STATE OF FLORIDA AGENCY FOR HEALTH CARE Anka ft see Ge ADMINISTRATION, HEAD Risk Arve Petitioner, 0 lr . | qu 7T Case No. 2006001028 2006001030 v. 2006001810 2006001811 DOS OF EDEN SPRINGS, L.L.C., A/K/A EDEN SPRINGS NURSING AND REHABILITATION CENTER, Respondent. / ADMINISERATIVE-COMPEAINE COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”) by and through the undersigned counsel, and files this Administrative Complaint agains‘ DOS OF EDEN SPRINGS, L.L.C., A/K/A EDEN SPRINGS NURSING AND REHABILITATION CENTER (“Respondent”), a skilled nursing facility, pursuant to Chapter 400, Part II, and Sections 120.569 and 120.57, Florida Statutes. NATURE OF THE ACTION 1. This is an action to impose two administrative fines in the amount of $10,000 each, pursuant to Section 400.23(8) and (8)(a), Florida Statutes. 2. This is an action to impose an administrative fine in the amount of $5,000, pursuant to Section 400.23(8) and (8)(a), Florida Statutes. 3. This is an action to impose a 6-month survey cycle fee pursuant to Section 400.19(3) in the amount of $6,000. 4, This is an action to impose a conditional license pursuant to Section 400.23(7)(b), Florida Statutes. Page 1 of 11 JURISDICTION AND VENUE 5. This tribunal has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 6. Venue shall be determined pursuant to Section 400.121 Florida Statutes and Rule 28-106.207, Florida Administrative Code. PARTIES 7. AHCA is the enforcing authority with regard to skilled nursing facilities “licensure pursuant to Chapter 400, Part Il, Florida Statutes, and Rule S9A~4, Florida _ Administrative Code. 8. Respondent, is a 120-bed skilled nursing facility located at 4679 Crawfordville Highway, Crawfordville, Florida 32326. At all times material hereto, Respondent has been a facility licensed under, and required to comply with, Chapter 400, Part I, Florida Statutes and Chapter 59A-4, Florida Administrative Code, having been issued license number 1582096. COUNT I CLASS I VIOLATION WARRANTING AN ADMINISTRATIVE FINE SECTION 400.23, FLORIDA STATUTES SECTION 400.102, FLORIDA STATUTES 9. AHCA realleges and incorporates Paragraphs 1 through 8 above as if fully set forth herein. 10. Section 400.23, Florida Statutes, states in pertinent part: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very Page 2 of 11 limited number of locations. ... The agency shall indicate the classification on the face of the notice of deficiencies as follows: (a) A class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because’ the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 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 II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. (b) A class II deficiency is a deficiency that the agency wooo dat erm ines has compromised the resident's ability to maintain or reach his’ ~~ ~~ or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessent, plan of care, and provision of services. A class I deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 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 II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 11. Section 400.102, Florida Statutes, states in pertinent part: (1) Any of the following conditions shall be grounds for action by the agency against a licensee: (a) An intentional or negligent act materially affecting the health or safety of residents of the facility. 12. On December 7, 2005, AHCA conducted a survey at Respondent's facility in response to a complaint. At that time, on the basis of record review, observation, and interview, AHCA determined that Respondent operated its facility in an intentional or negligent fashion which materially affected the health or safety of residents of the facility. Specifically, Respondent made solid food available to residents who could not safely consume it, and failed to take appropriate measures to protect those residents from Page 3 of 11 choking on that solid food. Respondent committed this violation by, inter alia, the following acts and omissions: (a) Respondent's care plan for resident #5, whom Respondent knew to be unable safely to consume solid food, requires that the snack cart be kept away from resident #5 and that food be kept off the staff desk so that resident #5 would not have access; but Respondent's staff did not follow this care plan. (b) Even after multiple incidents of resident #5 obtaining solid food at Respondent's facility and choking on it, Respondent's staff did not keep all solid food __ away from resident #5. (c) After an incident of resident #5 choking on solid food on October 25, 2005, Respondent failed to hold any inservice training relating to this problem and took no other correction action at that time. (d) On November 7, 2005, resident #5 again obtained solid food, having taken it from the snack cart, and choked on it. (e) Upon request by AHCA for records showing that Respondent held