Mar 3 2010 15:14 63/83/2818 15:09 8569210158 PAGE 15/53 STATE OF FLORIDA ) 0 ~ | 24 AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Nos. 2010001105 (Fines) 2010001113 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC, 2010001111 (Revoc.) d/b/a Capital Healthcare Center, Respondent f ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Admumustration (hereinafler “Ayency”), by and through the undersigned counsel, and files this Administrative Complaint against CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a Capital Healthcare Center (hereinafter “Respondent’’), pursuant to §§120 569 and 120 57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate a nursing home in the State of Florida pursuant to §§ 400.121(1)(a) and 408 815(1)(b) and (1)(d), Flonda Statutes (2009), nnposce an administrative fine of twenty thousand dollars ($20,000) based upon the citation of four (4) Class II deficiencies pursuant to §§400.102(1) and 400.23(8)(b), Florida Statutes (2009). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing January 15, 2010 JURISDICTION AND VENUE 1. The Agency has junsdiction pursuant to §§ 120.60, Florida Statutes, Chapter 400, Part If and Chapter 408, Part II, Florida Statutes (2009), and Chapter 59A-4, Flonda Administrative Code. Mar 3 2010 15:14 @3/03/2018 15:89 8589210158 PAGE 16/53 2 Venue les pursuant to Rule 28-106 207, Florida Admimstrative Code 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 Ommibus Reconcihation Act of 1987, Title IV, Subtitle C (as amended), Chapters 400, Part II, and 408, Part I, Florida Statutes, and Chapter 59A-4, Flonda Administrative Code. 4. Respondent operates a 156-bed nursing home, located at 3333 Capital Medical Blvd, Tallahassee, Florida 32308, and is licensed as a skilled nursing facility (license number 1073096). 5. Respondent was at all tunes material hereto, a hcensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable miles, and statutes. COUNTI 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. Florida law provides the following: Rule 594-4.109(1), F.A.W, “(1) Each resident admitted to the nursing home facility shall have a plan of care The plan of care shall consist of (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A preliminary nursing evaluation with physician’s orders for immediate care, completed on admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and 1s completed with 14 days of the resident's admission to the facihty and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, Mar 3 2010 15:14 63/83/2010 15:89 8569210158 PAGE 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment 8. The Agency conducted an unannounced annual hcensure survey and complaint survey (CCR 2010000090) starting January 11, 2010 and ending January 15, 2010 9. Based on observation and interview the facility failed to ensure 2 of 19 residents were accurately assessed. Resident #10 was not assessed for complications related to the indwellng Foley catheter, which resulted in actual harm. Resident #28 a dependent resident was not assessed for care needs related to monthly menstrual cycle The findings regarding Resident #10 mclude: 10.‘ That resident #10 bad a tear starting at the meatus where the catheter tubing was inserted and extends down the posterior side of the penis 3 centimeters long and 1 centimeter wide. 11. That the wound appeared to be recent, fresh bnght red blood was noted on the outside of the catheter tubing. The resident was also noted to be grimacing and stated, " Oh, that hurts. " 12 That the Foley catheter tubing was not anchored to prevent tugging, pulling, or tearing to the meatus 13. That on 1/13/10 at 12:00 p.m. an interview was conducted with resident #10. 14. That the resident stated that the tear to his penis has not always been there, but has only been there for about | or 2 months 15 That on 1/13/10 at 1 00 p.m. an interview with the nurse caring for resident #10 was done 17/53 Mar 3 2010 15:15 83/83/2018 15:89 8589210158 PAGE 16 That the nurse stated during this interview " the resident has always had the split in his penis and that the resident had redness to his pems when he returned from the hospital on 11/24/09." 17. That the nurse also stated the resident's wound care was started on 12/22/09. 18. That on 1/13/10 at 1.10 p.m. an interview with the wound care nurse was conducted. 19. That the wound care nurse stated, "J have not seen the resident's wound". 20 That the wound care nurse stated that she became aware of the wound to the resident's penis when the surveyor started asking questions 21. That on 1/13/10 at 2:00 p.m an interview was conducted with the aide canng for resident #10 22. That dunng this interview the aide stated that she has been caring for resident #10 for about 6 months now and that, “the resident's tear to his penis has not always been there, it has only been there for about a month or two." 23. That the aide also admitted that she had not reported the tear/wound to anyone. 24. That on 1/13/10 a record review revealed that the tear to resident #10's meatus was found on 12/22/09 at 1 15 am 25. That the"Weekly Skin Sweep" assessment dated 11/27/09 thru 1/8/10 does not show the tear to the resident's meatus. 26 That the "Weekly Skin Sweep" assessment only has documentation stating, " No new skin impairment " 27. That there 1s no care plan noted in resident #10's medical record addressing the tear/ wound to the resident's meatus. Mar 3 2010 15:15 63/83/2818 15:89 85892148158 PAGE 19/53 28 That there ts no evidence in resident #10's medical record that the resident's physician has been notified of the tear/wound to resident's penis Findings regarding Resident #28 include: 29. That an interview was conducted with resident #28 on 01/13/2010 at approximately 11:30 a.m. 30 That the resident stated that she was having her menstrual cycle at that time. 31. That the resident further stated that staff did nothing special when she had her monthly period 32 That the resident also stated she wears a buef all of the ume, and staff just used the same bnef even when she was having her monthly period 33. That the interview was continued with resident #28 on 01/15/2010 at approximately 9:45 am 34. That the resident stated sanitary pads have never been used since being in the facility during her menstruation cycles. 35, That the resident states staff just offered her pads yesterday, and she refused. 36. That an interview was conducted with the Unit Nursing Manager for B-wing on 01/14/2010 at approxumately 4:20 pm 37. That the nurse admitted not being aware of the resident having a menstrual cycle at this time. 38 That the nurse was asked how the monthly menstruation cycles for resident #28 were tracked and monitored Mar 3 2010 15:15 @3/03/2818 15:89 8589210158 PAGE 28/53 39. That the nurse could not state what assessment measures were in place to track and monitor menstruation cycles for beginning dates, length of cycle, heaviness of the cycle, or complications of the cycle 40. That the nurse further stated the cycle should be tracked in charting. 4) That a record review of the assessment information for this resident was conducted on 08/15/2010 at approximately 8:50 a.m 42 That the review of assessment information reveals no mention of assessing, tracking, recording of menstruation cycles for this resident. 43. The above findings reflect Respondent's failure to ensure that 2 residents were accurately assessed, thus the Respondent's actions constituted an isolated Class il deticiency, pursuant of § 400.23(8)(b), Flonda Statutes(2009). 44, The Agency provided Respondent with the mandatory correction date for this deficient practice of February 15, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nuysing facility in the State of Flonda, pursuant to § 400 23(8)(b), Flonda Statutes (2009). COUNT MI 45 The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count J of this Complaint as if fully set forth herem 46. Florida law provides the following Rule 59A-4.109(2), F.A.W., “The facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be Mar 3 2010 15:15 63/03/2010 15:09 8589218158 PAGE 21/53 completed within 7 days after completion of the resident assessment 47 The Agency conducted an unannounced annual licensure survey and complaint survey (CCR 2010000090) starting January 11, 2010 and ending January 15, 2010 48. Based on observations, staff interviews and record review, the facility failed to develop and ensure resident care plans were comprehensive tv address all assessed risk factors and included specific information or instruction in the areas of, personal hygiene,( Resident #28) skin integrity, anchoring, and preventing injury for resident with indwelling Foley catheters for 2 of 6 sampled residents (# 's 10, and 92) with Foley catheter's. This resulted in actual harm to resident #10. Findings for Resident #92 include the following: 49 That an observation of indwelling Foley catheter care was observed on 01/13/2010 at approximately 10:50 am. SO. That when the aide removed the blankets, and pulled the gown up to expose the area of the body upon which catheter care would be performed, it was observed that the Foley catheter tubing was laying under the nght leg of the resident. 51. That when the aide moved the catheter tubing to a position that it could be accessed for cleaning, the tubing was noted to not have been anchored (secured) to the resident's body to prevent the catheter tubing from being accidentally pulled resulting in accidental removal of the catheter, or causimg pain or mjury to the resident 52. That when the aide completed the catheter carc, it was noted that the aide did not secure (anchor) the Foley catheter to the bodv of the resident prior to transfernng the resident from the bed to the wheelchair using a mechanical lift. 53. That the plan of care was reviewed on 01/13/2010 at approximately 11:13 am. Mar 3 2010 15:16 03/83/2818 15:89 8509210158 PAGE 22/53 54 That a plan of care was developed on 10/14/2009 due to the resident having an indwelling Foley catheter, with a diagnosis of neurogenic bladder, and 1s at msk for complications related to infections and complications of an indwclling Foley catheter. 55. That approaches were identified in the plan of care as follows: e Foley catheter bag and tubing to bedside drainage to promote optumal drainage. * Change Foley per physician orders. ¢ Monitor for signs and symptoms of infections. « Arrange for Urology appointments as ordered and indicated - Provide incontinence care and Foley catheter care every shaft and as needed, using soap and water. ¢ Assist with toileting needs as needed, and check every 2 hours for toileting needs. 56. That the plan of care did not provide for interventions (approaches) to take to prevent accidental injury or pain from the indwelling catheter tubing, or accidental removal of the Foley catheter 57 The above findings reflect Respondent’s failure to develop and ensure resident care plans were comprehensive to address all assessed risk factors and included specific information or instructions, thus the Respondent's actions constituted an isolated Class IJ deficiency, pursuant of § 400 23(8)(b), Florida Statutes (2009) 58 The Agency provided Respondent with the mandatory correction date for this deficient practice of February 15, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Floiida, pursuant to § 400.23(8)(b), Florida Statutes (2009) Mar 3 2010 15:16 03/83/2818 15:89 8599210158 PAGE 23/53 59. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count J and IJ of this Complaint as if fully set forth herein. 60 Florida law provides the following Section 400.022(1)(I), F-S.,“ All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement The statement shall assure each resident the followmg: (1) The right to receive adequate and appropmate health care and protective and support services, wcluding social services; mental health services, if available; planned recreational activities, and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency Section 766.102(1), F.S., “The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in hight of all relevant surrounding circumstances, 1s recognized as acceptable and appropriate by reasonably prudent similar health care providers Section 464.003(3)(a), F.S., “Practice of professional nursing” means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social! sciences which shall include, but not be limited to’ 1. The observation, assessment, nursing diagnosis, planning. intervention, and evaluation of care; health teaching and counseling of the all, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of ulness of others. 2. The administration of medications and treatments as prescribed or authonzed by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing” means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infin and the promotion of weliness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a hcensed podiatne physician, or a licensed dentist Mar 3 2010 15:16 63/03/2818 15:89 8589218158 PAGE 24/53 61. The Agency conducted an unannounced annual licensure survey and complaint survey (CCR 2010000090) starting January 11, 2010 and ending January 15. 2010. 62. That a review of the facility ‘s policy and procedure for catheter care was done on 14/10. 63. That the facility's policy and procedure stated To provide safe and proper care of a resident/patient with an indwelling catheter by evaluating elimination status, minimizing risk of bladder intection, and maintamming skin integrity. Indwelling: © Check that the catheter 1s attached to the thigh or abdomen (male), or as ordered. e Mayntain catheter anchor to prevent excess tension * Monitor for cathcter complications that may result from, but are not limited to ® Obstruction * Catheter encrustation e Urethral erosion ¢ Bladder spasms * Hematuria e Leakage around catheter e Notify the physician of any changes or concems. 64. The above findings reflect Respondent’s failure to follow professional standards of nursing, thus the Respondent’s actions constituted an isolated Class If deficiency, pursuant of § 400.23(8)(b), Florida Statutes(2009). 65 ‘The Agency provided Respondent with the mandatory correction date for this deficient practice of February 15, 2010. Mar 3 2010 15:16 63/03/2818 15:89 8589218158 PAGE 25/53 WHEREFORE, the Agency intends to impose an admuinisiraive fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Flornda, pursuant to §400 23(8)(b), Florida Statutes (2009) COUNT IV 66 The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I, H, and UI of this Complaint as if fully set forth herein. 67 Florida law provides the following Section 400.102, F.S.,: In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materialiy affecting the health or safety of residents of the facility, 68. That based on observation, record review, resident and staff interview, the facility failed to assess, care plan or provide care and services consistent with currently accepted practice and facility policy related to the use of indwelling Foley catheters for 4 of 6 sampled residents with Foley catheter's. (#510, 54, 92, and 180) This resulted in hann to | resident #10. The findings regarding Resident #54 inchude: 69. That Resident #54 was readmitted on 8/4/09 with a diagnosis of renal insufficiency among others. 70. That the resident was readmitted with an indwelling Foley catheter for the treatment of urinary retention with kidney myury 71 That on 1/13/10 at 9 05 AM, catheter care of resident #54 by a certified nursing assistant (CNA) was observed. Mar 3 2010 15:1? 03/03/2018 15:89 8589218158 PAGE 26/53 72 That a wash cloth was used to clean the resident's entire perinea area before wiping the tubing with the same wash cloth. 73 That the catheter was connected directly to a leg bag strapped to left thigh. The catheter was not taped or strapped to resident's skin 74. That on 1/14/10 at 8:40 AM, observation of the resident after AM shift catheter care revealed the residcnt's catheter was not attached to the body. 75 That the CNA that performed the AM catheter care stated, "I don’t tape it because it makes it harder when we switch over to the regular bag and I am really careful not to pull on the catheter.” The resident agreed that this CNA 1» very careful but others are not and sometimes the catheter gets pulled causing discomfort 76 That a review of the facility policy for catheter care revealed item #16 "Check that the catheter is attached to the thigh or abdomen (thigh), or as ordered. Maintain catheter anchor to prevent excess tension ” The findings regarding Resident #180 inchude: 77. That resident #180 was readmitted on 1/7/10 with a diagnosis of stage 3 ulcer to the sacrum among other diagnoses after an initial admission of 10/23/09 78. That the resident had an indwelling Foley catheter for the protection of that ulcer. 79. That on 1/14/10 at 5:25 PM, an observation of resident #180 was made. The observation was made with a staff nurse in attendance. 80 ‘That the indwelling Foley catheter was not secured to the skin 81. That there was a foam strap around the left thigh just ahove the knee The strap was loose and allowed lateral and forward and backward movement of the catheter 82. That the staff nurse agreed that the catheter could be tugged. Mar 3 2010 15:1? €3/83/2018 15:89 8589218158 PAGE 27/53 83 That the C-wing unit manager was advised of the obscrvaton by the staff nurse 84 That on 1/15/10 at 3:50 PM, the resident stated that during care, the catheter sometimes gets tugged causing discomfort 85 That a review of the facility policy for catheter care revealed item #16 Check that the catheter 1s attached to the thigh or abdomen (thigh), or as ordered Maintain catheter anchor to prevent excess tension 86. The above findings reflect Respondent’s failure to assess, care plan or provide care and services consistent with currently accepted practice and facility policy, thus the Respondent’s actions constituted an isolated Class II deficiency, pursuant of § 400 23(8)(b), Florida Statutes(2009) 87 The Agency provided Respondent with the mandatory correction date for this deficient practice of February 15, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to §400.23(8)(b), Florida Statutes (2009) COUNT V 88 The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count J, ILI and IV of this Complaint as 1f fully sct forth herein 89. Based upon Respondent’s cited State Class Il deficiencies, it was not m substantal compliance at the time of the survey with criteria established under Part IJ of Florida Statute 400, or the mules adopted by the Agency, a violation subjecting it (vo assignment of a conditional licensure status under § 400 .23(7)(b), Florida Statutes (2009) WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, Mar 3 2010 15:17 63/83/2018 15:89 8509210158 PAGE 28/53 a nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2009) commencing January 15. 2010 (Exhibat 1). COUNT VI 90. The Agency re-alleges and corporates paragraphs one (1) through five (5), and Count IJ, II, UM, IV and V of this Complaint as if fully set forth herein. 91 The Agency may revoke any license under § 408 815(1)(b) and (1)(d). 92 Florida law provides the following Section 408.815(1)(b) and (d), F.S., (1) In addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownershyp application include any of the following actions by a controlling interest: (b) An intentional or neghgent act matenally affecting the health or safety of a client of the provider. (d) 4 demonstrated pattern of deficient performance 93. The Agency may revoke any license under § 400.121(1)(a). 94 Florida law provides the following: Section 400.121(1)(a), F.S., (1) The agency may deny an application, revoke or suspend a license, and impose an admimistrative fine, not to exceed $500 per violation per day for the violation of any provision of this part, part Il of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest (a) A violation of any provision of this part, part II of chapter 408, or applicable rules 95 That as set forth herein above, the Respondent has violated provisions of Chapter 400, Florida Statutes 96 That on or about May 10, 2002, the Agency issued an Administrative Complaint (Agency Case Nos. 200201542] and 2002021061) which cited Respondent for two Class Il Mar 3 2010 15:17 03/03/2018 15:89 8509210158 PAGE 29/53 deficiencies. A true copy of said complaint is attached hereto as Exhibit 2 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein 97. That on or about February 14, 2005, the Agency issued an Administrative Complaint (Agency Case No 2004011570) which cited Respondent for a Class II deficiency. A true copy of said complaint is attached hereto as Exhibit 3 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein 98 That on or about January 6, 2006, the Agency issued an Administrative Complaint (Agency Case Nos. 2005008392 and 2005008394) which cited Respondent for a Class II deficiency. A true copy of said complaint 1s attached hereto as Exhibit 4 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein 99 That on or about May 7, 2008, the Agency issued an Admuinistranve Complaint (Agency Case Nos. 2008005347 and 2008005348) which cited Respondent for two Class I deficiencies. A true copy of said complaint is attached hereto as Exmnbit 5 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein 100. That on April 11, 2008, the Agency issued an Emergency Order of Immediate Moratorium on Admissions (Agency Case No 208004593) for violating 400 102(1) F.S. (2007). A true copy of said complaint is attached hereto as Exhibit 6 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein 10). That on or about April 20, 2008, the Agency issued an Administrative Complaint (Agency Case Nos 2009002735 and 2009002736) which cited Respondent for a Class I deficiency. A true copy of said complaint is attached hereto as Exhibit 7 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein. 102. That on or about November 17, 2009, the Agency issued an Administrative Mar 3 2010 15:18 3/83/2818 15:89 8509210158 PAGE 30/53 Complaint (Agency Case Nos. 2009006274 and 2009006277) which cited Respondent for a Class I deficiency A tme copy of said complaint is attached hereto as Exhibit 8 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein. 103. That on or about December 8, 2009, the Agency issued an Admunistrative Complaint (Agency Case Nos. 2009008506, 2009008508 and 2009008509) which cited Respondent for three Class II deficiencies. A true copy of sad complamt is attached hereto as Exhibit 9 and the allegations set forth therein are re-alleged and incorporated as if fully set forth herein. 104. That the deficiencies set forth in paragraph 96 through 103 together with the deficiencies cited herein demonstrates a pattem of deficrent performance WHEREFORE, the Agency intends to revoke the license of the Respondent to operate a nursing home facility in the State of Flonda, pursuant to §§ 400.121(1)(a) and 408.815(1)(d), Florida Statutes (2009) CLAIM FOR RELIEF WHEREFORE, the State of Flonda, Agency for Health Care Adminstration, respectfully requests that this court: (A) Make factual and lzgal findings in favor of the Agency on Count I, Uy, IN, IV, V and VI, (B) Recommend an administrative fine against Respondent in the amount of $20,000; (C) Assign a conditional licensure status commencing January 15, 2010, (D) Assess attomey’s fees and costs, and (E) Grant the revocation of Respondent’s license number 1073096, (fF) Grant all other general and equitable relief allowed by law. Mar 3 2010 15:18 83/83/2818 15:89 8509216158 PAGE 31/53 Respectfully submitted February 5 , 2010. BME LG. D. Carlton Entineer Fla Bar.0793450 Agency for Health Care Admin 2727 Mahan Drive, MS #3 Tallahassee, Flonda 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE I CERTIFY that a copy hereof has been fumished to Thomas L McDamel, Administrator, Caputal Healthcare Centcr, 3333 Capital Medical Blvd., Tallahassee, Florida 32308, by US. Certified Mail, Retum Receipt No. 7004 2890 0000 $526 4888 and to Anna Small, Esq., Broad and Cassel, counsel for Respondent, at 215 South Monroe Street, Suite 400, Tatlahassee, FL iad 32301, by email and U S Mail on February 2. 2010. D. Carlton Enfinger Mar 3 2010 15:18 83/83/2810 15:09 8569210158 PAGE 32/53 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST THOMAS W ARNOLO GOVERNOR SECRETARY February 2, 2010 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator: The attached license with Certificate #16167 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information 1s correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Healih Care Adminsstration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Bunlding 3 Tallahassee, Florida 32308 Issued for status change to Conditional. Sincerely, Sulsatnarspoen Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management FLORIDA 2727 Mahan Orive. MS#33 COMPARE CARE Tailahassee, Florida 32308 Haaun Care in the Sunshine ww PlotideComparacara.gov 3 2010 15:18 Mar PAGE 33/53 15:89 8589218158 83/83/2010 aouenssy Alpend wyeapy jo woistaiq ‘ TyO@/0e/11 ‘ALVO NOILVadXS OlOC/S 1/10 “ALVO AANLLOSAdT TVNOLLIGNOD SCH 96t “TV.LOL 8OL7E ‘Td AASSVHVTIVL ‘CATE TVOICSW TV LIdVO feet UALNIO FUVOHLTVIH TW Ldvo ‘BUIMOTIOJ aty ajer9do 0] pazi0yjae ST dasuadl] ay] SB pUe ‘saINMeIs EPIOTY J] Wed ‘OOp Jaideyy ur pozisoyne ‘uonensrumpy aren WyeeaH 104 Aouady ‘epuoyyz jo ams atp Xq paidope suonendar pux sain ay} Guim porjduios sey Oy] ‘SALVIOOSSV AUVO HLIVAH TW.Ldv 9 iy) unyuoo 07 st sig IVNOLLIGNOO HINOH ONISUOIN AONVUNSSV ALITWNO HLTVdH dO NOISIAIC NOILVULSININGV dav HLTVEH YOsd AONSOV VPLIOL,] JO 2}kI¢ S60CLOTANS ‘# SSNHOIT LOIST -# ALWOILLAAO Mar 3 2010 15:19 83/03/2816 15:89 98509210158 PAGE 34/53 oo ome 27 ' FILED STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION MAY IN 92 AGENCY FOR HEALTH CARE atone ie AL, Ch PARIMCH 7 ERK ADMINISTRATION, ; Petitioner, vB. AHCA NO. 2002021061 CAPITAL HEALTH CARE . ASSOCIATES, LLC d/b/a a ‘ CAPITAL HEALTHCARE CENTER, rn Respondent. : ° : / ° . ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against CAPTIAL HEALTHCARE ASSOCIATES, LLC d/b/a CAPITAL HEALTHCARE CENTER (“Capital Healthcare Center”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001). and alleges: NATURE OF THE ACTION 1. Thais iS am action to assign a cond:tional license to Capital Healthcare Genter pursuant to Section 460.23(7), Florida Statutes (2001), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10). Florida Statutes (2001). The origina) conditional license 1s attached hereto as Exhibit “A”. EXHIBIT —_—2 Mar 3 2010 15:20 63/83/2018 15:89 8589218158 PAGE 35/53 JURISDICTION AND VENUE 2 This Court has jurisdiction pursuant co Sections 120.569 and 120.57, Florida Statutes (2001). 3. AHCA has jusisdicciun pursuant to Chapler 400, Part II, Florida Statutes (206)) 4. venue shall be decermined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES S. AHCA 1S the regulatory agency vresponsible for licensure of nursing homes and enforcement of all applicable Florida laws and xvules governing sx:lled mursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter S9A-4, Florida Administrative Code 6. Capital Health Care Associates, LLC, doing business as Capital Healthcare Center, is a Florida limited liability company with a principal address of One Professional Cencer, One Northeast First Avenue, Suite 302, Ocala, Florida 34470 on Capital Healthcare Center is a 156-bed skilled nursing facility located at 3333 Capital Medical Boulevard, Tallahassee, Florida 32308. Capital Healthcare Center is licensed by AHCA as a skilled nursing facility having been issued lacense number SNP1073096, certificate number 86446, with an effective date of March 1, 2002 and an expiration date of November 39, 2002. is) Mar 3 2010 15:20 83/03/2018 15:09 85892140158 PAGE 8. Capital Healthcare Center :s and was at all times material heretc a licensed skilled nursing facility required to comply with Chapter 400, Part It. Florida Statutes and Chapter S9A-4, Florida Administrative Code COUNT I EFFECTIVE MARCH 1, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO CAPTIAL HEALTHCARE CENTER BASED UPON THE DETERMINATION THAT CAPITAL HEALTHCARE CENTER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF TWO (2) UNCORRECTED CLASS KII DEFICIENCIES AT THE MOST RECENT SURVEY OF MARCH 1. 2002. § 400.23(7), Fla. Stat. (2001) 9. AHCA re-alleces and incorporates by reference paragraphs one (1) through ezghe ‘8) above as if fully set forth herein. FIRST UNCORRECTED CLASS III DEFICIENCY 10. On or about January 22-25, 20¢2, AHCA conducted a survey at Capital Healthcare Center. BR class III defaciency was cited against Capital Healthcare Center pesed cn the findings below. 36/53 Mar 3 2010 15:20 83/83/2018 15:09 8509218158 PAGE 37/53 10.1 On or about January 722-25, 2002, an AHCA surveyor observed medications left at Resident #1's bedside table. Fourteen (14) pills were opservec in a souffle cup. Additionally, a white liquid and a ycliow liquid were found in separate soufflé cups. Upon entering the resident's room, the surveyor observed no staff person in the room The AHCA surveyor interviewed Capital Healthcare Center’s Director of Nursing about the foregoing. During the interview, the Director of Nursing admitted to the AHCA surveyor that resident #1’s medication should not have been left on the bedside tabie unless resident #1 = self- administered medication. A review of Resident #1’s medical record by the surveyor revealed no physician's order for the self-administration of medication. 