STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION OF OU 4 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. —. 2008000109 (Fines) : 2008000110 (Cond.) PINNACLE HEALTH FACILITIES XXIV, LP, d/b/a St. Andrews Bay Skilled Nursing and Rehabilitation Center, - Respondent I: _ ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against PINNACLE HEALTH FACILITIES XXIV, LLC, d/b/a St. Andrews Bay Skilled Nursing and Rehabilitation Center St. Andrews Bay Skilled Nursing and Rehabilitation Center, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing December 13, 2007, impose an administrative fine in the amount of $30,000.00 and a survey fee in the amount of $6,000.00, based upon Respondent being cited for two State Class I deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4, Respondent operates a 120-bed nursing home, located at 2100 Jenks Avenue, Panama City, Florida 32405, and is licensed as a skilled nursing facility license number 1366095. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes, COUNTI RESPONDENT’S FACILITY FAILED TO PREVENT NEGLECT THAT AFFECTED THE HEALTH AND SAFETY OF THE RESIDENTS. § 400.102(1)(a), Florida Statutes (2007) . WIDESPREAD CLASS II DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. | | 7. That on or about December 13, 2007, the Agency conducted an annual licensure survey at Respondents facility. The survey was an off hour survey with the team entering the facility on Monday 12/10/07 at 7:30 a.m. 8. That based upon observation, the review of records, and interview, Respondent’s facility failed to prevent neglect that affected the health and safety of the residents at the facility. This is evidenced by: 1) The facility's failure to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by a lack of a system to ensure residents with weight discrepancies were consistently re- weighed using set parameters to ensure weights were accurate for Residents #7, (#20),(#21),and (#24); failure to consistently report weight changes to the Consultant Registered Dietitian (RD) resulting in nutrition assessments not being completed timely when significant weight loss occurred for Resident # 's (#7) and (#11); lack of feeding instructions for staff to assist a Resident (#22) with special needs; and failure to coordinate a referral to the RD for a Resident (#25) with chewing problems. 2) The facility's failure to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (Residents #15 and #9) of 28 total sampled ‘residents. This is evidenced by 1) The facility 's failure to ensure that the equipment was in proper working condition resulting in Resident (#1 5) sustaining an injury requiring sutures; 2) The facility's failure to ensure that safety devices were implemented for Resident #9 who had numerous falls and was assessed and care planned as a fall risk. 3) The failure of Administration to monitor staff and intervene in a timely matter resulting in harm to 4 active residents, (#11), (#7), (#25) and (#22) resulting in the failure for all residents to attain and maintain their highest level of well-being. Failure of the Administration to effectively and efficiently oversee and manage the facility to ensure that the dietary department was being run in a manner that ensured that all residents who were ordered therapeutic diets and fortified foods received these prescribed diets. And furthermore, failure of the Administration to effectively and efficiently oversee and manage the facility led to the facility's failure to ensure that the facility had adequate . dietary help to ensure systems were developed, implemented and revised when needed to. ensure all residents in the facility received a nourishing, palatable and well-balanced diet that met the daily nutritional and special dietary needs. These resulted in immediate jeopardy in the area of food and nutritional services which has the potential to cause imminent and serious harm to residents. 4) The failure of the facility to maintain acceptable parameters of nutritional status for body weight and protein levels resulting in severe, avoidable weight loss for 3 ( #'s 7, 18 and 20) of 18 active and 4 extended sampled residents. This is evidenced by: 1) Resident # 7 experienced a progressive, severe, avoidable weight loss of 26.3 ‘pounds (21.6% in a5 month period) from 121.6 pounds to 95.3 pounds since admission to the facility. The facility failed to obtain a prealbumin as ordered to monitor the resident's protein status and adequacy of her nutritional intake, The resident's Glucerna nutritional supplement was discontinued by the nursing staff | without a physician's order reducing the resident's intake by 700 calories per day resulting in continued weight loss. The resident was not provided with adequate calories to accommodate her increased calorie needs due to her wandering. behavior. The resident's care plan was not implemented, evaluated based on resident outcome and revised as needed. 2) Resident # 20 experienced a severe, avoidable weight loss of 21 pounds (15.7% weight loss in the last 180 days) from 116 pounds in 4/07 to 95 pounds in 10/07. Resident food preferences were not honored and the resident was provided with fortified foods which she did not like and did not consume. The nursing staff did not provide set up of the meal tray or. encouragement to eat per the resident's care plan. The resident's care plan was not implemented, evaluated based on resident outcome and revised as needed. 3) Resident # 18 experienced a severe avoidable weight loss of 12.2 pound (11.7% weight loss in 4 months) from 104.2 pounds in 8/07 to 92 pounds in 12/07. The resident's food preferences were not honored and the resident was not provided with adequate calories to accommodate her increased calorie needs due to her wandering behavior. There was no follow through regarding a recommendation for an appetite stimulant. The resident's care plan was not implemented, evaluated based on resident outcome and revised as needed. The findings include: 1) Resident #11 was admitted to the facility on 8/1/07. An initial dietary assessment was completed by the Consultant Registered Dietitian (RD) on 8/16/07 with Resident #11 having a weight of 165 Ibs. Review of the weight log in the clinical record revealed the resident had a weight on 8/28/07 of 136.8 lbs. This is a significant weight loss of 17% in the month of August. On 9/24/07 the record reveals the resident's weight tobe down to 117.4 Ibs., another significant weight loss of 14% for the month of September. The RD did not do another dietary assessment of the resident until 10/10/07. The RD was interviewed on 12/11/07 at 1:55 p.m. Asked why no assessment had been done while the resident had been rapidly losing weight, the RD stated "I just didn't know about it." The weight log for Resident #11 revealed the resident had . been weighed 5 times between the initial dietary assessment on 8/16/07 and the next assessment on 10/10/07. The facility did not communicate the weight loss to the RD for further assessment and intervention to attempt to stop the weight loss. 2) Record review for resident #22 revealed the resident has difficulty in swallowing and the recommendations from the speech therapist was for honey thick liquids and a blended diet (pureed), Review of discharge summary from the speech therapist dated 8/22/2007 revealed staff feeding residents should offer teaspoon size bites of food with a small spoon and alternate solids and liquids with close supervision. The current care plan is in line with the feeding instructions from the speech therapist. Observation of nursing assistant feeding the resident in auxiliary dining on 12/13/2007 at 5 p.m. revealed the use of a plastic spoon and no order of foods offered. The resident would take small bites when offered and several sips of liquid at a time. The resident was observed with an occasional cough after a bite or drink. Surveyor asked the nursing assistant why she was using a plastic spoon and she said it was because the resident did not open her mouth very wide. Interview with the same nursing assistant revealed there were no written instructions in the dining room for reference on how to feed this resident. When asked if she was aware of the special instructions when feeding this resident the nursing assistant stated no. The staff in charge of restorative dining instructed the staff on feeding instructions after surveyor intervention. Review of current physician orders and observation of resident's meal tray on 12/13/2007 at dinner revealed the resident was receiving regular fluids. Interview with the director of nursing on 12/13/2007 around 6 p.m. revealed she was not sure why the physician's orders were not written based upon the speech therapist's recommendations. Interview with the Administrator on 12/13/2007 around 6 p.m. regarding coordination of feeding instructions with the restorative staff revealed there was not a process in place. 3) Resident # 7 was admitted to the facility on 7/22/07 with diagnoses including Type 2 diabetes, Alzheimer 's disease, fractured right patella (knee), hypertension, depression and chronic insomnia. Review of the initial nutrition assessment, dated 8/4/07, revealed the Registered Dietitian (RD) assessed the resident as being at high nutritional risk and underweight. The resident's admission weight was noted as 121.6 pounds with a height of 64 inches. Documented weight on 7/23/07 was noted at 121.6 pounds. The RD noted Resident # 7's documented weight on 8/2/07 was 106.6 pounds, indicating a 15 pound weight loss in 11 days (severe weight loss of 12.3 % since admission). The RD noted the resident 's admission weight may have included the knee immobilizer. She noted the weight of the immobilizer was unknown. The RD did not document whether she confirmed how the weight was obtained with the restorative Certified Nursing Assistant (CNA). There was no documentation a re-weigh was requested to verify the resident 's weight. Further review of the nutrition assessments revealed no documented nutrition assessment for 9/07, The next documented assessment was completed by the RD on 10/18/07. Review of the 10/18/07 nutrition assessment indicated the resident's weight on 9/1/07 was 104.2 pounds. The RD used the 8/2/07 weight of 106.6 pounds to determine the resident had a 3.7% weight loss in 30 days. Review of the Resident Weight Record revealed the resident ' s weight of 8/2/07 had been written over on the form on top of the original weight of 106.6 pounds. The new recorded weight was 109.7 pounds. The form was not initialed as to who obtained the weight or whether this was a reweigh. The reweigh section was blank as well as the section which indicated the time dietary was notified of the weight change. Interview with the RD on 12/11/07 at 4:00 p.m. revealed she did not complete a nutrition assessment in 9/07 because she was never notified of the new weight obtained on 8/2/07. The RD stated if she had been informed of the weight of 109.7 pounds this would have indicated a 5% weight loss in 30 days instead of the 3.7% loss she calculated based