inservice education following the November 7 incident, Respondent produced none. (f) On November 21, 2005, resident #5 was taken by Respondent's personnel (CNA #1) to the shower area in a wheelchair and left there unattended. When CNA #1 returned to resident #5, resident #5 was eating solid food and went into obvious distress. Attempts to alleviate the distress and revive resident #5 were unsuccessful, and resident #5 died on November 21, 2005. (g) | Respondent's corrective action to provide inservice training on the snack cart procedure did not occur until November 22, 2005. Page 4 of 11 (h) Even after November 22, 2005, Respondent's personnel failed to follow the correct snack cart procedure, and instead left the snack cart unattended in the hallway. Consequently, multiple residents were able to and did help themselves to snacks from the cart. (i) Even after November 22, 2005, Respondent failed to ensure that all staff were familiar with which residents were on non-solid food diets and were mobile and cognitively impaired, so that if they saw such a resident in possession of solid food they could intervene before the resident ate and choked on the solid food. (j) Even after November 22, 2005, Respondent failed, with respect to another mobile and cognitively impaired resident on a non-solid food diet (resident #2), to take all necessary steps to secure solid food around resident #2 and/or to supervise resident #2 around solid food, despite a notation dated August 17, 2005, in resident #2's care plan indicating that resident #2 takes things from other residents' rooms and from the snack cart and medication cart, and despite knowledge on the part of Respondent's staff that resident #2 would consume solid food. (ix) Even after November 22, 2005, Respondent failed, with respect to another mobile and cognitively impaired resident on a non-solid food diet (resident #10), to take all necessary steps to secure solid food around resident #10 and/or to supervise resident #10 around solid food, despite knowledge on the part of Respondent's staff that resident #10 would consume solid food. 13. Respondent's conduct as aforesaid constitutes an isolated Class I violation with jeopardy, requiring immediate correction. 14. Respondent was notified of its violation and the immediate correction required. Respondent was also assessed a fine in the amount of $10,000. Page 5 of 11 COUNT I CLASS I VIOLATION WARRANTING AN ADMINISTRATIVE FINE SECTION 400.23, FLORIDA STATUTES SECTION 400.147(1), FLORIDA STATUTES 15. -AHCA realleges and incorporates Paragraphs 1 through 14 above as if fully set forth herein. 16. Section 400.147(1), Florida Statutes, states in pertinent part: (9) Every facility shall, as part of its administrative fimctions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly tc to ) identified quality ~~deficiencies The program: must includer’--——-—-————— : * * (e) The development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not limited to, education and training in risk management and risk prevention for all nonphysician personnel, as follows: 1. Such education and training of all nonphysician personnel must be part of their initial orientation; and 2. At least 1 hour of such education and training must be provided annually for all nonphysician personnel of the licensed facility working in clinical areas and providing resident care. 17. In November, 2005, there were 30 residents at Respondent's facility requiring non-solid food diets, 3 of whom were mobile and cognitively impaired, and consequently at high risk for choking (residents #2, #5, and #10). 18. Prior to November 21, 2005, Respondent had no measures in effect to minimize the risk of adverse incidents like the choking of resident #5. 19. Even after the death of resident #5 from choking, Respondent did not immediately put into effect appropriate measures to minimize the risk to other similarly mobile and cognitively impaired residents from choking. Specifically, in addition to the acts and omissions set forth above, Respondent failed to effectively address the following potential risk areas: Page 6 of 11 (a) A refrigerator was available to residents in the Restorative Dining Room, unlocked and unattended by staff, with solid food inside, and with residents in the same room, providing residents free access to this food. Only after observing the attention paid to this refrigerator by an AHCA surveyor on December 6, 2005, did Respondent's staff secure this refrigerator and the food within it. (b) Solid food in the form of medication pass supplements (for when residents are to take medication with food) was left on an unattended medication cart. 20. Respondent's conduct as aforesaid constitutes an isolated Class I violation with jeopardy, requiring immediate correction. 