O13951 STATE OF FLORIDA 7 JUL AGENCY FOR HEALTH CARE SOMINISTRATION 17 PH 4: 4g AGENCY FOR HEALTH CARE ADH See ADMINISTRATION, HEA ATIVE Petitioner, AHCA No.: 2007004596 AHCA No.: 2007004597 v. Return Receipt Requested: 7002 2410 0001 4235 6656 SALEM NURSING & REHAB CENTER OF 7002 2410 0001 4235 6663 HOMESTEAD, INC. d/b/a HOMESTEAD 7002 2410 0001 4235 6670 MANOR, 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 Salem Nursing & Rehab Center of Homestead, Inc. d/b/a Homestead Manor (hereinafter “Homestead Manor”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2006), 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 (2006), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Homestead Manor, pursuant to Section 400.23(7) (b), Florida Statutes (2006). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and Chapter 28- 106, Florida Administrative Code. 4s Venue lays in Miami-Dade County, pursuant to Section 400.121(1) (e), Florida Statutes (2006), 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 II, Florida Statutes, (2006), and Chapter 59A-4 Florida Administrative Code. 6. Homestead Manor is a 64-bed skilled nursing facility located at 1330 N.W. 1%* Street, Homestead, Florida 33030. Homestead Manor is licensed as a skilled nursing facility; license number SNF12410952; certificate 14374, effective 03/20/07. through 05/01/07 for the Conditional license. Homestead Manor 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. COUNT TI HOMESTEAD MANOR FAILED TO ASSURE SERVICES PROVIDED BY THE FACILITY MET PROFESSIONAL STANDARDS OF QUALITY Rule 59A-4.107(5), Florida Administrative Code (FOLLOW PHYSICIAN ORDERS) UNCORRECTED CLASS III DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During the Annual Licensure survey conducted 02/05/07 through 02/08/07 and based upon observation, record review and staff interview, the facility failed to ensure services provided met professional standards of quality for 8 (Residents #7, #9, #12, #2, #8, #3, #13, #4) of 14 active sampled residents. 10. Nurse's failing to administer Tylenol to Resident #7 as ordered by the physician for approximately 6 weeks; (a) Observation on 2/05/06 and 2/06/07 during the survey revealed Resident #7 is an alert and oriented elderly woman who was humming to herself while sitting in her chair. (b) Staff report in an interview on 2/06/07 at approximately 2:00 p.m. the resident's usual behavior is to hum, and this does not indicate that she is in any pain. (c) Resident #7 has an order for Tylenol Tab 325 mg - Give 2 tabs by mouth every 6 hours. (d) Review of the current Medication Administration Record (MAR) revealed the Tylenol was routinely not given at midnight and 6:00 a.m. The nurse circled the MAR, but did not record why the medication was not given. (e), Interview with the DON on 2/06/07 at approximately 3:00 p.m. revealed that he/she assumed the resident was asleep at that time. She stated that the doctor was not informed that the medication was not given as ordered for at least 6 weeks. (£) In a telephone interview on 2/08/07 at approximately 10:00 a.m. the resident's physician confirmed he was unaware the Tylenol was not being given as ordered. 11.. Nursing staff failed to assure a Resident (#9) with weight loss received his milkshakes and magic mouthwash as prescribed by the physician; (a) Review of the clinical record for Resident #9 revealed a physician order dated 1/28/07 for Magic Mouthwash (thickened) 10cc 15 min by mouth before meals for 14 days. (b) Review of the January 2007 MAR revealed it was given on 1/28 through 1/31 (4 days). (c) It did not appear on the February MAR for the additional 10 days it was ordered. (d) Interview with the DON on 2/06/07 at approximately 4:00 p.m. confirmed it was not given for the full 14 days as per the physician order. She stated, "It was dropped." (e) Review of the clinical note dated 01/15/07 for the Registered Dietitian (R.D.) revealed a recommendation for milkshakes-1 carton by mouth three times daily with meds-low weight loss. She further stated the resident was to receive extra portions of food at meals per family request. (f) Review of the February MAR’ revealed the physician signed the order for milkshakes dated 01/15/07. There was no documentation that the resident received any milkshakes before 02/01/07. (g) An interview with the RD on 02/07/07 at approximately 2:00 p.m. confirmed that the milkshakes were not started in a timely manner. 12. Nursing staff failed to assure that a Resident (#12) with weight loss resumed her nutritional supplement after readmission to the facility from the hospital; (a) Review of the clinical record for Resident #12 revealed that the resident is losing weight. The RD put an intervention in place to increase a supplement VHC 2.25 to 120 ml four times a day. A physician order dated 1/14/07 revealed she received the supplement 4 days and then was sent to the hospital until 1/19/07. There was no indication the supplement order was clarified or carried over on her return from the hospital. (b) The RD did another assessment on 1/30/07 revealing the resident "continues to lose weight." She indicated the resident was receiving a Regular NAS diet with supplement of VHC 2.25 120 cc po four times a day. She recommended a lab test to check her pre-albumin level. (c) Review of the MAR for February revealed the resident did not receive the supplement or have her blood draw for the pre-albumin. (d) Interview with the RD on 2/07/07 at approximately 5:00 p.m. confirmed the physician's orders were not followed. 