on the weight of 106.6 pounds. She stated this would have been a significant weight loss and would have triggered her to complete a nutrition assessment in 9/07. The RD further stated the weight process was implemented in 7/07 or 8/07 to address timeliness in obtaining weights to ensure accuracy in identifying and addressing significant or severe weight changes. The RD confirmed she had not consulted with the restorative staff to determine whether the resident ' s admission weight included the weight of the knee immobilizer prior to completing her nutrition assessment and determining severe weight loss. 4) Review of the Weight Process revealed all residents are weighed upon admission and weekly for 4 weeks. Residents with significant/severe weight loss will be weighed for 4 weeks with a list given to the restorative CNA 's by the restorative nurse each month of the residents needing to be weighed. Weights should be obtained in light clothing, without shoes, with empty catheter bags and without braces or prostheses. Initial monthly weights are given to the restorative nurse by the 7” of each month and reviewed by the Director of Nurses (DON), restorative nurse, dietary manager or RD to identify residents who may need to be reweighed. The restorative nurse gives a list of residents requiring reweigh to the restorative CNA ' s with reweighs obtained on the 8" of each month. Additional reweighs may be required as determined by the DON, restorative nurse, dietary manager or RD. All weights and reweighs are completed and recorded on the weight records by the 10" of each month. The weight process did not include documentation of the amount of weight change or time frame in which weight change occurs so there are consistent guidelines which can used to determine when a resident needed to be reweighed. Interview with the dietary manager on 12/12/07 at 10:45 a.m. revealed she was not aware of obtains the weights. She stated nursing gives her the weights and she gives them to the RD to calculate weight changes. The dietary manager stated she sometimes asks for a reweigh if the weight "doesn't look right" or she sees a large change in weight from the previous month. The dietary manager could not state the parameters she used to determine when a reweigh should occur. The dietary manager further stated the restorative CNA 's give her the reweigh weight the next day and this information is passed onto the RD. The dietary manager stated she did not know where the reweighs are recorded in the resident records. Interview with the restorative nurse on 12/12/07 at 2:15 p.m. revealed there are 2 restorative CNA 's who weigh residents. She stated the process is to obtain the weights, record the weights on the weight sheet and give the weight sheet to the restorative nurse, the DON and the dietary manager. She confirmed the facility has no set weight change parameters which they use to determine whether a reweigh is necessary or not. The restorative nurse further stated she uses a discrepancy of 3 pounds to determine whether a reweigh is necessary. Regarding Resident # 7's knee immobilizer, the restorative nurse stated the resident was probably weighed without the immobilizer but this was not recorded on the weight form. The restorative nurse stated she had never thought this and it would be a good idea to change the system to document when a resident was weighed _ with a brace or other device. Further interview with the restorative nurse on 12/12/07 at 3:30 p.m. confirmed she had spoken to the restorative CNA 's who informed her Resident # 7 had never been weighed with her knee immobilizer. Further interview with the RD on 12/ 13/07 at approximately 3:45 p.m. revealed the RD was still not getting the weight information consistently to complete nutrition assessments. She stated the weights are not always recorded in the resident records and she frequently has to find the restorative CNA 's and ask for the weight sheets. The RD confirmed the facility had not established set weight parameters to obtain reweighs and it currently was arbitrarily determined which residents were reweighed depending on who reviewed the weekly and monthly weights. 5) Further review of Resident # 7's Resident Weight Record revealed lack of documented reweighs on 8/20/07 when the resident decreased ‘from 109.7 to 100.2 pounds; lack of documented reweigh on 8/27/07 when the resident increased from 100.2 to 107.8 pounds; lack of documented rewei gh on 9/1/07 when the resident decreased from 107.8 pounds to 104.2 pounds; lack of documented reweigh on 9/10/07 when the resident decreased from 104.2 pounds to 100.5 pounds. A reweigh was completed on 9/17/07 when the resident lost less than 3 pounds to 99.9 pounds. A reweigh was obtained on 10/17/07 at 100.8 pounds. The record also lacked documentation of a reweigh on 10/28/07 when the resident decreased in a week from 100.4 pounds to 93.3 pounds. The resident was weighed on the first of the month on 11/1/07 at 93.3 pounds but reweighed on 11/5/07 at 96.6 pounds, This weight was not confirmed for accuracy. 6) Review of Resident #20 's Resident Weight Record revealed the resident weighed 102.6 on 7/16/07 and 91.8 on 7/23/07, a loss of 10.8 pounds. There is no evidence of any reweigh. The next recorded weight is on 7/30/07 at 97.8 pounds. There is no evidence of any reweigh. . 7) Review of Resident # 21's clinical record revealed the resident was admitted to the facility on 7/25/07. Review of the most recent weights for this resident revealed the following: 7/25/07- 162.3 Ibs 8/04/07- 153.4 Ibs 9/01/07- 152.3 Ibs 10/01/07 - 159.4 lbs 11/1/07 155.2 Ibs Clinical record review as well as facility record review lacked evidence that the facility was implementing their weight program by performing weekly weights every week for four weeks for all new admissions as well as performing reweighs after the resident had lost or gained 3 or more pounds. 8) Review of the clinical record for Resident # 24 on 12/13/07 revealed the tesident was admitted to the facility on 11/26/07. Facility policy states newly admitted residents are to be weighed weekly for the first 4 weeks. The weight log in the clinical record on 12/13/07 had an initial weight on 11/26/07 of 147.3 lbs. but none since. Interview with the staff nurse on the "400 hall" on 12/13/07 at 3:45 p.m. confirmed the record did not have any other weights documented on the Resident Weight Record, however, she stated the weekly weights might be in the restorative nurse's office. The staff nurse went to the restorative office and returned with weights taken on 12/3/07 of 151 Ibs. (no re-weigh) and 12/10/07 of 148 lbs. Weights and reweighs were not recorded on the weight record in the chart by the 10" of each month per facility policy. 9) Review of Resident # 25' s Resident Weight Record revealed the resident's weight was 85.6 pounds on 11/1/07 and 78.3 pounds on 12/8/07, a loss of 7.3 pounds. There is no evidence a reweigh was obtained to confirm the December 2007 weight. Interview with the RD on 12/13/07 at 3:45 p.m. confirmed Resident #25 should have been reweighed on 12/8/07 to verify the accuracy of the weight. Further review of Resident # 25 's clinical record revealed the resident's diet was downgraded from a regular diet to a pureed diet on 11/30/07. Review of nursing progress notes dated 11/30/07 at 2:00 p.m. revealed an order was received to change diet to pureed due to resident observed daily in assisted dining room having difficulty chewing and swallowing. Interview with the resident 's CNA on 12/13/07 at 12:10 p.m. revealed the resident told her she disliked the pureed food and won't eat it. Per the CNA she reported this to the nurse last week but nothing has been done about it. The CNA stated the resident is losing weight and " needs supplements or something. " Interview with the RD on 12/13/07 at 3:45 p.m. revealed she had not made the recommendation to downgrade the resident to a pureed diet and she didn't know who had requested this from the physician. The RD stated she spoke with the resident on 12/12/07 but the only food preference she could obtain from the resident was that she wanted orange juice at breakfast every day. The RD confirmed the nursing staff or rehab staff had not consulted her regarding the resident's diet texture. Interview with the staff nurse on 12/13/07 at 3:45 p.m. revealed she had requested an evaluation by the speech therapist after the resident was observed " chewing on spagheiti a long time. "| The nurse confirmed the referral was not in the resident's clinical record and she had not documented the referral in her nurse's notes. The nurse confirmed the resident was not referred to the RD for evaluation when chewing problems were observed. Observation on 12/13/07 at 3:50 p.m. revealed the nurse went to the rehab office and obtained copies of the referrals for Resident # 25. The first referral was sent on 10/26/07 by the restorative CNA indicating a referral was needed due to decreasing weight status and repetitive chewing. The speech pathologist responded on 11/28/07, " Unable to evaluate secondary to payor source." The resident is private pay per the clinical record. On 11/27/07, the staff nurse sent another referral to therapy noting, “Please evaluate for pureed diet. Restorative feéls this is best. "The speech therapist documented on 11/28/07 that the resident had a history of spitting out food and weight loss. The therapist noted she spoke with nursing about downgrading to a pureed diet. She noted the resident had a poor oral intake due to cognitive decline and the nurse could downgrade the diet "if wanted to." The note contained no documentation the resident was observed during meals to determine the proper diet consistency, the diet change was . discussed and coordinated with the RD and the diet change was discussed with the resident. 