21. Respondent was notified of its violation and the immediate correction required. Respondent was also assessed a fine in the amount of $10,000. COUNT HI CLASS II VIOLATION WARRANTING AN ADMINISTRATIVE FINE SECTION 400.23, FLORIDA STATUTES SECTION 400.102, FLORIDA STATUTES 22. AHCA realleges and incorporates Paragraphs 1 through 21 above as if fully set forth herein. 23. On January 19-20, 2006, AHCA conducted a survey at Respondent’s facility. At that time, based on observation, record review, staff interviews and resident interviews, it was determined that Respondent failed to provide appropriate treatment and services to a resident, materially affecting the resident's health. Specifically, Respondent failed, over the course of many months, to respond appropriately to the resident's isolation, withdrawal, significant weight loss, and comments that the resident wanted to die, as described in more detail in the survey report, the relevant portion of which is incorporated herein and attached hereto as Exhibit A. Page 7 of 11 24. The aforesaid failure by Respondent constitutes an isolated Class II violation, found since Respondent's last annual inspection. 25. Respondent has been notified of its violation and advised of a mandatory correction date of February 20, 2006, to correct its deficiency. Respondent has also been assessed a fine, the amount of which has been doubled to $5,000, due to the Class I deficiencies found during the previous survey of December 7, 2005, which are described hereinabove. COUNT IV VIOLATION WARRANTING 6-MONTH SURVEY CYCLE FEE aS 26. AHCA realleges and reincorporates Paragraphs 1 through 25 above as if set forth fully herein. 27. Section 400.19 provides in pertinent part: (3) . The agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with miles promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class I deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6- month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. . .. 28. Asa result of the Class I violations found during the December 7 survey, as well as the Class II violations found during the January 19-20 survey, AHCA has assessed a 6-month survey cycle fee in the amount of $6,000 against Respondent. Page 8 of 11 COUNT V VIOLATION WARRANTING CONDITIONAL LICENSURE SECTION 400.23(7)(b) 29. AHCA realleges and reincorporates Paragraphs 1 through 28 above as if set forth fully herein. 30. Section 400.23, Florida Statutes, states in relevant part: (7) 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. ~~ * Eg * (b) A conditional licensure status means that a facility, due to the presence of one or more class J or class I deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class IJ, class II, or class III deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. 31. AHCA has assigned a conditional licensure status to Respondent based upon the determination that the facility was not in substantial compliance with applicable laws and rules during the December 7, 2005 survey, due to Respondent’s Class I violations described above. The effective date of the conditional license is December 7, ~ 2005, and the conditional status of the license remains in effect until such time as AHCA determines that Respondent is in compliance. A copy of the conditional license is attached hereto and made a part hereof as Exhibit B. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: Page 9 of 11 . Make factual and legal findings in favor of AHCA as to the allegations contained in Counts I through V hereof. . Uphold each of the $10,000 administrative fines assessed for each of the two isolated Class I violations found during the December 7, 2005 survey. . Uphold the $5,000 administrative fine assessed for the Class II violation found during the January 19-20, 2006 survey. . Uphold the 6-month cycle survey fee in the amount of $6,000. . Uphold the issuance of the conditional license. . Such other relief as this tribunal may deem appropriate, including the assessment of costs related to the investigation and prosecution of ‘this - case, if applicable. DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Respondent shall post its most current 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. NOTICE 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. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. Page 10 of 11 RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, THE ALLEGATIONS IN THIS ADMINISTRATIVE COMPLAINT WILL BE DEEMED ADMITTED AND A FINAL ORDER WILL BE ENTERED. * Submitted on this YI day of e0. 