13. Nursing staff failed to assure Resident #2 received her Magic Cup as ordered by the physician; (a) Review of Resident #2's record revealed a physician order dated 2/03/207 that stated, "Add Magic Cup (which is a Nutrition supplement to increase calories and protein) BID (2 times a day) with lunch and dinner." . Further review revealed a dietary communication form that stated the resident was to receive a Magic Cup for lunch and dinner. Review of the nurse's progress notes revealed a note dated 2/03/07, stating, "Received note to add Magic Cup to lunch and dinner." (b) Observation of the resident during the lunch meal on 2/05/07 at 12:10 p.m. and the dinner meal at 5:10 p.m. revealed Resident #2 did not receive Magic Cup. (c) Observation on 2/06/07 during the lunch meal at 12:30 p.m. revealed the resident did not have Magic cup served to her. (d) Interview with the RD (Registered Dietitian) and the Corporate Dietitian on 2/06/07 at 1:40 p.m. revealed they were not aware Resident #2 had not received the Magic Cup. 14. Nursing and Dietary Staff failed to demonstrate evidence they were adhering to physician's orders related to a Fluid Restriction for Resident #8; (a) 5. Review of Resident #8's clinical record on 2/06/07 revealed the resident had diagnoses including, but not limited to Renal Failure, Anemia, Cerebral Vascular Accident, Diabetes Mellitus, Esophageal Reflux, and Edema. (b) Review of the clinical record revealed a physician order 2/03/07 for a fluid restriction of 1250 cc per day. Review of the MAR (Medication Administration Record), TAR (Treatment Administration Record), and Dietary Progress Notes, failed to include the distribution of fluids between the disciplines (Dietary and Nursing) . (c) Interview with the RD (Registered Dietitian) and the Corporate Dietitian on 2/06/07 confirmed they were not aware how the fluids were being distributed. (d) After numerous attempts of asking the DON on 2/06/07 at approximately 10:00 a.m., 6:00 p.m., and on 2/07/07 at approximately 2:00 p.m. and 6:00 p.m. concerning documentation of how fluids are distributed for Resident #8, she failed to produce any documentation. 15. Nursing staff failed to assure Resident #3 had a plate guard on her plate at all meals; (a) A review of the 02/07 physician’s orders for Resident #3 revealed that a plate guard is to be used at all meals. (b) Observation of lunch and dinner on 02/05/07 and breakfast on 2-02/06/07 did not reveal that a plate guard being used. 16. Nursing staff failed to follow physician's orders to dilute the potassium prior to administering to Resident #13; (a) While observing medication pass between 8:30 a.m. and 9:00 a.m. on February 6, 2007, it was noted that Resident #13 received 30 cc of Liquid Potassium. On later reconciling the observation with the most current physician's orders, it was determined the nurse was to dilute the medication prior to administering the medication to the resident and failed to do so. 17. Nursing staff failed to administer Lovenox and plain Vitamins as prescribed by the physician for Resident #4. (a) Observation of the medication pass on 2/06/07 at 9:00 a.m. for Resident #4 revealed the following: (b) The nurse flushed the gastrostomy tube with 30 cc (cubic centimeter) of water prior to administering the medications. (c) The nurse was then observed to administer medications via the tube, including Geriaton. liquid vitamins plus minerals, 5 cc. (d) At 9:40 a.m., the nurse stated: "He also has a Lovenox injection but he's out of Lovenox." (e) On 2/06/07 at 10:30 a.m. the nurse stated that the Lovenox injection had been ordered and. will be administered as soon as it reached the facility. (£) Upon reconciliation of the’ medications, it was revealed the following physician's orders for the resident: (aa) Theragran liquid, (liquid vitamins without minerals) give 5 cc via tube daily. (bb) Lovenox 40 milligrams subcutaneously daily, at 9:00 a.m. Correction Date: 3/10/07 18. During the follow-up conducted on 3/20/07 and based on observation, record review and staff interview, the facility failed to assure services provided by the facility met professional standards of quality for 3 residents (#1, #4 and #13). 