10) 1. Observations made on 12/10/07 revealed Resident #15 sitting in a high back wheel chair. Resident #15 was remarkable for having two black eyes, facial bruising and sutures just above the right eye. Resident #15 has both arms and hands drawn up into a contracted position without purposeful movement. Resident #15 was revealed to be cognitively impaired and did not communicate verbally. : : : Review of the Record revealed Resident #15's status to be "4/3 for transfer" (4=total dependence, full staff performance of activity; 3=two plus persons physical assist), The record revealed notes by nurses: 12/06/07 "5:45 am. When transferring Resident from bed to chair by lift, strap on lift tore. Resident went to floor..." The resident was transferred to the hospital. Residerit Transfer page dated 12/06/07 at 6:10 a.m, reveals “Hoyer lift strap broke and resident fell about 3 feet to the floor and landed on R side. Struck head-3 areas on head/face". Resident #15 returned from the Hospital the same day with sutures in place over the right eye. The facility did not medicate Resident #15 for pain after this event. During an interview. with the Risk Manager on 12/12/07 at 12:45 p.m. the Risk Manager stated the Hoyer lift strap had "broken", she "saw it herself" and that the sling involved “had been thrown away". The Risk Manager stated the facility had no policy on the use of a Hoyer lift but "the standard of care is two people" operating the lift. There were no photographs of the broken sling strap and the manufacturer had not been contacted. The Risk Manager stated all slings and straps in the facility had been checked after the accident. Because of this accident and in-sérvices had been held with the staff. These in-services focused on 4 things: 1) only use a lift after you have been trained on it; 2) inspect "lift sheets" for tears or fraying before use; 3) 2 people using the lift (only one staff member had been operating the Hoyer lift when Resident #15 was injured); and 4) never manually lift a resident off the floor. a. The facility failed to maintain Hoyer lift slings in good working condition. b. The facility failed to follow the "Standard of Care" as defined by the facility's Risk Manager. c. The facility failed to insure Resident #15's Care Plan was followed, after identifying the resident needs to be at least 2 people to transfer, by allowing one person to attempt the transfer. d. The facility failed to report injuries associated with the use of a Hoyer lift medical device, (The Safe Medical Devices Act of 1990 (SMDA) requires hospitals, nursing homes, and other user facilities to report deaths, serious illnesses, and injuries associated with the use of medical devices to manufacturers and the Food and Drug Administration.) During the exit conference on 12/13/07 at 9:40 p.m. The Administrator stated there was no device failure, the strap did not tear or rip, The Administrator stated the sling had simply not been applied correctly. When ask if the Risk Manager had not been truthful and if the Nurses had willfully documented misrepresentations of the facts there was no reply. 11) Clinical record review for Resident #9 conducted on 12/10/07 revealed that she was admitted to the facility on 1/19/05 with past medical history to include but not limited to history of multiple falls and status post (s/p) fracture of right hip and femur. Review of the physician's telephone orders dated 10/6/07 revealed, " 1) Sensor pad to bed to remind resident to call for assistance." 2) Clip alarm at all times while in w/c (wheel chair) to remind resident to call for assistance. " Review of progress notes dated 9/26/07 revealed that nursing staff was called into resident's room by certified nursing assistant (CNA) after being found on the floor after coming back from the bathroom. Review of progress notes dated 10/2/07 revealed that nursing staff was called in the resident 's room by (CNA) where again the resident was found on the floor after trying to transfer self to wheel chair. Review of progress notes dated 10/3/07 and again on 10/6/07 revealed that the resident was found on floor by (CNA) after the resident was transferring from the. toilet to the wheel chair. . Review of progress notes dated 10 8/07 revealed that nursing staff was called into the resident 's room by (CNA) when the resident was found on the floor sustaining skin tears to right elbow and leg. Review of progress notes dated 10/10/07 revealed that the resident was found by — facility staff on lmees on the floor in front of her bed with her wheel chair behind her. Review of the Review of the Significant Change Minimum Data Set (MDS) with a reference date of 10/19/07 revealed that Section G Physical Functioning and Structural Problems 1b (transfer) revealed that the resident was coded a 4-3 (indicating that the resident requires total dependence and two person physical assistance). Also under 1i (toilet use) revealed that the resident was coded a 4-3 11 (indicating that the resident requires total dependence of one person and two person physical assistance). Review of Section G3 Test for Balance was coded a 3-3 (indicating that the resident not able to attempt without physical help for both balance while standing and sitting position as well as trunk control), Review of Section J4 Health Conditions revealed that the resident was coded as having falls within the last 30 and 31-180 days. Review of the Care Plan dated 10/24/07 indicated that the resident was a trauma Tisk/falls related to history of falls as well as diagnosis of Osteoporosis, HTN, COPD, Stress Incontinence, Degenerated Joint Disease of the tight shoulder and knees, Rotator Cuff Syndrome. The goal was to reduce risk of injury daily. Under interventions listed personal alarm while in wheel chair and sensor alarm while in bed. Observation made on 12/10/07 at 10:05 a.m. revealed the resident up in her electric wheel chair in the way by her room after being assisted by facility staff. Observation revealed that the personal alarm was not attached to the resident, Observation on 12/10/07 at 11:30 a.m. while in the resident's room revealed that the personal alarm was still attached to her bed with the battery hanging out of the unit and only one of the connectors attached to the battery. There was no sensor alarm located on her bed. ‘ Observation made on 12/10/07 from 11:45 a.m. until 12:37 p.m. revealed that the resident was observed during lunch in the main dining room. Again the personal alarm was not attached to the resident. Observation non 12/10/07 at 4:00 p.m. revealed that the resident was up in her wheel chair without the personal alarm attached to the resident. This same observation was made at 5:00 p.m. and again at 5:30 p.m. during dinner. Observation made on 12/11/07 at 8:00 a.m. during breakfast revealed that the resident was in her room having breakfast. The personal alarm was again noted to be attached to bed. Not attached to the resident as well as the battery hanging out of the unit and only one connector attached to the battery, Also there was not a sensor alarm on the bed. This observation was confirmed in the presence of the Director of Nurses (D.O.N) 12), The Administration did not ensure that the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by a lack ofa system to ensure residents with weight discrepancies were consistently re-weighed using set parameters to ensure weights were accurate. Administration also did not ensure that weight changes were consistently being reported to the Consultant Registered Dietitian (RD) resulting in nutrition assessments not being completed timely when significant weight loss occurred. This failure by the Administration to ensure that all of the departments were coordinating care for the residents resulted in the residents experiencing significant weight loss. 13). The Administration failed to ensure that systems were developed, implemented and revised when needed to ensure all residents in the facility received a nourishing, palatable and well-balanced diet that met the daily nutritional and special dietary needs. This failure by the Administration to ensure that all of the kitchen was run in an efficient manner to ensure that proper therapeutic diets, fortified foods were provided and food items prepared as planned and proper portion sizes were being followed resulted in the residents experiencing significant weight loss. Cross refer to N407 14), The Administration failed to assure that facility's Policies and Procedures were implemented by nursing and dietary staff which resulted in weight loss. This failure by the Administration to ensure that direct care staff in addition to dietary staff was trained and competent for the resident's who were on therapeutic diets including fortified food resulted in the residents experiencing weight loss. Cross refer to N407 15) Interview with the Administrator on 12/13/07 at 8:30 a.m. revealed the Consultant Registered Dietitian (RD) meets weekly with the Director of Nursing (DON) and reviews her recommendations for nutrition. She stated she was not sure why nutrition recommendations were not ordered or implemented on a consistent basis. The Administrator further stated the quality indicators for weight loss did not trigger until this month at 89 %. Last month weight loss was at 52%. She stated the facility's thresh hold is 70% to review at quality assurance/quality improvement (QA/QI) meetings. The Administrator confirmed the weight process was implemented earlier this year to improve timeliness in obtaining weights and to.ensure accuracy in identifying and addressing significant or severe weight changes. The facility was unable to provide documentation the weight process was reviewed by the QA/QI committee to determine the effectiveness of the program after it was implemented in 8/07. , 16) 1. Resident #7 was admitted to the facility on 7/22/07 with diagnoses including Type 2 diabetes, Alzheimer's disease, fractured right patella (knee), hypertension, depression and chronic insomnia. Observation of Resident # 7 tray ticket on 12/10/07 at noon revealed the resident was on a consistent carbohydrate (CCHO) diet. The resident's tray ticket indicated “may have sweet desserts" due the resident experiencing significant weight loss. The staff served the resident applesauce instead of the cranberry square. Observation on 12/10/07 at noon revealed the dietary manager informed the cook that Resident # 7 was eating in the main dining room today, where she normally did not eat. The resident was assigned to eat in the auxillary (assisted) dining room. The dietary manager asked the staff to pull the resident's meal ticket and set up the resident's lunch tray. Observation of Resident # 7 on 12/10/07 at 12:15 p.m. revealed the resident eating soup and drinking lemonade in the main dining room. Observation of the resident at 12:40 p.m. revealed she had covered her entree with her napkin and not eaten any of it. The resident did not eat the applesauce. The resident was not cued or assisted to eat and left the dining room at 12:40 p.m. without being offered an alternate meal item. Observation of Resident #7 on 12/10/07 at 1:00 p.m. revealed the resident wandering in the hallway on the 200 hall. The resident could self propel her wheel chair by using her feet and holding onto the hand rail. The resident was asked why she had not eaten her lunch. The resident responded she was "sick with chest pain" and "couldn't eat." She stated she would eat later. Observation of Resident # 7 on 12/10/07 at 4:45 p.m. revealed the resident in the auxillary dining room waiting for her dinner meal. At 5:15 p.m. the resident was observed. crying at the nurse's station on the 300/400 unit. A CNA wheeled the resident back to the 100/200 unit where she lives. The'resident was observed wandering around the 100/200 unit in her wheelchair from 5:30 to 6:00 p.m. asking for her daughter and stating she wanted to go home. The resident's meal tray was not sent to the unit and the resident did not eat any dinner. Interview with the nursing staff on 12/10/07 at 6:00 p.m. revealed they were not informed that the resident had not eaten in the dining room before being brought back to the unit. The resident was agitated by this time and refused dinner. Observation of Resident # 7 on 12/11/07 