(Certified Mail Receipt) 7004 1160 0003 3739 9429 STATE OF FLORIDA “ AGENCY FOR HEALTH CARE ADMINISTRATION oe . : “ STATE OF FLORIDA, AGENCY FOR aon HEALTH CARE ADMINISTRATION, 2 a _ x. Petitioner, AHCA CASE NO.: 2005003568 wn ~ vs. 2005003575 LISENBY, LTD. d/b/a LISENBY ON LAKE CAROLINE, ~ N\A Respondent. OS _ ay *) OF / ADMINISTRATIVE COMPLAINT ADMINISTRATIVE COMFLAIN* COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by through the undersigned counsel, and files this Administrative Complaint against LISENBY, LTD. d/b/a LISENBY ON LAKE CAROLINE (“Lisenby on Lake Caroline”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2004), alleges: NATURE OF THE ACTION 1. This is an action to impose four (4) administrative fines for a total of Four Thousand dollars ($4,000), based upon three cited State Class II deficiencies pursuant to Section 400.23(8)(c), Fla. Stat. (2004), and 42 C.F.R. 483.20(k), 42 C.F.R. 483.65(a)(1)-3), 42 CER 483.65(b)(3), and Rules 50A-4.106(4)(v), 59A-4.107(5), and 59A-4.1288, Fla. Admin. Code, (2004). The Agency also intends to impose a conditional rating effective April 8, 2005 through March 31, 2006, pursuant to Section 400.23(7), Fla. Stat. (2004) case no. 2005003568. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part II, Fla. Stat., and Sections 120.569 and 120.57, Fla. Stat. (2004). 3, Venue lies in Bay County, Panama City, Florida, pursuant to Section 120.57, Fla. Stat. (2004); and 59A-4, Fla. Admin. Code (2004), and Section 28.106.207, Fla. Admin. Code (2004). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing home facilities pursuant to Chapter 400, Part Il, Fla. Stat. (2004), and Rule 59A-4 Florida Administrative Code. 5. Lisenby on Lake Caroline is a for-profit corporation, whose 22-bed skilled nursing home facility is located at 1400 W. 11° Street, Panama City, Florida. Lisenby on Lake Caroline is licensed as a nursing home facility license #SNF1296096; certificate 12469, effective April 8, 2005 through March 31, 2006. Lisenby on Lake number # Caroline was at all times material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT 1 LISENBY ON LAKE CAROLINE FAILED TO DEVELOP COMPREHENSIVE CARE PLANS TO MEET THE RESIDENT'S NEEDS FOR 3 OF 7 SAMPLED RESIDENTS. (RESIDENTS #4, 6, AND 7). FEDERAL TAG F279- RESIDENT ASSESSMENT Section 42 C.F.R. 483.20(k) RESIDENT ASSESSMENT Section 400.23(8)(c), Fla. Stat. (2004) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 59A-4.1288, Fla. Admin. (2004) EXCEPTION 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about April 8, 2005, AHCA conducted an annual licensure survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about March 4, 2005, Lisenby on Lake Caroline failed to develop comprehensive care plans to meet the resident’s needs for 3 of 11 sampled residents. (residents #1, 6, and 11). b.) During an annual survey on or about April 8, 2005, Lisenby on Lake Caroline failed to develop comprehensive care plans to meet the resident’s needs for 3 of 7 sampled residents (residents #4, 6, and 7). The findings are: 1. A review of the medical record for Resident #7 revealed the resident currently has a Urinary Tract Infection. Further review of the medical record revealed the resident was first diagnosed with a Urinary Tract Infection on 3/25/05. The resident was again diagnosed with a Urinary Tract Infection on 4/1/05. The medical record does not include a care plan to address the recurrent Urinary Tract Infections. The facility failed to complete a comprehensive care plan to address the needs of the resident to include nursing interventions to treat and prevent the recurrent Urinary Tract Infections. 2. A review of Resident #6's medical record revealed on 3/25/05 the physician ordered side rails up x 2 while in bed. The medical record reveals a care plan notation of "side rails up per M.D. orders." The current care plan was not comprehensive to include interventions needed to prevent injury from the side rail or measures to decrease the use of the side rail to the most restrictive means of restraint. 3. A review of Resident #4’s medical record revealed on 3/28/05 the physician ordered side rails up x 2 and tray to Geri-Chair on when resident in chair..." The medical record reveals a care plan notation of "Family requested resident have side rails up x 2..." The current care plan was not comprehensive to include interventions needed to prevent injury from the restraints or measures to decrease the use of the restraint to the most restrictive means of restraint. 8. The regulatory provisions of the Florida Statutes that are pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort 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. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class Il deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. * * * 42 C.F.R. 483.20 Resident Assessment (k) Comprehensive care plans. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describer the following— (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under Sec. 483.25; and (ii) Any services that would otherwise be required under Sec. 483.25 but are not provided due to the resident’s exercise of rights under Sec. 483.10, including the right to refuse treatment under Sect. 483.10(b)(4). Rule 59A-4.106(4)(v) Facility policies- Each facility shall maintain policies regarding resident care planning. 