2006. (arin M. Byrne, Esq. Assistant General Counsel Fla. Bar No.356255 Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MSC #3 Tallahassee, FL 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or (850) 413-9313 CERTIFICATE OF SERVICE J HEREBY CERTIFY that the original Administrative Complaint and Election of Rights forms have been sent by U.S. Certified Mail, Return Receipt Requested (receipt # 7003 1010 0000 9716 1660) to Eden Springs Nursing and Rehab Center, Attn. Administrator at 4679 Crawfordville Hwy., Crawfordville, Florida 32326; by U.S. Certified Mail, Return Receipt Requested (receipt # 7003 1010 0000 9716 1653) to Michael J. Schlesinger at 501 Brickell Key Drive, Suite 506, Miami, Florida 33131. DATED this a) day of_ Qn D 2006. Ze M. Byrne, 2 xs = Agency for Health Care Administration Page 11 of 11 ane . PRINTED: 01/30/2008 @ @ FORM APPROVED in (X3) DATE SURVEY COMPLETED \genty for Health Care Administratio [ATEMENT OF DEFICIENCIES 4D PLAN OF CORRECTION {X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 PROVIDER'S PLAN OF CORRECTION AME OF PROVIDER OR SUPPLIER :DEN SPRINGS NURSING & REHAB CENTER | (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Continued From page 4 the residents windows. Class Ill/Isolated Correction Date: February 20, 2006 N 216] 400.102(1)(a) Health and Safety of Resident 400. 102(1)(a) (1) Any of the following conditions shall be grounds for action by the agency against a. licensee; : (a) An intentional or negligent act materially affecting the health or safety of residents of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review the facility failed to provide appropriate treatment and services for 1 of 21 sampled residents (#12) who displayed mental or psychosocial adjustment difficulty in order for the resident to reach and maintain the highest level of mental and psychosocial functioning. The health and safety of resident #12 was affected as evidenced by weight loss, isolation, withdrawal, and comments that he/she wanted to die. Findings include: Record Review: Resident #12 was admitted to the facility from home on 3/8/05 with a diagnosis senile and presenile organic psychotic conditions, osteoarthritis, functional decline, rhabdomyolysis, hypothyroidism, recent fall, urinary tract infection and degenerative joint disease. Upon admission the ARNP (advanced registered nurse practitioner) note dated 3/10/05 stated ency for Health Care Administration : ‘ATE FORM eeea BZYH11 If continuation sheet 5 of 14 EXHIBIT A pot PRINTED: 01/30/2008 @ FORM APPROVED Agency for Health Care Administration {Xt) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING B, WING 26504 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 AME OF FROVIDER OR SUPPLIER EDEN SPRINGS NURSING & REHAB CENTER (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE, DATE DEFICIENCY) N 216] Continued From page 5 N 216 “resident admitted after fall without head injury or hip fracture, here for rehab and possible placement in assisted living facility." The same ARNP note also stated "psych eval, resident not able to accept decline in function." Upon the next visit by the ARNP on 3/17/05 her progress note stated "resident does not want psych to see her and she noted that resident #12 had increased -anger.and_was.refusing_care...A plan. was developed for staff to monitor behavior and social services to assess family issues. The initial social services eval on 3/8/05 revealed that resident #12 isolates self and is angry over family issues and current placement. Social services note dated 3/22/05 stated "residents stating he/she is threatening family to call a taxi and go home." No plans or interventions were Noted on the social services note. The next social services note dated 3/31/05 states "resident still desires to return home, angry at family for not allowing resident to return home.” Again, no plan or interventions were noted on the social services note. Nurses notes for 3/05 show the following: resident refusing medication 3/9/05; resident angry with family 3/9/05; resident unhappy and isolating self 3/12/05; unhappy, withdrawn and isolating self 3/13/05; angry and refusing medication 3/14/05; angry and refusing care 3/15/05; stays alone, angry and refusing care 3/17/05; alone, agitated and withdrawn 3/18/05; alone, angry and withdrawn but "talkative when others initiate conversation, isolates self in room but enjoys company for one on one conversations" 3/24/05; alone, angry withdrawn but talkative when others initiate communication 3/25/05. ancy for Health Care Administration ATE FORM gang BZYH11 If continuation sheet 6 of 14 a @ PRINTED: 01/30/2006 re FORM APPROVED aency for Health Care Administration @ (X3) DATE SURVEY ‘ATEMENT OF DEFICIENCIES COMPLETED (X1) PROVIDER/SUPPLIER/CLIA ID PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 \ME OF PROVIDER OR SUPPLIER ‘DEN SPRINGS NURSING & REHAB CENTER (4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N 216| Continued From page 6 N 216 MDS (minimum data set) initial assessment completed on 3/21/05 reveals the following: short term memory coded as 0 for "ok", Jong term memory coded as 0 for "ok", cognition coded as 0 for independent decisions consistent/reasonable. Resident #12 is further coded in the mood and behavioral section as not having made negative