at 9:45 a.m. revealed the resident sitting at the doorway to her room. The nurse gave the resident her medication and 120 cc of VHC supp The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 9, The Agency provided Respondent with the mandatory correction date for this deficient practice of January 5, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT IT Facility failed to ensure systems were developed, implemented and revised when needed to ensure all residents in the facility received a wholesome and-nourishing diet that met the daily nutritional and special dietary needs of residents. The facility failed to provide therapeutic diets and fortified foods as prescribed by the attending physicians § 407.141(9), Florida Statutes (2007) WIDESPREAD CLASS I DEFICIENCY 10. - The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. - 11. That on or about December 13, 2007, the Agency conducted a Health Recertification Survey at Respondent’s facility. The survey was an off hour survey with the team entering the facility on Monday 12/10/07 at 7:30 a.m. 12. That based on observation of 6 meals, review of the facility's approved menus, diet manual, written weight process and nutritional policies and procedures and interview with residents, management staff and dietary and nursing staff the facility failed to ensure systems were developed, implemented and revised when needed to ensure all residents in the facility received a wholesome and nourishing diet that met the daily nutritional and special dietary needs of residents. The facility failed to provide therapeutic diets and fortified foods as prescribed by the attending physicians for 97 residents prescribed therapeutic diets from a census of 103 including 1 (#14) active sampled resident with chronic kidney disease requiring dialysis on a low potassium, no added salt (NAS) diet with a 1500 cc fluid restriction; 1 (# 13) active sampled resident with congestive heart failure prescribed a 2000 cc fluid restriction and 1 random resident ( # 26) prescribed a 1200 cc fluid restriction; ] random sampled resident (# 28) prescribed a low residue diet; 3 random residents prescribed low fat diets; 2 random residents prescribed a high fiber diet; 23 residents prescribed fortified foods at all meals including 7 sampled resident (#'s 5, 6, 12, 15, 16, 18 and 20), 2 extended sampled residents (#'s 22 and 25) and 1 (#27) random sampled resident; 24 residents prescribed mechanical soft diets including 2 active sampled residents (#'s 5 and 18) and 1 extended sampled resident (# 24); 29 residents prescribed consistent carbohydrate (CCHO) diets including 4 active sampled residents (#'s 4, 7, 10 and 13) and 3 extended sampled residents (#'s 22, 23 and 24);13 residents prescribed pureed diets including 1 active sampled resident (# 15), 1 extended sampled resident (# 25) and 1 (#27) random sampled resident. This resulted in a system failure which places all residents at risk of not receiving adequate nutrition which has the potential to lead to immediate danger to the health, safety and welfare of all residents in the facility. This is evidenced by: 1) Dietary staff did not prepare and serve fortified foods per policy for residents determined to be at high nutritional risk and failed to follow the fortified food guidelines regarding special napkins and bowls which alerted the nursing staff to which item was fortified on residents' trays. Nursing staff were not aware of the appropriate fortified food items available and did not encourage residents to eat them as planned. The Special Nutrition Program (SNP) policy, on which the nursing staff were educated in 7/07, did not match the rotation policy being used by the dietary staff to serve the fortified/super food at meals. 2) Dietary staff did not prepare food items and provide correct portion sizes and/or food items as noted on the therapeutic menu extensions for low fat, consistent carbohydrate (CCHO), mechanical soft and pureed diets: did not develop a menu extension for a high fiber diet resulting in the residents not receiving adequate fiber-rich foods; did not develop a menu extension for low potassium diets resulting in a resident receiving inappropriate food items for meals and snacks; provided an incorrect dessert on a low residue diet and failed to coordinate and follow fluid restrictions as ordered for 3 residents (#'s 13,14 and 26). Correct portion sizes were not provided per the approved menu for 5 of 5 tray lines observed. The appropriate size and number of serving utensils were not available for the dietary staff to serve the correct portion sizes for all food items. The facility did not have an adequate number of china plates to serve the desserts. Desserts were served on Styrofoam plates on 12/10/07 at lunch. 3) Two of 6 meals observed were served from 20 to 90 minutes late. Four of 8 residents who attended the group interview complained that meals were frequently served late. 4) Lack of coordination between dietary and nursing to ensure meals were coordinated so both dietary and nursing knew where residents were dining for the meal and residents who needed assistance or cueing with dining who ate in an alternate location received this assistance whether they ate in the main dining room, the restorative/assisted dining room or in their rooms. 5) Lack of a system to ensure residents received the appropriate food items in accordance with their prescribed diets and texture and fluid modifications when snacks were passed on the units. Nursing staff continued to fail to provide appropriate snack items after they were educated on the snack program on 12/12/07. 6) Dietary staff did not follow sanitary procedures for thawing raw chicken and handling ready-to-eat foods to prevent the development or spread of harmful microorganisms which can cause food borne illness. 7) The dietary department was using an outdated version of the Florida Dietetic Association Medical Nutrition Therapy Manual from 2000 and not the current 2005 manual to ensure the most current medical nutrition therapy practices were implemented and therapeutic diets were followed. The findings include: 1. Observations throughout the 4 days of the survey revealed dietary staff did not prepare and serve fortified foods per policy for residents determined to be at high nutritional risk and failed to follow the fortified food guidelines regarding special napkins and bowls which alerted the nursing staff to which item was fortified on residents’ trays. Nursing staff were not aware of the appropriate fortified food items available and did not encourage residents to eat them as planned. The Special Nutrition Program (SNP) policy, on which the nursing staff were educated in 7/07, did not match the rotation policy being used by the dietary staff to serve the fortified/super food at meals. Observation of the dinner meal on 12/10/07 at 5:25 p.m. revealed the cook had not made the fortified soup for the meal per the fortified food/super food rotation schedule, All residents prescribed fortified foods did not receive a fortified food for the meal including 23 residents prescribed fortified foods including 7 sampled resident (#'s 5, 6, 12, 15, 16, 18 and 20), 2 extended sampled residents (#'s 22 and 25) and 1 (# 27) random sampled resident. Observation of Resident # 5 on 12/10/07 at 5:50 p.m., 12/11/07 at 7:30 a.m., and 12/13/07 at 6:50 p.m., observation of Resident # 6 on 12/10/07 at 5:30 p.m., observation of Resident # 12 on 12/10/07 at 5:00 p.m., observation of Resident # 20 on 12/12/07 at 8:15 a.m., observation of Resident # 22 on 12/12/07 at 1:00 p.m., observation of Resident # 18 on 12/12/07 at 8:25 a.m. and observation of Resident # 27 on 12/13/07 at 6:45 p.m. revealed these residents did not receive fortified foods as prescribed. ; Interview with the cook and dietary manager on 12/10/07 at 5:45 p.m. confirmed the fortified soup was not made on 12/10/07 for the evening meal. Review of the fortified food/super food rotation list available in the kitchen revealed it did not coordinate with the rotation list used to educate the dietary and nursing staff on 7/11/07. Interview with dietary, nursing and restorative staff throughout the 4 days of the survey revealed they were confused about how to implement the program and what foods were considered fortified even after they were re-inserviced on the SNP policy. 2, Observation of 6 meals revealed dietary staff were not following the planned, approved menus for portion sizes and specific food items. The appropriate size and number of serving utensils were not available for the dietary staff to serve the correct portion sizes for all food items at several of the meals. Incorrect portions were served on the breakfast meal on 12/10/07 at 8:00 a.m. for the hot cereal and the eggs. Incorrect portion size was served for the pureed bread on 12/10/07 at 11:50 a.m. and the menu was not followed for the desserts. Observation of the dinner meal on 12/10/07 at 5:00 p.m. revealed the staff did not make the squash for the pureed and mechanical soft diet and did not prepare the correct dessert for the CCHO diet. Observation of the breakfast meal tray line on 12/12/07 at 7:30 a.m. revealed residents on consistent carbohydrate (CCHO) diets were served skim instead of 2% milk as noted on the menu. The cook was observed using a 4 ounce ladle to serve oatmeal, pureed oatmeal and fortified oatmeal. Review of the approved menu revealed the correct portion size for the hot cereal was 6 ounces. Interview with the dietary staff working on the tray line on 12/12/07 at 7:30 a.m. revealed there were not enough 6 ounce ladles in the kitchen to serve all versions of the hot cereal. The staff stated they just overfilled the 4 ounce ladle to serve close to a 6 ounce portion. The employee confirmed she did not have egg substitute to serve on the low fat diets. The employee stated, "They don't order it." The dietary staff person further stated, " Frequently don't have the food to make the menu. We do the best with what we have." Interview with the dietary manager on 12/12/07 at 10:45 a.m. revealed the cook preferred to use ladles to serve the hot cereal but had scoops which could have been used. Review of the menu with the dietary manager revealed the cereal portion size was 6 ounces which is equivalent to a 6 ounces ladle. The dietary manager stated she was not aware there was a difference between a 6 ounce ladle (3/4 cup) and a 6 ounce scoop (2/3 cup). Observation of the lunch meal tray line on 12/13/07 at 12:30 p.m, revealed incorrect portion sizes were served for. the pureed chicken and gravy. 