9. The violation alleged herein constitutes an uncorrected class HI deficiency and warrants a fine of $1,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000. COUNT II LISENBY ON LAKE CAROLINE FAILED TO ESTABLISH AN EFFECTIVE INFECTION CONTROL PROGRAM TO INVESTIGATE OUTBREAKS OF INFECTION, MAINTAIN A RECORD OF INCIDENTS, AND DEVELOP CORRECTIVE ACTIONS TO PREVENT THE CONTINUED SPREAD OF INFECTION FOR 2 OF 7 SAMPLED RESIDENT (#6 AND 7). FEDERAL TAG F441-INFECTION CONTROL Section 42 C.F.R. 483.65(a)(1)-(3) INFECTION CONTROL Section 400.23(8)(c), Fla. Stat. (2004) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 59A4-4.1288, Fla. Admin. (2004) EXCEPTION 10. | AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. the Respondent’s facili 11. Onor about April 8, 2005, AHCA conducted an annual licensure survey at ty. AHCA cited the Respondent based on the findings below, to wit: a.) On ot about March 4, 2005, Lisenby on Lake Caroline failed to establish an effective infection control program to investigate outbreaks of infection, maintain a record of incidents, and develop corrective action to prevent the continued spread of infection. b.) On or about March 4, 2005, Lisenby on Lake Caroline failed to establish an effective infection control program to investigate outbreaks of infection, maintain a record of incidents, and develop corrective action to prevent the continued spread of infection. for 2 of 7 sampled residents. (#6 and 7). The findings are: 1. A review of the medical record for Resident #7 revealed the resident currently has a Urinary Tract Infection. The resident was first diagnosed with a Urinary Tract Infection on 3/25/05 and with a second infection on 4/1/05. A review of the Infection Control Log dated 4/7/05 reveals incomplete information. A review of the "Infection Report" reveals the top portion "Nosocomial Infection" was completed by the Licensed Practical Nurse. An interview with the Director of Nurses/Infection Control Coordinator on 4/8/05 at 11:50 AM. stated the Licensed Practical Nurse(LPN) completes this portion. The Director of Nurses stated she does not complete the Infection Control log and "Infection Report" with the investigation until "the next QA meeting." She stated she completes the information once a month and gives the reports to the QA committee. She denied investigating the infections as they occur and establishing preventative measures. She stated "| compile the information." She was unable to demonstrate an effective process of investigating the causative agent, the origin of the infection, and timely cautionary measures put in place to prevent the continued spread of infection. She denied any investigation or analysis of the reason this resident had 2 recent Urinary Tract Infections. She stated the facility does not analyze the infection until the monthly QA meeting and no measures are put in place until after the monthly meeting. 2. A review of the medical record for Resident #6 revealed she currently has an infection. A review of the Infection Control Log revealed the information was incomplete. A review of the "Infection Report" revealed the Nosocomial Infection portion was completed by the LPN. An interview with the Director of Nurses on 4/8/05 at 3:00 P.M. stated she has not analyzed the information and would not investigate the infection until immediately prior to the next QA meeting. 12. The regulatory provisions of the Florida Statutes that are pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident ot 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. A class Ill deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class 1 or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class If] deficiency is corrected within the time specified, no civil penalty shall be imposed. * * 42 C.E.R. 483.65 Infection Control- (a) (1)-(3) Infection control program. The facility must establish an infection control program under which it~ (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident’ and (3) Maintains a record of incidents and corrective actions related to infections. Rule 59A-4.1288 Exception- Requires that homes that participate in Title XVII or XIX must follow certification rules and regulations found in 42 C.F.R. 483, Requirements for Long Term Care + 26, 1991, which is incorporated by reference. Non-certified le and the standards contained in the Requirements for Long Term Facilities, Septembe facilities must follow the contents of this ru Conditions of Participation found in 42 C.F.R. 483, Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies. 13. The violation alleged herein constitutes an uncorrected class III deficiency and warrants a fine of $3,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $3,000. COUNT IL LISENBY ON LAKE CAROLINE FAILED TO ENSURE STAFF WASHED THEIR HANDS AFTER DIRECT RESIDENT CONTACT FOR 1 OF 2 OBSERVED STAFF MEMBERS. STATE TAG F444-INFECTION CONTROL Section 42 C.F.R. 483.65(b)(3) INFECTION CONTROL Section 400.23(8)(c), Fla. Stat. (2003) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 594-4.1288, Fla. Admin. (2004) EXCEPTION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. On or about April 8, 2005, AHCA conducted an annual licensure survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about March 4, 2005, Lisenby on Lake Caroline failed to ensure that staff washed their hands after direct resident contact for 4 of 6 observation staff members. (residents #2, 5, 6, and 9). b.) On or about March 4, 2005, Lisenby on Lake Caroline failed to ensure staff washed their hands after direct resident contact for 1 of 2 observed staff members. The findings are: 1. On 4/8/05 at 12:10 P.M. the Certified Nursing Assistant (CNA) was observed to serve the resident's food without gloves and did not wash her hands between direct resident contact. She was observed to pick up the sandwich for resident #8 and put it to the resident's mouth. She then went to obtain the lunch tray for resident #9. She did not wash her hands after contact with Resident #8. She opened resident #9's soup container, stirred the soup with a spoon, fed the resident #9 a spoonful of soup, then gave the spoon to resident #9 to continue eating. She then continued to distribute trays without sanitizing her hands for approximately 3 more residents. 