statements, not being: angry or annoyed, not self some sad facial expressions and some reduced social interaction. Under the-psychosocial section nothing is coded for unsettled relationships, no coding for openly expressing conflict or anger with family, and nothing is coded for past roles. Nothing was coded for resident expressing sadness or anger over lost roles/status. Nursing notes dated 4/1/05 state “resident cooperative with meds this shift allowed nurse to give antibiotics and stated "you know I've probably been hurting myself by refusing my medication." Social services notes dated 5/23/05 state "resident displays verbal aggression and anger when family present also refusing several medication." The only plan or intervention noted on social services note was to inform nursing staff that resident is not to leave the building with anyone other than approved family. The next social services note dated 6/17/05 stated "rasident's family member called and concern resident will follow through with threats to call other family members and go home." Again the only plan or intervention noted by social services is to alert nursing staff resident is not to leave facility with anyone other than approved family. A quarterly MDS assessment was completed on mney for Health Care Administration \TE FORM mse BZYH11 If continuation sheet 7 of 14 a @ PRINTED: 01/30/2006 gency for Health Care Administration e@ FORM APPROVED (X3) DATE SURVEY COMPLETED “ATEMENT OF DEFICIENCIES {D PLAN OF CORRECTION (X41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 4ME OF PROVIDER OR SUPPLIER :DEN SPRINGS NURS|NG & REHAB CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE concerns TAG » REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N 216| Continued From page 7 N 216 6/5/05 and there were no changes in regards to resident #12's cognition, mood, indicators or depression, anxiety, sad mood or behavioral symptoms. Resident was still coded as being cognitively aware with no negative statement, no persistent anger, no self deprecation and no withdrawal from activities. Nursing.notes.dated 8/12/05 at 8:00 p.m. quoted resident #12 as saying "I just want to leave this : world and die" as resident refused antibiotics and refused pain medication after complaining of buttocks pain. There was no documentation that the resident's physician was notified or social services being notified. It is further noted that no further nursing notes were entered until 5 a.m. on 8/13/05. Nursing notes dated 8/15/05 state “resident refusing antibiotics." ARNP notes dated 8/18/05 state "behavior stable" and no plans made in regards to mental health were noted. There were no social services notes from 6/28/05 until 9/4/05. In the 9/4/05 social services note, there was no mention of resident #12's statement that he/she wanted to die." There was no mention of the resident's behavior, isolation, anger, refusal of care and services and no plans or interventions were made. - Nursing notes dated 9/5/05 state "resident refusing to get out of bed and get dressed times several attempts." Nursing notes dated 9/6/05 resident noted as refusing antibiotics. Nursing notes dated 9/12/05 resident noted refusing antibiotics. ARNP notes dated 9/15/05 state "behavior ency for Health Care Administration ‘ATE FORM . . ome BZYH14 VF continuation sheet 8 of 14 7 ee PRINTED: 01/30/2006 - @ r FORM APPROVED n \gency for Health Care. Administratio TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 26504 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE . 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 AME OF PROVIDER OR SUPPLIER IDEN SPRINGS NURSING & REHAB CENTER (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX {GACH CORRECTIVE ACTION SHOULD BE TAG TAG CROSS-REFERENCED TO THE APPROPRIATE DATE REGULATORY OR LSC IDENTIFYING INFORMATION) DEFICIENCY) Continued From page 8 stable" with no plans in regards to mental health were noted. . Social services notes dated 10/10/05 state law office dropped by guardianship papers (daughter is guardian) and warns that the resident is likely to be upset. | Social services notes dated 10/13/05 states “resident very upset with court decision to appoint daughter as guardian." tis noted that no plans or interventions are made in the social services note. ARNP notes dated 10/20/05 state "resident anxious and wanting to go home but unable to at this time, refusing meds and turning." No plans in regards to mental health were noted. Social services note dated 10/25/05 stated ‘ "resident stating his/her daughter has taken control over their social security and retirement funds as well as their house and has stuck them in this facility. Resident states they has nothing to live for and every night prays for God to not let _| them see daylight again." The note states "will notify ARNP," however there were no notes or documentation ARNP was ever