10.2 On ox about January 27-95, 2002, an AHCA surveyor observed resident #4 with a gastrostomy tube in place. The surveyor further observed a nurse administer Calcium 600 + D, Sinemet, and Zyprexa to resident #4. The surveyor observed the nurse crush the medication and place all of the medication into one scufflé cup. The nurse then administered the medication to resident #4. The nurse did not verify the placement of the gastrostomy tube prior to administering the medication .v the resident. Mar 3 2010 15:20 63/83/2018 15:69 85892168158 PAGE 38/53 BR review of Capital Healthcare Center’s current Medication Administration Policy Manual by the AHCA surveyor revealed that all gastrostomy medicaticn must be ground separately, mixed wath a small amount of water, and administered separately A further review of the policy manual by the surveyor reveaied a facility policy of verifying the gastrostomy tube placement prior [to the administration of medication 11. Based on all of the foregoing, Capital Healthcare Center violated: fa) 42 CPR § 483.60(a) via Rule 59A-4.1288, Florida Administrative Code, by failing to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident; (b) Rule S9A-4.112(1), Plorida Administrative Code, by failing to adopt procedures that assure the accurate acquiring, receiving, dispensing, and administexang of all drugs and biologicals, to meet the needs of each resident: and (c) Rule 59A-4.106(4) (t), Plorida Administrative Code, by failing to maintasn policies and procedures in the area of pharmacy services. wa Mar 3 2010 15:20 83/83/2018 15:89 85909210158 PAGE 39/53 12. Pursuant to Section 400.232{8){c), Florida Statutes, the foregoing 1s a class III deficiency because it resulted in no more than minimal physical, mental, or psychosocial discomfort to the resident cr potentially compromised the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, pian of care, and provision of services. 13. AHCA gave Capital Healthcare Center a written mandated correction date ot February 23, 2002, in accordance with Section 400.23(8)(c), Florida Statutes. Capital Heaithcare Center, however, failed to correct the class III deficzency by the mandated correction date and the same deficzency was discovered at the survey conducted on or about March 1, 2002. Based on the foregoing, Capital Healthcare Center was ested for an uncorrected class III deficiency at the survey om or about March 1, 2002. 14. On or about March 2, 2002, AHCA conducted a survey at Capital Healthcare Center. An uncorrected class III deficiency was cited against Capital Healthcare Center based on the findings below Mar 3 2010 15:21 03/83/2818 15:89 8589218158 PAGE 40/53 14.2. On or about March 1, 2002 an AHCA surveyor observed resident #4 lying in her bed. The surveyor further observed on the resident’s dresser a 30-millilater vial of Heparin flush. The vial had a needleless access system through the rubber top and a resident specific label. 14.2. On or abcut March 1, 72002 an AHCA surveyor observed resident #17 ‘lying in his bed. The surveyor further observed a 30-milliliter vial of Sodium Chloride on the residert’s bedside table The vial had a needleless access system through the rubber top and a resident specific label. 14.3. On or about March 1, 2002 an AHCA surveyor interview Capital Healthcare Center’s Director of Nursing. During the interview, the Director of Nursing stated that, per facility policy, the medication for resident #4 and resident #17, respectively, should have been stored either zn the medication cart or in the medication rocm. 15. Based on all of the foregoing, Capital Healthcare Center violated: (a) 42 CFR § 483.60(a) via Rule S9A-4.1288, Florida Administrative Code, by failing cto provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident; Mar 3 2010 15:21 83/83/2018 15:09 8569218158 PAGE (b) Rule S9A-4.112(1), Florida Administrative Code, by failing to adopt ‘procedures that assure the accurate acculring, receiving, dispensing, and administering of ail drugs and biclogicals, to meer the needs cf each resident; and (c) Rule S9A-4.106(4)(t), Florida Administrative Code, by failing to mMaantaim policies and procedures in che area of pharmacy services. 16. Pursuant to Section 499.23(8}(c), Florida Statutes, the foregoing is a class III deficz:ency because it resulted an no more than minimal physicai, mental, or psychosocial discomfort to the resident or potentially compromised the resident’s abil:ty to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as Gefined by an accurate and comprehensive resident assessment, plan of care, and provision of services. SECOND UNCORRECTED CLASS IIY DEFICIENCY 17. On or about January 22-25, 2002, AHCA conducted a survey at Capital Healthcare Center. A class III deficiency was cited against Capital Healthcare Center based on the findings below 41/53 03/83/2018 Mar 3 2010 15:21 15:89 8589218158 17.1 On ox about January 22-28, 2002, an AHCA surveyor inspected resident room #79 The AHCA surveyor cbserved the nebulizer unit on the counter next co the sink. The aerosol face mask and tubing was covered with a plastic covering daced December 28, 2002 The surveyor interviewed Capital Heeitnhcare Center’s Assistant Director of Norsing regarding the foregoing During the interview, the Assistant Director of Nursing stated that the tubding in resident room #79 was out of compliance with facility polacy, which requires masks and tubingg to be changed every three (3) days 17.2. On or about January 22-25, 2002, an AHCA Surveyor observed a nurse administer medication to resident #4 via a gastrostomy tube. ‘The nurse allowed the barrel of the syringe used to flush the gastrostomy tube to touch resident #4's contaminated bedside table The table had not been cleaned praor to the feeding. Next, the nurse removed the syringe barrel from the syringe and al-owed the syringe to voll around on the contaminated bedside table. Finally, the nurse placed the contaminated syringe barrel into the syranye and “pushed” the medication into the gastrostomy tube PAGE 42/53 Mar 3 2010 15:21 83/03/2018 15:69 8509214158 PAGE 43/53 17.3. On or about January 22-25, 2002, an AXCA surveyor observed a Certified Nursing Assistent (“CNA”) feeding two (2) residents at the same time The CNA touched residents and food without washing her hands in between Specifically, the surveyor observed the CNA feeding resident #:9 and another resident simultaneously The CNA picked-up one piece of toast and handed it to a resident. The CNA then picked-up resident #19's milk and beld the straw for the resident The CNA did not wash her hands in between. The CNA had yellowish fingernails that were approximately one-half inches iong. 17.4. On or about January 22-25, 2002, an AHCA surveyor interviewed a family member of resident #26 The family member stated that several CNAs had long, dirty fingernails. 18 Based on all of the foregoing, Capital Healthcare Center violated: (a) 42 CFR § 483.6S(a)(1)-(3) via Rule S9A- 4.1288, Floxrada Administrative Code, by failing to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. An infection control program includes, but ig not limited to, the \ following: (at investigating, controlling and preventing infections in the facrlity; (21) deciding what procedures, such Mar 3 2010 15:21 83/03/2018 15:09 8509216158 PAGE 44/53 as isolation. should be appiiecd to an individuai resident; and (i212) maintaining a record of incidents and corrective actions related to infections; and (5) Rule 59A-4.106(4)(1). Florida Administrative Code, by failing to maintain policies and procedures in the area of infection control 19. Pursuant to Sectzon 40C.23(8)(c), Florida Statutes, the foregoing is a class III deficiency because it resulted in no more than minimal physical, mental, er psychosocial discomfort to the resident or potentially compromsed the resident’s ability to maintain cor reach his or her highest practical physical, mental, or psychosocial well-being. as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 20. Capital Healthcare Center was given a mandated correction date cf February 23, 2002, im accordance with Section 400.23(8) (c), Florida Statutes. Capital Healthcare Center, however, failed to correct the clase III deficaency by the Mandated correction date and the same deficiency was discovered at the survey conducted on or about March 1, 2062. Based on the foregoing, Capital Healthcare Center was cited for an uncorrected class I11 deficiency at the survey on or about March 1, 2002. Mar 3 2010 15:22 83/63/2018 15:89 8589210158 PAGE 45/53 21 On or about March 2, 2002, AHCA conducted 4 survey at Capital Healthcare Center. Capital Healthcare Center was cited for. an uncorrected class IIx deficiency based on the findings below 21.1. On or about March 1, 2002, an AECA surveyor observed resident #15's room. The surveyor vbserved an uncovered urinal containing dried residue sitting on top of a portable toilet at the resident's bedside. 21.2 On or about March 1, 20C2, an AHCA surveyor observed resident #14's room. The surveyor observed a used adult ancontinent brief with no protective barrier discarded in a waste paper basket next to the resident's bed. 21.3 On or about March 1, 2002 an AHCA Surveyor reviewed Capital Healthcare Center’s written polacy on "Diapers/Underpads”. Under the policy, soiled adult amcontinent briefs must be placed in designated hampers. 21.4. On or about March 1, 2062 the AHCA surveyor reviewed Capital Healthcare Center’s written policy on "Disinfection of Bedpans and Urinals” According to the policy, used urinais should be emptied, washed with a disinfectant solution, air-dried, covered, and returned to Che resident's bedside cabinet. Mar 3 2010 15:22 83/83/2018 15:89 9589210158 PAGE 46/53 21.5 On or about March 1, 2002 an AHCA surveyor Inferviewed Capital Heaithcare Center’s Director of Nursing. During the interview, the Director of Nursing admitted to the Surveyor that both the urinal in resident #15’s room and the used adult incontinent brief in the waste paper basket in resident #14°s room were not in compliance with the facility’s infection contro) standards. 21.6 On or about March 1, 2002 an AHCA surveyor observed resident #4 in room #49 The surveyor further observed a nebulizer at the resident's bedside with an uncovered aerosol face mask and Cubing attached. Neither the face mask nor the tubing was dated as per facility policy. 21.7. On or about March 1, 2002 an AHCA surveyor observed resident #18 in room #54. The surveyor further observed resident #18 with a nasal cannula cn and a nebulizer at the bedside. The tubing attached to the nebulizer was lying on the floor behind the resident’s bed. Neither of the tubings wag datcd as per facility policy. 21.8 On or about March 1, 2002 an AHCA Surveyor observed resident #19 in room #59. The suxveyor further observed resident #19 with a nasal cannula connected to a portable concentrator. The oxygen tubing was undated and the sterile water container was empty. Mar 3 2010 15:22 63/83/2018 15:89 8589216158 PAGE 47/53 21.9 Cn or about March i, 2002 an AHCA surveyor observed resident #20 in room #46 Tre AHCA surveyor further cbserved a bag on resident #20’s bedside table with an aerosol face mask and tubing inside, hoth were dated February 18, 2002. 21.210. Cn or about March i, 2002 an AHCA surveyor interviewed Capital Healthcare Center's Director of Nursing. During the interview, the Darector of Nursing stated that, per facility policy, tubing for nebulizers and oxygen must be changed every three (3) days. The Director of Nursing further stated that, per facility policy. all tubing must be dated. 22 Based on all of the foregoing, Capital Healthcare Center violated: (a) 42 CPR § 483.65(a)(1}-(3) via Rule SYA- 4.1288, Florida Administrative Code, by fazling to establish and Maintain an intection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. An infection control program includes, but is not limited to, the following: (2) investigating, controlling and preventing infections in the facility: (ii) deciding what procedures, such as isolation, should be applied to an individual resident; and (i11} maintaining a record of incidents g and corrective actions related to infections; and (b) Rule 59A- j4 Mar 3 2010 15:22 03/03/2818 15:09 8589214158 PAGE 48/53 4.106(4) (1), Florida Administrative Code, by failing to maintain policies and procedures in the area of infection conzrol 23. Pursuance to Section 469.23(8)(¢), Florida Statutes, the foregoing 1s a class III defaciency because it resulted in no more than minimal physical, mental, or psychosocial discomfort to the resident or potentially compromised the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 24. Capital Healthcare Center failed to correct the two {2) class III defacaencies found at the January 22-25, 2002, survey by the mandated correccion date of February 23, 2002. Therefore, AHCA cited Capital Healthcare Center for two (2) uncorrected class III deficiencies at the survey on or about March 1, 2002. 25. AHCA assigned a conditional licensure status to Capital Healthcare Center based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the Presence of two (2) uncorrected class III deficiencaes at the most recent survey on ox about March 1, 2002. Mar 3 2010 15:22 03/03/2818 15:89 8589216158 PAGE CLAIM POR RELIEF WREREFORE, AHCA respectfully requests the foliowing relief: 1) Make actual and legal findangs in favor of AHCA on Count I; 2) Uphold the issuance cf the conditional license attached hereto as Exhibss “A” 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.321(10), Florida Stazures (2001); and 4) Grant any other generai and equitabie relief as deemed necessary in the furtherance of justice. DISPLAY OF LICENSE Pursuant to Section 400 23(7){e}, Florida Statutes, Capital Healthcare Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. 16 49/53 Mar 3 2010 15:23 83/03/2018 15:89 8509210158 PAGE 58/53 NOTICE Capital Healthcare Center hereby is notified that it has a right to request an administrative hearing pursuant to Section 120.969, Florida Statutes Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Expianation of Rights (one page). All requests for bearing shall be made to the Agency for Health Care Administration, and delivered to hora C. Desnick, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. CAPITAL HEALTHCARE CENTER IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS oF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE PACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY ACHA. Respectfully submitted on this 10th Gay of May 2902. hori C Desnick Fla. Bar. No. 0129542 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Plorida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) uv Mar 3 2010 15:23 3/03/2018 15:89 8589210158 PAGE 51/53 CERTIFICATE OF SERVICE a Y HEREBY CERTIFY that the or:ginal Adminascrative Complaint Oy and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9184) to Paul Kovary, Adninistcator, Capirtal Health Care Associates, LLC d/b/a Capital Healthcare Center, 3333 Capital Medical Bouievard, Tallahassee, Florida 32308 and that a txue and correct copy of the Administrative Complaint and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9191) to Cc. T Corporation System, Registered Agent tor Capital Health Care Associates, LLC d/b/a Capital Healthcare Center, 1200 South Pine Island Road, Plantation, Florida 33324. dee © Qearwele LORI CC. DESNICK, ESQUIRE COPIES TO: Elizabeth Dudek Deputy Secretary Managed Care and Health Quality Assurance Agency fox Health Care Administration 2727 Mahan Drive, M.S. #9 Tallahassee, Florida 32308 (via interoffice mail) 1K Mar 3 2010 15:23 83/83/2018 15:89 8509216158 PAGE Exhibit “A” CONDITIONAL LICENSE License # SNF1073096, Certificate #8446 Ef{feclive Date. 3/01/02 Expiration Date 11/30/02 52/53 3 2010 15:23 Mar PAGE 53/53 15:89 | 8589218158 83/83/2018 CERTIFICATE 4: LICENSE #: _SNF1073096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY SKILLED NURSING FACILITY CONDITIONAL This is (o confirm that CAPITAL HEALTH CARE ASSOCIATES, LLC has complied with the rules and regulations adopted by the State of Florida, Agency For Heaith Care Administration, authorized in Chapter 400, Part U, Florida Statutes, and as the licensee is authorized {0 operate the following: CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD. TALLAHASSEE, FL 32308 with 156 beds Change In Status ACTLON EFFECTIVE DATE: 03/01/2002 LICENSE EXPIRATION DATE. 11/30/2002 Deputy Secretary, Mar 3 2010 15:32 PAGE 82/58 03/83/2018 15:31 8569218158 ALD Leib. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION MAY fo 9% AGENCY FOR HEALTH CARE AMG Ulan MoH TERK ADMINISTRATION, Ais Petitioner, Sy ve. AHCA NO. 200201542 Ee CAPITAL HEALTH CARE SS - ASSOCIATES, LLC d/b/a : CAPITAL HEALTHCARE CENTER, Respondent . / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counse!, and files this Administratave Complaant against CAPTIAL HEALTHCARE ASSOCIATES, LLC @/b/a CAPITAL HEALTHCARE CENTER (“Capital Healthcare Center”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This 1S an action TO impose a $3,000 fine against Capital Healthcare Center pursuant to Section 400.102(1) (a) and Section 400.23(8} (¢c), Florida Statutes (2001), based on two (2) uncorrected class III deficiencies, and to assess costs related to the investigation and Prosecution of this case pursuant to Section 400.2121(10), Florida Statutes (2001). Mar 3 2010 15:33 03/83/2810 15:31 85869218158 PAGE 63/58 JURISDICTION AND VENUE 2. This Court has jurisdictien purauant to Sections 120.569 and 120.57, Florida Stacutes (2001). 3. AHCA has jurisdiction pursuant to Chapter 400, Part Il, Florida Statutes (2001). 4. Venue shali be determined pursuant to Rule 28-106.207 Florida Administrative Code (2001) PARTIES S. BHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of ail applicable Florida laws and rules governing skiiled nursing facilities pursuant to Chapter 400, Pare Ir, Florida Statutes, and Chapter S9A-4, Florida Administrative Code. 6. Capital Health Care Associates, LLC, doing business as Capital Healthcare Center, 1s a Florida limited liability company with a principal address of One Professional Center, One Northeast Farst Avenue, Suite 302, Ccala, Florida 34470. 7 Capital Healthcare Center is a 156-bed skilled nursing facality located at 3333 Capital Medical Boulevard, Tallahassee, Florida 32308. Capital Healthcare Center is licensed by AHCA as a skilled nursing facility having been issued license number SNF1073096, certificate number 8446, with an effeccive date of March 1, 2002 and an expiration date of November 30, 2002. Mar 3 2010 15:33 83/83/2018 15:31 8569216158 PAGE 8 Capital Healthcare Center is and was at all cimes material herete a licensed skilled Aursing facility required to comply with Chapter ¢00, Part ZI, Florida Statutes and Chapter S59A-4, Florida Administrative Code. COUNT [I CAPITAL RKEALTHCARE CENTER FAILED TO PROVIDE PHARMACEUTICAL SERVICES TO MEET THE NEEDS OF RESIDENT. 42 CFR § 483.60(a) (2001) Rule 594-4.1288, Fla. Admin. Code (2002) Rule 59A-4.106(4)(t), Fla. Admin. Code (2001) Rule 59A-4.112(1), Fla. Admin. Code (2001) UNCORRECTED CLASS III DEFICIENCY ISOLATED 3. AHCA re-alleges and incorporates by reference paragraphs one {1) through eight (&€) above as if fully set forth herein. 20. On or about January 22-25, 2002, AHCA conducted a survey at Capital Healthcare Center. A class III deficiency was cited against Capital Healthcare Center based on the findings below involving two (2) residents 10.1. On ocr about January 22-25, 2002, an AHCA Surveyor observed medications left at Resident #1's bedside table. Fourteen (14} pills were observed in a souffié cup. Additionally, a white raguid and a yellow liquid were found 04/58 Mar 3 2010 15:33 PAGE 85/58 83/83/2018 15:31 85892108158 in separate soufflé cups Upon entering the resicent’s room, the surveyor observed no staff person un the room. The AHCA surveyor interviewed Capital Healthcare Center’s Director of Nursing about the foregoing. During the interview, the Director of Nursing admizted to the AHCA Surveyor that resident #1"s medication should net have been left on the bedside table unless resident #1 self- administered medication The surveyor reviewed Resident #1’s medical record, which revealed no physician's order for the self-admanistration of medication. 10.2. On or about January 22-25, 2002, an AHCA Surveyor observed resident #4 with a gastrostomy tube an Place The surveyor further observed a nurse administer Calcium 60C + D, Sinemet, and Zyprexa to resident #4. The surveyor observed the nurse crush the medication and place all of the medication into one souffle cup. The nurse then administered the medication to resident #4 The nurse did not verify the placement of the gastrostomy tube prior to administering the medication to the resident. A xeview of Capital Healthcare Center's current Medication Administration Policy Manual by the AHCA Surveyor revealed that all gastrostomy medication must be ground separately, mixed with a smail amount of water, and administered separately A further review of the policy Mar 3 2010 15:33 83/03/2018 15:31 8509210158 PAGE 06/58 manual by the surveyor revealed a facility policy of verifying the gastrostomy tube placement prior to the administration of medication 12 Based on all of the foregoing, Capital Healthcare Center violated: ‘a) 42 CFR § 483.60(a} via Rule 59A-4.1288, Florida Administrative Code, by failing ts provide Pharmaceutical services, including procedures that assure the accurate acquiring, recciving, dispensing, and adininistering of all drugs and biologicals, to meet the needs of each resident; (ob) Rule S9A-4.112(1), Florida Acministralive Code, by failing to adopt procedures that assure the accurate acguiraing, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident; and (c) Rule S9A-4.106(4) (t), Florida Administrative Code, by faaling to maintain policies and procedures in the area of pharmacy services, i2 Pursuant to Section 400.2348) (c), Florida Statutes, the foregoing is a class III deficiency because it resulted in mo more than minimal physical, mental, or psychosocial discomfort to the resident or potentially compromised the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate ana comprehensive resident assessment, Plan of care, and Provision of services Mar 3 2010 15:33 83/83/2818 15:31 8589218158 PAGE 087/58 13. AHCA gave Capital Healthcare Center a written mandared correction date of February 23, 2002, in accordance with Section 900.23(8){c), Plorida Statutes. Capital Healthcare Center, however, fazsled to correct the class III deficiency by the mandated correction date and the same deficiency was discovered at the survey conducted on or about March 1, 2002. sHased on the foregoing, Capital Healthcare Center was cited for an uncorrected class III deficzrency at the survey on or about March 1, 2002. 14. On or about March 1, 2002, ANCA conducted a survey at Capital Healthcare Center. An uncorrected class III deficiency was cited against Capital Healthcare Cenrer based on the findings below invelving two (2) residents 14.2. On or about March 1, 2002 an AHCA surveyor observed resident #4 lying in her bed The surveyor further observed on the resident’s dresser a 30-millilater vial of Heparin flush. The vial had a needleless access system through the rubber top and a resident specific label. The surveyor interviewed Capital Healthcare Center’s Director of Nursing. The Director of Nursing stated that, per facility policy, resident #4’s medication should have been stored either in the medication cart or in the medication room Mar 3 2010 15:34 158 63/03/2018 15:31 8589218158 PAGE 88 14.2 On or about March 1, 2002 an AHCA surveyor Observed resident #17 lying in his bed The surveyor fuxther observed a 30-milliliter vial of Sodium Chloride on the resident’s bedside table. The vial had a needleless access system through the rubber top and a _ resident specific label . The surveyor anterviewed Capital Healtheare Center’s Director of Nursing. The Director of Nursing stated that. per facility policy, resident #17’s medication should have been stored either in the medication cart or in che medication room. 15. Based on the foregoing. Capital Healthcare Center violated: (a) 42 CFR § 483.60(a) via Rule S9A-4.1288, Florida Administrative Code, by failing to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicais to meet the needs of each resident; (b) Rule S9A-4.112(1), Florida Adminisrrative Code, by failing to adopt procedures that assure the accurate acquiring, recexving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident: and (c) Rule 59A-4.106(4) (t), Florida Administrative Code, by failing to maintain policies and procedures in the area of pharmacy services Mar 3 2010 15:34 89/58 83/03/2018 15:31 8589218158 PAGE 46. Pursuant to Section 409.23/8) {c), Florida Statutes, the foregoing 1s a class III deficiency because it resulted in no more than minimal physical, mental, or psychosocial discomfort to the resident or potentiaily compromised the resident's ability to maintain or reach his or her haghest Practical physical, mental, or psychosocial well-being, as defined by an accurate and comprenensive regident assessment, plan of care, and Provision ot services. 17. Pursuant to Section 4900 23(8). Florida Statutes, the foregoing is an “isolated” class JIi deficzency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally ox in a very limited number of locations 28. Pursuant to Section 400 23(8)(c}, Florida Statutes, AHCA may impose a $1,000 fine against Capital Healthcare Center for an isolated uncorrected Class ITI deficiency. COUNT II CAPITAL HEALTHCARE CENTER FAILED TO ESTABLISH AND MAINTAIN AN INFECTION CONTROL PROGRAM DESIGNED TO PROVIDE A SAFE, SANITARY, AND COMFORTABLE ENVIRONMENT AND TO HELP PREVENT THE DEVELOPMENT AND TRANSMISSION OF DISKASE AND INFECTION. 42 CFR § 483. 65{(a) (1) -(3) (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) Rule 59A-4.106(4) (1), Fla. Admin. Code (2001) UNCORRECTED CLASS YII DEFICIENCY PATTERN @3/83/2018 15:31 8569216158 PAGE 19. On or about January 22-25, 2002, AHCA conducted a survey at Capital Yealthcare Center A class III defic:ency was Mar 3 2010 15:34 cited against Capital Healtheare Center based on the findings below. 19.1. On or about January 22-25, 2002, an AHCA Surveyor inspected resident room #79. The AHCA surveyor observed the nebulizer unit on the counter next to the Sink. The aerosol face mask and tubing was covered with a plastic covering dated December 28, 2001. The surveyor interviewed Capital Healthcare Center’s Assistant Director of Nursing regarding the foregoing During the interview, the Assistant Director of Nursing stated that the tubing in resident rocm #79 was out of compliance with facility policy, which requires masks and tubings to be changed every three (3) days. 19.2. On or about January 22-25, 2002, an AHCA surveyor observed a nurse administer medication to resident #4 via a gastrostomy tube. The nurse allowed the barrel of the syringe used to flush the gastrostomy tube to touch resident Aas contaminated bedside table. The table had not been cleaned prior to the feeding. Next, the nurse removed the syringe barrel out of the syringe and permitted the syringe to roll around cn the contaminated bedside table. Finally, the nurse piaced the contaminated syringe 18/58 Mar 3 2010 15:34 83/03/2018 15:31 85892108158 PAGE 11/58 barrel anto the syringe and “pushed” the medication into the gastrostomy tube. 19.3 On or about January 22-25, 2002, an AHCA Surveyor observed a Certified Nursing Assistant (“CNA”) teeding two (2) residents at the sane time. The CNA was touching residents and food without washing her hands in between. Specifically, the surveyor observed the CNA feeding resident #19 and another resident Sinullaneously. The CNA picked-up one piece of toast and handed it to a resident. The CNA then picked-up resident #19's milk and held the straw for the resident The CNA did not wash her hands ain between. The CNA had yellowish fingerna2ls approximately one-half inches long. 19.4. On or about January 22-25, 2002, an AHCA Surveyor interviewed a famzly member of resident #20. The family member stated that several CNAs had long, dirty fingernails. 20. Based on all of the toregoing, Capital Healthcare Center violated (a) 42 CFR § 483.65(a)(i)-{3) via Rule S9A- 4.1288, Florida Administrative Code, by failing to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the @evelopment and transmission of disease and infection. Mar 3 2010 15:34 PAGE 12/58 83/83/2018 15:31 8589218158 An infection control program includes, but is not limited to, the following: (i) investigating, controlling and preventing infections in the facility, deciding what procedures, such as ieolation, should be applied to an individual resident; and (111) maintaining a record of incidents and corrective actions related to infections; and (b) Rule S9A- 4.106(4) (1), Florida Administrative Code, by failing to maintain policies and procedures in the area of infection control. 21. Pursuant to Section 400.23(8) lc), Fiorida Statutes, the foregoing deficiency is a class Ilr deficiency because it resulted in no more than minimal physical, mental, or psychosocial discomfort to the resident or potentially compromised the resident’s ability to maintain or xeoach nis or hex highest practical physical, mental, or psychosocial well- being, as defined by an accurate and comprehenaive resident assessment, plan of care, and provision ef services. 