SE ee ON HS 92/87/85 13:37:34 Broad and Cassel-> fsa 921 @158 RightFax Page HH2 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No. 2004010406 (Cond. Lic.) vs. AHCA No. 2004010404 (Fine) DELTA HEALTH GROUP, INC. dibia WINDSOR MANOR, - _ NG Respondent. D> UL b { K __ MINISTRATIVE COMPLAINT ADMINISTRATIVE COMER COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (‘(AHCA* or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against DELTA HEALTH GROUP, INC. d/b/a WINDSOR MANOR (‘Respondent’), pursuant to Sections 420.589, and 120.57, Florida Statutes, and allages: ATURE OF THE ACTION NATURE OF THE ACTIUN to Section 400.23(7)(c), Florida Statutes, and an administrative fine of ONE THOUSAND DOLLARS ($4 000), upon Respondent, pursuant to Section 400.23(8\(c), Florida Statutes. JURISDICTIO ID VENUE 2) AHCA, and the Division of Administrative Hearings upon a request for formal hearing, have jurisdiction pursuant to Sections 420.569 and 120.57, Florida Statutes. Adrainistrative Complalnt 20040104068 2004010404 Certified Mall € 7003 2260 0007 2000 5538 Page 10f8 pages cna ee a a gz/a7/85 q3iae 4? Broad and Casse!? p58 921 ise weyers eo nent nee awe vee i) rguant to Rule 28-106.207. Florida pdministrative section 4%. ul 59A-4.1288) Fila. in y through (6) above a& eerie MN PO ALAA: a ES a2/a7/aS 13:38 ‘68 Broad and Cassel asa 921 8158 RightFax Page 464 8) The regulatory provisions of the Code of Federal Regulations and Florida Administrative Code that are pertinent to this alleged violation, read as foltows: g 483.25(4)2), Quality of care. mprehensive assessment, the facility must ensure that-...A resident Based on the residert’s co who is incontinent of bladder recelves appropriate treatment and services to prevent urinary tract infections and to restore 2s much normal bladder function as possible.” 9) AHCA surveyors conducted a survey of Respondent's facility on or about August 26, 2004, and found the following: a. Record review of Resident #10 and interview with staff on 8/23/04 at 9:35 a.m. revealed the resident was incontinent, requiring the usa of pads and briefs and was documen as having @ diagnosis of recurrent UTIs. b. AHCA survey staff observed the Incantinent care for Resident #10 on August 25, 2004 at 3:00pm performed by two Certified Nursing Assistants (CNAS). The observations included: j. While one CNA rolled the resident over and held him/her on hisfher side, the other CNA obtained @ clean, damp washdoth and began aeaning the resident, who was actively having a bowel movement. ii. The CNA wiped the resident eight times using the sai washcloth was obtained and this time the CNA was wiped the resident five times with the same washcloth. There w38 NO other changing of washcloths observed. c¢. On 08/26/04 et §:00 p.m., AHCA survey staff reviewed the records for Resident #25. According to the records, Resident #25 had @ history of urinary incontinence since his Cereora! Vascular ‘Accident (CVA) and had a urology consultation: on 07/1 8/04 for his discharge around his Indwelling catheter. Further record review revealed that he was currently being treated for Urinary Tract Infections (UTIs). d. AHCA survey staff observed the urinary catheter care for 4:00 p.m. The observations inckuded: i. This resident had a milky substance at the head of his penis und the genitals. Certified Nursing Assistant while providing catheter __ ec. AHCA survey staff reviewed the resident currently had & diagnosis of urinary retention and required an indwelling catheter. The record review revealed a history of UTIs. AHCA survey staff observed Resident #13's catheter care on 8/25/04 at 2:36 p.m, The observations included the following: i. The CNA obtained two clean washcloths, both were damped, one with soap and cone with only water. The perineal area was cleaned with up end down motions from above to below the catheter. naher the perineal area was cleaned, {he catheter wes cleaned with up and down motions. After the perineal area and cathater was deaned with soap the same technique wae [e with the i. AHCA survey staff review the facility's policy and procedure named “Urinary, Catheter Care,” which states that Cleaning és to be done from least to the most contaminated area. Administrative Complaint 20040104068 2004010404 Cerified Mail # 7003 2280 0007 2000 5538 Page 3088 --aneaemenaane ae 82/87/85 43:30:41 ay puquve! ————— — caren en SS = gee Broad and Cassel-? asa 921 158 RightFax wie ant perewreet gengour maTyt 40)AHCA gave and the Respondent received the mandatory correction date of September 26, 2004. 41)On or about October 5, 2004, the Agency surveyors conducted a follow-up survey. The findings of the survey team were the following: a. The medical record on resident #13 revealed that the resident has 8 diagnosis of urinary ire an indwelling catheter. atthe rs review revealed & MSIOY C order dated g/2a04 for Augmentin 500 mg (antibiotic) two times 3 of the Physician Orders revealed the resident wes b. The catheter care was observed 071 with water. explaining one was for , Upon observation, the resident was somewhat contracted with her legs bent making i difficult to access the perineal area a hed the front of the vaginal area with the same washcloth 6 times then wiped the Foley catheter. c. The CNA proceeded to tum the resident on her right side with some difficutty stating that we usually do this with two people. When questioned as to why she did not get he'p she stated, ‘well! didn't see anyone around when 1 was getting ready, ” Observation reveal she had xed for assistance. resent. The resident wes tumed and & clean washcloth was to dean more feces from the oT NA removed & soied, 0006 8 sing wes rel . The CNA then also wasned the open area with the same ‘on the Coccyx. washdtoth. She stated “the nurse will put a new dressing on it later. was applied, the soiled linen Wa changed and the resident was reposition on her back. 42) The Respondent did not have this deficiency corrected after the mandatory correction date of September 26, 2004. Page “o> 43) Respondent's failure to ensure & resident incontinent of bladder raceived appropriate treatment and services to prevent urinary tract infections is a violation of Rule 59A-4.1288, Florida Administrative Code, which incorporates by reference 42 CFR 483.25. 