3. Observations throughout the 4 days of the survey revealed the facility did not have dietary staff competent to carry out the functions of dietary services to serve meals timely using appropriate dishware. During the group interview that was conducted on 12/10/07 at 1:30 p.m., 4 of 8 alert and oriented residents in the group complained that their meals are often served 15-20 minutes late on a consistent basis. Review of the breakfast delivery times revealed the first breakfast cart is to be delivered at 7:00 a.m. to the auxillary dining room. Observation of the brealcfast meal on 12/12/07 at 7:15 a.m. revealed. the breakfast cart for the auxillary dining room did not leave the kitchen until 7:20 a.m. resulting in the remainder of the breakfast carts being served to the halls 15 to 20 minutes late. Observation on the 200 hall revealed the last tray was passed to the resident at 7:50 a.m., 20 minutes after the cart arrived on the unit. Review of the dinner delivery times revealed the first cart was to arrive at the auxillary dining room at 4:45 p.m. The cart for the 200 unit was to arrive at 5:00 p.m. The dining room was to be served at 5:15 p.m. The 100 hall was to receive their trays at 5:30 p.m., 300 hall at 5:45 p.m. and the 400 hall at 6:00 p.m. Observation of the dinner meal on 12/13/07 at 5:05 p.m. revealed the residents seated in the auxillary dining room waiting for their dinner meal which was to be served at 4:45 p.m. The residents were not served any beverages while they waited, Resident # 7 and # 25 left the dining room prior to meal delivery and could not be redirected to wait in the dining room for their meals. Interview with the Administrator on 12/13/07 at 5:30 p.m. revealed the dietary manager had informed her the dietary staff were at inservice training all day and the dinner meal was not prepared on time. The administrator went to the main dining room at 5:30 p.m. and obtained the beverage cart and soup crock and served soup or yogurt to residents while they were waiting for their dinner to arrive. . The resident trays arrived at the auxiliary dining room at 5:33 p.m., 45 minutes after the meal was to be served. Observation on the 100 unit revealed the food cart arrived at 6:40 p.m., which was 70 minutes after the cart was scheduled to be delivered. Observation of the 300 unit revealed the food cart arrived at 7:00 p.m., which was 75 minutes after the cart was scheduled to be delivered, Observation of the 400 unit revealed the food cart arrived at 7:10 p.m., which was 70 minutes after the cart was scheduled to be delivered. The last tray was served on the 400 unit at 7:22 p.m. with the resident receiving the meal tray over 90 minutes later than it was to be delivered to the unit for the evening meal. Observation of the lunch meal on 12/10/07 at 11:50 a.m. revealed the desserts were served on Styrofoam plates. Interview with the dietary manager on 12/10/07 at 12:15 p.m. revealed there were not an adequate number of china dessert plates in the kitchen to serve desserts that need to be plated for 2 meals in a row. Interview with the Administrator on 12/12/07 at 8:15 a.m. revealed there were no budgetary restrictions for the dietary department and the dietary manager should have purchased an adequate amount of china and serving utensils to meet the needs of the residents, 4. Observation throughout the 4 days of the survey revealed a lack of coordination between dietary and nursing to ensure meals were coordinated so both dietary and an nursing knew where residents were dining for the meal and residents who needed assistance or cueing with dining who ate in an alternate location received this assistance whether they ate in the main dining room, the restorative/assisted dining room or in their rooms. Observation of the lunch meal on 12/10/07 from 11:50 a.m. to 1:00 p.m. revealed the staff in the kitchen were interrupted throughout the meal service to set up trays for residents who were eating in different locations than scheduled, Numerous - residents came to the main dining room who normally did not eat there. The tray tickets had to be located and the trays assembled. The nursing staff were also observed interrupting the tray line throughout the meal service to request missing and special items. Observation at noon revealed the dietary manager informed the cook that Resident # 7 was eating in the main dining room today, where she normally did not eat. The resident was assigned to eat in the auxillary dining room. The dietary manager asked the staff to pull the resident's meal ticket and set up the resident's . lunch tray. Observation of Resident #7 on 12/10/07 at 12:15 p.m. revealed the resident eating soup and drinking lemonade in the main dining room. Observation of the resident at 12:40 p.m. revealed she had covered her entree with her napkin and not eaten any of it. The resident was not cued or assisted to eat and left the dining room at 12:40 p.m. without being offered an alternate meal item. Interview with the dietary manager on 12/10/07 at 12:45 p.m. revealed when residents eat in alternate locations this slows down the tray line and puts the dietary staff behind on getting the trays out timely. Observation of the dinner meal in the auxillary dining room on 12/10/07 at 4:50 p.m, revealed the food cart arrived to the dining room with 18 trays. A second cart arrived at 4:55 p.m. with 8 additional trays. Ten residents and one restorative Certified Nursing Assistant (CNA) was observed in this dining room. A second aide came in to assist with passing the trays. A nurse was not present to supervise. At 5:05 p.m., 13 trays remained on the food cart. The restorative CNA wheeled the cart to the 300/400 unit and left the cart in the hallway. At 5:07 p.m., a CNA who was working on the unit retrieved the empty lateral cart from the auxillary dining room and divided up the trays onto the 2 carts for the 300 and 400 unit. The cart with the trays for the residents on the 400 unit was brought to that hallway and left for the aides on the unit to pass. The last tray was passed on both the 300 and 400 units at 5:15 p.m. Interview with the restorative CNA on 12/10/07 at 5:10 p.m. revealed the residents whose trays were left on the cart were supposed to come to the auxillary dining room so they could be assisted with their meals. The restorative CNA stated the CNA's on the hallways were responsible for ensuring these residents 937 who were now eating in their rooms ‘were assisted and/or cued to eat, Observation after the trays were passed revealed the aides on the floor did not attempt to assist or cue the residents. Observation of Resident # 7 on 12/10/07 at 4:45 p.m. revealed the resident in the auxillary dining room waiting for her dinner meal. At 5:15 p.m, the resident was observed crying at the nurse's station on the 300/400 unit. A CNA wheeled the resident back to the 100/200 unit where she lives. The resident was observed wandering around the unit in her wheelchair from 5:30 to 6:00 p.m. The residents meal tray was not sent to the unit and the resident did not eat any dinner, ; Interview with the nursing staff at 6:00 p.m. revealed they were not informed that the resident had not eaten in the dining room before being brought back to the unit. , Lunch observation in the auxillary dining room on 12/13/07 at noon revealed 19 trays were delivered. Interview with the staff in charge of the dining program on 12/13/07 at 12:00 p.m, revealed 19 residents were assigned to eat in the auxillary dining room at lunch, This dining room is for residents who need cueing to eat, assistance with meals or need to be fed. Four of the 19 resident trays were removed and sent to the hall. Continued interview of the staff in charge revealed if residents do not want to come to the dining room, the hall staff assist the residents. There was no observation of staff attempting to determine why those 4 residents were not in the dining room or follow up to see if they ate. 5. Observation of staff passing snacks on 12/12/07 at 2:00 p.m.and 12/13/07 at 3:00 p.m. revealed a lack of a system to ensure residents received the appropriate food items in accordance with their prescribed diets and texture and fluid modifications when snacks were passed on the units. Nursing staff continued to fail to provide appropriate snack items after they were educated on the snack program on 12/12/07, Observation of the CNA passing snacks on the 200 hall on 12/12/07 at 2:00 p.m. revealed the aide had a tray with packages of graham crackers and a pitcher of apple juice. There was no snack selection for residents on pureed diets or thickened liquids. The aide did not have a diet list to use when passing snacks to _ ensure therapeutic diets were followed, Interview with the CNA on 12/12/07 at 2:00 p.m. confirmed he was not provided with a diet list. The CNA stated, "I know my residents, so I know if they can have this snack." The aide confirmed he did not have any food items to offer to residents on thickened liquids or pureed diets. Staff were re-inserviced on the snack program on 12/12/07. Observation of staff passing out snacks on the 100, 200, 300 and 400 halls on 12/13/07 around 3:00 p.m. revealed a'snack cart with only regular consistency fluids and no thickened fluids. The snacks included pureed pimento cheese, AnD applesauce, bananas, vanilla wafers, cheese and peanut butter crackers, 1/2 tuna sandwiches and animal crackers. The puree snack was blended pimento cheese and bread in a cup. The staff did not have list of resident diets ensuring the residents would receive a correct and safe snack. Interview with a nursing assistant on the 200 hall at this time revealed she had attended the inservice on 12/12/07. She validated she did not follow through with what had been taught. Interview with the Consultant Registered Dietitian (RD) on 12/13/07 at 4:00 p.m. validated the staff should have a diet list io refer to when passing snacks to ensure the diets are followed. 6. Observations in the kitchen on 12/10/07 at 11:15 a.m., 12/10/07 at 12:32 p.m revealed dietary staff did not handle ready-to-eat foods in a sanitary manner and observation on 12/11/07 at 2:20 p.m. revealed dietary staff did not following sanitary procedures for thawing raw chicken and handled clean dishes with unsanitary hands. These poor food handling practices can lead to the development or spread of harmful microorganisms which can cause food borne illness. 7. Observations throughout the 4 days of the survey revealed dietary staff did not following the menus for therapeutic diet extensions, did not consistently preparing or providing food items for high fiber, low fat, consistent carbohydrate, mechanical soft and pureed diets, and did not providing the correct portion sizes for therapeutic diets for 5 of 5 tray lines observed. 