22. Capital Healthcare Center wae given ai iandated correction date of February 23, 20062, in accordance with Section 900.23(8)(c), Plorida Statures. Capitai Healthcare Center, however, tailed to correct the class [It Qeficiency by the mandated correction date ana the same deficiency was discovered at the survey conducted on or about March 1, 2092. Based on the foregoing, Capital Healthcare Center was cited for an oy Mar 3 2010 15:35 / 63/63/2018 15:31 8509218158 PAGE 13/58 uncorrected class i1I deficiency at che survey on or about March 1, 2002. 23. On or about March 1, 2952, AHCA conducted a survey at Capital Healthcare Center, Capital Healthcare Center wags cited for an uncorrected class Iz1 deficiency based on the findings below 23.2 On or about March 1, 2002, an AHCA Surveyor observed resident #15's room The surveyor observed an uncovered urinal containing dried residue sitting on top of a portable toilet at the resident's bedside. 23.2 On or about March 1, z00z, an AHCA surveyor observed resident #14's room. The surveyor observed a used adult incontinent brief with no protective barrier discarded in a waste paper basket next to the resident's bed. 23.3. On or about March 1, 2002 an AHCA Surveyor reviewed Capital Healthcare Center’s written policy on *Diapers/Underpads" . Under the policy. soiled adult incontinent briefs must be placed in designated hampers. 23.4. On or about March 1, 2002 the AHCA surveyor reviewed Capital Healthcare Center’s written polzcy on "Disinfection of Bedpans and Urinals". According to the policy, used urinals shoulda be emptied, washed with a 83/83/2018 Mar 3 2010 15:35 15:31 8569218158 PAGE disinfectant solution, air-dried, covered, and returned to the resident's bedside cabinet 23.5. On or about March 1, 2092 an AHCA surveyor interviewed Capital Healthcare Center’s Oirector of Nursing. During the interview, the Director of Nursing admitted to the surveyor that both the urinal in resident #15’s room and the used adult incontinent brief in the waste paper basket in resident #14's room were not in compliance with the facality’s infection contrel standards. 23.6. On or about March 1, 2002 an AHCA surveyor observed resident #4 in room #49. The surveyor further observed a nebulizer at the res:dent’s bedside with an uncovered aerosol face mask and tubing attached. Neither the face mask nor the tubing was dated as per facility policy. 23.7. On or about March 1, 2002 an AHCA surveyor observed resident #18 in room #54 The surveyor further observed resident #18 with a nasal cannula on and a nebulizer at the bedside. The tubing attached to the nebulizer was lying on the floor behind the resident’s bed. Neither of the tubings wae dated ae per facility polacy. 23.8. On or about March 1, 2002 an AHCA surveyor ‘observed resident #19 in room #59 The eurveyor furthers observed resident #19 with a nasal cannula connected to a 14/58 Mar 3 2010 15:35 /58 63/03/2018 15:31 8549216158 PAGE 15/5) portable concentrator. The oxyger. tubing was undated and the sterile water container was empty. 23.9 On or about March 1, 2002 an AHCA surveyor observed resident #20 in room #46. The AHCA surveyor further observed a bag on resident #20’s bedside table with an aerosol face mask and cubing inside, both were dated February 18, 2002 23.10 On or about March 1, 2002 an AHCA surveyor interviewed Capital Healthcare Center’s Director of Nursing. During the interview, the Director of Nursing stated that, per facility policy, tubing for nebulizers and oxygen must be changed every three (3) days. The Director of Nursing further stated that, per facility polacy, all tubing must be dated. 24. Based on all of the foregoing, Capital MNealthcare Center violated: (a) 42 CFR § 483.65{a)(1)-(3) via Rule 59~- 4.1288, Florida Administrative Code, by failing to establish and Maintain an infection control Program designed to provide a safe. sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. An infection control program includes, but is not limited to, the following: (2) investigating, controlling and preventing infections in the facility; (i1) deciding what procedures, such as isolation, shoud be applied to an la Mar 3 2010 15:35 PAGE 16/58 —_— eee 63/03/2818 15:31 8569218158 individual resident; and (i114) maintaining a record of incidents and corrective actions related to infections; and (b) Rule Soa- 4.196(4) (1), Florida Administrative Code, by farling to maintain policies and procedures in the area of infection control 25. Pursuant to Section 400.23(8) (ce), Flor:da Statutes, the foregoing is a Cless IIrz Qeficiency because it resulted in nO more than minimal Physical, mental, or psychosocial discomfort to the reeident 9 or potentially compromised the resident’s ability to Malntain or reach nis or her highest practical physical, mental, or psychosocial weli-being, as defined by an accurate and comprehensive resident assessment, Plan of care, and Provision of services. 26. Pursuant to Section 400.23(8), Florida Statutes, the foregoing is a “pattern” class I2I deficiency because more than a very limited number of residents were affected, more than a very limited number of Sstatf were involved, he Situation occurred in geveral locations, or the same resident or residents were affected by repeated occurrences of the same deficient practice bue the effect of the deficien practice was not pervasive throughout the facility. 27. Pursuant to Section 400.23(8)(c). Plorida Statutes, AHCA may impose a $2,000 fine against Capital Healthcare Center for a pattern uncorrected class III deficiency Mar 3 2010 15:36 PAGE 17/58 83/03/2010 15:31 8589210158 CLAIM FOR RELIEF SEP WHEREFORE, ANCA respectfully requests the following relief: 1) Make factual and legal findings in favor of AHCA on Counts I and In; 2) Impose a $3,000 fine against Capital Healthcare Center, 3) Assess costs related to the investigation and Prosecution of this case Pursuant to Sectien 400.121(10), Florida Statutes (2901); and 4) Grant any other general and equitable relief as deemed necessary in the furtherance of justice. NOTICE Capital Healthcare Center hereby 1s notified that it has a right to request an admainistratave nearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Lori C. Degnick, Senior Attorney, Agency for Health = Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 312308. Mar 3 2010 15:36 PAGE 18/58 63/03/2018 15:31 8589218158 ieee CAPITAL HEALTHCARE CENTER IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS oF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN aN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A PINAL ORDER BY ACHA. Respectfully submirte@ on this 10th day of May 2002. doe C0 Desrwrrch, Lor: C. Desnick Pla. Bar. No. 0129542 Counsel for Petitioner Agency fox: Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) Mar 03/83/2018 15:31 8569210158 CERTIFICATE OF SERVICE 3 2010 15:36 PAGE 19/58 feos oy 7 9 2 ‘s hy % fey wo t HEREBY CERTIFY chat a true and correct ‘Copy. , of the ‘OS Administrative Complaint has been sent by U.S. Certifiéd Mazi Return Receipt Requested (return receipt # 7196 4575 i294 2049 9160) to Paul Kovary, Administrator Capital Health Care Associates, LLC d/b/a Capital Healthcare Center, 3333 Capital Medical Boulevard, Tallahassee, Florida and by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9177 to c Corporation System, Registered Agent for Capital Heaith Care Associates LLC d/b/a Capital Healtncare Center, 1200 South Pine Island Road, Plantation, Florida 33324. Ane C. Qos, LORI C. DESNICK, FSQUIRE COPIES To: Elizabeth Dudek Deputy Secretary Managed Care and Health Quality Assurance Agency for Health Care Administration 2727 Mahan Drive, m.s. 49 Tallahassee, Florida 32308 (via interoffice mail) 18 Mar 3 2010 15:36 83/83/2018 15:31 8589218158 PAGE 26/58 wo EXHIBIT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, . Case No. 2004011570 CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a CAPITAL HEALTHCARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA”), by and through the undersigned counsel, and files this Administrative Complaint agamst CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a CAPITAL HEALTHCARE CENTER (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and alleges: NATURE OF THE ACTION 1 This ts an action against Respondent to impose an administrative fine in the amount of $7,500, pursuant to the various citations, statutes, and rules cited in the count below. 2. In summary, Respondent was cited as follows: November 17, 2004 complaint investigation. Respondent was cited for a Class II violation. EXHIBIT RX Page 1] of 7 Mar 3 2010 15:36 03/03/2018 15:31 8549218158 PAGE 21/58 JURISDICTION AND VENUE 3 This tbunal has junsdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Stamtes (2004). 4. Venue shall be determined, pursuant to Chapter 28-106.207, Florida Admimstrative Code (2004). PARTIES 5. Pursuant to Chapter 400, Part II, Florida Statutes (2004), and Chapter S9A-4, Florida Admunistrative Code (2004), AHCA is the licensing and enforcing authonty with regard to nursing facility laws and rules. 6. The Respondent 1s a nursing facility located at 3333 Capital Medical Blvd, Tallabassec, Florida 32308. The Respondent is and was at all tumes matenal hereto a licensed nursing facility under Chapter 400, Part I], Florida Statutes (2004), and Chapter 59A-4, Florida Administrative Code (2004), having been issued license number 1073096. COUNT I (N 069) Respondent failed to self impose an admission moratorium due to the fact that they were below the minimum staffing hours for two consecutive days. § 400.141(15)(d), Fla. Stat. § 400.23(8)(b), Fla. Stat. 7. AHCA re-alleges paragraphs 1-6 above. 8. On November 17, 2004, AHCA conducted a complaint inveshgation at Respondent’s facility. AHCA cited Respondent for a violation, based on the following findings below: a) A review of the facility census date sheets for 8/1/04 and 8/2/04 was done on 11/17/04 around 10:30am. The census was 154 residents and 152 residents, which should have had mmimum staffing hours of 400.4 and 395.2 hours respecnvely, However, thc actual hours for whe facility staffing were below those numbers at 380.00 and 388.60 respectively for those dates There was no Page 2 of 7 83/83/2010 Mar 3 2010 15:37 15:31 8589218158 oe @ evidence that the facility had self imposed a new admussion moratorium as required by rule. The facility was short 20.4 CNA hours on 8/01/2004 and short 6.6 CNA hours on 8/2/2004 b) In interview with the administrator on 11/17/04 around 10:30am she stated she could provide no cvidence that the facility had self imposed a moratorium on new admissions following the below staffing days of 8/1/04 and 8/2/04 on 8/3/04 for the next 6 days as required. PAGE 22/58 9. Respondent failed to self impose an admission moratonum due to the fact that they were below the minimum staffing hours for two consecutive days, as required by Section 400.141(15)(d), Florida Statutes, which provides in pertinent part, as follows: “400.141 Administration and management of nursing home facilities — Every licensed facility shall comply with all apphcable standards and rules of the agency and shall: (15) Submut semuannually to the agency, or more frequently if requested by the agency, information regarding facility staff-to-resident ratios, staff turnover, and staff stability, including information regarding certfied nursing assistants, licensed nurses, the director of nursing, and the facility administrator. For purposes of this reporong:...(d) A nursing facility that has failed to comply with statc minimum- staffing requirements for 2 consccutive days is prohibited from accepting new admissions unul the facility has achievcd the minimum-staffing requirements for a period of 6 consecutive days. For the purposes of this paragraph, any person who was a resident of facility and was absent from the facility for the purpose of receiving medical care at a separate location or was on a Ieave of absence 1s not considered a new admission. Failure to impose such admussions moratorium constimtes a class I deficiency.” 10. The foregoing violation constitutes a Class I violation, due to the nature of the violation and the gravity of its effect on the residents and warrants a fine of $7,500, to wit: “(b) A class 0 deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial we}l-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a pattemed deficiency, and $7,500 for a widespread deficiency. The fine amount shail be doubled for each deficiency 1f the facility was previously cited for one or more class J or class 0 deficiencies during the last annual inspection or any inspection or complaint invesnigaton since the last annual inspection. A fine shall be ened normthstanding the correction of the deficiency.” § 400.23(8\b), Fla. Stat. Page 3 of 7 Mar 3 2010 15:3? 03/83/2018 15:31 8509210158 PAGE 23/58 3 @ 11. AHCA, in determining the penalty unposed, considered the gravity of the violation, the probability thar death or serious harm will result, the actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. " WHEREFORE, AHCA demands the following relief. 1. Enter factual and legal. findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $7,500 for the referenced violation; and 3. Impose such other relief as this tribunal may find appropnate. NOTICE Respondent, CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a CAPITAL HEALTHCARE CENTER, is notified that it has a right to request an admunistrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explamed in the attached Explanation of Rights (one page). All requests for hearing shalj be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. Page 4 of 7 Mar 3 2010 15:3? 63/83/2818 15:31 8589210158 PAGE 24/58 RESPONDENT IS FURTHER NOTIFIED, IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. hb Submitted on this_|4 day of la Morn ah\ ox 2005, Tim _ELbeA Timothy B. Elliott, Senior Attomey Fla. Bar No. 210536 Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3, MSC #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U‘S. Certified Mail, Return Receipt Requested (receipt # 7000 1530 0000 5684 9181) to Capital Healthcare Center, Attention: Administrator, 3333 Capital Medical Blvd, Tallahassee, Flonda 32308. ; . Lie << Submitted on this J 4 day of palma 2005. Tim ef Timothy B. Ethott, Senior Atlomey Agency for Health Care Administration Page 5 of 7 Mar 3 2010 15:37 03/03/2016 15:31 8589210158 PAGE 25/58 f a STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE AHCA CASE NO: ADMINISTRATION, 2005008392 2005008394 Petitioner, RETURN RECEIPT REQUESTED: 7004 1160 0003 3739 1645 vs. 7004 1160 0003 3739 1652 CAPITAL HEALTHCARE ASSOCIATES, a/k/a CAPITAL HEALTHCARE CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”) by and through the undersigned counsel, and files this Administrative Complaint against CAPITAL HEALTHCARE ASSOCIATES, ak/a CAPITAL HEALTHCARE CENTER (“Respondent”), a skilled nursing facility, pursuant to Chapter 400, Part II, and Sections 120.569 and 120.57, Flonda Statutes (2005). NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $1000.00 pursuant to Section 400.23(8)(c), Florida Statutes (2005). 2. This is an action to impose a conditional license pursuant to Section 400.23(7)(b), Florida Statutes (2005). JURISDICTION AND VENUE 3 This tnbunal has jurisdiction pursuant to Sections 120.569 and 120 57, Flonda Statutes (2005) and Chapter 28-106, Florida Administrative Code (2005) Pape 1 of 9 Mar 3 2010 15:38 , /58 03/83/2018 15:31 8599218158 PAGE 26/8 ( f 4. Venue shall be determined pursuant to Section 400.121 Flonda Statutes and Rule 28-106.207, Flonda Admunistrauve Code (2005). PARTIES 5 AHCA 1s the enforcing authonty with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part Nl, Flonda Statutes (2005), and Rule 59A-4, Flonda Administrative Code (2005). 6. Respondent, is a 156-bed skilled nursing facility located at 3333 Capital Medical Boulevard, Tallahassee, Florida 32308. At ail umes matenal hercto, Respondent has been a facility licensed under, and required to comply with, Chapter 400, Part 0, Florida Statutes and Chapter 594-4, Flonda Administrative Code, having been issued license number 1073096 OUNTI CLASS II VIOLATION WARRANTING AN ADMINISTRATIVE FINE SECTION 400.141, FLORIDA STATUTES 7. AHCA re-alleges and incorporates Paragraphs 1 through 6 above as if fully set forth herein. 8. Section 400.141 states in relevant part: Administration and management of nursing home facilities.--Every licensed facility shall comply with all applicable standards and rules of the agency and shall- * + * (22) Before November 30 of each year, subject to the availability of an adequate supply of the necessary vaccine, provide for immunizations against influenza viruses to all its consenting residents in accordance with the recommendations of the United States Centers for Disease Control and Prevention, subject to cxemptions for medical contraindications and religious or personal beliefs. Subject to these exemptions, any consenting person who becomes a resident of the facility after November 30 but before March 31 of the followmg year must be immunized within 5 working days after becoming a resident Immunization shall not be Provided to any resident who provides documentation that he or she has been immunized ay required by this subsection This subsection does not Page 2 of 9 Exhibit ~~ Mar 3 2010 15:38 63/03/2018 15:31 8589218158 PAGE 27/58 prohibit a resident from receiving the immunization from his or her persona] physician if he or she so chooses. A resident who chooses to receive the immunization from his or her personal physician shall provide proof of immunization to the facility. The agency may adopt and enforce any rules necessary to comply with or implement this subsection. (23)Assess all residents for ehgibility for pneumococcal polysaccharide vaccination (PPV) and vaccinate residents when indicated within 60 days after the effective date of this act in accordance with the recommendations of the Umited States Centers for Disease Contro! and Prevention, subject to exemptions for medical contraindications and religious or personal beliefs Residents admitted after the effective date of this act shall be assessed within 5 working days of admission and, when indicated, vaccinated within 60 days in accordance with the recommendations of the United States Centers for Disease Control and Prevention, subject to exemptions for medical contrandications and religious or personal beliefs. Immunization shall not be provided to any resident who provides documentation that he or she has been immunized as required by this Subsection. This subsection does not prohibit a resident from receiving the immunization from his or her personal physician if he or she so chooses. A resident who chooses to receive the immunization from his or her personal physician shall provide proof of immunization to the facility. The agency may adopt and enforce any rules necessary to comply with or implement this subsection. (24)Annually encourage and promote to its employees the benefits associated with immunizations against influenza viruses 1n accordance with the recommendations of the United Staics Centers for Disease Control and Prevention. The agency may adopt and enforce any rules necessary to comply with or implement this subsection. 9. On March 3, 2005, AHCA conducted a survey at Respondent’s facility At the time, based on record review and interview, it was determined that Respondent failed to meet state immunization requirements for 5 of 24 sampled residents 10. Respondent was notified of this violation and given a date of Apni 2, 2005, for mandatory correction. 11. Section 400.23(8)(c) states (c) A class III deficiency ys a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort tu the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or Page 3 of 9 Fehine 7 Mar 3 2010 15:38 83/63/2018 15:31 8589210158 PAGE 28/58 psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class IN deficiency 1s subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a pattemed deficiency, and $3,000 for a widespread deficiency The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspecuun or complaint investigation since the Jast annual inspection. A citation for a class III deficiency must specify the time within which the deficiency 1s required to be corrected. If a class IN deficiency is corrected within the time specified, no civil penalty shal] be imposed 12. The aforesaid failure by Respondent to meet state immunization requirements constitutes a pattern Class II violation 13. On Apnil 11, 2005, AHCA conducted a follow-up survey at Respondent’s facility 14, At that time, based on record review and interview, AHCA determined that Respondent failed to meet state immunization requirements for 3 or 11 sampled residents. 15. This failure to meet said requirements constitutes a failure to correct the Class IT violation found during the March survey, although AHCA determined that the violation was downgraded from a pattem violation to an isolated violation. 16. At the time of the Apni survey, Respondent was notified that the Class III violation found during the March Survey remained uncorrected. Respondent was also assessed a fine in the amount of $1000 pursuant to Section 400.23(8)(c), Florida Statutes (2005) COUNT Ik UNCORRECTED VIOLATION WARRANTING CONDITIONAL LICENSURE SECTION 400.23(7)(b) Page 4 of 9 Den.bes qT _— Mar 3 2010 15:39 PAGE 29/58 03/83/2818 15:31 8509210158 Gi 17. AHCA tealleges and reincorporates Paragraphs | through 14 above as if set forth fully herein 18. Section 400.23(7), Flonda Statutes (2005), states in relevant part: (7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of comphance by each licensee with the established rules adopted under this part as a basis for assigning a licensure Status to that facility. The agency shall base its evaluation on the most recent mspection report, taking into consideration findings from other official reports, surveys, interviews, imvestigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home. rhe (b) A conditional licensure status means (hat a facility, due to the presence of one or more class I or class II deficiencies, or class I deficiencies not corrected within the time established by the agency, Js not in substantial compliance at the time of the survey with cnteria established under this part or with rules adopted by the agency. If the facility has no class I, class II, or class III deficiencies at the time of the follow-up Survey, a standard licensure status may be assigned. 19. AHCA assigned a conditional licensure status to Respondent based upon the determination that the facility was not in substantial comphance with applicable laws and rules during the April 11, 2005, survey, due to Respondent's failure to correct the previously-cited violation described in Count J above. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1. Make factual and legal findings in favor of AHCA as to the allegations contained in Counts I and IT hereof. 2 Uphold the administrative fine assessed in the amount of $1000.00 for the unconected Class III violation found during the Apni 11, 2005, follow-up survey 3. Uphold the issuance of the conditional hcense with an effective date of 12/01/2005, a copy of which is attached hereto as Exhibit A. Page 5 of 9 Fyhihit 7 Mar 3 2010 15:39 63/83/2018 15:31 8509210158 PAGE 36/58 ( f y 4. Such other relief as this tnbunal may deem appropnate, including the assessment of costs related to the investigation and prosecution of this case, if applicable DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, CAPITAL HEALTHCARE ASSOCIATES, a/k/a CAPITAL HEALTHCARE CENTER shall post the conditional license in a prominent place that 1s in clear and unobstructed public view at or near the place where residents are being admitted to the facility NOTICE CAPITAL HEALTHCARE ASSOCIATES, a/k/a CAPITAL HEALTHCARE CENTER is notified that it has a night to request an administrative heanng pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights and explained im the attached Explanation of Rughts. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Taliahassee, Florida, 32308; Attention: Agency Clerk. CAPITAL HEALTHCARE ASSOCIATES, a/k/a CAPITAL HEALTHCARE CENTER IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, THE ALLEGATIONS IN THIS Page 6 ofy Evinthot Tv. Mar 3 2010 15:39 63/83/2818 15:31 8569218158 PAGE 31/58 ‘ ( ADMINISTRATIVE COMPLAINT WILL BE DEEMED ADMITTED AND A FINAL ORDER WILL BE ENTERED. Submitted on this 5 Maay 06 OS dn Pes 200. arin Mt e, Esq. Senior Attorney Fla Bar No 356255 Agency for Health Care Administranon 2727 Mahan Dnive, Bldg #3, MSC #3 Tallahassee, FL 32308 Phone: (850) 922-5873 Fax. (850) 921-0258 or (850) 413-9313 CERTIFICATE OF SERVICE THEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certitied Mail, Retum Receipt Requested (receipt 7004 1160 0003 3739 1645) to CAPITAL HEALTHCARE ASSOCIATES, a/k/a CAPITAL HEALTHCARE CENTER, Attention Administrator, 3333 Capital Medical Blvd., Tallahassee, Florida 32308 and (receipt 7004 1160 0003 3739 1652) to Corporation Service Company, 1201 Hays Strect, Tallahassee, Florida 32301-2525. Submitted on this S day of roma ry 200 G ann M. Bye, Esq. Agency for Health Care Administration Page7of9 = Exhibit 7 NNN “y MM OM Me OR OY OE OY OY NaN IN OVEN ONAN ENGNG a » - ¢ NEV IN EN ON SN PN EN AS oO wo ~ N mo ud S a ao 8589216158 15:31 03/83/2016 / avn / an GaN Mar 3 2010 15:41 63/63/2018 15:31 8569210158 PAGE 33/58 ; ty Mn STATE OF FLORIDA Og Pk, hy : AGENCY FOR HEALTH CARE AUMINISTRATION Wy <5 “HG AY. 2; STATE OF FLORIDA, CY Oe Vy AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, Case Nos. 2008005347 (Fines) 2008005348 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC, o/o/a Capital Healthcare Center, Respondent ; st) é ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency”), by and through the undersigned counsel, and files this Administrative Complait against CAPITAL HEALTH CARE ASSOCIATES, LLC, w/a Capita] Healthcare Center, (hereinafter “Respondent”), pursuant to §§120.569 and 120 57. Flonda Statutes (2007), and alleges: NATURE OF THE ACTION This as an action to change Respondent’s licensure status from Standard to Condational commencing Apni, 11, 2008, impose an adminstrative fine in the amount of $30,000, and a survey fee in the amount of $6,000, based upon being cited for two widespread State Class J deficiencies. JURISDICTION AND VENUE 1. The Agency has junsdicton pursuant to §§ 120.60 and 400 062, Flonda Statutes (2007) 2. Venue lies pursuant to Flonda Admunustranve Code R 28-106.207. PARTIES 3 Vhe Agency is the regulatory authonty responsible for censure of nursing homes and Mar 3 2010 15:41 83/83/2018 15:31 8509218158 PAGE 34/58 enforcement of applicable federal regu/ations, state statutes and rules governing skilled nursing facilities pursuant to the Onuubvus Reconciliahon Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Flonda Statutes, and Chapter S9A-4, Flonda Adminstrative Code 4 Respondent operates a 156-bed nursing home, located at 3333 Capital Medical Blvd , Tallahassec, Florida 32308, and 1s licensed as a sxilled nursing facility hcense number 1073096 5. * Respondent was at all trmes matenal hereto, a licensed nursing facility under the licensing authority of the Agency, and was requ:red to comply with all applicable rules, and Statutes COUNTI RESPONDENT'S FACILITY NEGLECTED TO PROVIDE CARE AND SERVICES TO MEET THE RESIDENTS NEEDS. § 400.102(1), Fla. Stat. (2007) WIDESPREAD CLASS { DEFICIENCY 6 The Agency re-alleyes and mcorporates paragraphs one (1) through five (5), as if fully ser forth herein. 7. That Flonda Law provides the following 400.102 In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) Au intentional or negligent act materially affecting the health or safety of residents of the facility; 8. That on Apni 9, 2008, through Apnil 11, 2008, the Agency conducted three unannounced complaint surveys at Respondent's facility. The complaint allegations were confirmed. 9 Based on observation, interview, record review and policy review the facihty neglected to provide care and services to meet the residents needs for 15 of 19 sampled residents (#1,2,3,4,5, 6,7,8,9,10,11,12,13,14)3 5), which included madequate supersion of the Starlight Program, adequate staffing, failure to provide fall Monitonng with unplementation of the facility's fall Mar 3 2010 15:41 83/83/2818 15:31 8589218158 PAGE 35/58 policy and procedures and failure to follow Standard of Nursiag Practice for the treatment and care ofa resident with a head injury which resulted in Resident's #1 condition detenorating while at the facility with the ultimate outcome of death. The findings include: 1. An interview with the family member of Resident #1 on 4//9/08 at 11:15 AM. revealed his famaly member (resident #1) had fallen on 3/27/08 He stated the resident fell out of the wheelchair and int his/her head. He stated the facility told him the resident had been attending movie tume and was in the Starlight program at the time of the fall He stated the resident sustained a large knot the size of a tennis ball on the forehead. He stated Resident #1 was taken to the hospital and diagnosed with a concussion. The resident was released back to the facility on 3/27/08 The family member stated the resident had a high fever and had been unresponsive since 3/29/08 The resident was sent back to thc Hospital on 3/31/08 and the hospital stated the Tesident had a stroke and bleeding in the brain as a result of the fall on 3/27/08. On 4/10/08 at 930 AM. the family member stated to this surveyor that the resident had died in the hospital as a result of the injunes incurred at the facility 2. Dunng the imitial tour of the facility on 4/9/08 at Li 35 A.M. the Administrator volunteered information conceming the recent fall of the Ressdent #1 witha hematoma to the head. He stated the facility had a Jarge amount of falls but the numbers were improving The surveyor questioned what measures the facility had put in place to decrease the number of falls. The Administrator stated ‘there were no new measures put in place. He stated the facility had just ensured the current fall protocols were being followed. 