16. The regulatory provisions of the Florida Statutes that are pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort 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. A class HI deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class | or class I] deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class Il] deficiency must specify the time within which the deficiency is required to be corrected. If a class IIT deficiency is corrected within the time specified, no civil penalty shall be imposed. * * * 42 C.E.R 483.65 Infection Control (b)(3)-The facility must require staff to wash their hands after each direct resident contract for staff hand washing is indicated by accepted professional practice. * e Rule 59A-4.1288 Exception- Requires that homes that participate in Title XVIII or XIX must follow certification rules and regulations found in 42 CER. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. Non-certified facilities must follow the contents of this rule and the standards contained in the Conditions of Participation found in 42 C.E.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies. 17. The violation alleged herein constitutes an uncorrected class III deficiency and warrants a fine of $3,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2 Impose a fine in the amount of $3,000. COUNT IV LISENBY ON LAKE CAROLINE FAILED TO FOLLOW PHYSICAN ORDERS FOR 1 OF 7 SAMPLED RESIDENTS (#1). STATE TAG N054-PHYSICIAN ORDERS Section 42 C.F.R. 483.65(b)(3) PHYSICIAN ORDERS Section 400.23(8)(c), Fla. Stat. (2003) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 59A-4.107(5), Fla. Admin. (2004) PHYSICIAN SERVICES 18. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. On or about April 8, 2005, AHCA conducted an annual licensure survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: 10 a.) On or about March 4, 2005, Lisenby on Lake Caroline failed to follow physician orders for 2 of 11 sampled residents (#1, #5). b.) On or about April 8, 2005, Lisenby on Lake Caroline failed to follow physician orders for 1 of 7 sampled residents (#1). The findings are: 1. An observation of Resident #1 on 4/8/05 at 11:00 A.M. revealed her lying in bed asleep with Side rail up x 1. A review of the medical record revealed the resident's side rail had been discontinued by the physician on 3/25/05. An interview with the Director of Nurses on 4/8/05 at 11:15 AM., she reviewed the side rail had been discontinued. She had no medical record and confirmed the explanation for why the side rail was in use. 20. The regulatory provisions of the Florida Statutes that are pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class HI deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort 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. A class II] deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was ly cited for one or more class I or class I deficiencies during the last annual previous tion since the last annual inspection or any inspection or complaint investiga inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. ee Rule 59A-4.107 Follow Physician Orders- (5) All physician orders shall be followed as prescribed, and if not followed, the reason shall to re-sign a facsimile order when he visits a facility. x * * 11 21. The violation alleged herein constitutes an uncorrected class II] deficiency and warrants a fine of $1,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000. The above con statutes a violation of Section 400.23(7), Fla. Stat. (2004), requiring that the agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Fla. Stat. (2004). Specific options for administrative act-on 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 the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMINISTRATION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 12 J —_ Respectfully submitted this sn day of ___. ane, 2005. NedtU\arn Michael O. Mathis Fla. Bar. No. 0325570 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, FL 32308 (850) 921-0055 (office) (850) 921-0158 (fax) ERTIFICATE OF SERVICE CERTIFICATE OF SERVICE I HEREBY CERTIFLY that a true and correct copy of the foregoing has been served by certified mail on _3t___ day of __- unk , 2005 to: John Kerrigan, Administrator, Lisenby on Lake Caroline, 32401. Michael O. Mathis, Esq. 13 Co, STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES “4 (To be used with Election of Rights for Administrative Complaint form — attacl In response to the allegations set forth in the Administrative Complaint issued by the Agency 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 received by AHCA within twenty- one (21) days from the date you receive the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. _ 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 the election of rights form. A final order will be entered setting forth the allegations as being deemed admitted and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION 2. If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Complaint.), Respondent may request an informal hearing pursuant to Section 420.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. If the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under 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, PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: Respondent’s Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent's selected option is not received by 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 and/or violations charged and imposing the penalty sought in the Compiaint. In order to preserve the right to a hearing,

Docket for Case No: 05-002209