8. Resident # 14 was admitted to the facility on 1/29/07 with diagnoses including Stage 5 chronic kidney disease requiring hemodialysis, right hip fracture with hip -prosthesis, hypertension, congestive heart failure, ischemic heart disease, hyperkalemia (elevated potassium level) and a history of a low phosphorus level. Review of the resident's care plan dated 12/4/07 revealed the resident was at high nutritional risk secondary to chronic kidney disease, hypertension and congestive ’ heart failure. The approaches included set up meal tray, weigh weekly for 4 weeks and maintain fluid restriction. Review of Resident # 14's lab data, dated 11/28/07 revealed the resident's potassium level was elevated at 5.4 mmol/L and his phosphorus level was elevated at 8.6. Review of the physician telephone orders dated 12/6/07 revealed the diet was changed to NAS, omit high potassium foods, large portion of meat at meals and a 1500 cc fluid restriction. Review of the 1500 cc fluid restriction allocation between dietary and nursing revealed Resident # 14 was to receive 120 cc (4 ounces) of 2% milk and 120 cc of ao? coffee at breakfast and 240 cc (8 ounces) of 2% milk at lunch and dinner for a total of 720 cc of fluid from dietary. Nursing was to provide 120 cc of fluid 6 times a day with medication pass and 60 cc of fluid with the evening snack for a total of 780 cc. Observation of Resident # 14 at breakfast on 12/12/07 at 7:40 a.m. revealed the resident was served 240 cc of coffee instead of the allocated 120 cc and 120 cc of milk. The resident's meal ticket noted "double meat." The resident was served only 1 hard boiled egg. The meal ticket noted no salty meats. The resident was served bacon. , Interview with the resident, who was alert and oriented, on 12/12/07 at 7:40 a.m. revealed the resident stated he usually gets a “large milk” indicating a 240 cc carton of milk at breakfast. Interview with the dietary manager on 12/12/07 at 11:30 a.m. revealed the nursing staff serves the coffee from a carafe placed on the cart. She stated the nurse's aide should have checked the meal ticket for the allocated amount of fluid prior to pouring the coffee. The dietary manager further confirmed the double meat portion should have been 2 hard boiled eggs and the resident should not have been served bacon. Observation of the resident's room on 12/12/07 at 12:30 p.m. revealed a large banana and a package of Ritz bits mini peanut butter crackers on the resident's bed side table which had been delivered to the resident for a morning snack, Review of the resident's diet restrictions in the dietary computer revealed the resident is not to be served peanut butter, bananas or salty snacks to comply with his potassium and sodium restrictions. Observation of Resident # 14 at the lunch meal on 12/12/07 at 12:30 p.m. revealed the resident eating lunch in the main dining room. The resident was served banana pudding with sliced bananas which was not allowed on his diet. The resident was also served 240 cc (8 ounces) of 2% milk and 180 cc of apple juice. Per the meal ticket the resident was to receive only 240 cc of milk at the meal. Interview with the consultant RD on 12/12/07 at 12:30 p.m. revealed the Certified Nursing Assistants (CNA's) pass out the snacks between meals. She stated she was not aware if the aides had a copy of the diet list so they would know the appropriate foods to offer to residents on therapeutic diets. The RD further confirmed the nursing staff pass the fluids in the dining room and should be aware of the residents who are on fluid restrictions. Interview with the dietary manager further on 12/12/07 at 10:45 a.m. revealed the cooks have a list of high potassium foods which are not allowed on potassium restricted diets. She stated all of these foods are not listed on Resident # 14's meal ticket because the computer system does not allow for adequate space to list all of the restricted items on the meal ticket, The dietary manager stated the list of high potassium foods to avoid is posted on the window of her office and not available on the tray line for access by the staff serving the meal. _ Review of the posted list of high potassium foods to avoid revealed bananas, melon, oranges, orange juice, peaches, dried fruits, nuts, beans and legumes, broccoli, spinach, tomatoes, greens, potatoes, sweet potatoes, french fries, instant potatoes and yams are restricted on this diet. Review of the facility's action plan, dated 12/12/07, revealed to ensure compliance with potassium restrictions for dialysis residents the list of high potassium foods would be available on the tray line and dietary staff would receive in service education from the dietary manager on the foods to restrict on low potassium diets. Observation of the lunch meal tray line on 12/13/07 at 12:45 p.m. revealed the list of high potassium foods had not been provided on the tray line to the dietary staff serving the meal. ’ Observation of Resident # 14's room on 12/13/07 at 6:05 p.m. revealed the resident's 3:00 p.m. labeled snack was on his bedside table. The resident had been provided 240 cc of apple juice with a package of animal crackers. This fluid was not allocated in the resident's fluid restriction from dietary. The resident stated he liked apple juice and was going to drink it before dinner. Observation of Resident # 14's dinner meal tray on 12/13/07 at 6:15 p.m. revealed the resident was served foods not allowed on his diet restrictions including a cheeseburger without double portion of meat, french fries, tomato slices, and 8 ounces of milk. Interview with the unit nurse manager delivering the tray revealed she would return the tray to the kitchen and have it corrected after observing the foods served with the surveyor. The nurse manager returned with a new tray at 6:20 p.m. and stated the RD had set the resident's first tray up in the kitchen and she did not know how he was served the incorrect food items. Observation of the new meal tray on 12/13/07 at 6:20 p.m. revealed the resident was served one hamburger without double meat and 8 ounces of iced tea. The RD noted on the ticket that she had taken the milk off of the tray and instructed the nurse to inform the resident that he was allowed only 1/2 cup of milk per day due to his renal status. The resident had been receiving 2 1/2 cups of milk per day prior to this change by the RD. The tray contained mustard and ketchup packets. The nurse removed the ketchup packet stating this was not allowed on the resident's diet. : 9. Resident # 13 was admitted to the facility on 11/8/07 with diagnoses including pneumonia, congestive heart failure, diabetes, chronic obstructive pulmonary disease, hypertension and chronic renal failure. The resident was prescribed a CCHO, NAS diet with a 2000 ce fluid restriction. Review of the 2000 ce fluid allocation between nursing and dietary revealed the resident was to be provided 360 cc at breakfast and 240 cc at lunch and dinner _ from dietary and 480 cc from nursing on the day shift, 300 cc from nursing on the evening shift and 380 cc from nursing on the evening shift. Observation of Resident # 13 room on 12/10/07 at 10:45 a.m. revealed a large Styrofoam cup of water at the resident's bedside. : Observation of the resident in the main dining room on 12/10/07 at 12:15 p.m. revealed the resident was served a 180 cc bowl of soup. The nurse's aide came by and offered the resident a second bowl of soup. The resident was also served 180 cc of ice tea and 240 cc of coffee. The resident was observed drinking all of the beverages and eating 100% of the soup which provided her with an additional 360 cc of liquids at the meal, There was no designation at the table to indicate the resident was on a fluid restriction and the nurse's aide was not observed with a diet list so she could verify the residents' diets. Observation of Resident # 13 on 12/11/07 at 12:55 p.m. revealed the resident was served 480 cc of fluids instead of the 240 cc allocated for the meal. The resident was served 180 cc of soda, 120 cc of coffee and 180 cc of soup. Observation of Resident # 13 at lunch on 12/13/07 at 12:30 p.m. revealed the resident drinking a 12 ounce can of soda. A second can of soda was on the table. The resident stated she ate 3 bowls of soup. The resident had a polka dot napkin at her place setting. Interview with the nurse monitoring the dining room and the dietary manager on 12/13/07 at 12:30 p.m. revealed a family member had brought the resident the soda and the resident was being non-compliant with her fluid restriction. The nurse stated the resident had been provided one bowl of soup (180 cc) and 180 cc of water from nursing in addition to the soda. The resident's fluid allocation allowed only 240 cc of fluid at lunch. The nurse stated the resident had asked for a cup of coffee but was told she had already been given too much fluid. The nurse did not indicate she was keeping track of the amount of fluid the resident drank at the meal so it could be reported to the resident's nurse to adjust the nursing fluid allotment for the remainder of the day, The dietary manager stated the polka dot napkins had been implemented to alert the nursing staff to the resident's on fluid restrictions on 12/12/07 at part of the action plan to address the dietary issues. Review of Resident # 13's weights revealed an admission weight of 211.8 pounds on 11/8/07 and a weight of 219.2 pounds on 12/8/07, indicative of a 7.4 weight gain ina month. This lack of compliance with the resident's fluid restriction may have contributed to the resident's weight gain. 3 10, Resident # 5 was re-admitted to the facility on 11/16/07 with diagnoses including anemia, emphysema, cancer and coronary artery disease. Review of the clinical record revealed Resident # 5 has been losing weight and fortified foods had been ordered by the physician as well as mechanical soft texture diet. . Observation of Resident # 5's dinner meal on 12/10/07 at 5:50 p.m. revealed the resident was served a regular texture diet including whole kemel corn, No fortified foods were served. Review of the mechanical soft menu revealed residents on this diet were to be served yellow squash at the meal instead of com. * Observation of Resident # 5's breakfast meal on 12/11/07 at 7:30 a.m. revealed the resident was not served any fortified foods. Observation of Resident # 5's dinner meal on 12/13/07 at 6:50 p.m. revealed the resident was served whole sliced marinated cucumbers and no fortified foods. Review of the mechanical soft menu extension for the dinner meal on 12/13/07 revealed residents on mechanical soft diets were to receive finely chopped lettuce, tomatoes, onions and marinated cucumbers with the meal. The resident also received whole grapes as the fresh fruit cup. Review of the diet interpretation list from the clinical guidelines manual, effective 1/06, revealed residents on mechanical soft diets should receive raw vegetables that are finely chopped and canned fruits that are easily masticated. Raw fruits may be served chopped, seeded and pineapple should be avoided. Weights recorded on the RAI (Resident Assessment Instrument) for Resident # 5 indicated the resident weighed 124 Ibs. on 10/31/07 and-115 Ibs. on 11/26/07; a 7.5% weight loss in less than one month. 11. Resident # 6 was re-admitted to the facility on 02/23/07 with diagnoses including CHF (Congestive Heart Failure), HTN (Hypertension) and dementia. Review of the clinical record revealed Resident # 6 has been losing weight and fortified foods had been ordered by the physician. Observation of the Resident # 6's dinner meal on 12/10/07 at 5:30 p.m. revealed the resident was served a regular diet. No fortified foods were served. Weights recorded on the RAT (Resident Assessment Instrument) for Resident # 6 revealed a weight of 129 Ibs. on 09/25/07 and 113 Ibs. on 12/07/07; a 12.4% weight loss in a 3 month period. 