remained blank. 225. The Maintenance Director was observed walking past the South Unit Nurse's Station, The fire alarms and bright lights remained ringing and flashing. 226. A police officer was observed standing in front of the South Unit Nurse's Station. 227. At 8:45 p.m., a nurse picked up the telephone and made an announcement of a "Major Malfunction" over the facility's intercom system and for staff to ignore the fire alarms. 228. The Maintenance Director confirmed that he did not say there was a malfunction. He stated that he said that he came in to check and see if there was an actual fire or a malfunction. 229. There was no confirmation during that time that a fire was not present in the facility. 230. The Maintenance Director stated the nurse should not have made an announcement of a "Major Malfunction" when that determination had not been made and the staff "should still be responding as if there was a fire.” 231. The police officer stated he was the "first responder" and because he was told that there 29 was a malfunction, "he called dispatch and told them to cancel the fire department.” 232. The officer confirmed he was misinformed by a staff member and did not know that a final determination of whether a fire was in the building had yet been confirmed by the Maintenance Director. 233. At this point no one had yet determined whether or not a fire was in the building since the initial ringing of the alarms and flashing lights fifteen minutes earlier. 234. At 8:46 p.m., the Maintenance Director was observed walking up to the panel to the South Unit. The panel was blank. Lights continued to flash and alarms continued to sound. 235. The Maintenance Director began pressing buttons on the panel, then, walked away. He confirmed that the fire panel was not working, advising that the panel leads into the Deep South Panel and should assist in informing the staff of where fire is located. 236. The Maintenance Director was observed walking toward the front lobby, general offices in the front of the building and therapy department checking pull stations. He proceeded, while lights remained flashing and alarms continued to ring throughout these areas, to check pull stations located near central supply, the maintenance department, the laundry room, the linen room and he then proceeded toward the North Unit Nurse's Station. 237. A nurse was observed pushing a medication cart in the corridor. Residents were out of their rooms. The Maintenance Director informed the staff to disregard the malfunction announcement and to get the residents back into the rooms. He stated, "There could be a fire somewhere in this building.” 238. At 8:55 p.m., the Maintenance Director returned to the South Unit Nurse's Station, which remained blank. The fire alarms continued to ring. 239. A nurse was observed pushing a medication cart toward an open door of a resident's room 30 while the fire alarms and bright lights were flashing. As the Maintenance Director walked past her the nurse yelled, "When are the fire trucks coming?" The nurse continued to push the medication cart down the hall and failed to secure resident safety. 240. At 9:00 p.m., thirty minutes after the fire alarms sounded inside the facility, the Maintenance Director was able to confirm that a fire station pull box had been broken into and that there was no presence of a fire within the facility. 241. The surveyors conducted interviews at approximately 9:15 p.m. with the facility's Executive Director (ED), Maintenance Director and DON. The ED confirmed that the same fire alarm system was throughout the entire building. 242. When queried, the ED stated that the panel tells you where the fire is located in the building by looking at the diagram of the facility that has been coded into areas. 243. The code presented to the Charge Nurse at the panel was not on the diagram. 245. He indicated that the Deep South panel didn't work (nor did the South Unit panel) and that the numbers that were showing on the panel were from a "default mechanism" set up by the system. 246. The ED stated that these codes are not readable by the nurses and no one therefore would be able to tell where the fire would be coming from. He stated that the nurses don't have access to this code. 247. The ED, Maintenance Director and DON confirmed that they were not aware that the fire alarms were not working in the Alzheimer’s Unit and that if there was a fire in the building at this time the residents’ safety would be threatened. 248. The administrative staff were not aware that there was a continued lack of response by the staff members in the Alzheimer's Unit for approximately fourteen minutes, even after the 31 Charge Nurse went into the unit and informed them that the alarms were sounding and after numerous staff from other units went into the unit (some with fire extinguishers) to determine the location of the possible fire by looking at the panel. 249. The Maintenance Director confirmed that the panel was, "working off and on." However, he could not indicate when it was consistently working without defect. 250. He stated that the nurses were supposed to use it to determine where a fire could be located and that the panel was a direct feed into the panel at the Deep South (the Alzheimer’s Unit). 251. He confirmed that the panel in the Deep South Unit also wasn't working properly. He indicated that there must have been a "power surge” which prevented it from working properly. 252. The administrative staff confirmed that the nurse who spoke over the intercom system and reported a "Major Malfunction" was in error and should not have made the announcement to the staff without validating there was no fire in the facility. 253. They confirmed that residents’ and staff members’ lives were at risk by that announcement. 254 The Maintenance Director confirmed the nursing staff were trained to read the "fire panels" at the South Wing and Deep South nursing units. He stated that he takes the nurses over to the panels and demonstrates how they work and how to read the facility map and code, but he does not provide any written information or educational materials for the nurses to use, nor is there a plan in place for periodic updated training. 