3. On 4/9/08 at 12 1S PM the Director of Nurses (DON) brought the surveyor the medical record for Resident #) and stated everything was in order. She stated she had already reviewed the record She stated the resident fell on 3/27/08 and Was sent to the ER for evaluation Resident #1 was sent back to the facility with a diagnosis of UTI and change ia mental status She stated over the weekend of Mar 3 2010 15:41 03/83/2018 15:31 8509210158 PAGE 36/58 3/29/08 and 3/30/08 the resident began spiking “temps”. She stated the staff were calling the DON and Advanced Registered Nurse Practinoner (ARNP) over the weckend as the 1esident declined The staff called the DON on Sunday 3/30/08 and stated the resident was not responsive to name. On Monday (3/31/08) the DON stated she was on vacation but called the facthty to check on the resident and was told of the status. She stated she instructed the staff to send Resident #1 to the Emergency Room. The resident was sent to Tallahassee Memonal Hospital (TMH) which had a neurosurgeon The neurosurgeon stated the resident had a slow bleed and there was nothing that could be done for them The DON stated she was the Risk Manager and Quality Assurance Coordinator for the 156 bed facility. She stated she had assumed these responsibilities as of approxumately 2/29/08 after the previous Risk Manager left the facility. The Surveyor and the DON reviewed the facility's investigation of the Resident #1's fall. She stated the resident was in the Starlight program when the fall occurred She stated the CNA (Certified Nursing Assistart) slated the resident was attempting to cross their legs and the chair upped to the side and the resident fe]] Out of the wheelchair onto floor. The D ON stated the CNA was provided a coaching plan, after Resident #) sustained the fall on 3/27/08 A "coaching plan” 1s the process in which the facility uses for staff disciphne The DON siated she had completed uu further investigation or corrective action sunce the untial investigauion 4. On 4/9/08 at 1:38PM aninternew with a Starlight aide (#1) revealed they usually work with 10-12 residents, they are often understaffed in the Starlight program and even if there is only one aide avaslable to work in Starbght, they work im Starhght alone. She stated she was working the day the Resident #1 fell She said she had left to take 2 other residents back to thei room and was not present when Resident #1 actually fell, 5. baterview with the 2nd Starlight aide (#2) on 4/9/08 at 1-45 P.M. Dunng this imlerview she revealed they usually work with 8-10 residents in the Starlight 43/83/2018 16:31 Mar 3 2010 15:42 8589218158 PAGE 37/58 program She stated her shiftis from 1-9 PM and after 7 00 P M shes the only staff member in Starlight. The aide stated on 3/27/08 she pushed the resident #1 ui the wheelchair from Hall C to the Starhght area, which was iu the restorative dining room (main dining room) When she entered the Dining Room another resident was stopped m the middle of the floor, blocking the pathway. The aide Jeft Resident #1 to push the other resident out of the way. She stated her back was to Resident #1 when she fell. She said the acnviues lady yelled out to get the resident and when she tumed around the resident was on the floor She said the resident does not normally try to get up and it looked like the resident fell out of the wheelchair sideways She stated the resident's wheelchay was upnght and did not fall over with the resident She stated the resident had foot rests on the wheelchair and the resident's feet where in the foot rest prior to the fall. She said dunng the time of the fall there were 8 residents in the Starlight area. She said that if the facility had provided more staff then the Resident #1's fall would not have occurred A 2nd interview was conducted wth Starlight Aide #2 on 4/10/08 at approximately 2.50 PM the aide repeated the information as above and stated the facility needs more staff assistance in the Starhght Room and throughout the facility. She reported that she told the Administration staff that Resident #1's fal] could have been prevented if there were more staff available to assis| with the residents. She additionally stated that she often works alone because there 1s not enough staff 6. Intcrmew on 4/9/08 at 2:00 P M. with the Activites aide stated she was previously the Staffing Coordinator aud had been with activitics 2 months, She stated the Starlight program is totally separate frorn Activities Program and some Starlight residents will attend some group activities. She stated she did observe Resident #1's fall on 3/27/08 She stated she was in the main dining room directing bingo for the residents im Activitics The Starlight residents were ina Separate area off of the dining room The aide stated she happened to glance up could see Resident #1 was falling She stated the resident "Jerked" and fell “comer wise” The aide stated she had not worked with the residents in the 83/03/2819 15:31 Mar 3 2010 15:42 85892108158 PAGE 38/58 Starlight Program unul they began joining ww Acuvities. The aide stated she had noted the residents in the Stariight Program require a hot of care and supervision The aide stated the current staffing 1s not adequate to meet the needs of the residents in Starhght 7. A review of the Resident #1's medical record on 4/9/08 revealed s/he was admitted to the facility on 12/4/07 ‘The medical record revealed the following sequence of evcnts from the resydent's fall on 3/27/08 to hospitahzation on 3/31/08 The nurse notes stated on 3/27/08 the aide called the nurse to the dining room. Resident #1 was found lying on the floor on his/her side. The resident was observed with a large hematoma to the forehead Yhe nurse documented the resident's upper extremities were "very stiff" and the resident was “keeping armas stretched out" The nurse documented the resident was not responding to name but "was breathing” The resident wag taken back to her room and placed in bed. The resident's Vital signs were B/P 209/110, 82, 16,982. The resident began to answer to their name after she was taken to the room but was not oriented. The ARNP was contacted and gave orders to transfer the resident to the hospital The resident vomuted twice before the transfer to the hospital by ambulance ‘Resident #1 was discharged back to the facility wath a diagnosis of Urinary Tract Lafection and a Concussion The resident amved back at the facility on 3/27/08 at 745 P.M. The LPN documented on the resident was NPO (nothing by mouth) except for medications per the ER nurse. The nurse did not document how long the resident was to be NPO The medical record did not contam a physician order for NPO. The medical record did not contain the Emergency Room discharge Lostractions and orders The LPN wrote an order for Cipro, an antibiouc for the Unnary Tract Infection, but no further new orders on 3/27/08 The LPN documented the resident with a hematoma to the left side of the forehead The LPN completed no further assessment Mar 3 2010 15:42 83/83/2018 15:31 8509216158 PAGE 39/58 On 3/27/08 at 815 P.M the LPN notified the family member of the resident's status The nurse assessed the resident's vital signs which were blood pressure 161/88, pulse 68, respirations 18 and temperature 97 7. The nurse did not complete any other assessment On 3/28/08 at 12.15 PM the LPN documented the resident was sleeping most of the morning and would respond when name was called. The resident had to be fed soup and fluids. The nurse documented the Hematoma "small on forehead.” The nurse documented vitals signs stable but did not list the vital signs. No further assessment of the resident's neurological status was completed. The medical record did not contain documentation of the resident's nutrivonal status to include the percentage of food consumed The resident's ADL & Nutnuon/Hydration Care Record was incomplete with the Jast entry on 3/19/08 The medical record did not indicate when the resident was removed from NPO Status. On 3/28/08 during the 7-3 shift the aide listed the vital signs on the assignment sheet of blood pressure 160/88, pulse 76, temperature 98 2, and respirations of 20 The vital signs as hsted here and below were obtained from the aide assignment sheets, which listed only vital Signs On 3/28/08 a Fall Action Team report was completed and signed by the LPN The fall rev:ew did not mention the resident's bead injury with interventions. The interventions listed were to momutor the resident more closely and keep the Head of the Bed up 40 degrecs for 24 hours There is not evidence these interventions were unplemented and followed The resident's care plan was not updated with new interventions after the fall of 3/27/08 On 3/28/08 at 7:30 P M the resident would respond to voice and touch. The LPN documented the hematoma to the “forehead has disrupted." Pupils were reactive to light. No further assessment of the resident's status was completed. On 3/29/08 there 1s no nursing entnes in the nurse notes The resident's Medication Administration Record (MAR) stated on 3/29/08 the resident refused 03/83/2018 15:31 Mar 3 2010 15:43 408/58 8569210158 PAGE momuing medications The medical record did not contam any communication of the resident's refusal to the physician or fanaly member Tbe MAR on 3/29/08 revealed the nurses did not complete accucks at 1630 and 2] 00. The MAR for 3/29/08 1s not consistent, with some medications imtiajed by the nurse as given, while others are initialed with a circle which indicates the medicatons were.held The back of the MAR does not provide further explanation which would clarify if the resident received their medications. On 3/29/08 during the 3-1] shift the aide documented on the assignment sheet vital signs of blood pressure 149/94, pulse 73, and respirations 22 On 3/30/08 at9.10 P.M. was the first assessment by a RN since the resident's return lo the facaltty on 3/27/08 The RN documented the resident was responding to Painful sumuli, The resident had a hematoma to the forehead. The resident's vital signs were temperature 192 4, blood pressure 190/100, Respirations 22 and Poor appetite. The resident's pulse was nul assessed. The RN contacted the ARNP which gave orders tor lab work of CBC with diff, CMP and straight cath for UA and C&S, chest x-ray, blood cultures, Tylenol, IV fluids of DS 1/2 NS at 60 cc/hr, and changed the resident's anubiotic. On 3/30/08 dunng the 3-11 shift the aide documentation the assignment sheet the resident's vital signs were blood pressure 190/100, temp 101 4, pulse 95, and respirations 22. There is not documentation of the nurses notification, or if these are the vital signs the RN used for ber assessment. (see above) On 3/30/08 at 10.40 P.M. the resident's IV Huds were begun. The temperature was rechecked which was 100.6 There was vo further assessment or vital signs On 3/30/08 the vital sign record stated on 11-7 shift the vital signs were temperature 98 6, pulse 70, respirations 22, and blood pressure 155/88 On 3/31/08 at 12 01 A.M. the nurse documented the resident was hard to awaken The resident would open their eyes and grasp hand. The resident's eyes were PERL (Pupils Equal and Reactive to Light) No further neurological or nursing assessment was completed Mar 3 2010 15:43 83/83/2018 15:31 8509218158 PAGE 41/58 On 3/31/08 at 5 30 AM. the nurse attempted twice to collect unne via a straight catheter The nurse was unable to obtain the urme. The Physician was not notified On 3/31/08 at 10:15 AM the nurse assessed the resident and found them unresponsive to name, verbal or painful stumul). The resident's pupils were constacted Blood sugar was 12, Blood pressure 160/80, pulse 88, respirations 24, temperature 100.6 The ARNP was phoned and stated to send the resident to the hospital The Ambulance amved at 10:40 A.M and transported the resident to the hospital The resident was diagnosed with an Intracranial (Occipital) Hemorthage 8. The record review revealed nursing neglect with a lack of assessment and nursing care for Resident #1 with a known head injury. According to the Lippincott Manual of Nursing Practice a concussion is an indirect injury to the bra. A concussion is a temporary loss of consciousness that results from a transient interruption of the brain's normal functioning. An intracranial hemorrhage is a significant blecding into a space or a potential space between the okul) and the brain. This is a senous comphication of ahead imury with a agh Mortality rate. The oursing interventions include an assessment of the level of consciousness which is the most sensitive indicator of a change in the resident's condition The Glasgow Coma Scale is recommended which assesses eye opemng, verbal response, and motor response. A change of 2 or more points may be significant and requires notification of the physician and reassessruent of the resident's neurological status. The nurse should evaluate vital signs Hypertension and bradycardia indicate an increasing lotracramal pressure Head- mjured patents may have assocjated cardiac dysrhythmias, noted by an unegular pulse or a fast pulse Changing pattems of respirations and elevated temperatures are associated with a head wyury. The pupils should be assessed for unequal or unresponsive pupils The resident should be monitored for confusion or personality changes, impaired vision, eyes appear sunken, seizure activity, thinorrhea or otorrhea which is indicalive of leakage of CSF. The resident should 63/03/2018 15:31 Mar 3 2010 15:43 8589218158 PAGE be monitored for penorbital ecchymosis with indicates antenor basilar fracture The resident's fluid volume and IV fluids should be restnoted 9 A review of the facility's neurological assessment flow sheet revealed the following components of the neurological assessment date, time, level of Consciousness, pupil response, mvtor functions, band grasps, movement of extremities, pain response, vital signs, observations of seizure activity, headaches, vomiung, and paralysis. The facylity's fall procedure stated a neurological assessment is to be completed after a head injury 10. On 4/11/08 at 10.30 AM the DON stated the resident was seen by the ARNP on 3/28/08 The last MD note an the medical record 1s dated 2/22/08 The DON stated she would have to locate the note. The DON stated the ARNP ordered jabs On 3/28/08 The medical record contained an order for a CBC and BMP to be collected on 3/31/08. The order 1s signed by the LPN and does not contain the name of the physicran/ARNP which ordered the Jab, and ifat was a verbal order or a telephone order. The ARNP did not wnite the order 1). On 4/) 1/08 at approximately 12:00 P M. the DON provided this surveyor an ARNP note dated 3/28/08 for resident #1. The DON stated she had called the ARNP and the ARNP brought a copy of the note. The ARNP’s note is a pre- printed note which 1s very simular to the other ARNP notes in the medical record. The progress note did not address the resident's fall on 3/27/08 and her new diagnosis of UTI and Concussion. The ARNP wrote mental status was bascline, but did not provide further assessment The ARNP was phoned on 4/11/08 at apprommately 12 15 P.M. The ARNP stated the facility had phoned her this morning and requested the note. The ARNP stated she did visit on 3/28/08 and the original note must be waiting to be filed. She stated she had just realized she dod not document the resident had gone to the ER on 3/27/08 She stated she couldn't remember much about the visit but 42/58 83/03/2018 15:31 Mar 3 2010 15:44 9589210158 PAGE she thought the resident fell from a standing level She stated she was not contacted again by the facibty unt! 3/31/08 when the resident was sent to the Emergency Room The ARNP could not recall if she gave any orders on 3/28/08. She could not recall sf the resident had a history of falls or the resident's mental and neuro status on 3/28/08 The ARNP was asked if she gave the orders on 3/30/08 for the blood cultures etc ~The ARNP stated she could not secall if she gave any orders but stated she “probably” gave some orders She was asked why she ordered the blood cultures, IV and other labs She stated she could not tremember 12. A review of the Starlight Program Guide Policy and Procedure. The Policy is located in the manual under "recreational and therapeutic activities.” The policy Stated the Starlight program 3s a structured program for cognitive enhancement, nursing rehabilitauon and behavioral management provided for a sinall yroup of nursing facility residents The objective of the program is to provide a safe, structured environment, consistent approaches and programming for persons with decreased cogmutive function and impaired physical abilities Outcome goals include. decreases injuries, decreased weight loss, relief of behavioral symptoms, maximzed functional independence, and waproved copniuon. The program is provided by Nursing Assistants, monitored by the Activity Director and/or Nursing Staff provide most of the care and services provided The program includes activity opportunities, ADL care that can be done ina public setting and behavior management. The Admission Critena includes the resident Is demonstrating behaviors associated with Alzheimer's and/or dementia such as, memory dysfunction, poor judgement, disonentation to ume, place and person, decreased attention span, mood fluctuations, wandenng and exit-seeking, expressions of anxiety, high nsk for falls/accidents due to poor safety awareness and/or impasred physical function The 0) recommends the resident for the Starlight program The Staffing requirements include one aide for 8-10 residents, one assigned Starlight Program Coordinator, designated nurse assigned to care of resident, and aide staff responsible for the care needs of the residents The Program 43/58 83/83/2818 15:31 Mar 3 2010 15:44 8509210158 PAGE 44/58 Coordinator and Unit Manager are responsible for the management of the program, coordinating the screening and placement or removal of residents in the programa, program development (planning, scheduling and monitoring), communication between the program. facilty leadership and families, supervising and scheduling of all program staff, monstonng the delivery of services, collaborating with department heads, and Modeling excellent resident care. The Role of the Starlight aide includes provide structured activities and companionship. provide meals and snacks, maintain cleanliness, monitor residents for safety, monitor for pain, assist with lung, provide grooming nail and hair care, provide every 2 hour positioning, monitor behaviors, and document on ADL sheets The aides are to be provided with a Walkie talkies to communicate with nursing staff outside of the room. The Starlight Schedute Form is a sample schedule for the aides to initiate with the residents. Its to be updated daily. The activsties are to be selected based on each residents preference The preferences are found in the resident's medical record. A review of the Starhght program manual revealed this form was not completed for each individual resident with thei identified activity picferences and parucipation The manual contained one form for random dates. The schedule form was not completed daily and was not signed by the person complenng the form. The schedule stopped at 7 30 P M., when in fact the program continued with the last aide until 9:00 P.M The forms did not contain the daily uames of the residents attending the program or staff working each day. The manual did not contain the names of the residents in the program 13. An interview with the DON on 4/9/08 at 2:00 P.M. stated she could not provide the staffing in the Starhght Program because the Activities Ducctor dues the staffing She stated the Achvities Director was out of the building and did not know when she would return At 2°40 P M the Activity Director amived. She Stated she does not do staffing for Starlight She stated the staffing coordinator does the scheduling She stated she gives the Starlight aides the schedule of activites for the day She stated there were staffing issues in the facility and her activity aides are often pulled to cover the floor 83/63/2010 15:31 Mar 3 2010 15:44 8589216158 PAGE 45/58 The surveyor walked with the Activity Director to the DON's office. The Activity Director stated to the DON she did not do stafting for Starhght The DON stated she did, the Activity Director stated agamn that she didn't and left the room 14, An imtennew with the Achvities Director on 4/10/08 at 10-40 AM She reviewed the above Starlight policy, stated she 1s not providing supervision of the program She stated she knew the policy stated that she was, bul she was not the Starlight Program Coordinator. She stated the Staffing Coordmator staffs the Starlight program. She stated if an aide is abscnt then she tells the Staffing Cvordimator and/or nursing since the aides fal] under pursing. She stated she does not function as a Supervisor over the staff in the Starhght program. A review of the staff present dunng the resident #1's fal). she stated the aide listed for 8 hours was not present. She stated “I know she wasn't there, J interviewed her after the fall." She left the roum (o clanfy the information She was observed discussing the stating w:th the Administrator. She retumed and stated the ade was working but she was not in the room when the resident fell. She stated the ade had taken another resident to a room for toileting. She stated the Starlight aides take the residents to their roomn cvery 2 hours for toileting She provided the staff sign in sheet for 3/27/08 which did not agree with the pnnted staffing provided by the facihty The form did not contain the signatures for any of the Starlights aides and did not include 2 of the 4 Starlight aides listed on the staffing information provided by the facility The Activities Director stated the facility had no means of documentng daily the number of residents present in the Starhght program and the daly staffing of the Starlight program. She stated nursing was responsible for assessing the resident for the Starlight program and providing on-gomg monitoring. 15. On 4/10/08 at 12:50 P Man interview was conducted with the Staffing Coordinator She stated she does all the staffing for the nurses and aides, including the Starlight Program. She stated she began the position 1-2 months ago. The staffing for the Starhght program was reviewed She stated she did not know which residents were in the Starhgbt program She stated she had not seen 3/03/2018 15:31 Mar 3 2010 15:45 8509210158 PAGE a list of residents and did not know the tulal number of residents m lhe program She stated the staffing should be } aide for & residents in the Starlight program She stated she attempts to schedule at least 2 aides in the program. She stated when an aide calls in she attemp‘s to obtain an aide from the floor, but they often refuse She stated the residents in the Starhght program are residents which are combative or fel] in the last 6 months 16 Observation of the Starhght Program on 4/9/08 ai 138 P.M. the Starlight residents are participating in a group activity with other residents outside the building All the residents are in wheelchairs, many with chair alamms. The wheelchairs do not contain identification of fall nsk (star) Observation of the Starlight Program on 4/10/08 at )}145 AM , S residents were in the Activities oom with 2 aides All the residents were ip wheeichams, many with chaar alarms There was no falling stars on the wheelchairs to idenufy the high risk residents A review of the list of the 13 residents provided by the facility was completed with the aides They stated there were many residents that were not there. Thev stated that not all the icsidents come everyday. They stated some residents are in they rooms, in therapy, or with family. They are unsure the location of each resident in the Starhght program They stated there is not a current mechanism in which they document which residents are attending the progxam, the times of attendance, and any care issues. An ubservation of the Starlight program on 4/10/08 at 6-10 PM. there were 5 residents with 1 staff member. The program was located 1m the common area in front of the nurse statian oo Hall B. All the residents were cogmuvely impaired and in the wheelchair One resident was self propelling themsejives down the hallway. The resident had gone approximately 1/4 down the hallway when the Starlight aide went to catch them. The aide had her back to the other 4 residents A second resident was extremely agitated and attempung to self propel themselves into the nurse station A third resident was observed attempting to take off their lap belt The atmosphere was one of chaos The Activity Director arrived and asked the aide what did she nommally do with the residents atmght The aide began to read the paper from a standing position, - 46/58 83/63/2010 15:31 Mar 3 2010 15:45 8569216158 PAGE 47/58 she was told by the Director to sit down The aide cid not brng the residents to her proor to beginning to rcad. The Director stated she was not engaging the residents and this was not working as the residents continued to be agrtated Dunng each of the observations of Starlight there was not a mechanism of communication with nursing staff, eg walkie talkies as per the pohcy. The aides were observed taking residents to ther rooms ot for other care needs leaving the program with one aide A review of 7 of 7 (#3, 3,4,5,7,8,1 1) sampled residents m the Starlight program, thei medical record revealed no assessment pnor to placement in the program, the date of placement, and ongoing momtonng for effectrveness of the program. 17. A review of the facility's “Fall Rusk Reduction and Management” clinical program stated residents which were identified as a bogh nsk for falls a “star” symbol would be placed in an easily identified area near the resident e g. bed, wheelchay, doorway etc The Fal] Achon Team was to be notified if a resident experienced a fall The ‘Fall Risk Identification and Plan of Care” form is to be updated when a fall occurs The resident's fall risk factors arc to be assessed which include. Limited onentation to own himutations, History of falls, altered elimanauon status, diuretics or medications with sedanve effects, assistance required with transfemng or ambulatng. The Plan of Care is to he reviewed with intervenuions to minimize or eliminate falls. The Interdisciphnary Tcam works with the resident and family to provide education on expectations related to fall prevention and management Strategies ifa fall should occur. Post fall management includes appropriate resident care, evaluation and revision of exisung interventions, and investi gauon into potential factors to determine areas ofimprovement The policy stated the resident's medical record and circumstances surrounding the fal) wall be reviewed by the Fall Acton Team by the next business day A referral to 1s to be made to therapy after each fall. Therapy is to evaluate for skilled services, positioning or adaptive equpment, and restoralve nursing services. The facihty 1s to monitor and document the effectiveness of the interventions in prevention of recurrent falls Mar 3 2010 19:45 83/83/2818 15:31 98589214158 PAGE 48/58 The policy stated the staff are to document in the medical record the following date and ume of incident, bref, factual and objective descnption of the incident, Tesults of climcat findings, immediate interventions, resident Jocation after occurrence, physician contact and family member contact. The staff are to evaluate and document on chnical condition once per shift for at least 72 hours post fall This evaluation and documentation should include’ vital signs, resident Status, changes im cognition, physical status, pain, ability to participate in daily care ard rouune, response tc changes in medications, treatments or interventions, results of lab/tests with notification of the physician, communication with the physician, family member and Interdisciplinary Team of any changes. 