notified, no orders were made, no nursing notes addressing resident's second statement about wishing to die. {-Furthermore; there-were-no notes made by the social services staff until one month later on 11/23/05. Nursing notes dated 11/19/05 states resident's sister passed away. Nursing notes dated 41/22/05 state “resident pulled out foley catheter.” Social services notes dated 11/23/05, 29 days after resident stated "every night | pray for God to wncy for Health Care Administration ; \TE FORM . . ates BZYH11 if continuation sheet 9 of 14 PRINTED: 01/30/2006 aye @ @ FORM APPROVED \gency for Health Care Administration (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED TATEMENT OF DEFICIENCIES YD PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 AME OF PROVIDER OR SUPPLIER IDEN SPRINGS NURSING & REHAB CENTER (4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N 216} Continued From page 9 N 246 not let me see the light of day" resident is quoted as saying "! wish | would die." Social services also reported resident stated they pulled out their foley catheter themselves and refuses to let anyone put it back in and that the resident is showing high anxiety and agitation. There was no mention of notifying the MD, ARNP or nursing staff in regards to the resident's desire to die. _| There was also no mention of the resident's recent loss of a sister or plan/intervention ~~ addressing the residents mental health. The next social services note was not until one month later on 12/23/05 which had no mention of the residents deceased sister, claims or wanting to die, refusal of care and services or weight loss. It is further noted that no further MD/ARNP notes were on the chart since the last entry on 10/20/05 and that no nursing notes made after 11/23/05 addressed the residents desire to die. It is noted that resident #12 went from 147 pounds 12/1/05 to 133 pounds on 1/4/06 representing a 14 pound or 9.5% weight loss in 34 days. Another weight was taken of resident #12 on 1/10/05 which again was 133 pounds. It is noted that every month since admission in 3/05 there has been a standing order for a psych eval prn (as needed.) After reviewing each telephone order-since.3/05 there has been no orders for a psych eval and no mention of a psych ‘eval since 3/14/05. There was no documentation in the mental health section of the resident's chart whatsoever and no documentation made by the Psychiatrist that contracts with the facility in the resident's chart. There has also been no mention of crisis intervention, individual, group or family counseling, drug therapy or other rehabilitative . ney for Health Care Administration ‘TE FORM : bee BZYH11 If continuation sheet 10 of 14 «. Agency for Health Care Administration @® TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION AME OF PROVIDER OR SUPPLIER =DEN SPRINGS NURSING & REHAB CENTER (X4) ID PREFIX TAG N 216 incy for Health Care Administration \TE FORM | (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 26501 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 services offered or provided to the resident. Record review of resident #12's care plans addressing behavioral issues through 2/27/06 state the following: monitor residents for behaviors and redirect as needed, document adverse behaviors in nurses notes and on behavior monitoring record located on MARS | (medication administration record, refer to social worker for adverse. behaviors as needed, notify family of adverse behaviors and psychiatrist consult as needed. On 1/19/06 at approximately 2:00 p.m. an interview was conducted by this writer and another surveyor with the unit manager of the station resident #12 resides in. During this interview the unit manager reports social services not having reported the resident's claims of wanting to die from 10/05 or 11/05 thus being unable to follow through with the care plans. During this interview the unit manager also stated she was unaware of any recent psych consults "possibly one on admission, but | don't know of any recently," or other form of psychotherapy interventions being provided for resident #12. On 1/19/06 at approximately 7:45 p.m. an interview was conducted by this writer and another surveyor with both. social workers. ‘During'this:interview:the social worker who charted on resident #12 in 11/05 reported that she did write in her social notes that resident #12 did state that he/she wanted to kill thernseives and the social worker confirmed that nursing was never informed, by herself, of this issue. The social worker also acknowledged that resident #12 pulled out their catheter, that resident #12 was “unhappy and depressed” and often refused medications. When this surveyor asked the asap STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 ID PREFIX TAG N 216 (X2) MULTIPFLE,CONSTRUCTION A, BUILDING B. WING PRINTED: 01/30/2006 @ FORM APPROVED (X3) DATE