14) Respondent's to ensure a resident incontinent of bladder received appropriate treatment and services to prevent urinary tract infections is an ‘intentional or negligent Administrative Complaint 200401 04068 2004010404 Certified Mall # 7003 "7960 0007 2000 5538 Page 4af9 g2/a7/aS 13:39°89 Broad and Cassel-> euagutuue t ps8 921 8158 RightFax Page HAG act materially affecting the health or safety of residents of the facility.” Section 400.102(1)(a), Fla. Stat. 45) AHCA classified the nature and scope of this violation as a class lil “isolated” violation. Pursuant to Section 400.23(8){c), this classification constitutes grounds for the imposition of an administrative fine of ONE THOUSAND DOLLARS ($1 ,000). A class IU! violation is defined as one that “the agency determines will result in no more than minimal physical, mental, or psychosocial digcomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services.” Section 400.23(8)(c), Fla. Stat. 16) Respondent's failure to ensure a resident incontinent of bladder received appropriate treatment and services to prevent urinary tract infections constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(c), Florida Statutes. CLAIM FOR RELIEF Tee WHEREFORE, the Agency respectfully requests the following relief: A. Factual and legal findings in favor of the Agency on Count I. B. Uphoid the imposition of conditional licensure status. C. Imposition of an administrative of ONE THOUSAND DOLLARS ($1,000). DISPLAY OF LICENSE Pursuant to Section 400.23{7), Florida Statutes, Windsor Manor shall post the license in a prominent place that is in clear and unobstructed public view at or near the Ackninistrative Complaint 20040104068 2004010404 Certtied Mall # 7003 2280 0007 2000 5538 Page 5 of 8 az/a7/85 13:39:38 Broad and Cassel-> gsa@ 921 6158 RightFax Page AH? ene vie £e at pargucz us pus pusuue t semis wan) place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit “A”. NOTICE Respondent is notified that it has 4 right to request an administrative hearing pursuant to Section 420.589 and 420.57, 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 Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, Bullding 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308. T IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A RESPONDEN REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSTITUTE AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. Seo Seiiiiaiee Aaa Respectfully submitted this P| day of ,2 , fanna Daniels FL BAR #011 8321 ency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 2308 (850) 922-5873/ Fax (B50) 921-0158 CERTIFICATE OF SERVICE i hereby certify that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Administrative Complaint 20040104068 2004010404 Carthed Mal # 7003 2260 0007 2000 5538 Page 6 of 9 62/87/85 13:39:51 Broad and Casse!-> 858 921 8158 RightFax Explanation of Rights Under Section 120.569, Florida Statutes form, have been forwarded by certified mail, return receipt requested, on this day of to: DARCIELLE GRAY, ADMINISTRATOR JAY ADAMS ESQ. WINDSOR MANOR BROAD & CASSEL 602 LAURA ST PO BOX 11300 STARKE FL 32091-4026 TALLAHASSEE FL 32302-3300 Certified # 7004 1160 0003 3739 7418 7004 1160 0003 3739 7418 Certified # 7003 2260 0007 2000 5538 7003 @2b0 0007 2000 5538 = JOANNA DANIELS Page HHH Administrative Complaint 20040104068 2004010404 Certified Mad # 7003 2260 0007 2000 5536 Page 7 of 9 ere etnc ea: AE ncaa Re RS 82/87/85 13:48:85 Broad and Cassel-> asa 921 8158 RightFax Page &89 pus sUTUUE! erumave mast STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION UNDE! 120 FLORIDA STATUTE EXPLANATION OF RIG {fo be used with Election of Rights for Administrative Complaint) tn response to the atlegatlons set forth in the Administrative Complaint issued by the cy for Health Care Administration (‘(AHCA’ or "Agency’), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be recaived by AHCA within. twenty- ane (21) days from the date you receive the Administrative Complaint Please make your election of the attached Election of Rights form and retum it fully executed to the address listed on the form. OPTION! If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on final order will be entered setting forth the allegations as being ought in the Administrative Complaint. You will be OPTION2. If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Complaint), ion 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present before Mion and oral evidence to reduce the pensily ban for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. . if the Respondent disputes the allegations set forth in the Administrative Complaint {you do not admit them) you may request & formal hearing pursuant to Section 120.57(1), Florida Statutes, To obtain a forma! hearing, Respondent should select OPTION 3 cn the Election of Rights form. in order t iain a forma XS : ative Hearings Orde Section 120.57(1), F.S., Respondent's request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida ‘Administrative Code (F.A.C), and must state the material facts disputed. if you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent's original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent int. If the election of rights form with Respondent's selected not AHCA within twenty-one (21) days from the date of Respondent's receipt of the Administrative Complaint, a final order will be issued finding the deficiencies naity sought in the Complaint. Administrative Complaint ZODA0104068. 2004010404 Certified Mail # 7003 2260 0007 2000 $538 Page 8 of 9

Docket for Case No: 05-000698