12. Resident # 1 was re-admitted to the facility on 04/10/07 with diagnoses including dementia, CVA (Cerebral Vascular Accident) and HTN (Hypertension). Review of the clinical record revealed Resident # 12 has been losing weight and fortified foods had been ordered by the physician. Observation of Resident # 12's dinner meal on 12/10/07 at 5:00 p.m. revealed the resident was served a regular diet. No fortified foods were served. Weights recorded on the RAI (Resident Assessment Instrument) for Resident # 12 revealed weights of 153 lbs. on 07/12/07 and 146 Ibs. on 11/27/07; a 4.5% weight loss in 3 months. 13. Review of Resident # 20's clinical record revealed diagnoses including failure to thrive and depression. Per the diet list dated 12/10/07, the resident is prescribed a regular diet with fortified foods. Observation of Resident #20 at breakfast on 12/12/2007 at 8:15 a.m. revealed the resident did not receive a fortified food. Observation of lunch on 12/13/2007 at approximately 1:00 p.m. revealed the resident was provided whole milk for a fortified food. The resident does not like milk. Special request food items added as part of the nutrition care plan to include a sandwich and pudding at lunch and dinner, were not on resident's tray for lunch or dinner on 12/12/07 at 1:05 p.m. and and 12/13/2007. Observation of the nursing staff at these meals revealed they did not offer the resident those items when they were not provided on the meal trays. Review of the weight record revealed Resident # 20 has had a significant weight Joss of 15.7% in 180 days, decreasing from 116 pounds to 95 pounds. 14, Review of the clinical record for Resident # 22 revealed the resident is on an appetite stimulant and supplements due to a decreased appetite and swallowing ‘difficulties. Current dietary order for this diabetic resident is puree, consistent , carbohydrate (CCHO) diet with fortified foods. Currently her weight is stabilized. The approved fortified food for this resident at lunch is whole milk. Observation of lunch on 12/12/07 at approximately 1:00 p.m. revealed she received 2% low fat milk. 15. Review of the clinical record for Resident #18 revealed a significant weight loss of 11% in the last 180 days, from 105.2 to 95.3 pounds. The resident's diagnoses include history of swallowing difficulties, senile dementia and depression. Resident is on a mechanical soft diet with fortified foods and ice cream is to be served with lunch and dinner to provide additional calories and protein. : Resident did not get a fortified food for breakfast on 12/12/07 at 8:25 a.m. Resident did not get ice cream on her lunch tray on 12/12/07 at 12:15 p.m. Recorded weight in December 2007 is 92 pounds. Resident continues to lose weight and is still on monthly weights. Dietary notes reveal resident likes to snack between meals and likes hot dogs, pizza and toasted sandwiches. None of those foods were offered to the resident during meal and snack observations for the 4 days of the survey. Lack of provision of the resident's fortified foods and high calorie items added per _ the resident's nutrition care plan and not honoring resident food preferences has the potential to contribute to the resident's weight loss. 16, Observation of the dinner meal on 12/13/07 at 5:30 p.m. revealed Résident # 26 is prescribed a 1200 cc fluid restriction. The resident's meal ticket indicates the resident is to be served 240 cc of unsweetened tea with the dinner meal. Observation of the resident on 12/13/07 at 5:30 p.m. and 5:40 p.m. revealed the resident was served 180 cc of water before the meal and 240 cc of tea with the meal. The resident was observed in the auxiliary dining room where staff was offering pre-meal drinks to all of the residents without a diet list to reference. 17, Observation of Resident # 27 on 12/13/07 during dinner at 6:45 p.m. revealed the resident was to receive a pureed diet with fortified foods. The meal ticket noted the resident was lactose intolerant and avoided milk products, Lactaid milk was allowed, Observation of the resident's dinner tray on 12/13/07 at 6:45 p.m. revealed the resident was served regular chicken noodle soup. There were large noodles as well as pieces of chicken present in the soup. This was brought to the attention of the nursing staff just before the resident was going to eat the soup and it was removed from her tray. The resident was not served a fortified food on her meal tray. ‘ Interview with nursing staff at this time revealed the resident should have received the cream of mushroom soup which was the fortified food item but served chicken noodle due to the resident being lactose intolerant. The staff stated they did not know why the soup was not provided in a pureed version. Observation Resident # 27 on 12/13/07 at 7:00 p.m. revealed the staff person returned with a bow! of tomato soup. The staff were questioned whether the tomato soup contained milk or lactose. The staff person and nurse stated they didn't know and served the soup to the resident without checking with the litchen. 18. Observation of the dinner meal service on the 400 hall on 12/13/07 at 7:15 p.m. revealed Resident # 28 was prescribed a low residue diet with no milk or milk products. The resident was served orange sherbet on her tray. Review of the label revealed it contained milk. The nursing staff were not aware this was not allowed on the resident's diet, When the tray was pulled from the cart to be checked by the nurse, she stated the tray was correct because it didn't contain ice cream. 19, Observation of the dinner meal on 12/10/07 at 5:25 p.m. revealed the cook had not made the fortified soup for the meal per the fortified food/super food rotation schedule, All residents prescribed fortified foods did not receive a fortified food for the meal including 23 residents prescribed fortified foods including 7 sampled resident (#'s 5, 6, 12, 15, 16, 18 and 20), 2 extended sampled residents (#'s 22 and 25) and 1 (#27) random sampled resident. Interview with the dietary manager on 12/10/07 at 5:45 p.m. confirmed the fortified soup was not made tonight. The cook only prepared chicken noodle soup. Review of the fortified food/super food rotation list available in the kitchen did not match the rotation list being used by nursing which was provided to nursing and dietary staff during in-service education in 7/07. The rotation list in the kitchen stated to serve 8 ounces of whole milk in place of 2% milk. The rotation list provided with the in-service noted to allow 8 ounces milk, whole chocolate or thickened. Observation of the facility's chocolate milk revealed it was low fat but provided adequate calories and protein to meet the requirements of a fortified food for this program. Interview with dietary staff on 12/10/07 at noon revealed they were serving whole white milk to all residents on fortified foods: The staff was not aware that chocolate milk was allowed. Review of a memo dated 5/30/07 revealed a change to the fortified food program. The memo stated, "To identify a tray with fortified foods there would be a colored napkin. To identify the food item that is the fortified option it will be in a‘green bowl. This will allow the staff to easily identify what food item will provide the most nutrition for the resident. These of course should be highly recommended to the resident." Observations on 12/10/07 and 12/11/07 at lunch from 11:50 a.m. to 1:00 p.m. revealed the fortified food was not put in a green bowl and residents were not consistently provided with red napkin to alert the staff that the resident received a fortified food. Observation of the breakfast meal on 12/12/07 from 7:15 a.m. to 8:30 a.m. revealed the fortified cereal was riot consistently provided in a green bowl. Observation of the dinner meal on 12/10/07 at 5:00 p.m. in the auxiliary dining room revealed the dietary staff served resident's on fortified foods both a carton of whole milk in a green bow] and a container of low fat chocolate milk if it was a food preference on the resident's meal ticket. Interview with staff on 12/12/2007 at 7:25 a.m. revealed the following: -A nurse on the 300 hall did not know what the red napkin on the tray signified. One nursing assistant did not know what a fortified food was. When asked what a fortified food may be stated some grapes or a banana. -A nursing assistant from the 400 hall knew the fortified program involved a red napkin and a green bowl but did not know what the fortified food was, -A nursing assistant on the 200 hall knew about a red napkin but was not aware the food in a green bowl was fortified. _-A nursing assistant on the 100 hall knew the red napkin meant a fortified food was on the tray but was not aware it was served in a green bowl. Interview with the restorative CNA on 12/13/07 at noon revealed she was not aware of which food on the meal tray was the fortified food for the meal. She stated she thought the fortified foods served were mashed potatoes, whole milk and cream soup. The restorative aide stated, "They don't make fortified mashed potatoes anymore?" Random observation on 12/13/07 at noon of a resident at the restorative table revealed the resident was not served whole milk on her meal tray. She was served low fat chocolate milk. The restorative CNA stated she was not aware that the low fat chocolate milk was allowed on the Special Nutrition Program (SNP). Interview with the unit nurse manager for the 300/400 unit on. 12/13/07 at noon revealed she had conducted in-service education with her staff including the restorative CNA's on 7/11/07. She stated the program allowed whole white milk, low fat chocolate milk and thickened milk because the calories and protein were equivalent. She stated she did not know why the restorative staff did not know what was allowed on the SNP program. Interview with the dietary manager on 12/13/07 at 12:35 p.m. revealed the facility used to have a variety of fortified foods to offer residents such as fortified potatoes and fortified pudding, but they were instructed to switch to the Special Nutrition Program (SNP) which provided only super cereal, milk and super cream soup daily. The dietary manager stated this was due to budgetary constraints. The dietary manager confirmed there were no other fortified foods available to serve to resident who did not like milk or super cereal. Review of the SNP in-service materials, dated 7/11/07, revealed instructions on how to obtain an order and document substitutions for residents who disliked hot cereal and milk and which SNP foods to provide to replace the calories and protein provided by these fortified foods. Observations throughout the 4 days of the survey revealed dietary and nursing staff was not implementing these substitutions as outlined in the SNP plan. 20. Observation of the lunch meal tray line on 12/10/07 at 12:40 p.m. revealed a . randomly observed resident prescribed a high fiber diet was given a slice of wheat bread that was not 100% whole wheat. The resident's tray ticket noted "wheat bread" as the high fiber food to add to the tray. The resident also received cooked peas. Interview with the dietary manager on 12/12/07 at 10:45 a.m. confirmed there is not a menu extension for the high fiber diets. The manager stated residents are given wheat bread and bran cereal for additional fiber. She could not explain how much total fiber was provided on the high fiber diet. The dietary manager showed the surveyor the wheat bread being used for this diet. Review of the label with the manager revealed the bread was "honey wheat bread" with 1 gram of fiber per slice. The manager stated she was not aware that this was not 100% whole wheat bread and not a high fiber food. Review ofthe facility's approved diet manual revealed the facility was using an out dated version of the Florida Dietetic Association Medical Nutrition Therapy Manual from 2000 and not the current 2005 manual to ensure the most current medical nutrition therapy practices were implemented. Review of the facility's approved diet manual revealed residents on high fiber diets should receive 25-35 grams of fiber a day. This affects 2 random residents prescribed high fiber diets. 