SURVEY COMPLETED 01/20/2006 PROVIDER'S PLAN OF CORRECTION (x8) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BZYH11 ffcontinuation sheet 11 of 14 yo Ne e @ ‘PRINTED: 01/30/2006 cn FORM APPROVED \gency for Health Care Administration TATEMENT OF DEFICIENCIES YD PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A, BUILDING 8. WING 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 AME OF PROVIDER OR SUPPLIER IDEN SPRINGS NURSING & REHAB CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (GACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N 216] Continued From page 11 N 216 social worker how resident #12's sisters death on 11/19/05 affected the resident, the social worker stated she was unaware of resident #12's sisters death. The social worker then confirmed she saw resident #12 on 11/23/05 without addressing this issue. This surveyor then informed the social worker that the event of resident #12's sisters death was documented in the nurses notes, the read them better." This surveyor then asked if there were any incidences where a resident would be charted on more frequently than once a month. The social worker stated the charting and monitoring would be more frequent if there was a problem. This surveyor then asked if signs and symptoms of worsening depression would be one of those problems and the social worker said "yes." This surveyor then asked the social worker what signs and symptoms of depression or worsening depression she would look for in a resident and the social worker responded “isolation, withdrawal, weight loss are just a few.” This writer then informed the social worker of rasident #12's 9.5% (14#) weight loss in one month and the social worker stated "she was unaware of the actual amount of weight loss and did not realize it was that much." When this writer asked about resident #12's habits of staying in his/her room and only wearing a gown the social worker stated "yes it is very hard to get Fesidént #12 out of their room or dressed and resident #12 often refuses care." Thus the social worker confirmed resident #12's weight loss, and patterns of isolation and withdrawal. Observations made by this surveyor and two additional surveyors of resident #12 on 1/19/06 at approximately 10:00 a.m. revealed the resident sitting in a wheelchair in their room only dressed in the facilitys' gown, 2:00 p.m. on 1/19/06 the ney for Health Care Administration TE FORM usa BZYH11 If continuation sheet 12 of 14 social. worker.then.stated."| guess [should have_.|. ; counts onsen 7 - oe PRINTED: 01/30/2006 . ee @ @ FORM APPROVED \gency for Health Care Administration TATEMENT OF DEFICIENCIES 4D PLAN OF CORRECTION (x3) DATE SURVEY (X1) PROVIDER/SUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 AME OF PROVIDER OR SUPPLIER IDEN SPRINGS NURSING & REHAB CENTER (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION x8) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N 216] Continued From page 12 N 216 resident was sitting in a wheelchair their room only dressed in the facilitys' gown and 4:00 p.m. on 1/19/06 the resident was sitting in a wheelchair in their room only dressed in the facilitys' gown. Observations were again made by this writer and two other surveyors on 1/20/06 at approximately 10:30 a.m. and 11:30 a.m. revealed the resident sitting in a wheelchair in .|.their.room.only dressed in the facilitys' gown. An interview was conducted by this writer on 4/19/06 at approximately 2:15 p.m. During this interview resident #12 claimed to be very upset about his/her daughter having guardianship and being placed in the facility. Resident #12 stated the desire to return home. When this writer asked about if social services comes around and talks to them about the situation the resident stated "what social worker." When this writer asked about his/her history of refusing medications the resident stated "I just don't like to take a lot of medicines." This writer then asked if the resident liked talking and visitors and the resident stated "| love visitors, there is one CNA (certified nursing assistant) in the facility who visits with me and talks to me but no one else really does." The resident went on to say "the only contact [ have with the outside is this newspaper" as he/she was clutching the Tallahassee Democrat. The interview lasted -approximately-30-minutes:—During the course of the interview resident #12 was very open and willing to talk about the guardianship issue and general information about his/herself. Resident #12 thanked this surveyor for visiting at the end of the interview and asked this writer to return. Later on 1/19/06 approximately 4:00 p.m. another surveyor visited with resident#12. During that visit resident #12 was again very open and willing ney for Health Care Administration \TE FORM sees BZYH11 if continuation sheet 13 of 14 ee @ eR ER, 01/30/2006 woe : RM APPRO' dency