18. An observation of the resident #2's room on 4/11/08 at 10:15 AM it was noted the resident's room mate was on a low bed with mats. The room mate's name plate beside the door contained a symbol of 2 feet. The Activity Director was in the hallway pushing a resident She was asked what the feet represented. She stated they are for fail precautions. The resident #2 review of medical record revealed a history of fall and fall precauuons were care planned. ‘Lhe resident did not have any symbols near the bed to identify the resident as a fall nsk The resident had a symbol of a star on the door. The room mate did not have a star symbol on the door or on the bed as per policy. An observation of the Starlight residents, which were in a group religious activity on 4/11/08 at 1020 A.M. The dining room area contained more than 20 residents in wheelchairs, many with chaw alarms There were not any star or other symbols noted on the wheelchairs to identify which residents are fall risk. An interview with an aide present dunng the activity was asked how she identified which residents were high nsk for falls She stated they would have a guardian angle beside the door to thar room (This answer 1s not per the facility policy ) 16 Mar 3 2010 15:46 63/03/2018 15:31 8589210158 PAGE 10 The above constitutes a violation of § 490 102(1), Fla Stat. (2007), and constitutes a widespread Class J deficiency pursuant to § 400 23(8)(a), Fla. Stat. (2007) -1 The Agency provided Respondent with a mandatory immediate correction date WHEREFORE, the Agency utends to impose an admmisirauve fine in Ge amount of $15,000.00 against Respordent, a skilled nursing facility in the State of Flonda, pursuant to §§ 400 23(8)(a) and 400.102, Florida Statutes (2007) COUNT I RESPONDENT’S FACILITY FAILED TO IMPLEMENT AN EFFECTIVE QUALITY ASSESSMENT AND ASSURANCE PROCESS. § 400.147(1), Fla. Stat. (2007) WIDESPREAD CLASS I DEFICIENCY 12. The Agency re-alleges and incorporates paragraphs one (1) through five (13), as if fully set forth herem 13 That Florida Law provides the following 400.147 (1) Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: (c) Policies and procedures to implement the internal risk management and quality assurance program, which muyt include the investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents to residents 14, - That on Apnl 9, 2008 through Apnl 11, 2008, the Agency conducted three unannounced 49/58 Mar 3 2010 15:46 83/83/2018 15:31 8569216158 PAGE 58/58 complaint surveys at Respondent's facility The complaint allegations were confirmed 15 Based on record review, observation, resident and staf‘ interview the faciuty faved to ensure Administranon effectively administered the facility to ensure the residents were able to maintain the highest practicable physical and psychusocial well-being through the implementation of an effective Fall and Starbght Program to provide increased supervision and safety to the most compromised and at nsk population. The findings include: 1 Dunng the survey of the facility 4/9/08 to 4/11/08 a systemic failure of the Fall and Starlight program was identified The facility failed to implement the policy and procedures for the Starlight and Fall programs to ensure the provision of Quality Nursing Care to meet the needs of the residents. The Administration failed to ensure the Quality Assurance program was effective and provided on- going monitoring to ensurc the resident's care needs were being met 16 Based on observation, record review and interview the facility failed to implement an effective Quality Assessment and Assurance process to ensure the provision of care and services were provided by staff per the facility's pobcy and procedures and Standard of Practice. The facihty failed to identify, investigate, develop and implement an effective plan of action with an on-going process to monutor the effectveness ot the action plan. The findings include: 1. Arevicw of the Fall Risk Reduction and Managancnt clinical program stated the facility 1s to complete an analysis of facality fall data for quality improvement Opportunities. The analysis 1s to be completed no less than monthly. Leadership review 1s to be done at the direction of and through the nsk management/quahty improvement committee. Trending reports will include: time of fall, location in facility, type of fall, resident activity associated with fall. The trend data is collected to identify facility outcomes related to fall management. The Quality Improvement procedure includes the following 1) Review of all intemal reports related to falls 2) Trend data to :dentify facility outcomes related to fall Mar 3 2010 15:46 83/83/2818 15:31 8589216158 PAGE 51/58 management The trend data compares fails from week to week, potential reasons for repeat falls, and environmental data 3) Evaluate information gathered from the “Fal Action Team. Fail Review Too! 4) Develop a systemic modifications to addcess identified fall risk 1ssues 5) Evaluate effectiveness of unplemented Modifications 6) Provide ongoing staff education related to falls prevention 2. Ateview of the fall log on 4/9/08 revealed 5 falls for Apn] 2008 and 23 falls for March 2008 In an interview wrth the DON at 315 P.M on 4/9/08, she gave the surveyor a fall log for February, which listed 19 falls She stated the risk manager left the end of February and the DON could not find any logs for February She stated she Pulled the fall information from the computer. She stated they prepare a weekly report for corporate which includes falls and this is what she used to make a February fall log She stated she did not have a fall log for December or January, She stated the computer only goes back to February 2008 She stated the falls were ngh in December and January and the facihty had unplemented an action plan. She reviewed the current measures in place to improve the falls at the facilty which included the following. 1) the staff were to call her with each fall- she would assess for staff intervention, medications, labs etc, 2) the facihty increased aide accountability 3) DON would decide if the resident was to go out. 4) call family/MD__ 5S) add alarms as needed 6) each moming each fall is reviewed with fall action committee 7) all falls get therapy screemmng The DON provided Weekly Clinical Indicator reports which 1s reported lo the corporate office. The report listed total numbers of falls each week. The report hsts the Jast names of the residents, but did not Jist the Ist name, date of fall or any other information related to the fall. The facility had many residents with the same last name and there was no way to idennfy the resident The report listed 26 falls for January 2008 and 40 falls for December 2007 3/83/2018 15:31 Mar 3 2010 15:46 8509210158 PAGE 3 An nterview with the DON on 4/11/08 at 10 30 AM stated all residents receive a therapy screen after a fali_ A review of the therany screen manual agaist the falj log revealed many discrepancies. In Apsil 2008 there were hsted 2 therapy screens. There was not a therapy screen for the other 3 residents which fell from Apn] } to Ap! 7. In March 2008 there were 23 falls listed but only 15 therapy evaluations There were 2 therapy evaluations which did not correspond with the dates of the falls listed in the fall log. In February 2008 there were 19 falls listed with only 5 therapy evaluations There was one therapy evaluation Which did not correspond with the date of the fall listed in the Jog. Furthenmore, the resident #14 had a therapy screen on 3/19/08 for a fall, which 1s not bsted on the fall log The resident #13 had a therapy screen on 3/17/08 for a fall which is not listed on the fall log, The resident #15 had a therapy screening on 3/10/08 for a fall which occurred on 3/8/08. The therapist documented the resident had fallen with a skin tear to the right knee and hematoma to the nght postenor head The resident was transferred to an acute hospital. There 1s no further information provided. The resident was not hsted on the facility's fall log In January 2008 there were 26 falls listed but only 18 therapy evaluations were completed In December 2008 there were 40 falls listed but only 21 therapy evaluations were completed. Review of the therapy screens did nat agree with the fall log which was often incomplete as ta the name, date, and injury A review of the screens revealed the following - December 2007- 3 residents receved head wyunes from falls and 3 residents fell from thew wheelchairs -January 2008- 3 residents recerved an jury to their heads, 2 fell out of their wheelchasr and 2 residents fell while attermpung to find something to eat -Febmary 2008 - 4 residents fell out of their wheelcharr and 1 received a head imyury 20 52/58 Mar 3 2010 15:47 83/63/2818 15:31 8589218158 PAGE 53/58 -March 2008 - } resident reccived a head mjury and 3 residents fell out of ther wheelchairs. (Record review revealed a total of 3 resident's received head myuries #), #4, #15) “April 2008 - | person fell out of their wheelchait 4 An interview was conducted with the DON on 4/10/08 at 3.30 PM Resident #1's fall of 3/27/08 was reviewed with her ‘Ihe DON's investigation had Indicated the resident fell out of the wheelchair sideways. The DON stated the Activity Aide, which actually saw the fall, stated the resident went ngid and it looked hke seizure activity inamediately pnor to the fall. The resident had no history of seizures The DON was questioned on corrective measures put in place after the resident #1's fall on 3/27/08 She stated an in-service and coaching plan was provided to the Starlight aide #2 on safety and prevention of falls. The DON was questioned on the lack of nursing assessments including neurological assessment of the resident after the fal] on 3/27/08. The DON confined the lack of nursing assessment She stated she was aware of the lack of nursing care. She confirmed she had not implemented any interventions with the Bursing staff which cared for the resident after the fall on 3/27/08. The medical record did not contain documentation to support the earlier interview with the DON which stated she had been notified of the fail with frequent phone calls to her and the ARNP over the weekend. She stated the first communication she received was from the RN on 3/30/08 at 9:10P M The DON was asked who was the Starhght Coordinator. She stated that there had been confusion on who was Tesponsible for the program She stated after the surveyor questioned the program On 4/9/08 11 had been clarified and now the Activity Director is responsible for the program. She confinmed previously there was not a supervisor responsible for the Starlight program. She was asked which staff member was responsible for ensuring the fall policy and procedure was implemented aud {ullowed. She stated itis a Risk Management Tesponsibility and since she xs the Risk Manager, it would be her responsibility She stated the DON, QA, and RM position is too much for one person. 2t 83/03/2014 15:31 Mar 3 2010 15:4? 8509218158 PAGE The DON provided a copy of the aforementioned coaching plan with aide #2 Tins plan 1s dated 3/26/08, which is the day before the fail of 3/27/08 The date of the coaching plan was brought to the attention of the DON on 4/10/08 at 3.30 P.M. The DON provided no explanation for the discrepancies in the date The plan stated the aide failed to keep a resident safe The plan does not specify the name of the resident which was neglected The plan did not provide enough informanon to verify the plan 1s in relation to resident #1 and not another resident The coaching plan stated "Tag 226” "Negiect to keep resident safe in assigned group area." Ii does not lst the specific resident or further details. The plan was to provide an in-service on resident safety. A copy of an m-service dated. 3/27/08 was provided which stated the aide was in-serviced on safety and falls prevention. Ivis unclear how this was completed the same day as the fall, when the fall did not Occur unti] 2:15 PM and the resident did not retum to the facility unul 7:45 PM 5. On 4/11/08 at 10.30 A.M the DON produced an analysis of a time line of the events from 3/27/08 to 3/31/08 for the resident #1. The tume line was noted to be wmaccurate, such as, the RN assessment was listed as completed on 3/27/08, when in fact it was not completed until 3/30/08. The DON stated the resident was seen by the ARNP on 3/28/08. The last MD note in the medical record is dated 2/22/08. The DON stated she would have to locate the note. The DON stated the ARNP ordered labs on 3/28/08 The medical record contained an order for a CBC and BMP to be collected on 3/31/08. The order is signed by the LPN and does not contain the name of the physician/ARNP which ordered the lab, and if twas a verbal order or a telephone order. The ARNP did not write the order. The DON documented on 3/30/08 neuro checks were completed 1-3 times each shift. Shc could not provide documentation of these checks. She could not provide documentation of the Physician's notification of the resident's lack of unne output on 3/31/08. The DON's ume Jine was not supported by the medical record. 6 On 4/9/08 at 2.00 P.M the DON located an Action Plan dated November 19, 2007 with revision of December 14, 2007 to assist with the excessive amount of 22 54/58 Mar 3 2010 15:4? 03/83/2018 15:31 8509218158 PAGE 55/58 falls idenufied by the facyhty She stated she was unable to locate any further achon plans She stated the facility had implemented the plan which had decreased the amount of falls She was unable to provide evidence the plan had been momtored for effectiveness with revision as needed On 4/31/08 at 10:30 A.M_ the DON reintroduced the Action Plan which she stated addressed the identified areas of a lack of resident supervision and staff accountabiuty She stated the facility was tracking and trending falls by shift and wing. The tracking did not include the :csident’s names or other information. The DON was unable to provide evidence of the assessment of the effectiveness of the action plan since it was mmplemented in December 2007 She was unable to provide evidence of the implementation of the process to ensure the methods used to collect fall data was accurate. She was unable to provide evidence of an on-going monitoring of falls to ensure the staff 1s following the facility's fall policy. 17. The above constitutes a violation of § 400 147(1)(c), Fla. Stat. (2007), and constitutes a widespread Class I deficiency pursuant to § 400.23 (8)(a), Fla. Stat. (2007). 18, The Agency provided Respondent with a mandatory immediate correction date WHEREFORE, the Agency intends to Impose an administranve 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, Flonda Statutes (2007) COUNT IW 19. The Agency re-alleges and incorporates Counts I and IU of this Complaint as if fully set forth herein 20. Based upon Respondent's two State Class I deficiencies, 1t was not in substantial comphiance at the time of the survey with cntena established under Part II of Florida Statute 400, 23 Mar 3 2010 15:48 PAGE 56/58 63/03/2018 15:31 8549216158 or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional censure status under § 400 23(7)(b), Florida S‘arutes (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), Flonda Statutes (2007) commencing April 11, 2008 COUNT IV 21 The Agency re-alleges and incorporates Counts I, U and LU] of this Complaint as if fully set forth herein 22 Respondent has been cited for {wo State Class I deficiencies and therefore is subject toa six (6) month survey cycle for a penod of two years and a survey fee of $6,000 pursuant to Section 400,19(3), Florida Statutes (2007) WITEREFORE, the Agency mtends to unpose 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 nursing facility in the State of Flonda, pursuant to Section 400 19(3), Flonda Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Adnumistradion, respectfully acquests that this court: (A) Make factual and legal findings in favor of the Agency on Count J through Count Vv; (B) Recommend an admimistratyve fine against Respondent in the amount of $36,000 for Count I: It, and IV; (C) Assess attomey’s fees and costs; and (D) Grant al! other general and equitable rehef allowed by law. 24 Mar 3 2010 15:48 03/03/2018 15:31 8509210158 PAGE 57/58 L Respectfully submitted this a day of May, 2008. Mark Hinely, Esq Fla. Bar. No. 48084 Agency for Health Care Admin 2727 Mahan Dnve, MS #3 Tallahassee; Flonda 32308 850.922.5873 (office) 850 921.0158 (fax) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Florida Statutes (2007), Respondent shall post the most current lcense ima prominent place that js in clear and unobstructed public view, at or near, the place where residents are being admitted to the facahty Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120 569, Flonda Statutes Respondent has the nyht to retain, and be Tepresented by an allomey in this matter Specific options for administrative action are set out mn the attached Election of Rights, All requests for hearing shall be made to the atiention of The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Retum Receipt No 7004 2890 0000 5526 8152 to Facility Administrator Thomas L. McDamel, 3333 Capital Medical Blvd., Tallahassee, Florida 32308, by U S. Certified Mail, Retum Receipt No 7004 2890 0000 5526 8169 to Owner Capital Health Care Associates, 25 Mar 3 2010 15:48 83/83/2018 15:31 8589210158 PAGE LLC, d/b/a Capital Healthcare Center. 10210 Highland Manor Drive, Suste 250, Tampa, FL 33610, and by U.S. Cerufied Mail, Retum Receipt No 7004 2890 0000 5526 8176 to Registered Agent Corporation Service Company, 1201 Hays Sueet, Tallabassee, Flonda 32301 on May &*, 2008 Mark Hinely, hs | Copy fumished to. Barbara Alford, FOM 26 58/58 Mar 3 2010 16:04 83/03/2818 16:03 8589216158 PAGE @2/45 ww FIOUOA AGENCY FOR HEAT CARE ADNAN STRATOS . CHARLIE CRIST ItOLLY BENSON GOVERNOR SECRETARY April 29, 2008 Mr. Thomas McDaniel Administrator Capital Healthcare Center 3333 Capital Medical Boulevard Tallahassec, FL 32308 RE: Capital Healthcare Center Dear Mr. McDanie)- The Agency for Health Care Administrauon, Tallahassee Field Office, has inspected Capital Health Care Center and the conditions that resulted in the p.acement of a moratonum against the facility on Apnl 11, 2008, have been reviewed. Field Office staff reported to this office that the necessary corrections have been made. In view of this, we are hereby lifting the moratonusn on admissions effecuve April 29, 2008 If you have questions concerning this matter, please contact Jacquie Willams in the Long-Term Care Unit at (850) 488-5861 ox Barbara Alford, Field Office Manager on the Tallahassee Field Office, ai (850) 922-8844. Sincerely, Keccomie cee Elizabeth Dudek, Deputy Secretary Division of Health Quality Assurance ED.jmw ce: Barbara Alford, Manager, TalJahassee Field Office Medicaid Program Office AHCA General Counsel's Office Se 272? Mahan Drive, MS¥ Talianassee. Florida 32308 Visit AHCA online at nip //ane EXHIBIT Mar 3 2010 16:05 03/83/2018 16:03 8509210158 PAGE @3/45 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No. 2008004593 VS CAPITAL HEALTH CARE ASSOCIATES, LLU, d/b/a CAPITAL HEALTH CARE CENTER, Respondent. i f EMERGENCY ORDER OF IMMEDIATE MORATORIUM ON ADMISSIONS THIS CAUSE came on for consideration before the Secretary of the Agency tor Health Care Admunistration, or his duly appointed designee, who upon a careful review of the matter at hand and being otherwise duly advised in the premises, finds and concludes as follows: PARTIES 1, The Agency for Health Care Administration (hereinafter “the Agency”) is the hcensing and regulatory authority that oversees skilled nursing facilities in Flonda and enforces the applicable federal regulations and state statutes and miles governing such facilities. Ch. 408, Part I, Ch. 400, Part Il, Fla. Stat (2007), Ch 59A-4, Fla Admin Code. As part of its authority, the Agency may issue emergency orders, mchiding an ummediate moratorium on admissions of residents, when the circurnstances dictate this action. §§ 120.60, 408 814, Fla Stat. (2007). 2 The Respondent, Capital Health care Associates, LLC, d/b/a Capital Health Care Center (hereinafter “‘the Respondent”), was issued a license by the Agency to operate a 156-bed skilled nursing facility in Florida (License Number 1073096) located at 3333 Capital Medical Mar 3 2010 16:05 84/45 63/03/2018 16:83 8509216158 PAGE Blvd, Tallahassee, Florida 32308 (heremafter “the Facility”), and was at all matenal tunes required to comply with all applicable federal regulations and state statutes and rules governing such facalities 3 As the holder of such a license, the Respondent is licensee. “Licensee” means “an individual, corporation, partnership, firm, association, or governmental entity, that 1s issued a permut, registration, certificate, or license by the Agency.” § 408.803(9), Fla Stat (2007). “The heensee is legally responsible for all aspects of the provider operation.” § 408 803(9), Fla. Stat (2007). “Provider” means “any activity, service, agency, or facility regulated by the Agency and listed in Section 408 802, (Florida Statutes (2007)).” § 408.803(11), Fla. Stat. (2007) Skilled nursing facilities are regulated by the Agency under Chapter 400, Part Il, Florida Statutes.(2007), and listed in Section 408 802, Flonda Statutes (2007). § 408.802(13), Fla. Stat. (2007). Skilled . nursing facility residents are thus chents “Client” means “any person receiving services from a provider.”” § 408.803(6), Fla. Stat. (2007) 4. The Respondent holds itself out to the public as a skilled nursing facility that complhes with the laws governmg skilled nursing facihues These laws exist to protect the health, safety and welfare of the residents of skilled nursing facilities. As individuals receiving services from a skilled musing facility, the residents are entitled to receive the benefits and protections under Chapters 120, 408, Part II, and 400, Part I, Flonda Statutes (2007), and Chapter 594-4, Flonda Admunstrative Code 5. The Agency has yunsdiction over the Respondent and its Facility 6. As of the date of this Emergency Order of Immediate Moratorium on Admissions, the census at the Respondent’s Facality 1s one hundred and fifty (150) residents/chents THE AGENCY'S MORATORIUM AUTHORITY Mar 3 2010 16:05 83/03/2018 16:03 8589210158 PAGE 05/45 7, The Agency may impose an immediate morator:um or emergency suspension as defined in Subsection 120 60, Flonda Statutes (2007), on any provider if the Agency determines that any condition related to the provider or licensee presents a threat to the health, safety, or welfare of a clicnt. § 408 814(1), Fla. Stat (2007) If the Agency finds an immediate serous danger to the public health, safety, or welfare requires emergency suspension, restriction, or lumtation of a heense, the Agency may take such action by any procedure that is fair under the cucumstances § 120 60(6), Fla Stat. (2007) LEGAL DUTIES OF A SKILLED NURSING FACILITY Resident Rights 8 Under Florida law, all licensees of nursing home facilites shall adopt and make public a statement of the nghts and responsibilities of the residents of such facilities and shall (reat such residents in accordance with the provisions of that statement § 400.022(1), Fla Stat (2007). The statement shall assure each resident the following. . The nght to receive adequate and appropnate health care and protective and Support services, including social services, mental health services, if available, planned recreational activities, and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with mules as adopted by the agency. § 400.022(1)(1), Fla Stat. (2007) Intentional or Negligent Act Materially Affecting Resident Health or Safety 9. Under Florida law, the Agency 1s authonzed to take action against a skilled nursing facility for “an intentional or neghgent act materially affecting the health or safety of residents of the facility’ § 400.102(1), Fla Stat (2007). APRIL 2008 SURVEY OF THE RESPONDENT ive) Mar 3 2010 16:05 83/83/2018 16:63 8589216158 PAGE 86/45 10 The Agency completed a survey of the Respondent and its Facility on or about Apni 11, 2008 1] Based upon the results of this survey, the Agency finds as follows 14. The population of skilled nursing facihtes 1s at imcreased msk of and 1s Susceptible to severe injury because of falls 15. Flomda law defines the “practice of professional nursing” as the performance of those acts requinng substantial specialized knowledge, judgment, and nursing skill based upon apphed principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care, health teaching and counseling of the ill, injured, or infirm; and the Promotion of wellness, maintenance of health, and prevention of illness of others, (2) The administration of medications and treatments as prescribed or authonzed by a duly licensed practitioner authonzed by the laws of thus state to prescnbe such medications and treatments, and (3) The supervision and teaching of other personnel in the theory and performance of any of the above acts. Section 464 003(3)(a), Florida Statutes (2007) 16 Florida law defines the “practice of pracucal nursing" as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintcnance of health, and prevention of ilness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatnic physician, or a licensed dentist. Section 464 003(3)(b), Florida Statues (2007) 83/83/2018 16:03 8589218158 Mar 3 2010 16:06 17. Respondent has failed in its responsibilities rejating to the provision of adequate and appropmate health care and protective and support services, and with established and recognized practice standards within the community 18 Those persons requiring care and services in nursing homes often suffer from disease processes which increase their risk of falls These same diseases and condiuons of aging severally enhance the risks of injury and umpinge upon the healing processes. Falls of the elderly and infirmed are factors of hgh risk to long term health and well-being. The effects of falls and resulting 1o)ury may contribute to conditions of long term scverity or even death, 19 Florida’s licensed providers must be vigilant to these concems in providing for residents. Here, Respondent has demonstrated a systemic failure to ensure that adequate and appropniate health care and protective and Suppoit services are provided to its residents at nsk of, or who have suffered falls. These failures are jllustrated from multiple facets by the facts found herein 20 Respondent's nursing staff knew that at least two of the residents sampled had experienced falls resulting to impact to the head One of these residents had been diagnosed with a concussion, presumably as a direct result of that fall The practice of nursing. the service offered and provided by Respondent, would mandate the assessment of the resident's condition to momtor for emergent conditions related the resident falls. In addition, Respondent's policy and procedure requires that all residents who suffer from a fal! be assessed by nursing staff within seventy-two hours of that fall 21. Tn the sample taken, Respondent has demonstrated 1ts failure to ensure such assessments are conducted Resident A, known to be suffering from a concussion, was not assessed by nursing staff upon return to the Facility, though vital signs were taken Between the a PAGE 07/45 Mar 3 2010 16:06 83/03/2018 16:03 8589218158 PAGE 08/45 time of the resident’s retum from the hospital, Respondent’s only documented assessment of the resident’s well-being consisted of a noted check of pupil reactivity the following day, no noted assessmicnt on the second day following the fall, and on tne third day following the fall, vital signs of great concem, which prompted the noting nurse to achon Resident B was monitored for the day of the fall, no further attention to potential effects noted as monitored or assessed 22 In fact, of the seven resident records reviewed, none reflected that the seventy-two (72) hour Respondent mandated assessments had ocewred. 23 Similarly, Respondent requires interdisciplinary assessments on a daily basis for regarding those residents who have experienced falls No evidence that such monitoring occurred was presented While at may not be concluded that the failure to conduct daily interdisciplinary meetings resulted im other systemic faslures, it may be concluded that the effected resident care plans did not contain annotation or recognition of the resident falls. no root analysis of the causation of the falls, no plan to prevent recurrence, and no interventions for implementation. These failures, individually and collectively, are subsumed within the conclusion that adequate and appropmate health care and protective and support services are not being provided by Respondent to its resident population 24 While all reviewed resident falls did not occur while the effected resident participated in the Respondent’s Starhte program, Respondent has demonstrated numerous areas of concern related to the operation of the program and the supervision of residents participating therein. A census of participants was not readily available, supervision or responsibility of its operations was not demonstrated, staffing pattems were developed and mmplemented without consideration of the participant’s Jevel of acuity and needs, and concems of inadequate staffing were apparently left unaddressed While a resident tall may not necessanly relate to an Mar 3 2010 16:06 63/83/2018 16:03 8509210158 PAGE 89/45 imadequate staffing pattern, the concers in the Respondent's operation of this program are devoid of considerations which are integral to the provision of adequate services for participant residents 25 The Respondent knew or should have known of the above descnibed deficient practices. Where Facility policy and procedure is not followed, Respundent’s systems to ensure resident care and services, supportive and preventative, have failed These actions and mactions therefore demonstrate that Respondent has engaged in intentional or neghgent acts which matenally cffect the health or safety uf residents 26 A facility must take a{firmative acts to assess and address such concems. Here, in several instances, Respondent’s has failed to meet this requirement. 