21. Observation of the breakfast meal tray line on 12/12/07 at 7:15 a.m. revealed there was no egg substitute on the steam table to serve to residents on low fat _diets. The cook was observed serving regular scrambled eggs or hard boiled eggs to residents on low fat diets. Review of the low fat menu extension revealed residents were to be served a #16 scoop (1/4 cup) of egg substitute. Interview with the dietary staff working on the tray line on 12/12/07 at 7:30 a.m. confirmed she did not have egg substitute to serve on the low fat diets. The employee stated, "They don't order it." The dietary staff person further stated, "Frequently don't have the food to make the menu. We do the best with what we have." Interview with the dietary manager on 12/12/07 at 10:45 a.m. confirmed egg substitute was not ordered and kept in stock for the low fat diets as noted on the menu extension. She stated the RD had told her these residents could have regular eggs 3 times a week. When asked for the written policy, the dietary manager stated they did not have this in writing. She confirmed the low fat/low cholesterol menu extension had not been changed to reflect this policy. Observation of the lunch meal tray line on 12/13/07 at 12:30 p.m. revealed residents were to be served 2 ounces of baked chicken with 1 ounce of low fat gravy. Observation of the chicken revealed it had been baked but the cook confirmed she had not prepared the low fat gravy. A # 16 scoop was not on the line to serve the correct portion size of cornbread dressing for residents on low fat diets. This affects 3 random residents prescribed low fat diets 22. Observation of the lunch meal tray line on 12/10/07 at 11:50 a.m. revealed the residents on consistent carbohydrate (CCHO) diets were served skim milk and applesauce for dessert. Review of the approved menu for Monday, Week 2 revealed residents on CCHO diets weré to receive 2% milk and the regular cranberry square dessert. Interview with the dietary aides at this time revealed they serving these foods because the residents were "diabetic." Observation of the evening meal on 12/10/07 at 4:50 p.m. revealed residents on CCHO diets were served ambrosia. Review of the approved menu revealed residents were to be serve 1/2 cup of mandarin oranges. Interview with the dietary staff on 12/10/07 at 5:45 p.m. revealed the mandarin oranges had not been prepared for the meal, Observation of the lunch meal tray line on 12/13/07 at 12:30 p.m. revealed residents on CCHO diets were served a plain piece of cake without frosting, The menu indicated the residents were to be served the regular applesauce cake. Per the approved menu, the residents on CCHO diets were to receive the regular applesauce cake. Per the diet aide, the residents on the CCHO diet were being served a plain piece of diet cake without frosting. Review of the diet interpretation list from the clinical guidelines manual, effective ‘ 1/06, revealed the CCHO diet is a regular diet with a consistent amount of carbohydrates served throughout the day. "Sweet" desserts are served one time a day in the same portion as the regular diet. These practices affected all residents prescribed CCHO including 4 active sampled residents (#'s 4, 7, 10 and 13) and 3 extended sampled residents (#'s 22, 23 and 24). Observation of Resident # 7 tray ticket on 12/10/07 at noon revealed the resident was on a CCHO diet. The resident's tray ticket indicated "may have sweet desserts" due the resident experiencing significant weight loss. The staff served the resident applesauce instead of the cranberry square. Review of Resident #7's telephone orders revealed the physician ordered to “liberalize sweet intake" due to weight loss and poor appetite on 10/25/07. Observation of the resident’s prescribed CCHO diet with fortified foods on 12/10/07 at 11:50 a.m. revealed these residents were served skim milk instead of the whole milk noted on the fortified food rotation list. Another fortified food was not provided to any of these residents. This affected 4 residents prescribed CCHO diets with fortified foods including extended sampled Resident # 22. 23. Observation of the lunch meal tray line on 12/10/07 at 11:50 a.m. revealed the cook was using a #24 (2 2/3 T) scoop to serve the pureed bread instead of the # 12 (1/3 cup) noted on the approved menu. This portion size was served to all residents on pureed diets except one randomly observed resident who did not receive any pureed bread at all. All residents on pureed diets were also served applesauce for dessert. The menu indicated the residents were to be served pureed cranberry square. Interview with the diet aide on 12/10/07 at 12:15 p.m. revealed the pureed dessert had not been prepared for the meal. Observation of the dinner meal service on 12/10/07 at 4:50 p.m. in the auxiliary dining room revealed residents on pureed diet were not served gravy on their food and residents were served pureed corn which had pieces of cor kemels throughout the food product. Review of the approved menu revealed residents were to receive | ounce of gravy on the:pureed meat loaf, 1 ounce of gravy on the mashed potatoes and pureed yellow squash Interview with cook on 12/10/07 at 5:45 p.m. revealed she was not serving gravy on the pureed foods. The cook stated she was not aware that she needed to make pureed yellow squash and confirmed the pureed corn was not prepared to the proper consistency. The cook further confirmed she had gravy on the steam table but was not serving it to residents on pureed diets. Observation of the lunch meal tray line on 12/13/07 at 12:30 p.m. revealed the cook was serving the incorrect portion size for the pureed meat. The cook was using a # 12 scoop (1/3 cup) instead the # 8 (1/2 cup) portion listed on the pureed diet extension. The cook was also serving a 2 ounces ladle of gravy instead of using a # 30 (2 T) scoop as noted on the menu. This affected 13 residents prescribed pureed diets including 1 active sampled resident (# 15), 1 extended sampled resident (# 25) and 1 (#27) random sampled resident. ~ 24. Observation of the dinner meal service on 12/10/07 starting at 4:50 p.m. revealed all residents on mechanical soft diets were served whole kernel corn. This affected 24 residents prescribed mechanical soft diets including 2 active sampled residents (#'s 5 and 18) and 1 extended sampled resident (# 24). She confirmed the pureed corn was not prepared to the proper consistency. The cook further confirmed she had gravy on the steam table but was not serving it to residents on pureed diets. Observation of the tray line and interview with the cook on 12/10/07 at 5:45 p.m. revealed the cook had not prepared the seasoned yellow squash as noted on the menu for mechanical soft diets. The cook stated she knew corn was not allowed on mechanical soft diets. Interview with the dietary manager on 12/10/07 at 5:45 p.m. confirmed she had reviewed the menu with the cook prior to the meal and told her to prepare the yellow squash. She stated the cook had "no excuse" for not preparing the foods for the therapeutic diets. 25, The dietary department was using an outdated version of the Florida Dietetic Association Medical Nutrition Therapy Manual from 2000 and not the current 2005 manual to ensure the most current medical nutrition therapy practices and current therapeutic diets were implemented. 12. That these actions or inactions of the Respondent are a failure to provide adequate and appropriate health care and protective and support services entrusted to the Respondent’s care and is contrary to law. 13. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 14. The Agency provided Respondent with the mandatory correction date for this deficient. practice of January 5, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT DI 15. The Agency re-alleges and incorporates Counts I and II of this Complaint as if fully set forth herein. 16. Respondent has been cited for two (2) State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes (2007). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of $6,000.00 against Respondent, a skilled uursing facility in the State of Florida, pursuant to Section 400,19(3), Florida Statutes (2007). COUNT IV 17. The Agency re-alleges and incorporates Counts 1 and II of this Complaint as if fully set forth herein. 18. Based upon Respondent’s two cited State Class I deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2007). WHEREFORE, the Agency intends to assign a conditional licensure status to . Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2007) commencing December 13, 2007. We CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I, II, If, and Count ‘; . ) (B) Recommend administrative fines against Respondent in the amount of $30,000 for Count I and Count I; (C) Assess attorney’s fees and costs; and (D) Grant all other general and equitable relief allowed by law. Respondent is notified that il 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter, RESPONDENT 1S FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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. Respectfully submitted this a day of January, 2008. yA fo ihe ; Wlaukt stetley Mark Hinely ” Fla. Bar. No.pending Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE IL HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7004 2890 0000 5526 7957 to: Facility Administrator Ruth Bentley, St. Andrews Bay Skilled Nursing and Rehabilitation Center, 2100 Jenks Avenue, Panama City, Florida 32405, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 : 7964 to: Owner Pinnacle Health Facilities XXIV, LPO, 5420 W. Plano Parkway, Plano, Texas 75093, and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 7971 to Registered Agent Capitol Corporate Services, Inc., 155 Office Plaza Drive, Suite A, Tallahassee, Florida 32301 on January “2°, 2008: Maske Mindy Mark Hinely * Copy furnished to: Barbara Alford, FOM 329

Docket for Case No: 08-000619