255. Review of the education files of the Charge Nurse, hired 08/20/03, and the nurse hired 09/24/03, who made the announcement over the intercom revealed there was no evidence that either nurse received any update training regarding fire procedures. 32 256. Review of the unannounced fire drills that were conducted by the facility from January 2004 through August 2004 revealed that neither nurse had attended. 257. The DON indicated she was new to the facility but confirmed that all staff are trained regarding fire/life safety procedures upon hire during orientation. She confirmed that the current policies and procedures for "Fire Procedure" were incorrect and needed to be rewritten since the addition of the Alzheimer's Unit. 258. The DON confirmed that staff are not instructed to pick up phones unless the facility has been "cleared" by the fire department. 259. Review of the facility's unannounced fire drills for the "evening shift (3p-11p)" revealed drills were conducted quarterly in November 2003, February 2004, and August 2004. A fire drill had not been conducted in May 2004. 260. On 09/22/04, the files of the employees who were working in the Alzheimer's Unit during the fire alarms from the previous evening were reviewed. Of the four staff members who were present only one had attended a fire drill. 261. An interview with the CNA, who had been observed leaving the Alzheimer's area the previous night, revealed she that could not explain what the facility's procedures were in the event of a fire and confirmed that she had not attended any fire drills. 262. A second CNA was interviewed and she indicated that after "shutting the door the nurse told her to shut", she came to the nurse's station to "find out what she was supposed to do.” This CNA confirmed she had attended one fire drill since working at the facility since April 2004. 263. Interview with the ED and DON revealed that all staff are given a plastic laminated card upon hire with their name badge which guide the staff on how to respond in the event of a fire. 264. The DON confirmed that the staff that were working in the Alzheimer's Unit during the 33 * evening of the fire alarm, had a card attached to their badge. 265. The DON stated that she had just spoken with the same CNA (#1) and verified that she was not using her card; even after talking with her. 266. The DON further indicated that the staff just "didn't turn their card around and use it like they are supposed to if they are not sure as to what to do in the event of a fire..." 267. The Agency determined that Grace Healthcare had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in the facility, and cited this deficient practice as a patterned State Class I deficiency. 268. The Agency provided Grace Healthcare with the mandatory correction date for this deficient practice of 09/28/04. 269. A patterned State Class I deficiency subjects Grace Healthcare to an administrative fine in the amount of $12,500.00. 270. A Default Final Order was issued on 04/26/04 citing Grace Healthcare for a Class II deficiency resulting from an annual survey conducted on 11/06/03. Pursuant to § 400.23(8)(b), Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $25,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT VII 271. The Agency re-allegcs and incorporates paragraphs (1) through (5), (7) through (43), (47) 34 through (107), (111) through (130), (134) through (158), (162) through (186), and (190) through (268) as if fully set forth herein. 272. Based upon Grace Healthcare’s one cited patterned uncorrected State Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part Tl of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Fla. Stat. (2003). WHEREFORE, the Agency intends to assign a conditional licensure status to Grace Healthcare, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Fla. Stat. (2003) commencing 09/15/04 and extending through November 4, 2004. COUNT VII 273. The Agency re-alleges and incorporates paragraphs (1) through (5) and (190) through (268) as if fully set forth herein. 274. Grace Healthcare has been cited for one Class I deficiency and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes (2003). WHEREFORE, the Agency intends to impose a survey fee in the amount of $6,000.00 against Grace Healthcare, a skilled nursing facility in the State of Florida, and conduct surveys every six months for two years, pursuant to Section 400.19(3), Florida Statutes (2003). Respectfully submitted this IF Ah day of December 2004. Leul) Abt Gerald L. Pickett Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330K. St. Petersburg, FL 33701 727.552.1526 (office) 35 i if a, DISPLAY OF LICENSE 05 Jay OS 6) 7] is 4 4: 7A Pursuant to § 400.23(7)(e), Fla. Stat. (2003), Respondent shall post the most curteAtines Aha prominent place that is in clear and unobstructed public view, at or near, the place whats / Ra my . residents are being admitted to the facility. NGS ; 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, T allahassee, Florida, 32308, (850) 922-5873. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail, return receipt no: 7002 2030 0002 7109 5561 on December , 2004 to: Traci Owens, Administrator, Grace Healthcare of Clewiston, 301 S. Gloria Street, Clewiston, Florida 33440, and by U.S. Mail to NRAI Services, Inc., Registered Agent, Grace Healthcare of Clewiston, 526 E. Park Avenue, Tallahassee, Florida 32301 Ld) Lf Gerald L. Pickett, Esquire Copies furnished to: NRAI Services, Inc. Traci Owens Gerald L. Pickett, Esq. Registered Agent Administrator Senior Attorney Grace Healthcare of Clewiston _ Grace Healthcare of Clewiston Agency for Health Care 526 E. Park Avenue 301 S. Gloria Street Administration Tallahassee, Florida 32301 Clewiston, Florida 33440 525 Mirror Lake Drive, (U.S. Mail) (Certified U.S. Mail) Suite 330K St. Petersburg, FL 33701 36

Docket for Case No: 05-000049