27 Residents of skilled nursing facilities are entitled to adequate and appropnate health care services. The Respondent and its Facility in this stance has failed to ensue thal these services are consistently provided 28 ‘Whe Agency has determined that the threat to the health, safety or welfare of the current residents of the Facility 1s sufficient to warrant acuon that will preclude any addihonal persons becoming subject to such threat. This determination does not preclude the Agency from takang any further action that it may find necessary, cluding but not limited to, the emergency suspension of the Respondents’ license and emergency injunctive reliet. The Agency has determined that an immediate moratorium on admissions is necessary not only to protect prospective residents from the threat to residents’ health, safety or welfare, but also to assure the prompt action of the Facility to immediately correct the facility-wide deficient practices that exist and are hkely to continue to exist w the future in the absence of such prompt action by the Agency ~) Mar 3 2010 16:07 63/03/2018 16:03 8589216158 PAGE 10/45 29, This rmmediate moratonum on admissions 1s a narrowly-tailored remedy that is fair under the circumstances. The moratorium prevents the admission to the Facility of new residents, thereby precluding other potential res:dents from being subject to the risks that have been described above Second, this moratorium should force the Respondent to take immediate and appropniate corrective action to ensure that the current conditions are addressed and that its systems become functional, thereby preventing the recurrence of the conditions which prompted this action The Agency wall continue to monitor conditions at the Facility Less restrictive means, including but not limited to the assessment of administrative fines or the requirement of the submission of plans of correction would meet the immediate risk presented No current or future resident should be subjected to these risks, and immediate action is necessary to ensure that ammedhate corrective action be implemented 30. The moratorium does not im any way preclude the Agency from taking any further action that 1t may be necessary, including but not limited to, an emergency suspension order of the Respondents’ license and emergency injunchve rehef Lhe Agency is extremely mindful of the effects that an emergency suspension order may have on the vulnerable residents of this Facility, sometimes referred to as “transfer trauma.” Nevertheless, if the Respondent does not act promptly and appropmiately, the Agency has the nght and the duty to effectuate such a remedy. CONCLUSIONS OF LAW 31 The Agency has jurisdiction over the Respondent pursuant to Chapters 120, 408, Part II, 400, Part I, Florida Statutes (2007) Mar 3 2010 16:07 03/83/2018 16:03 8583218158 PAGE 11/45 32 As set forth above, the Agency has the authority (vu impose a moratormum on admissions on any skilled nursing facility when the Agency determines that any condition in the facility presents a threat to the health, safety, or welfare of the residents in the facihty. 33 As set forth above, the Agency concludes that the current conditions in the Respondent’s Facility present a direct and immediate threat to the health, safety or welfare of the residents and warrants an immediate moratorrum on admissions as set forth above to the Respondent’s Facility, mcluding but not limited to, admissions to beds which may be have been held by the Respondent for any specific resident, 34. As set forth above, the Agency conchides that this immediate moratorium on admissions is a narrowly-tailored remedy that 1s fair under the circumstances IT IS THEREFORE ORDERED THAT: 35. The Respondent is placed under an IMMEDIATE MORATORIUM ON ADMISSIONS and shall not admit any residents until further notice of the Agency 36. During the moratorium, no new residents or previously discharged residents as set forth above shall be admuttcd to the Facihty Residents for whom the Facility is holding a bed may retum to the Facility only after being informed that the Facility »s under a moratorium and with the prior approval of the local Agency office 37. This moratorium shall continue in effect without limitation or interruption until the Agency determines that the deficiencies at the Respondent’s Facility have been corrected in order to make it appropriate for the Agency to Inft this moratorium. The moratorium shall not be lifted unt the deficiencies have been corrected and the Agency has determined through an appraisal survey that there 1s no longer any threat to the residents’ health, safety, or welfare. Any Mar 3 2010 16:07 83/03/2018 16:83 8589210158 PAGE 12/45 future removal of the moratornun will be communicated by a telephone call and confinned by written notification 38 During the moratorium, the Agency shall regularly momutor the conditions at the Facility and notify the Respondent when the moratorium 1s Jifted. 39. The Respondent shall immediately post this Emergency Order of Immediate Moratortum on Admissions in a conspicuous location in its Facility until the moratonum is lifted by the Agency 40. Within ten (10) days of the receipt of this order, the Kespondent shall provide the Agency a wmitten plan to comect the deficient practices) The Respondent shall thereafter promptly notify the Agency at its local area office when all of the deficiencies and violations have been corrected so that the Agency may inspect and survey the Facility to determine if the moratorium may be lifted 41. The Agency shall promptly proceed with any other admumstrative action to be brought against the Respondent based upon the facts set out herein and shall provide notice to the Respondent of the right to a hearmg under Section 120 57, Florida Statutes (2007), at the tme such action is taken The Agency and the Division of Admunustrative Hearings, upon request for a formal hearing, have junsdsction, pursuant to Sections 120569 and 120.57, Florida Statutes (2007). DONF AND ORDERED in Tallahassee, Leon County, Flonda, on this the Lith day of Apmil, 2008 Holly Benson, Secretary Agency for Health Care Admimstration Mar 3 2010 16:07 83/83/2018 16:83 8503216158 PAGE 13/45 NOTICE OF RIGHT TO JUDICIAL REVIEW This emergency order of immediate moratorium on admissions is a non-final order subject to facial review for legal sufficiency. See Broyles v. State, 776 So.2d 340 (Fla. lst DCA 2001). Such review is commenced by filing a petition for review in accordance with Florida Rules of Appellate Procedure 9.100(b) and (c). See Fla.R.App.P. 9.190(b)(2). To be timely, the petition for review must be filed within thirty days of rendition of this emergency order of immediate limitation of license restricling new admissions and procedures. Mar 3 2010 16:08 @3/03/2818 16:03 8509210158 PAGE 14745 ray 21°99 13:20 MAY-21 2689 44:33 tl HEALTH CORRE ALI IN 25@ 921 8159 P.8B STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs Case Nos 2009002735 (Fines) 2009002736 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a Capytal Healthcare Center, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administranon (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against CAPITAL HEALTH CARE ASSOC JATES, LLC, d/b/a Capital Healthcare Center (bereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing February 13, 2009 and ending March 17, 2009, and impose an admimstrative fine m the amount of $2,500.00, based upon Respondent being cited for one State Class I] deficiency. JURISDICTION AND VENUE 1, The Agency has yunisdiction pursuant to §§ 120.60 and 400.062, Flonda Statutes (2008) 2 Venue lies pursuant to Rule 28-106 207, Flonda Adnnistrative Code EXHIBIT — i> Mar 3 2010 16:08 83/83/2018 16:03 8569216158 PAGE May 21 7709 13:21 MAY-21-2409 14:33 b ACY HEALTR CARE SDMIN 852 921 8158 P.@2 PARTIES 3. The Agency is the regulatory authority responsible for hcensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilitics pursuant to the Omnibus Reconcijation Act of 1987, Title IV, Subdtitle C (as amended), Chapts: 400, Part II, Florida Statutes, and Chapter 594-4, Flonda Administrative Code 4 Respondent operates a 156-bed nursing home, located at 3333 Capital Med:cal Blvd, Tallahassee, Florida 32308, and is licensed as a skslled nursing facility (license number 1073096). 5 Respondent was at all tunes material hereto, a licensed nursing facility under the licensing authonity of the Agency, and was required to comply with all applicable rules, and statutes COUNT I 6. The Agency re-alleges and incorporates paragraphs one (i) through five (5), as if fully set forth herein 7 Flonda law provides the following: a Section 400 102(1), F.S., “In addition to the grounds lasted in part II of chapter 408, any of the following conditions shail be grounds for action by the agency against a licensee: (1) An intentional or neghgent act materially affecting the health or safety of residents of the facility.” b Secuion 400.022(1)(1), F.S., “All licensees of nursing home facilities shal adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement The statement shall assure each resident the fo}lowing: The right to receive adequate and appropnate health care and protective and support services, including social services, mental health services, if available; 15/45 Mar 3 2010 16:08 83/03/2018 16:83 8589216158 PAGE 16/45 May 21° 9 13-21 MAY-21-2899 14:34 A. Ct HEALTH CARE ADIN e5@ 92. 2158 P 16 planned recreational activities, and therapcutte and rehabilitative services consistent with the resident care plan, with establisbed and recognized practice standards within the community, and with rules as adopted by the agency.” ¢ Section 400.121 (1)(a), F.S , “The agency may deny an application, revoke or suspend a license, and impose an admimstvative fine, not to exceed $500 per violation per day for the violation of any provision of this part, part N of chapter 408, or apphcable rules, against any applicant or licensee for the following oiations by “he applicant, licensee, or other controlling interest: A violation of any provision of this part, part IT of chapter £08, or applicable mules,” 8 The Agency conducted a re-licensure survey starting on February 9, 2009 and ending February 13, 2009 9 Based on observation, staff and resident interview and record review the facility fasled to provide adequate and appropriate health care when it failed to follow the plan of care for hand mobility and range of motion and implement treatment that resulted in decline in range of motion and contracture for 3 (#56, 98, 127) of the 7 sampled residents Also, the facility failed to provide adequate and appropriate health care when it failed to provide proper foot care and treatment for 1 of 7 sampied residents (#89). The lack of proper care caused harm to the resident in the form of pan and drainage 10. The findings regarding Resident #89 include: ll. An observation of Resident #89's toenails was conducted an 2/12/09 by (wo surveyors and a facility nurse. The resident’s bilateral great toe nails were about lcm long, thick, discolored, and they curved upward at about a 90 degree angle to the toe A 1.5em, area of yellowish drainage had soaked through the left sock where the sock touched the left great toe. On the left foot, the 2° and 4" toenails were aiso long and in need of tnmmung On the night foot, the 3" and 4" toenails were also noted in need of trimming Mar 3 2010 16:08 03/03/2818 16:83 8589216158 PAGE 17/45 Way 22 1G 13-24 MAY-21~2089 14:34 + LNCY HEALTH CARE ADMIN 859 921 21598 Pita 12, “An interview was conducted dumng the observauon on 2/12/09 with Resident 489. Resident #89 was asked about his/her toes. Resident #89 stated, “Oh, they hurt so bad.’ The resident was asked if he/she had told anyone at the facility, Resident #89 replied, “I’ve told everybody.” The nurse who was present stated that Resident #89 had not told her about the painful toe nails 13 ; On 2/12/09 the nurse stated that she had notified the Unit Manager (UM) who will call the podiatrist. An interview was conducted with the Unit Manager The UM confirmed that she was about to notify the podiatrist. The UM was asked about the drainage from the left great toe. The UM stated that she was unaware of the drainage and would go and assess the foot 14. Physician progress notes were reviewed The most recent progress note was dated 12/18/08. There was no mention of the toenails 15 The 'Weekly Skin Sweep’ form was reviewed beginning or. 7/31/08 through present, 2/11/09. On 10/30/08, a nurse wrote, “Toenails need clipping ' There 18 no other mention of the Jong, Uuck, angled toenails on the forms. There is no indication that the toenails were trimmed 16 The care plans were reviewed. There was no mention cf the tocnails on the care plans. Resident #89 has a diagnosis of Diabetes Mellitus. No interventions regarding foot assessment, or nail care was found on the care plans. 7 In the care plan section of the medical record, a form dated 11/6/08 was found. The form stated that "Toe Nails Need Clipping” and was signed by the resident and the Minimum Data Set (MDS) coordinato), The next entry on the form was dated 1/23/09. There was no mention of the nails. The form was signed by the MDS coordinatoz, but not by the resident. 18 The most recent Mirimum Data Set (MDS), dated 1/23/09, wag reviewed. Resident #89 was assessed as requiring extensive assistance with one person physical assist for bed mobility, Mar 3 2010 16:09 83/83/2018 16:83 8589210158 PAGE 18/45 May 2: 9 23:22 MAY-21-2649 14°34 » NCY HEALTH CARE ADIN 258 921 @15@ = P12 transfer, dressing and personal nygiene. Under section M6 for Foot Problems and Care, the section for "None of the Above” was marked. 19. An interview was conducted with the MDS and Care Plan Coordsnator The MDS coordinator confirmed that both she and the resident signed the form that stated "Toe Nails Need Chpping ° The MDS coordinator stated that she does not make the appointment, but that she lets nursing staff know. She stated that nursing staff will call the pod:atrist. The MDS coordinator stated that the facihty does not routinely initiate a care plan for diabetes. She stated that care necds specific to problems identified are zncluded on other care plans. The MDS coordinator referred to a nurses note dated } 1/7/08 that showed a podiatrist was contacted concerning Resident #89’s toenails 20. The nurse's note was revicwed, On 11/7/08 at 2 1Sp m,, 4 nurse wrote, “(name of physician) office called No longer has (insurance name) Has appomtment for Navember 24th at 2:00p.m.” 21. An interview was conducted with the nurse who wrote the above note. The nurse confirmed that she made the appointment. However, the nurse stated that she did not follow-up on the appointment because Resident #89 transferred off of her wing on 11/12/08. 22. The nurses notes from 11/12/08 through present were reviewed. There was no further mention of Resident #89s toenails. There was 90 mention of the drainage from the left toe. of the resident's complaint that the toenails “hurt so bad”, nor was there mention that the toe nails were thick, long, or growing upward at a 90 depree angle to the toes. 23 An interview was conducted with the Director of Nursing (DON) about the long toenails idenufied 4 months ago in November 2008 The DON confirmed that the appointment was made, Mar 3 2010 16:09 83/03/2818 16:63 8589218158 PAGE 19/45 az 21% 13-22 PIAY-21-2209 14 235 ‘ YCY HERLTH CARE ADMIN 8528 921 9158 P.13 but the resident did not get his/her toenails timmed on that date [he DON confirmed that the facility did not follow up on the toena)) care 25. Findings regarding Resident #56 include: Observation noted resident #56 in bed with right hand closed without a splinting device to prevent contractures. Interview with the resident undicated he/she had a stroke and tus left the hand paralyzed. The resident's hand was ohserved on the following days at breakfast and lunch without splinting devices in the hand te prevent contractures 2/9/09, 2/10/09, 2/13/09 and’ 2/12/09. Observation of these meals indicated the resident trying to feed self with one hand 26 Intermew with resident indicated he/she never bas anythung on the nght hand to prevent contractures 27 Review of the most current plan of care indscates limited range of motion to nigh! hand with interventions to provide passive range of motion daily during mormung and evening care and to monitor for changes in functional abilities 28 Dung an interview with the resident indicated the staff never does any range of motion to my hand 29 During an interview with an aide, tbe aide stated, “we do range of motion during care.” 30 A nurse stated that the aides do range of motion to residents during care. 31. Review of the most current assessment dated 10/14/08 indicates lmnitation on one side with partial Joss to the hand, fingers and wrist and indicates extensive assistance of one aide to total assistance with one aide for dressing, transfer, toileting and personal hygiene Assessments dated 7/08 and 2/08 indicated the same The record jacked evidence of a current restorative program or therapy program for range of mouon or contractures Mar 3 2010 16:09 03/03/2018 16:03 8509210158 PAGE 26/45 Way 217° 9 13-22 MAY-21-2869 14:35 § a'r HEALTH CARE QUMIN aS@ 92: 8158 P.14 32. Record review indicated a referral dated 2/9/09 (aher resident #56 was identified by the surveyor) for a therapy screen due to decrease in range in motion of nght hand and digits and would benefit trom skilled occupational therapy The referral indicates splinting issues for nght hand, impaired range of motion, and needing extensive assistance with activities of daily living for dressing 33 The staff failed to implement treatment which resulted in decline in range cf motion and contracture to hand. 34, Findings for Resident #127 inciude the following 35. Observation 2/9/09 noted res.dent #127 in the dining room for lunch with both hand closed without splinting devices. 36. Observation of iunch 2/10/09, 2/11/09 and 2/12/09 from indicated the same. 37 Review of quarterly Minimum Data Set (MDS) dated 11/18/08 and 8/20/08 noted. total . care with activities of daily living (ADL's). Functional limstatons in range of motion indicated band limitatjon on both sides with partial loss. {t also indicated total dependence with full staff performance of one person assist for ealng No therapy was indseated in last 7 days of the assessment period, and no restorative program or devices was noted MDS dated 12/24/07 indicates no limitation with range of motion related to hand 38. The record lacked a plan of care for limited range of motion or contractures The plan of Care statcs tota] assistance with assistance with activities of daily hying 39. Observation on 2/12/09 with staff nurse indicated the tesident had difficulty opening Jeft hand The hand smelicd sour and the resident had Jong diny najls that were digging into palm of hand. Mar 3 2010 16:10 83/03/2018 16:03 8589218158 PAGE 21/45 May 21 99 13:23 MAY-21-2089 14°35 NY HEALTH CARE ALi [ty 852 321 8158 P15 40 Dunng an interview with an aide, the aide staled, “do range of motion curing care and Teport issues to nurses.” 4}. The Occupational Therapist (OT) was interviewed and he stated he worked with this resident last year in 6/08 with a Jong term goal tor staff to provide range of motion to prevent decline. 42. The director of nursing (DON) stated, “If assessment shows limited range of motion then a screen should have been completed.” 43 A screen was completed by Occupational Therapy on 2/; 2/09 which indicated contractures of both hands with shortening of night and left fingers and would benegt from Occupationa) therapy interventions 44 Findings regarding resident #98 include: 45." Observation of res;dent 498 during the imtial tour conducted revealed the resident's left hand was balled into a fist wth the thumb protruding betwcen the turd and fourth fingers. There was no observation of any splinting device or any other type of demcc applied. 46 Dunng observation of resident #98 on 2/11/09 while the resident was in the activity room it was noted the left hand was )n the same condition as described above A nursing assistant familias with the resident, though not working with the resident on this date, attempted to have the resident open her left hand but was unable to do so. At that ume the resident's Unt Manager, who is also a Licensed Practical Nurse (LPN) wag successful in having the resident open her left hand but stated at thar time the resident was beginning to show signs of having the left hand contract and would need to have something placed in her hand to help prevent contracture. She Stated she would ask Occupational Therapy to screen the resident Mar 3 2010 16:10 03/03/2818 16:03 8509210158 PAGE 22/45 May 21.°°19 13:23 HAY-21-2299 14:36 ' "CY HEALTH CARE ADMIN 858 321 @1S6 Pli6 47 A review of the residen"'s most recent Miniurpum Data Set assessment dated }2/12/08 does not document any functional range of motion to exther hand 48. Interview and record review with the Occupational Therapist revealed he had screened the resident and although the resident does not have a contracture he/she does have impaired upper extremity range of motion and he agreed wich the unit LPN that the resident would have issues with contracture of the left hand without treatment He documented bis plan on a form labeled “Interdisciplinary Functional Status Form” dated 2/12/09 that he would "instruct CNAs (certified nursing assistants) On ma:ntenance program to prevent contracture.” 49. The Respondent has the legal duty to provide adequate and appropnate health pursuant to s. 400.022(1)(1), F.S. The Respondent untenhonally or negligently fazled to provide adequate and appropnate health care when it failed to implement treatment for contraction and provide occupational therapy for 3 residents: #56, 98, and 127 Also, the facibty failed to provide | adequate and appropiate health care when it failed to provide proper foot care and treatment for resident #89. The Respondent’s intentional or negligent acts matenally affected the residents’ health because the Respondent’s failurcs led to dectine in range of motion and contracture for 3 residents and pain and drainage for one resident Therefore, the Agency has authonty pursuant to § 400.102(1), F.S , 10 take action against the Respondent 50. The above findings reflect Respondent's intentional or neghgent failure to provide adequate and appropriate health care, thus the Respondent’s actions constituted a Class II deficicncy, pursuant of § 400.023(8)(b), Flonda Stratutes(2008) 5} Pursuant to § 400 102(1). FS, any intentional or negligent act that materially affects the health or safety of a resident 1s grounds for administrative action The Respondent has been sited for multiple acts, intemnaticnal ot negligent, that matenally affected the health of its Mar 3 2010 16:10 83/83/2018 16:03 8589216158 PAGE 23/45 May 21 709 13°23 MAY-21-2009 14:36 -NCY HEALTH CARE ADMIN 852 921 @158 Poi? ‘residents. The Agency has supported its citations with specitic factual findings thal support the alleged deficiencies. Thcreforc, pursuant to §§ 400.022(1)(1), 400.192(2}, and 400 023(8){a) Flonda Statutes (2008), the Agency has sufficient grounds for taking this administrative action agains! the Respondent. 52. The Agency provided Respondent with the mandatory correction date for this deficient practice of March 13, 2009 WHEREFORE, the Agency intends to impose an administrative fine m the amount of $2,500.00 against Respondent, a nursing facibty in the State of Flonda, pursuant to §§ 400.23(8)(b) and 400 102, Florida Statutes (2008). COUNT IL 53 The Agency re-alleges and incorporates Count 1 of Us Complaint as if fully set forth herein 54. Based upon Respondent's cited State Class LI deficiency, it was not in substantial compliance at the time of the survey with cntena established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subyccting It to assignment of a conditional licensure status under § 400.23(7)(b). Flonda Statutes (2008). WHEREFORE. the Agency intends to assign a conditional licensure status to Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(7), F.orida Statutes (2008) commencing February 13, 2009 and ending March 17, 2009 CLAIM FOR RELIEF WHEREFORE, the State of Flonda, Agency for Health Care Adininistration, respectfully 1equests that this court Mar 3 2010 16:10 03/03/2018 16:43 8589210158 PAGE 24/45 May 22 99 13:24 MAY-2Z1-20i49 14°36 -NCY HEALTH CARE ADMIN 858 921 Bise P.1d (A) Make factaei and legal findings in favor of the Agency on Count i and Ul (B) Recommend an administrative Spe against Respondent in the amount of $2,500 fos Count], an isolated Class {J deficiency, (C) Assign 4 conditional licensure status commencing February 13, 2009 and ending March 17, 2009; (D) Assess attomey’s fees and cosis: and () Grant all other general and equitabje relief allowed by jaw Respondent is notified that it has a ight ic request an admunistrative 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 shal] be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Flonda 32308, (850) 922-5873 If you want to hire an altomey. you have the nght to be represented by an attomey in this matter. RESPONDENT IS 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 Apnl } & , 2009 Mark Hinely Fla. Bar.18084 Agency for Health Care Admin 2727 Mahan Dnve, MS #3 Tallahassee, Florida 32308 850 922.5873 (office) 850.921.0158 (fax) Mar 3 2010 16:11 83/83/2018 16:03 8589218158 PAGE 25/45 . May 2° 09 12 2a MAY-2:-2089 14-36 wthCY HEALTH CARE ADMIN 852 $21 g158 P19 CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has been served by US Certified Mail, Retum Receipt No 7004 2890 0000 $526 8985 to: Facihty Admmuistrator Thomaas L. McDaniei, Capital Healthcare Center, 3333 Capztal Medical Blvd , Tallahassec, Florida 32308, by US. Certitied Maul, Retum Receipt No 7004 2890 0000 5526 8992 to: Owner Capital Health Care Associates, LLC, d/o/a Capital Healthcare Center, 10210 Highland Manor Drive, Suite 250, Tampa, Flonda 3361 0, and by US Cernfied Maj), Return Reccipt No. 7004 2890 0000 5526 9005 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Flonda 32301 on Apri 3... 2009 Vode Hud Mark Hinely ‘ Copy furnished to: Barbara Alford, FOM Mar $3 2010 16:11 03/03/2818 16:83 8589218158 PAGE 26/45 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos 2009006274 (Fine) 2009006277 (Cond) CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a CAPITAL HEALTHCARE CENTER, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration CAgency”), by and through the undersigned counsel, and files this Adminisirative Complaint against Capital Health Cae Associates, LLC, d/b/a Capital Healthcare Center (“Respondent”), pursuant to sections 120 569 and 120.57, Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action against a skilled mursing facihty to impose an administrative fine in the amount of $10,000.00, based upon one Class II deficiency and upon the citation of one Class II during the last inspection of ‘the same facibty and to impose conditional licensure status coramencing May 7, 2009, and ending May 31, 2009 JURISDICTION AND VENUE L. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2008). 2 The Agency has jurisdiction over the Respondent pursuant to Section 20 42 and Chapter 120, and Chapter 400, Pat I, and Chapter 408, Part IT, Flonda Statutes (2008). Filed December 3, 2009 1-20 PM Division of Administrative Hearings. Mar 3 2010 16:11 PAGE 27/45 03/63/2818 16:03 8589214158 3 Venue lies pursuant to Rule 28-106 207, Flonda Adimumstrative Code PARTIES 4 The Agency is the heensing and regulatory authority that oversces skilled nursing facilities, more commonly referred to as nursing homes, in Florida and enforces the applicable fedcral regulations and state statutes and rules governing such facilities Chs 408, Part I, 400, Part I, Fla Stat, (2008), and Ch 594-4, Fla. Admin, Code The Agency is authorized to deny an application for hcensure, revoke or Suspend a license, and impose an administative fie for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or the applicable mules. §§ 408.813, 408.815, 400.121, 40023. Fla Stat (2008). ln addiuon, the Agency may impose an additional six-month survey cycle fine for certain classes of violations that take place within a specified period of time, assign conditional licensure Status, and assess costs related to the mvesbgation and prosecution of this case §§ 400. 19(3), 400 23(7), 400 121(8), Fla. Stat (2008) 5. The Respondent was issued a hicense (License Number 1073096) by the Agency to operate a 156-bed skalled nursing facility located at 3333 Capital Medical Blvd., Tallahassee, Flonda 32308, and was at all times material required to comply with the appicable statutes and sules relating to skilled nursing facilities COUNT I 6 The Agency te-alleges and incorporates by reference paragraphs 1 through 4 7. Under Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilites of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement, The statement shall assure each resident the following. the right to receive adequate and appropriate health care and an Mar 3 2010 16:11 PAGE 28/45 03/03/2018 16:03 8589216158 protective and support Services, including socia! services; mental heal*h services, 1f available; planned tecreational achvities, and therapeutic and rehabilitative Services consistent with the resident care plan the ight to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints — § 400 022, Fla. Stat. (2008) 8 Under Flonda law, in addition to the grounds listed in part II of chapter 408, any ’ of the following conditions shall be grounds for action by the Agency against a licensee: an mtentional or negligent act matenally affecting the health oz safety of residents of the facihty shall be grounds for action by the agency against a licensee § 400. 