STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE Ze ADMINISTRATION, ee Sa. (ati) Petitioner, AHCA No.: 2005008380. AHCA No.: 2005007048) v. Return Receipt Requested: 7002 2410 0001 4234 6190 RENOVA REHABILITATION AND HEALTH 7002 2410 0001 4234 6206 CENTER, LLC., d/b/a: RENOVA 7002 2410 0001 4234 6213 ‘REHABILITATION AND HEALTH CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Renova Rehabilitation and Health Center, LLC, d/b/a Renova Rehabilitation and Health Center (hereinafter “Renova | Rehabilitation and Health Center”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2004), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $2,000.00 pursuant to Section 400.23(8), Florida Statutes (2004), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Renova Rehabilitation and Health Center, pursuant to Section 400.23(7) (b), Florida Statutes (2004). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and Chapter 28- 106, Florida Administrative Code. 4. Venue lies in Palm Beach County, pursuant to Section 400.121(1) (e), Florida Statutes (2004), and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part ITI, Florida Statutes, (2004), and Chapter 59A-4 Florida Administrative Code. 6. Renova Rehabilitation and Health Center is an 85-bed skilled nursing facility located at 750 Bayberry Drive, Lake Park, Florida 33403. Renova Rehabilitation and Health Center is licensed as a skilled nursing facility; license number SNF14720952; certificate number 12911, effective 07/29/2005, through 02/28/2006. Renova Rehabilitation and Health Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. 2 7. Because Renova Rehabilitation and Health Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, Florida Administrative Code. COUNT I RENOVA REHABILITATION AND HEALTH CENTER FAILED TO ENSURE THAT RESIDENTS’ ENVIRONMENT REMAINS FREE OF ACCIDENT HAZARDS BY FAILING, AMONG OTHER THINGS, TO IMPLEMENT ITS OWN POLICIES AND PROCEDURES REGARDING OXYGEN ADMINISTRATION Title 42, Section 483.25(h), Code of Federal Regulations, and/or Rules59A-4.106(2), and 59A-4.122, Florida Administrative Code. (QUALITY OF CARE) UNCORRECTED CLASS III DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During the licensure and re-certification survey conducted from June 21, 2005 through June 23, 2005 and based on observation the facility did not ensure that the resident environment remained as free of accident hazards as is possible. During the survey, the Agency surveyors observed that the facility oxygen safety precautions were not being implemented. The surveyors observed items stored on light fixtures and equipment stored in hallways blocking doorways. 10. During the initial tour on 6/21/05 from 9:30 AM to 11:00 AM the following observations were made: a) The resident in room #24 whose bed was located nearest to the door was observed to have an oxygen concentrator with oxygen running by nasal canula. The resident did not have a pneumatic call bell. b) The resident in the bed closest to the door in room #20 had oxygen running from an oxygen concentrator by nasal canula and there was no oxygen sign on the door. The room also had an electric wheelchair charging by the bed near the window. The electric cords and the two chargers were observed to be laid out across the floor in front of the entrance to the bathroom. This poses a hazard for falls for anyone crossing the room. 11. The policy and procedure for Oxygen Administration was obtained form the Director of Nursing on 6/23/05 by the surveyor. The policy documented that procedural step #8 was: "Place the Oxygen in Use sign on the outside of the room entrance door." 12. During a tour of the facility on June 21, 2005, at 9:30 AM observations of Division Four revealed two (2) metal framed linen carts blocked the door to room #48. The carts remained there until 10:30 AM. In addition, during this time, there was a Geri chair, merry walker, a medication cart, and two wheelchairs in the same hallway, posing a hazard as the equipment was blocking egress down the hail. 13. During the initial tour of the facility Division Three on 06/21/05 beginning at approximately 9:20 AM, it was revealed that room #37 contained a large light fixture above bed 1, which was used to store gloves, a water pitcher, anda thermal cup. The wound care nurse which was accompanying this surveyor on tour removed the items and placed them on the resident's night stand. This surveyor touched the top of bed 2's light fixture and noted it was very warm. The call bell system box for bed 1, in room #37, was hanging out of the wall by just a few wires. This metal box, with sharp corners, was observed to be dangling above the headboard of bed 1. Correction Date: July 23, 2005. 