19. Nursing staff’s failure to keep the wound to the resident’s (Resident #1) sacrum free from fecal contamination as ordered by the physician. (a) Observation on 3/19/07 at approximately 11:00 p-m. revealed Resident #1 was in her room and in bed. A CNA (Certified Nursing Assistant) was leaving the resident's room and two nurses were walking in, preparing to perform wound care. (b) After assisting the resident to a right side lying position, Nurse #1 unfastened the resident's brief, exposing evidence of feces near the anus, buttocks, and sacrum. A small opened wound to the sacral area was observed. The nurse stated a CNA (Certified Nursing Assistant) had just cleaned the resident and applied a new brief. She confirmed a dressing should have ‘been placed on the wound to prevent contamination before the brief had been applied. (c) Observation on 3/19/07 at approximately 1:00 p.m. revealed a CNA and Nurse entering the resident's room to perform wound care. They washed their hands and donned gloves. After assisting the resident to a left side lying position, the CNA unfastened the resident's brief and exposed the wound to the sacral area. A large amount of feces was observed near the resident's anus and buttocks. (d) The CNA moistened. a dry towelette and wiped the anus from front to back twice and tossed the towelette into a 10 trash receptacle. She moistened a second towelette and wiped the resident from front to back and back to front using a quick "swipe" and the same side of the towelette. With same gloved hands, she placed a clean brief under the resident and the nurse applied dry gauze to the wound. The CNA fastened the brief and covered the resident and stated she was finished with peri care. (e) A review of the clinical record reveals that the resident was admitted to the facility on 5/08/05 with multiple diagnoses including, not limited to, Decubitus Ulcer and Dementia. (f) Physician's orders for March 2007 reveal, "KEEP WOUND FREE OF FECAL CONTAMINATION AT ALL TIMES WHEN POSSIBLE...KEEP WOUNDS CLEAN AND DRY." (g) The CNA failed to notify the nurse that she was completed with peri care so that the nurse could apply a clean dressing to the resident's sacral ulcer. The wound was exposed to fecal material, contaminating the wound. (h) During the second attempt at wound care, the CNA failed to use soap and water or a cleansing agent to adequately remove the feces from the resident's anus and buttocks. This failure increases the risk of contaminating the open wound and increases the resident's risk of skin excoriation. 11 20. Nursing staff's failure to apply = anti-embolism stockings to Resident #4’s lower extremities in an effort to prevent the potential of deep vein blood clots. (a) Resident #4's record review revealed doctor's orders dated 3/12/07 which included the medication Lovenox, (an anticoagulant used as a prophylaxis to prevent deep vein embolism), to be discontinued when resident receives Thigh High Ted Hose to wear from 9:00 a.m. - 9:00 p.m. daily. (b) Additional doctor's orders dated 3/13/07 state, "discontinue Lovenox 40mg subcutaneous, Ted Hose initiated." Ted Hose are elastic stockings used to prevent embolisms. A record review of the Medication Administration Record (MAR) revealed the Resident received the last dose of Lovenox on 3/12/07. (c) On 3/19/07 at 12:30 p.m., Resident #4 was observed sitting in a Geri-chair. The Licensed Practical Nurse (LPN) was administrating a bolus feeding through the Gastric Intestinal tube and the Resident was not wearing the Ted Hose. (d) The Resident was also observed at 1:00 p.m., 2:00 p.m., and 3:00 p.m. not wearing the Thigh High Ted Hose as ordered. (e) On 3/20/07 at approximately 9:00 a.m., the resident was observed without the TED HOSE. Subsequent to surveyor intervention, the Director of Nurses was notified and staff applied the hose according to physician's orders. 21. The nursing staff's failure to obtain vital signs as ordered by the physician for Resident #13 who was recently readmitted from the hospital with known diagnoses of Hypertension, Coronary Obstructive Pulmonary Disease, and Asthma, (a) A record review revealed Resident #13 was readmitted to the facility from the hospital on 3/03/07 with multiple diagnoses including, not limited to, Asthma, Hypertension, and Coronary Obstructive Pulmonary Disease. (b) A review of the physician's orders dated 3/03/07 revealed the resident's vital signs are to be taken every shift for 14 days. (c) Further review of the record revealed that vital signs were taken once on the 3:00 p.m. - 11:00 p.m. shift for the dates of 3/4/07, 3/5/07, 3/6/07, 3/8/07 and 3/9/07. There was no evidence that vital signs were taken daily on ALL shifts as ordered by the physician. (d) An interview with the Director of Nurses on 3/20/07 at approximately 3:00 p.m. confirmed the vital signs were not taken as ordered by the physician. Uncorrected deficiency from the 2/08/07 survey. 22. Based on the foregoing, Homestead Manor violated Rule 59A-4.107(5), 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 pattern 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, Homestead. Manor 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 vA". 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 $2,000.00 against Homestead Manor on Count I for a pattern deficiency. c. Assess and assign a conditional license status to Homestead Manor 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 (2006). 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 REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. mw elson E. Rodney Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 NW 52" Terrace Miami, Florida 33166 Copies furnished to: Kriste Mennella Field Office Manager Agency for Health Care Administration 8355 NW 53°¢ Street, First Floor Miami, Florida 33166 (Interoffice Mail) 15 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, Florida 32308 (Interoffice Mail) 16

Docket for Case No: 07-003259