102(1), Fla. Stat. (2008). 9. On May 7, 2009, the Agency concluded an unannounced complaint survey of the Respondent and its Facility ‘ 10. Based upon observation, interview and record review of 5 sampled residents, the Facility failed to update an assessment at least quarterly for Resident #5 who developed a stage II pressure sore; failed to provide care and physician ordered treatment to existing pressure sores for Residents #1 and #4; and failed to anticipate, recognize and teat pam consistent with the comprehensive assessment and care plan for Residents #4 and #6 Resident #5 , 11 A visual observation of Resident #5 on May 6, 2009, at 6-45 p.m, revealed the Resident lying in bed on his or her back 12. The bed had an altemating low air loss mattress. 13. The Resident had a pressure ulcer jocated on his or her COCCYX. 14. The Resident had two Stage I pressure ulcers, one on each side of the buttocks, measunng approximately | cm long x cm wide and0.$ cm deep Mar 3 2010 16:12 PAGE 29/45 83/03/2818 16:83 8589218158 15. A record review on May 6, 2009, reveaied that Res:dent #5 had been admitted to the Facility on January 13, 2006 16. A Braden scale dated December 14, 2008, revealed a total score of 16 (mild sk 15-18) 17, There was no other assessment of the Resident. 18. According to the Facility’s Skin Care and Wound Management-Chinical Programs Manual, the Braden scale is used to identify factors for skin breakdown and is supposed to be completed quarterly. 19. The skin grid for bottom {sacral) was last dated April 16, 2009, and the wound measured 1 cm long x | em wide x 0.3 cm deep wath nothing else checked 20. The weekly skin sweeps indacated as follows. March 2, 10, 17, 30, 2009, Apnil 14, 21, 27,2009, and May 5, 2009, all of which indicated no new skin impairments 21 There were no weekly skin sweeps for the weeks of March 23, 2009, and Apnil 6, 2009, 22. According to the Facility Skin Care and Wound Management-Clinical Programs Manual, skin sweeps are Supposed to be conducted weekly to identify new skm impairments. 23. The nursing progress notes indicated as follows: On March 30, 2009, at noon, “observed small open area on lower left outer aspect of leg 1 cm x 1 cm measured, no drainage noted wound bed pink and red, no odor. Resident unaware it's there. New order per facihty protoco]. Attempted to notify responsible party with no avail. Will continue to monitor Physician notified". 24. The physiciar. orders for Apnil 2009, dated April 3, 2009, indicated that there was no order for treatment to the Jower left leg Mar 3 2010 16:12 PAGE 30/45 03/83/2018 16:03 8509216158 25 The treatment record fo: Apni 2009 indicated that there was no treatment to the lower left leg. 26. The physician orders for May 2009, which were not signed or dated by the physician, have an order to clean the outer aspect of Resident's left lower jeg with wound cleanser, dry with gauze, apply transdermal dressing every 72 hours 27. There was no skin gnd, weckly skin sweeps, assessment, romtoring, treatment, o1 care plan addressing the open area on the lower left outer aspect of Resident #5's jeg. 28. The only Minimum Data Set (MDS) ow the chart has an Assessment Reference Date (ARD) date of December 26, 2008. 29 During an interview with the MDS coordinator on May 6, 2009, at 9:00 p.m., it was confirmed there was no other MDS on the chart 30 The MDS coordinator printed an MDS with an ARD date of March 20, 2009, and provided this to the surveyor at 9.16 Pm. stating this was not a signed MDS and she could not find the signed MDS and would look for itin her office 31. During an internew with the MDS coordinator with the Director of Nursing (DON) in attendance on May 7, 2009, at 131 pm, the MDS coordinator confirmed that she was stil] not able to locate the MDS for Resident #5 Resident #4 32. Dunng observations of Resident #4 on May 6, 2009 at 4:59 pm, it was revealed as follows: a. The Resident's right outer ankle had a dressing dated May 6, 2009, with initials LG. The Unit Manager LPN put on gloves, removed o}d dressing and replaced the old dressing with the same gloves A white creamy sudstance was observed on the ankle Mar 3 2010 16:12 63/83/2018 16:83 8509210158 PAGE 31/45 The wound was eépproximately the size of 2 quarter. The wound bed was red, the margins weie clean, and there was no infection noted The rurse stated that the stage might be a II, however, the treatment nurse would know the stage. . b 4 wound was noted on right outer aspect of the Resident’s nght foot The wound was the size of pencil] eraser, was dry, and located in a necrotic area. c. On the Resident’s left hip/ischeal area, there was a dressing dated May 6, 2009, with the muitiats LG. The size of the wound was approximately 5 cm long x 6 cm wide x - lcm deep, stage IV with full thickness of skin Joss with extensive destruction of muscle and supporting structures A white creamy substance was noted when dressing was removed. The Unit Manager put on gloves, removed cld dressing, gathered supplies to clean and redress the wound. The Unit Manager put on new gloves, cleansed wound with Cara Klenz and gauze and without changing gloves, placed Mesalt and Stratasorb over the wound. d There was a wound on the Resident’s sacral a1 e€a-approximately 8 cm long x 8 cm wide x 2 cm deep. It was classified as stage IV with full thickness of skin loss with extensive destruction of muscle and supporting structures. There was top right tunneling of approximately 1 cm. The area was cleansed with Cara KJenz. The left side appeared to be bright red and inflamed and there was some granulation of the wound bed. Mesalt dressing and Strasorb were applied. There was significant undermining of the wound, where the wound extends under the skin edges so the pressure uicer is larger at the base than it is at the skin surface. There appeared to be a new area of undermining at approximately 2 o'clock. The Unit Manager stuck her gloved pinky finger into the area and took out her finger und moasured about 2 cm deep This wound area had not been Mar 3 2010 16:13 83/03/2018 16:03 8589210158 PAGE 32/45 previously idenufied, or assessed, and there was no physician order to pack the area’ The Resident was opening and closing eyes and attempting to mumbie 33 During interviews with RN Unit Manager and the LPN Unit Manager on May 6, 2009, at 618 p.m, while dressing changes were being performed, it was revealed that these nurses had no knowledge of the weatment for these pressure ulcers or Low often the dressings were supposed to be changed 34 Neither of these nurses had knowledge of the pressure ulcer on Resident #4's left ankle that was observed by the surveyor and the wound care nurse on the following moming 35 When asked how they would know whether or not the Resident had pain during the dressing change, the LPN Unit Manager stated they thought the Resident did not speak. 36. When asked if the Resident received pain medication prior to the dressing change, the LPN Unit Manager stated they could give the Resident something for payn, but was unaware if the Resident had ever received anything for pain prior to the dressing change 37 During an observation of Resident #4 on May 7, 2009, at 11.26 am., with the wound care nurse, it was revealed that the Resident was lying on his or her nght side, pillows in place for positioning. 38. The left ankle dressing was mtact, but with no date or mrtals 39 This pressure ulcer was not ident:fied by the two Unit Managers on the evening before 40. The dressing on the Resident’s left hip was saturated with bloody, serosanguinous drainage 41, The dressing on sacral area was saturated with bloody, serosanguinous drainage, which also saturated the adult diaper that had been on the Resident Mar 3 2010 16:13 33/45 63/83/2018 16:03 8589218158 PAGE 42 During an interview with the wound cere nurse at this ume, it was revealed that nurses aie responsible for checking the dressings to determine xf they are so:led or need to be changed. If so, the nurse then lets the wound care nurse know by puttiag the information m the 24-hour repost or leaving the wourd care nurse 2 note. The nursing assistant wall tell the nurse if a dressing 1s soiled or needs to be changed 43 The wound care nurse stated that she attends nursing class from 8-10 am and then comes into work The wound care nurse stated that she starts wound care on the C wing because the residents on C wing are at the Facility for therapy and she likes to get their dressing done first so that they can go to therapy The residents on wing A and B wing are in them rooms and thus they usually recerve their treatments in the afternoon 44. he wound care nurse further stated she tells the nurse on the wing what tme treatment wil] be performed so that the nurse cat premedicate the resident to allow the resident to be comfortable during the treatment 45. The wound care nurse stated she always asks the nurse if the resident has been premedicated, and if not, she will ask the nurse to provide the resident pain medication and come back after a while. 46, When asked how Resident #4 communicates patn, the wound care nurse stated that the Resident moans or may move his or her hand to push the nurse away The Resident seldom speaks. 47. The wound care nurse stated that she documents in the progress notes the tumes when she performs the treatment 48 A record review on May 6, 2009. revealed that Resident #4 had a Mmisnum Data Set (MDS) with an Assessment Reference Date (ARD) of January 30, 2009 Mar 3 2010 16:13 4/45 83/83/2018 16:83 8589210158 PAGE 3 49. Sector. G(A) was coded that the Resident was totally dependent on staff for care 50 Section M1 indicated that the Resident had two stage III pressure ulcers and two stage IV pressure ulcers 51. Section J2a ceded J-pamm Jess than daily in the last seven days and section J2b coded 1-muld pain 52. The physician orders for April 2009, signed and dated April 3, 2009, indicated Hydrocodone-APAP (acetaminophen) 7 S-500, one tablet 30 minutes prior to dressing, change one per day, do not exceed 400 mg APAP per day 53. This order is on the May 2009 physician orders, howevei, the orders are not signed and not dated 54 Hydrocodone with Acetammophen (brand names Lortab, Lorcet, Vicodin) is an analgesic narcotic used for relief of moderate to severe pain 55 The Medication Admmnistration Record (MAR) for April 2009 revealed that this pain medication was given to the Resident at $ OOa.m. every day in April except April 16, 2009, and April 19, 2009, when it was not given at all 56 The MAR for May, which does not have a date but was confirmed by the DON as the MAR for May, indicates that the Resident received this medication on May 1-2, and 4-6, 2009, daily at 9:00 am 57. The Resadent did not receive the pau medication on May 3, 2009 This was cross checked with Resident #4's controlled drug record-indsvidual patient's narcotic record, 58. The nursing progress notes indicated dressing changes on April 5, 2009, at 11:00 am., Apnl 7, 2009, at 11:50 am, Apml 13, 2009, at 2:00 p.m., April 22, 2009, at 1:30 pm, Apu] 24, 2009, at 2:00 p.m., April 30, 2009, at 9:00 a.m., and May 1, 2009, at 10:00 am. Mar 3 2010 16:13 5/45 03/83/2018 16:03 8589218158 PAGE 3 59 The Resident was not bemg given pain medication 30 mmutes pnor to wound care treatment m accordance with the physician orders The physician’s order was to administer the pain medicanon 30 minutes prior to the dressing change. The medication was not given at all on April 16 and 19, 2009 On all other dates in April, the medication was given at 9.00 am. Under the Plan of Care dated March 5, 2009, 1: indicates to evaluate and/or pre-medicate the Resident prior to wound care 60 The Braden scale for predicung pressure ulcer risk was dated November 9, 2008, and the score was 13. A total score of 13-14 indicates moderate risk. 61. According to the Facility Skin Care and Wound Management-Clinical Programs Manual, the Braden scale is used to identify factors for skin breakdown and is supposed to be completed quarterly 62 The Resident's Braden scale had not been completed in almost 6 months. 63. The weekly skin sweeps beginning on December 13, 2008, revealed no new skin impainment, however, there were no weekly skin sweeps between January 17, 2009, and February 7, 2009 (3 weeks) and no weekly skin sweeps hetween February 7, 2009, and February 28, 20U9 (3 weeks) 64 The last documented skin sweep was April 18, 2009 (3 weeks). 65 According to the Facility Skin Care and Wound Management-Clinical Programs Manual, skin sweeps are supposed to be conducted weekly to idenufy new skin impairments 66. Under the Plan of Care, it stated pressure ulcer dated February 11, 2009, indicated that the Resident had a stage IJI on left ankle, stage Tlf on right ankle, stage IV on left ishium, and stage IV on coccyx 67. Measurements were dated April 17, 2009, and indicated 2 x 18 x 04 (no Mar 3 2010 16:14 83/83/2018 16:03 8589216158 PAGE 36/45 location); R 25x 1x 0.5; ishial6 2x5 5x1, sacral8x 7x22 68 A note dated April 24, 2009 stated apply Maxorb Extra AG q (every) 72 hours to bilateral ankles and left hip and sacral 69 Under the Plan of Care, it stated pressure ulcer dated March 5, 2009, indicated the following: sacral 8 x 7 x 2.2 stage IV: left ishtwm 6.2x55x1 stage IV; left ankle 2 x 18x 0.4 stage I, right ankle 25x 1.4x 0.3 stage I] and 2.5 x Lx 0.5 (no stage) 70. A note dated April 22, 2009, stated: cleanse ali wounds with normal saline, apply moist to dry to all ulcers every day for 1 week and then change to Mesalt dressings every day. 71 A noted dated April 29, 2009, stated. right and left ankle-apply Silvadene pack moist to dry clean, normal saline with border gauze every day and sacral and ischial-irrigate with normal saline, apply Silvadene pack with mois‘ to dry-cover border gauze every day. 72. According to the Facility Skin Care and Wound Management-Clinical Programs Manuai, the care plan is reviewed quarterly at a minimum. 73 According to the Facility Skin Care and Wound Management-Clinical Programs Manual, the skin grid-pressure is to be done weekly until the area is healed to document status of the pressure area 74 The nurse 1s supposed to use one form per identified pressure area 75 Resident #4 had only two grid-pressures performed, one for the coccyx dated Apnil 13, 2009, and then again on May 6, 2009 76. From March 2, 2009, through April 13, 2009, the pressure ulcer measurements were unchanged 77. On Apri] 13, 2009, there was no description of the wound 78 On May 6, 2009, the wound was documented as stage IV, 8 cm x 5 cm x 2 cm, Mar 3 2010 16:14 63/83/2018 16:03 8589218158 PAGE 37/45 with no description of the wound 79 ibe second skin grid that was perfornied was for the left ishial area beginning on March 24, 2009, to Apnl 13, 2009, documented as a stage IV 80 The next entry ss May 6, 2009, stage IV, measuring Scmx6emx liom 81 There are no skin grids for the pressure ulcers on the left and vight ankles, 82. The physician orders signed and dated April 3, 2009, state: cleanse bilateral ankles, coccyx and left ischuum with wound care cleanse, apply Dakuns 1/4 solution moist to dry dressings, cover with gauze and border gauze daily and as needed. 83 A verbal order dated April 22, 2009, stated. discontinue Silvadene dressing, start normal saline wet to dry dressing to all decubitus ulcers every day for one week and then change to Mesalt dressing. 84. This order was not signed or dated by a nurse and there was no date when the physician signed the order. 85. A physician order dated April 24, 2009, indicated to apply maxorb extra AGt every 72 hours and as needed to ri ght ankie, sacral and left hip. 86 There is n0 order for the left ankle pressure ulcer. 87. A verbal order dated April 30, 2009, indicated to cleanse the sacral wound, xschea] wound and bilateral ankles with wound care cleanse, apply mesalt dressing or equivalent and cover with statosorb composite qod soiling 88 This order 1s not dated by the nurse and not signed or dated by the physician. 89. Dunng an interview with the DON on May 6, 2009, at 959 p.m, it was confinmed that there were no May 2009 orders in the medical record. 90. There were orders, however, they were not signed or dated Mar 3 2010 16:14 PAGE 38/45 83/03/2816 16:03 8589218158 91. The DON confirmed that there were no treatment orders, only medication orders 92 The ueatment record for Resident #4 for April 2009 revealed that physician ordered treatments were not Provided to the bilateral ankles, ischeaVhip area, or coccyx area on April 5, 18, 19, and 24-27, 2009 . 93 During an interview with DON on May 7, 2009, at 1:00 p m., it was revealed that there seemed to be systemic problems with obtaming physician orders, gethag physicnan orders signed, and getting consults on the charts timely 94. She stated that the only consult they could find for Resident #4 for a certain physician was March 11, 2009, but they knew the physician saw the Resident after that time and that the Resident was also seen by another Physician and they could not find any documentation from that other physician Resident #1] 95. A review of the clinical record for Resident #1 revealed treaunent orders to cleanse the Resident’s sacral area with wound cleanser, apply Hydrocolloid every 3 days and as needed, and PRN soihng with a start date of Apri) 27, 2009, 96. Another treatment order Was present that stated to cleanse the Resident’s right calf with wound cleanser, apply Hydrogel sheet, cover with bordered gauze and change every 3 days with a start date of Apmil 25, 2009. 97. During an interview with the LPN on May 6, 2009, at 8-10 p.m., it was revealed that Resident #]'s dressings were typically changed by the wound care nurse on the day shift 98. The 3-11 shift did not change Resident #1's Oressings unless the Resident was - incontinent and the dressings were soiled 99 An observation of Resident #1's secral wound and right calf revealed that neither Mar 3 2010 16:14 Pa 39/45 03/03/2818 16:03 9509218158 GE area had a dressing in place 100. The sacral area was open, superficial, approximately 1 cm, with no drainage. 101. The right calf had two areas, a 4 cm raised blister and a 3 cm lacerated area with a small amount of dried blood. 102, The LPN stated that al} of the areas should have been dressed, but could not say why the dressings were not on, 103. At that time, the LPN cleansed the wounds and apphed the dressings as ordered. 104. A review of the Resident's treatment record revealed that both dressings were scheduled to be changed on the 11-7 shift 10S. Both were anitialed as completed, but the initials were marked through 106. There was no documentation indicating whether the treatment was administered, ‘or whether the records were initialed wi error 107. The LPN stated the imtials were those of the wound care nurse 108. During an interview with the wound care nurse and review of the treatment record at on May 7, 2009, at approximately 12:15 p.m., it was revealed that the teatment nurse was going to do the dressing, but realized it was schedwed for 11-7 shift. 109. Thus, she scratched through her initials because she did not do the dressing. 110 When asked how it was decided who does the wound care, the floor murse or the treatment nurse, the wound care nurse Stated that she tnes to look at them all, but as aqule she does the deep more complicated wounds and the floor nurses do the smaller ones and the skin tears. 11l. A xeview of the most recent MDS assessment, reference date February 27, 2009, revealed that Resident #1: has a stage II pressure ulcer Mar 3 2010 16:15 PAGE 40/45 63/03/2018 16:03 8589218158 112. A cuent care plan revealed that the ght lower leg and the sacral area were identified as having open areas 113. The current treatment was included in the interventions, but those interventions were not followed by the staff Resident a6 114. An observation with LPN Unit Manager performing wound care and the CNA assisting on May 6, 2009, at 7.00 pm, revealed Resident #6 lying on his or her back 115. The bed had an alternating low air loss pressure mattress, 116. The Resident has bilateral above the knee amputations. 117. The Resident had. a A stage I pressure ulcer located in his or ber upper mid-back, size approximately 1 cm long x 0.5 cm wide. The dressing was dated May 4, 2009, w:th initials LG b. A Stage II pressure ulcer located on his ox her right buttock, dressing dated May 6, 2009 with initials LC. The Unit Manager removed the dressings with gloves. The wound was approximately 4 em jong by 3 cm wide. The wound bed area was red. The suyrounding tissue was pink. There were no signs or symptoms of fection 118. During tweatment to the right buitock, Resident #6 yelled out in pain as the nurse cleaned right buttock wound 119. The Resident was in pain and attempted to hit the nursing assistant and said “leave me alone." 120. The surveyor asked the Resident if the treatment hurt and Resident said "yca.” 121. The nurse was asked if the Resident was medicated for pain before the dressing change. Mar 3 2010 16:15 PAGE 41/45 83/83/2018 16:03 8589210158 122. The nurse did not know and did not know if resicent had pan medication ordered 123, The physician orders for Apni 2009, were signed and dated April 3, 2009 124. The May 2009 physician ordeis were not signed and dated by the physician 125. There was no order for either Apnl or May for Tylenol 126. Both the April and May 2009 physician orders had an order for Hydrocodone - APAP, 10-500, one tablet per tube every 4 hours as needed for pain, not to exceed 4 grams of Tyleno] in 24 hours. 127. Hydrocodone with Acetam:nophen (brand names Lortab, Lorcet, Vicodin) is an analgesic narcotic used for the relief of moderate to severe pain 128. The Resident had not received this medication, the resident did not receive any pain medication in Apul or May 129. There was no indication im the progress notes dated March 13, 2009, through the last note of April 28, 2009, that the Resident was assessed for pain prior to dressing change or treated for pain. Sanctions 130. The Respondent’s actions or mactions constituted a class I] deficiency. 131, Aclass I deficiency 1s a deficiency that the Agency determunes has compromised the resident's ability to maintam o1 reach his or her highest practicable physical, mental, and psychosucial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services § 400.23(8)(b), Fla. Stat (2008) 132 A class Il deficiency is subject to a civil penalty of $2,500 for an isolated deficrency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. ‘The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Mar 3 2010 16:15 PAGE 42/45 83/83/2018 16:83 8589218158 class I og class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last livensure mspecnon A fine shall be levied notwithstanding the comection of the deficiency § 400 23(8)(b), Fla. Stat (2008) 133, In this instance, the Agency is seex:ng a fine in the amount of ten thousand dollars ($10,000), as a patierned class {I deficiency. On April 20, 2009, in an Administrauve Complaint, the Agency cited the Respondent for one Class Il deficiency for failing to provide adequate and appropriate health care when it failed to follow the plan of care for hand mobility and range of motion and implement treatment that resulted in decline in range of motion and contracture for 3 of the 7 sampled residents. Also, the Respondent was cited in the April 20, 2009 Administrative Complaint for failing to provide adequate and appropriate health care when it failed to provide proper foot care and weatment for 1 of 7 sampled residents The lack of proper care caused harm to the Resident in the form of pain and drainage 134. Under Florida law, as a penalty for any violation of this part, authouzing statutes, , or applicable rules, the Agency may impose an admunistratrve fine. Unless the amount or aggregate limitation of the fine is prescnbed by authorizing statutes or applcable rules, the Agency may establish criteria by mule for the amount or ageregate limitanon of administrative fines applicable to this part, authorizing statutes, and apphcable rules. Each day of violation constitutes a separate violation and is subject to a separate fine. For fines imposed by final ordet of the Agency and not subject to further appeal, the violator shall pay the fine plus roterest at the rate specified in section 55 03, Florida Statutes, for each day beyond the date set by the Agency for payment of the fine § 408.813, Fla Stat. (2008) 135 Under Floiida law, the Agency may deny an application, revoke ot suspend a Ucense, and impose an administrative fine, not to exceed $500 per violanon per day for the Mar 3 2010 16:15 PAGE 43/45 03/83/2018 16:83 8589210158 violation of any provision of this part, part Il cf chapter 408, or applicable mes, against any applicant or licensce for the followsng violanons by the applicant, licensee, or other controlling interest’ A violation of any provision of this part, part II of chapter 408, or applicable miles. § 400.121(1)(a), Fla. Stat (2008). 136. Under Florida law, in addition to any other sanction imposed under this part or Part LU of Chapter 408, in any final order that imposes sanctions, the Agency may assess costs telated.to the mvestigation and Prosécuuion of the case Payment of Agency costs shall be deposited into the Health Care Trust Fund § 400.121(8), Fla Stat (2008). WHEREFORE, the Petutioncr, State of Flouida, Agency for Health Care Adminstration, intends to impose an administrative fine against the Respondent in the amount of $5,000.00 COUNT I 137, The Agency re-alleges and incoiporates by reference paragraphs | through 135 138. A conditional licensure Status means that a Facility, due to the presence of one or more class I or class I deficiencies, or class TI deficiencies not corrected within the time established by the Agency, was not in substantial comphance at the time of the survey with enteria established under this part or with rules adopted by the Agency. If the Facility has no class I, class IZ, or class IT deficiencies at the time of the follow-up survey, a standard licensure Status may he assigned § 400 23(7)(), Pla Stat. (2008) 139. Due to the presence of one or more state class II deficiencies, or class III deficiencies not comected within the time established by the Agency, the Respondent was not in substantial compliance at the time of the survey wath critena established under Chapter 400, Part Tl, Florida Statutes, or the rules adopted by the Agency. 140. As a result of these deficiencies, the Respondent was subject it the assignment of Mar 3 2010 16:16 PAGE 44/45 83/03/2018 16:83 8589210158 a conditional licensure status, ‘41 The Agency issued the Respondent a conditional license with an action effective date of May 7, 2009. a copy of the onginal certificate is attached as Exhibit A 142° The Agency issued the Respondent a standard license with an action effective date of June 1, 2009. A copy of the original certificate is attached as Exhibit B WHEREFORE, the Petitioner, State of Flonda, Agency for Health Care Administration, intends to assign a conditional censure status on the Respondent as set forth above CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests a final order that, 1 Makes findings of fact and conclusions of law in favor of the Agency. 