for Health Care Administration @ VED (X3) DATE SURVEY COMPLETED ‘ATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (%1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: {X2). MULTIPLE CONSTRUCTION A. BUILDING B, WING 26501 01/20/2006 STREET ADDRESS, CITY, STATE, ZIP CODE 4679 CRAWFORDVILLE HWY CRAWFORDVILLE, FL 32326 \ME OF PROVIDER OR SUPPLIER iDEN SPRINGS NURSING & REHAB CENTER (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX _ (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX. (EACH CORRECTIVE ACTION SHOULD BE CONFLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N 216] Continued From page 13 N 216 to talk about the guardianship issues and general information about his/herself. The resident was appreciative to talk to a visitor. On 1/20/06 at approximately 10:30 a.m. a third surveyor visited with resident#12. During that visit resident #12 was again very open and talkative and appreciative to talk to a visitor. In a document from the circuit court of a mental examination made on 9/3/08 it states: "It is believed resident #12's current difficulty is related to a combination of their disturbance in mood, possibly due to poor adjustment to his/her placement in an extended care facility, and due to the presence of a progressive cognitive impairment. To some extent, the current difficulties may be reversible if the depressive symptoms were addressed through psychotropic or psychotherapeutic intervention. Based on these findings the facility failed to properly address and provide appropriate treatment and services to identify and prevent the worsening of psychosocial adjustment difficulties. Class II/Isolated Correction Date: 2/20/06 ney for Health Care Administration \TE FORM sage BZYH11 ifcantinuation sheet 14 of 14 — OS LIGIHX3 9002/TE/L0 ‘ALVG NOLLV WdxXd ASNHOIT 9002/02/10 ‘HALVG HALLOSANA NOLLOV HDONVHD SN.LVLS SCH OCT “IVIOL 9CETE Td “ATHACYOIMVAO AMH STUACYOAMVED 6L9P YALNaD GVHAA CNV ONISANN SONTYdS NAG :SUIMOTIO} ay] ayeIado 0} PAZHOUINE Sf S9SUedl] SU] Se PUR ‘saINIeIS BPHOLY ‘T] Wed ‘OO JeideyD ur pozuopne ‘uopeNstupy areD WEaTy 10,7 Aouady “epHOpy Jo ay1g ay} Aq paydope suoneinBar pue seynz ayy ysis parjduioo sey ‘DTI ‘SONTEdS NACA AO SOC ey) wuyuod 0} st sty, ‘TVNOLLIGNOD ALITIOVA DNISMON GATS HONVANSSV ALITVNO HLTVAH dO NOISIAIC NOLLVULLSININGV FaVvO HUIVHH dod AONADV BPO] JO 9389S 960C8STANS “# ASNHOIT “# ALVOMILYED y ‘SENDER: COMPLETE THIS SECTION - & 1653 Postage | 5 Certified Fas ___ Return Reciept Rae | aii {Endorsement Hequired) Pest are es Restricted Delivery Fee i (Endorsement Required) | i } I . 1 Total Postage: & Sree Michael J. Schlesinger . 901 Brickell Key Drive, Suite 506 7003 1040 onoo 471 COMPLETE THIS SECTION ON DELIVERY |. @ Complete Items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. 0 Agent ® Print your name and address on the reverse u CO Addressee so that we can return the card to you. . . livery) Attach this card to the back of the mailplece, B, Received by ( Printed Name) ° pee ii a) or on the front if space permits. = L z D. 1s delivery addrass different from Item 1? 1 Yes C1No 1. Article Addressed to: ; §01 Brickell Key Drive, Suite 506 if YES, enter delivery address below: Michael J. Schlesinger 3. Service Type PS Form 3811, February 2004 Domestic Ratu Recelpt 102595-02-M-1840 ! Miami, Florida 33131 i El Coniied Mall Express Mall | i Registered Return Recelpt for Merchandise y 1 Insured Mall G.0,D. ! L 4, Restricted Delivery? (Extra Fee) (Yes } 2, ‘Article Number i (Transfer from service fabel) 7003 4010 OOOO Fb Ubs3 { i we Postage Conifi 7 —_______| Postmark _Retumn Reclapt Fee (Endorsement! Required) Here D000 W?ib 1bbo “(C1 Restricted Delivery Fee | A (Endorsement Required) | I Total Fostege 5 den Springs Nursing and Rehab Shr Te Center = Attn. Administrator 4679 i ‘ Crawfordville, Florida 32326 COMPLETE THIS SECTION ON DELIVERY A. wa iy ff Leh 1 Agent x af rytilin, NE 40) Addressee B,, Received by (Printed Name) C. Date of Delivery ie , 4a sp. Axtcpr He az [piles D. Is delivery address different from tem 1? Yes If YES, enter dalivery address below: .No ‘SENDER: COMPLETE THIS SECTION = Complete Items 1, 2, and 3, Also complete | item 4 if Restricted Delivery Is desired. {mt Print your name and address on the reverse so that we can return the card to you. Attach thls card to the back of the mailpiece, or on the front if space permits. 4, Article Addressed to: Eden Springs Nursing and Rehab Center Attn. Administrator 4679 Crawfordville Hwy. Crawfordville, Florida 32326 3. Service Type i Certified Mail - 1 Express Mall C1 Registered &)-Return Receipt for Merchandise D1 insured Mail $1 6.0.0. ‘ : 4, Restricted Delivery? (Extra Fee) 0 Yes i 2. Arlicte Number O04 4010 0000 47ib bbbo i | i | \ | \ | \ { i \ (Transfer from service label) sasnegnenneman ps Form 3811, February 2004 Domestié Return Recelpt 402595-02-M-1540

Docket for Case No: 06-001947