14. During the revisit conducted on July 29, 2005 and based on observation and staff interviews it was determined the facility did not ensure that the residents’ environment remains as free of accident hazards as is possible, specifically related to potential hazards located in all four divisions of the facility. The specific deficiencies are as follows: (a) Residents receiving oxygen were not provided with pneumatic call bells for rooms/beds 19-2 and 33-2. (b) Storage of items on light fixtures above the resident's beds for rooms/beds 17-1 included a stuffed duck; a baseball cap in room /bed 23-1; 2 baseball caps and a poster in room/bed 20-2; and 1 stuffed bear and 2 stuffed dogs in room/bed 36-1. (c) The resident in room/bed 19-2 receives oxygen treatments and there was no oxygen sign posted outside of this room. (d) Beds contained mattresses that were short and exposed the metal frame underneath the mattress for the following rooms/beds: Room/bed, 31-3 had a 6" gap between the mattress and the bed; room/bed 33-2 had an 8-10" gap between the bed and the mattress; and room/bed 43-2 had a 6" gap between the bed and the mattress. 15. After interview and observations with the DON (Director of Nursing) on 07/29/05 at approximately 10:30 AM and subsequent interview with the Administrator and DON at 4:00 PM, both acknowledged that the residents with oxygen should have been provided pneumatic call bells; that the facility had been previously cited for placing items on the light fixtures and staff had been in-serviced that items should not be stored on the light fixtures; oxygen signs should be posted outside the room of residents receiving oxygen treatments; and that the facility would immediately place bolsters in the gaps in the beds. 16. During a tour of the facility on July 29, 2005, starting at 9:20 AM, the following observations were made: a) The resident in room #10 was using oxygen as part of the treatment for the resident’s. diagnosis. Observation of the call bell revealed it was electric, not pneumatic as required. The Administrator was informed of the situation. b) Observation of room #15, bed 1, revealed an approximately 8-12 inch gap from the foot of the mattress to the footboard. The metal frame was exposed due to the short mattress. The Administrator witnessed the short mattress. c) Observation of room #22 revealed that the bed to the right had an approximately 8-12 inch gap between the end of the mattress and the footboard, exposing the metal frame. The Administrator was shown the short mattress. d) Observation of the bed near the window in room #24 revealed an approximately 6-8 inch gap between the foot of the mattress and the footboard of the bed. The metal frame of the bed was exposed. The Administrator was again shown the short mattress. e) Observation of room #47 revealed an electric cord on the floor, going across the entry to the bathroom in the resident's room. The cord was plugged into a wall on the opposite side of the wall where the resident’s bed was. In addition, an outlet next to the resident’s bed which was in use was observed to have the plug hanging out of the socket. The porcelain plug was broken and when the plug was pulled out of the socket, the socket came away from the wall, exposing wires inside the socket. The Administrator was shown the above hazards and stated that it would be fixed. Uncorrected deficiency. 17. Based on the foregoing, Renova Rehabilitation and Health Center violated Title 42, Section 483.25(h), Code of Federal Regulations, and Rules 59A-4.122, and 59A-4.106(2), Florida Administrative Code, herein classified as an uncorrected Class III deficiency pursuant to Section 400.23(8)(c), Florida Statutes, which carries, in this case, an assessed fine of $2,000.00 for a patterned deficiency. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b) . DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Renova Rehabilitation and Health Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit “A” CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of 52,000.00 against Renova Rehabilitation and Health Center on Count I. c. Assess and assign a conditional license status to Renova Rehabilitation and Health Center in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922- 5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A = COMPLAINT WILL RESULT IN AN ADMISSTI FACTS ALYEGED THE COMPLAINT AND THE ENTRY OF A ENCY, Tria Lavton-Russell Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52™ Terrace Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 Bast Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Plorida 32308 (Interoffice Mail) EXHIBIT “A” Conditional License License No. SNF 14720952 Certificate No. Effective date: 07/29/2005 Expiration date: 02/28/2006 1 CERTIFICATE OF SERVICE t HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished U.S. Certified Mail, Return Receipt Requested to Peggy A. Booth, Administrator, Renova Rehabilitation and Health Center, 750 Bayberry Drive, Lake Park, Florida 33403; Renova Rehabilitation and Health Center, LLC, P.O. Box 190699, Lauderhill, Florida 33319, and to ucc Filing & Search Services, c., 526 East Park Avenue, Tallahassee, Florida 32302 on Qa , 2005. Tria Lawton-Russell Ro ea 4 7O02 2410 O001.: aus

Docket for Case No: 05-004704