2 Imposes the above-referenced rehef sought by the Agency 3 Enters any other relief that is Just and appropriate. Respectfully submutted this / ? day of November, 2009 D. Carlton Enfinger, I Esq Florida Bar No. 7934§0 Agency for Health Care Admunistration 2727 Mahan Dnve, MS #43 Tallahassee, Florida 32308 Telephone: 850 922 5873 Facsimile: 850 921.0158 The Respondent has the Tight to request a bearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, and to be represented by counsel or other qualified representative. Specific options for the administrative action are set out withiy the attached Election of Rights form. Mar 3 2010 16:16 PAGE 45/45 83/03/2018 16:03 9509210158 The Respondent is further notified if the Election of Rights form is uot received by the Agency for Health Care Admiuistration within twenty-one (21) days of the receipt of this Administrative Coimplaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mait Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873, CERTIFICATE OF SERVICE SERICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served to: Thomas L. McDaniel, Administrator, Capital Healthcare Center, 3333 Capital Medical Blvd 5 Tallahassee, Florida 32308, by US. Certified Mail, Retum Receipt No. 7004 2890 0000 5526 9333, and Corporation Service Company, Registered Agent, 1201 Hays Street, Tallahassee, Florida 32301, by U.S. Matt on this { Z day of November, 2009: D Carlton Enfinger, Il, E 20 @3/03/2018 16:27 8509210158 TLORIDA AGENCY FOR HEALTH CARE ADMIN STRATION CHARLIE CRIST GOVERNOR June 16, 2009 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator: Mar 3 2010 16:29 PAGE 02/38 HOLLY BENSON SECRETARY The attached license with Certificate #15735 is being issued for the operation of your facility. Please review it thoroughly to ensure that ali information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop,#33 2727 Mahan Duve, Building 3 Tallahassee, Florida 32308 Issued for status change to Standard Sincerely, SPOOR | Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need FLORIDA GOMPARE CARE Hwalip Care in ine Sunsnine 2727 Mahan Orive, MS833 Tallahassee, Florida 32308 ww FloridaCompareGare gov ” Viset AHCA online at http //abea myllonda com 3 2010 16:29 Mar PAGE 63/30 16:27 8509216158 83/83/2018 GO07OE/TE -ALVG NOILV Idx ASNADT 6002/10/90 ‘ALWG SALLOd ddd NOILOV SONVHO SALLVLS Sad 951 “IVLOL 80t%e Wd ‘SASSVHWITTVL GATE TWOILdAW TW Lid¥5 cece MALNAO TAVOALTVEH TV LIdv5 SULMOT{O} ay} aeIado 0) pezuouae St aasbaal] oly se pue “SaynjeIS EPUoLy ‘[} Hed ‘Oop sadeys ui pazuousne ‘uoreNsTanupy 3D W[eaH 204 Aauasy ‘Epvojy JO aes ayy Aq poydope suone[ndor pure sajna am wim parjdusoo sey “y]'] “SALWIOOSS¥ FUWO HLTWSH Tw Lidvo ren OLIFUOD OFS” SY L CTaYVANVLS HINOH DONISUAN FONVUNSSV ALLIVNO HLTVdH AO NOISIAIC NOLEVULSININGY Fav HLTVaH YOd AONADV BPHO[Y JO 938} 83/03/2018 16:27 8589218158 wy FORIOA AGENCY FOR HEANYH CARE ADMINISTRANON CHARLIE CRIS] GOVERNOR June 16, 2009 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator. Mar 3 2010 16:30 PAGE 04/38 HOLLY BENSON SECRETARY The attached license: with Certificate #15734 is bemg issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records: If errors o1 omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Admimstration Long Term Care Section, Mai) Stop 433 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for status change to Conditional Sincerely, N& OM Agency for Health Care Administration Division of Health Quality Assurance Enclosure cc: Medicaid Contract Management Certificate of Need FLORIDA GCOMPARE GARE Howlth Core In the Sungnine 2727 Mahan Orive, MS#33 Tallahassee, Florida 32308 wor Floris eComparaCare gor Visit AHCA ontine at hitp://ahca. myflorlda com 3 2010 16:30 Mar PAGE 05/38 16:27 8589218158 3/03/2018 aouemssy Append uyeapy Fo uorstatg ‘ 6007/06/31 ‘ALVA NOILVUIdKS ASNAOII 600¢/L0/S0 ALVA SALLOFIIG NOLLOV AONVHO SALVLS SCAG 9ST“ TVLOL BOEZE Td “AASSVHVTTVI. GATE TVDIGAN TYLIdV9 tfc YALNGO FYVOHLIVGH Ty Lidvo Butmoryoy oy avrado 0} pazuogne St aastiad![ ay) Se puw ‘saynjeig epUuoj, ‘YT ued ‘OOp Jaideys ut pezuotjne Donegsmupy ase) jeay 10g Aouady “EpHLoLy Jo aes an 4q paidope suone(ndal pur s3[ry atp tin paydwioo sey YT] ‘SALVIOOSSY FUVO HLTVAH IVLIdVO 124) wuTUOS 0 s1 STUY TINOH ONISUAN FONVUNSSV A.LITWNO HL1V9H dO NOISIAIC NOILVULSININGY JUV HLITVAH YOsd AONSDV BPIIOL] JO 3923S “# ALWOLALL NID Mar 3 2010 16:31 63/83/2818 16:27 85892168158 PAGE 06/30 TATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA. AGENCY FOR HEALTH CARE ADMINISTRATION, Pehuoner, vs Case Nos 2009008506 (Fines) 2009008508 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC, 2009008509 (Revoc.) d/o/a Capital Healthcare Center, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files tis Admunistranve Complaint aganst CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a Capital Healthcare Center (hereinafter “Respondent’), pursuant to §§120.569 and 120.57 Flonda Statutes (2008), and alleges NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate a nursing home in the State of Florida pursuant to §§ 400 121(1)(a) and 400.121(3)(d), Flonda Statutes (2008), impose an admumustrative fine of fifteen thousand dollars ($15,000) based upon the citation for three (3) Class I deficiencies pursuant to § 400.102(1), Flonda Statutes (2008). Addstionally, this 1s an action to change Respondent’s licensure status from Standard to Conditional commencmmg July 18, 2009 and ending Seplember 3, 2009 JURISDICTION AND VENUE 1 The Agency has junsdiction pursuant to §§ 120 60, Flonda Statutes, Cha EXHIBIT ig Mar 3 2010 16:31 03/03/2818 16:27 8509210158 PAGE 87/38 and Chapter 408, Part II, Flonda Statutes (2008), and Chapter S9A-4, Flonda Admunstratve Code 2 Venue hes pursuant to Rule 28-106 207, Flonda Administrative Code PARTIES 3. The Agency is the regulatory authonry responsible for heensue of nursing homes and enforcement of applicable federal regulations, state statutes and miles govermng skilled nursing facilities pursuant to the Ommibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapters 400, Part IJ, and 408, Part IJ, Flonda Statutes, and Chapter S9A-4, Flonda Admumstrative Code. 4 Respondent operates a 156-bed nursing home, located at 3333 Capital Medical Blvd , Tallahassee, Flonda 32308, and is licensed as a skilled nursing facility (license number 1073096) 5 Respondent was at all times matemal hereto, a licensed nursing facility under the licensing authonty of the Agency, and was required to comply with all applicable rules, and Statutes COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein 7 Flonda law provides the followmg a Section 400 102(1), F S , “in addition to the grounds lasted in part Ul of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee (1) an intentional or neghigent act maternally affecting the health or safety of residents of the facility .” Mar 3 2010 16:32 03/83/2018 16:27 8509210158 PAGE 08/30 b Section 400 022(1)(n), F.S , “The nght to be treated courteously, fairly, and with the fullest measure of digmity and to receive 2 written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis c. Section 400 121(1)(a), FS, “The agency may deny an appiscauon, revoke or suspend a hiceuse, and impose an adinuuotrative fing, not to exceed $500 per violation per day for the violation of any provision of this part, part IL of chapter 408, ot applicable niles, against any appucant or icensee for the following violations by the applicant, licensee, or other controlling interest: A violation of any provision of ths part, part II of chapter 408, or applicable rules.” 8 The Agency conducted two complaint investigations in conjunction with a re-hcensure survey starting on July 13, 2009 and ending July 18, 2009 9 Based on observation, staff interview and record review the facility failed to provide care in a manner to enhance dignity and respect for 3 of 4 residents nm the sa m ple, by not providing incontinent care resulting in harm for resident #208, use of insulting terms to descnbe resident #166, and for neglecting the emotional needs of resident #140. The facility faaied to ensure 10 of 10 residents on the A wing were treated with dignity and respect for individual preferences dunng meals 10 The findings regarding Resident #208 include: V1. Observation of resident #208 on 7/16/09 at 8.50 AM ,915AM,1020AM, 11:45 AM. and 1.10 P.M revealed the resident was in the Starlight program. with 3 restorative aides, “12. Review of the sign in and out record where aides document when the residents are toileted revealed the resident had not been toilcted since entenng the program. at 8:00AM 13 When interviewed at i 10P M Starlight program staff stated that they requested the staff on the unit to come and get the resident for toileting but they did not respond to the request Mar 3 2010 16:32 83/03/2018 16:27 8589218158 PAGE 89/38 14 Observation of continent care at approx:matcly ! 30 P.M reveaied the resident smelled of mne, unne soaking resident’s pants and running down tnughs, diaper completely saturated and a pool of urine on cushion in wheelchar The resident's buttocks and groim area were red 15 In an interview on 7/16/09 at 2 30 P M staff stated the resident requires extensive assistance with care, 1s incontinent of bowe! and bladder and 1s toileted every ‘wo hours. The resident goes to Starlight which 1s a program. for confused residents, and stays there all day Staff maintained they check on the resident throughout the day 16. Review of the 90 day mimumum data set (MDS) dated $/12/09 revealed the resident to need extensive assistance with toileting and mcontunent of bowel and bladder The assessment indicates the resident 1s on a scheduled toileting plan. 62. Review of the plan of care for 3/09 indicates the resident 1s incontinent of unne and Is net a candidate for retraining Approaches include to provide incontinent care as needed and to toilet prior to meals, acuvities and therapies 17 Findings regarding Resident #166 include: 18 In an interview on 7/14/09 at 10.15 AM resident #166 stated “(A] week ago I overheard several aides telling a nurse it took 30 minutes to put me, my roommate and another resident to bed because I was fat. I was crying I talked to the nurse about this and she ued to explain it away.” 19 In an interview on 7/15/09 at 5.30 P M, the 3-11 shift aides and nurse stated the resident likes to stay up and they tell the resident nicely that they can stay up and they will get to her/ham when we can They stated resident #166 walches TV late and goes to bed around 10-00 P.M - 1100PM Mar 3 2010 16:32 Q3/83/2818 16:27 8589210158 PAGE 18/36 20 The nurse remembered an incident when she was talking to several aides on the floor in ear shot of the resident She stated she was trying to explain to the aides to share duties and team up to gave time She stated the aides were explaining that several residents require a lot of tme to be put to bed and some are heavy The nurse stated there was no intention to hurt the resident's feching 21 Findings for Resident #140 include the following 22. Interview with resident #140 on 7/14/09 at 11.02 A M revealed the resident to feel that the staff, particularly some of the nursing assistants, do not give him/her individual attention "The staff are always talking around you Sometimes when they leave my room they are talking to me and have their back to me and I don't hear a thing they say, especially if I don't have my hearing aid in Then they may say 'I told you that before’ At one point when I was having lots of falls some nursing assistants said ] was falling to get staff in trouble that I didn't like and J would never do that." 35 Findings regarding Wing A include: 36. Observation of 10 residents in the A Wing Day Room on 7/13/09 at 11:50 A.M. revealed clothing protectors were placed on all 10 residents without asking any of the residents 1f they wanted the clothing protectors placed or minded having the clothing protectors on. 37, Observation in the A Wing dining room on 7/15/09 at S40 P.M revealed a resident to pull his clothing protector off as staff assisted him with his meal The staff member immediately picked up the clothing protector, said "Now why did you pull your bib off” , and proceeded to replace the clothing protector on the resident 38 The Respondent has the legal duty to treat residents courteously, fairly, and with the fullest measure of dignity and to receive a wntten statement and an oral explanation of the Mar 3 2010 16:32 03/83/2016 16:27 8589210158 PAGE 11/30 services provided by the iacensee, inchiding those required to be cffered on an as-aceded basis pursuant tos 400.022(*)(n), FS 39 Therefore, the Agency bas authonty pursuant to § 400 102(1), FS , to take action against the Respondent 40 The above findings reflect Respondent's failure tu teat residents with digmity, thus the Respondent’s actions consituted a Class II deficiency, pursuant of § 400 023(8)(b), Flonda Statutes(2008). 4). The Agency provided Respondent with the mandatory correction date for this deficient practice of August 18, 2009 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000 00 against Respondent, a nursing facility in the State of Flonda, pursuant to §§ 400.23(8)(b) and 400 102, Flonda Statutes (2008) COUNT IX 42 The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I of this Complaint as if fully set forth herein 43 Flonda law provides the following a Section 400 102(1), FS , ‘tn addition to the grounds lasted in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee (1) an intentional ox neghgent act matenally affecung the health or safety of residents of the facility. ” b Section 400.121(1)(a), F S., “The agency may deny an application, revoke or suspend a license, and rmpose an administrative fine, not to exceed $500 per violation per day for the violation of any provis:on of this part, part If of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlhng interest Mar 3 2010 16:33 83/03/2018 16:27 8509218158 PAGE 12/38 Aviolanon of any provision of this past, part I of chapter 408, or applicable rules” 44 The Agency conducted two complaint investigations in conjunction with a re-licensure survey starting on July 13, 2009 and ending July 18, 2009 45 Based on observation, staff interview and record review the facility failed to provide incontinent care for resident #208 resulung in hai, farled to assess, care plan and treat exconiation for resident #53 which resulted sn harm The facility failed to assess. care plan and follow physician orders for weight loss for resident #240 which resulted m harm, failed to provide toileting asistance and prevent abuse for resident 4140, and failed to provide care and services related to pain and pressure sore treatment to attain or maintain the highest practicable physical and mental weli-being for resident #239 (5 of 26 sa.m pled residents) 46 Findings for Resident #53 include the following 47 Interview with resident #52 on 7/15/09 at 11.52 P.M. revealed resident to be complaining of itching under gown nea arm. The resident stated that they tell staff all the time that it hurts and staff does nothing 48. Observation with nurse at the sam e found large areas of exconation under both breasts Renew of quarterly assessment dated 5/23/09 made no mention of excomation and the record lacked further assessment of exconation 49. Review of skin sweep dated 6/22/09 indicated redness under left breast Review of further skin sweeps did not indicate exconation 50 Review of skin grid sheets lacked documentation of exconation. $1 Review of treatment sheets for 6/09 and 7/09 lacked documentation of excoriated breast and treatment. Review of nurses notes for 6/09 and 7/09 lacked documentation of excoriation Mar 3 2010 16:33 83/83/2818 16:27 8589218158 PAGE 13/30 52 Review of the most current plan of care dated 5/27/09 lacked documentation of exconation under breast or any revision 53 Tn an mterview on 7/15/09 at 11:30 AM wound nurse stated ther policy if a new area 1s found its monitored and documented on the skin gnd sheet or in the nurses notes The nurses failed to assess, complete a care plan, cr call the physician for treatment for excoriation under both breast. 54 Review of nurses notes dated 7/15/09 at 12 noon identified the exconation under both breast with mild odor present and the resident complammmg of itching with muld burning. The physician was called and orders recexved to apply antifungal cream. two umes a day until healed 63 Findings for Resident #240 include the following 64 Observation of resident #240 between 2 00 PM and3.00PM on7/16/09 dunng snack tame revealed no milkshake was given 65 The resident in an interview at the same time stated ‘IT don't get miikshakes and J didn't get one this morning” 66 Interview with staff on 7/14/09 at 12 43 PM. mdicated the resident does not receive a mulkshake 67. Restorative aide passing the snacks in an interview on 7/16/09 at 3:19 P.M_ stated the resident was given a choice of other snecks and aide does not give her/ham a milkshake. 68 Interview with kitchen manager on 7/16/09 at 3.19 P M indicated the aides on the unit keep track of the consumption of the milkshakes 69 Aide on the umt interviewed at the sa.m.e time stated that they do not document the percentage taken by the resident, dietary staff perform that function Mar 3 2010 16:33 03/03/2018 16:27 98509218158 PAGE 14/38 20 The record lacked documeniauion of offering the shake and the amount consumed 71. Review of physician orders d:rected that the resident recieve a regular diet wth large portions and a health shake between meals for added calores due to nsk of weight loss 72 Record rewew of dietary notes mdicated the resident was admutted 7/7/09 with a weight of 98 lbs. The assessmeni indicated at 1isk for weight loss. 73. The resident was weighed again 7/14/09 which indicated a weight loss of 7.5 Tbs in 7 days. Further record review after the 7/14/09 weight lacked further assessment or change in treatment or notifying the physician Record review lacked a plan of care for potential weight loss 74 Findings for Resident #140 include the following 75 In an interview on 7/15/09 at 1115 A.M resident #140 revealed their toilet habits had completely changed since having a stroke several years ago The resident now needs to be assisted to the bathroom after lunch and he/she needs the ass:stance of staff for that acuvity 76 The resident stated that staff asked why he/she didn't go to the bathroom in the AM and gaid, “I bet you couldn't reyulate your body". The resident also stated staff wall at umes close the room door to the hallway which scares the resident as he/she 1s unable to do anything once placed mm the bed The resident keeps two "football" type whustles by the bed to use to alert statt as they don't always come when the resident uses the call bel) and the resident is totally dependent when in bed Resident stated "{I}1's like being in pnson I can't do anything and when that door is closed it makes 1t worse”. According to the resident these events usually occur on the 3-11 shift 77 Dunng another interview with the resident on 7/16/09 at 9 00. AM the resident felt he/she was humiliated by the treatment of staff not always assisting to the bathroom and on Mar 3 2010 16:34 63/83/2018 16:27 8589218158 PAGE occasion has soiled self The resident had tears in their 6yes, and said he/she knew they requiréd alot of help and said “Do you think J would have 11 this way if I had any choice?" The resident also stated s/he had advised the new Unit Manager of her problems 78 Record review of the resident's most recent full assessment dated 5/9/09 and care plan dated 5/14/09 revealed the resident to require lmirtcd asssstance to torjet and to have left upper extresruty flaccidy and left lower extremity weakness The care pian did not mclude the resident's desire to be toileted after lunch, instead the plan stated "check for toileting needs Q2-3 hours as needed, toilet pnor to meals, activities, therapyes and as he/she requests” The resident 1s also assessed as being continent of bowel 79. Interview with the A-Wing Unit Manager on 7/16/09 at 9.40 AM revealed she knew nothing about the resident wanting to be toleted after Junch or to have her door always opened 80 The resident's nursing assistant during an interview with on the sam.e day at 9:45AM stated she was not aware the resident wanted to be tosleted after lunch ox to have her door always open. 81. Findings fur Resident #239 include the following 82 Resident #239 was observed at approximately 9.00 am. on 7/14/09, lying on their back in bed with the head of the bed up slightly. Dunng an interview on 7/13/09 the resident stated that the pain in his/her bones had not quite gone away Agam, dunng the observation of wound care on 7/16/09 at approximately 8-45 am , the resident comp)ained of heel pain to the surveyor The treatment nurse entered the room just minutes pnor to adrninistering the wound care and asked if the resident was in pain fhe resident stated “I think I'll make it" The nurse left and did not retum with pain medication, nor did any staff provide pain medicatior. to the resident prior to Mar 3 2010 16:34 83/83/2818 16:27 8589210158 PAGE 16/30 the treatment. Later in the day at approximately 11 $0.am_ the resident stated that the heel still hurt, but had received a pain medication which helped some 84. Review of the clinical record revealed an admission note dated 7/1/09 at 11 00 aim., staumg in part, that the resident told the nurse an area lo the nght heel 1s sore to touch 85. An additional nursing note dated 7/08/09, reveals in part "Res. heel noted with dark soft place to R heel, painful to touch * 86 Review of the resident's record reveals a care plan for Discomfort and pain, initiated on 7/2/09. The pain is descnbed as generalized, intermittent and no explanation of what exacerbates the pain is listed. What reheves discomfort/pain? Answer stated as Tylenol ES with the first approach to administer medications from pain management as ordered. Secondary approaches are listed as position to comfort - with no descmption in the care plan, encourage exercise/activity and to educate the resident to report the pain 87 A history and physical from the previous hospital stay revealed the resident had chronic complaints of diffuse myalgias 88. Review of the resident's medication administration record on 07/18/09, revealed the resident had received the pain medication on 7 occasions snce admission on 07/01/09: 07/02, 07/08, 07/09, 0711, 07/14; 07/16 and 07/17. 89 Interview with a staff LPN on 07/18/09, revealed the standard procedure is to document effectiveness of the pain medication on a momitonng sheet. No pain medication monitonng sheets could be located for the resident. No documentation could be located for the effectiveness of the pain medhcations given. 90 This resident with diffuse and chromic pain did notrecerve monitonng and treatment to ensure his/her highest level of physical and mental comfort Mar 3 2010 16:34 83/83/2018 16:27 8509210158 PAGE 17/30 a Observations of resideuit 4239's skin on 07/16/09 at approximately 8.45 am before and during wound care revealed the following Skin on the nght heel Large dark bister hixe area, flat, darker - close to black, at the end closest tu the resident's outer ankle, edges of area red and bloody looking. Dressing removed pnor to the observation contained a scant amount of brownish drainage Measurement by treatment nurse’ 75cm x 45cm Areas to the resident's buttocks: Left buttock, large nickel to quaster sized, regular open red/raw area - 2 smaller areas above the Jarger area, both red and raw looking AJ] with the appearance of stage 2 wounds Right buttock - J wregular open red and raw area nutcd, approxumatcly nickel sized Appears as a stage 2 wound Sacral area. The nurse lifted the left buttock, revealing a sphit in the sacral crease. The length of the split appeared as approximately 2 $ to 3 inches in length. The edges of the tissue just inside the split appeared yellowish in color, as if slough, the narrow slender center appeared dark brown Measurements of the sacrai split conducted by the Weatment nurse were stated as 7.5 cm. x4Scm by02cm depth. 92 The treatment nurse stated dunng an interview to the dressing changes that dressings are sometimes done at the preferred tame for the residents and she was not certain as to when the dressing to resident #239's heel would be done. 93. On 07/16/09, just pnor to observation of wound care for resident #239, the wound care nurse stated that new areas had "just opened up” and the resident previously had only had exconation. She stated they had been treating only the sacral spht 94, Review of the resident's climcal record reveals a History and physical information from the immediately previous hospital stay, in part Stage 2 pressure sore 1 noted underlying the sacral region No cther open lesions seen : Mar 3 2010 16:34 @3/63/2010 16:27 8569216158 PAGE 18/38 Admission assessments with conflicung infomation b Nursing data collection sheet 07/01/09 documentation reflects 19 history of skin breakdown and no current skin breakdown Sheet completed by an LPN c. Initial weekly skin sweep dated 07/01/09 Darkened area to nght bottom heel, exconation redness to buttocks and buttock crease No mention of sacral decubitis on either sheet. d. Skin sweep 7/06/09 - No new impainnent e. Skin sweep 7/11/09 - New Skin Impairment - abrasion to inner thigh f. Skin sweep 7/13/09 - No new skin umparment g Skin sweep 7/16/09 - New skin impairment h. New areas sdentfied on 7/14/09, 1 00 p.m. treatment nurse progress note Noted with opened area to sacral upon skin assessment, area measured 5.5 x 4x 0.3, with small amount of exconation, edges intact, wound bed red, granulation, smai] ammount of serous drainage 1. Then on 7/16/09. Skin Grid pressure Rt buttock visualized stage 2 pressure area 3 x 25x 0.2 and Lt. Buttock visualized Stage 2 aread 5x 05x03. y Nursing notes on 7/16/09 at 0600 record Resident with reddish brownish drainage to r heel. Resident had bhster to R heel. K heel cleaned with wound care cleanser, small upen area noted. k Progress notes 07/01/09 att1 00 AM_ Redness noted to coccyx area, dark area noted to R. heel measunng 8x 6x US The other skin concerns documented list surgical scars Initial Braden Score (assessment for the nsk of developing pressure sores) Score 15 - Kesidents are identified as at high 1sk with a score of 12 ox below Mar 3 2010 16:35 @3/83/2018 16:27 8589218158 PAGE 19/38 1 Minumuim Data Set assessment dated 07/08/09, section M1 - Ulcers, identifies the resident as having | stage 2 skin breakdown and section M6 Foot Problems - none, other skin problems or leasions present - none Plan of care for Pressure Ulcer form dated 97/01/09: float heels in bed, complete weekly skin sweeps m. Other observations ot the resident revealed the following 07/14/09 1°50 pm. - Up in wheelchair in his/her room, feet down, left fool on the floor, non- skid sock on and night foot propped on foot rest with his/hersock off exposing the heel. 108. Observation of the resident on 7/16/09 at 11.05 am., resident remaans on his/her back m bed, head of bed up shghtly, tumed very slightly to the nght and with his/her feet elevated. 07/16/09 at 2.00 p.m, resident remaims in bed on his/her back, head of bed up Left foot on mattress, nght foot elevated shghtly on a pillow 7/16 at 4:15 p m observed lying on his/her back on bed with the head of the bed elevated, with ins/hber feet not elevated and heels lying on sheets at foot of bed, feet stcking out from under covers m. 07/17 approximately 815 am _ - On back in bed, head of bed slightly raised. 07/17/09 approximately 9 00 am - Up in wheclchan, feet on bilateral footrests 110. The above findings reflect Respondent’s failure to provide health and safety to residents, thus the Respondent’s actions constituted an uncorrected Class I deficiency, pursuant of § 409 023(8)(b), Flonda Statutes (2008) n. The Agency provided Respondent with the mandatory correction date for this deficient practice of August 18, 2009 Mar 3 2010 16:35 83/83/2018 16:27 85092148158 PAGE 20/38 WHEREFORE, the Agency intends (o mmpuse an admumistvative fine in the amount of $5,000.00 against Respondent, a nursing facyhty in the State of Flonda, pursuant to §§ 400.23(8)(>) and 400.102, Flonda Statutes (2008) 95. The Agency re-alleyes and incorpoxates paragraphs one (1) through five (5), and Count I and I of this Complaint as if fully set forth herein 96. Florida law provides the followmg a Section 400 102(1), F S., “In addition to the grounds listed in part I of chapte: 408, any of the following conditions shall be grounds for action by the agency against a licensee (1) an intentional or negligent act matenally affecting the health or safety of residents of the facility d Section 400.121(1)(a), F.S , “The agency may deny an application, revoke or suspend a license, and impose an admunistrative fine, not to exceed $500 per vnolation per day for the violation of any provision of this part, part I of chapter 408, or applicable rules, against any applicant or hcensee for the following violations by the applicant, licensee, or other controlling interest’ A violation of any provision of this part, part I] of chapter 408, or apphcable rules ” S Section 415 102(1), F S., "Abuse" means any willful act or threatened act by a relative, caregiver, or household member which causes or 1s likely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health. Abuse includes acts and omissions. 97. The Agency conducted two complamt investigations in conjunction with a re-licensure survey starting on July 13, 2009 and ending July 18, 2009 98, Based on observation and interview with resident and staff, the facility failed to protect 1 (#140) of 3 sam pled residents from abuse to include feeling scared at tumes The findings are. 99 Joterview with resident #140 on 7/15/09 at 11:15 AM revealed the resident to say ther torlet habits had completely changed since having a stroke several years ago The resident now Mar 3 2010 16:35 83/83/2818 16:27 8509218158 PAGE 21/38 needs to be assisted to the bathroom after lunch and he/she needs the assistance of staff for that activity The resident stated that staff asked why hevshe didn't go to the bathroom in the A.M. and said, told one nursing assistant "I bet you couldn't regulate your body. "The res:dent also stated staff will at times close the room door to the hallway and this scares the resident as he/she 18 unable to do anything once placed in the bed. The resident keeps two "footbal]” type whistles by the bed to use to alert staff as they don't always come when ‘he resident uses the call bell and the resident is totally dependent when in bed-"1"'s like being in pnson--I can't do anything and when that door is closed it makes it worse” According to the resident these events usually occur on the 3-11 shift. 100. During another intermew with the resident on 7/16/09 at 9:00 A.M the resident felt he/she was humiliated by the treatment of staff noi always assisting to the bathroom and on occasion has soiled self The resident had tears ut them eyes, and said he/she knew they required a lot of help and sand "Do you think | would have :t this way if [had any choice?" The resident also stated s/he had advised the new Unit Manager of her problems. 101. Record review of the resident's most recent full assessment dated 5/9/09 and care plan dated 5/14/09 revealed the resident to require limited assistance to toilet and to have left upper extremity flaccidy and left lower extremity weakness 102. The care plan did not include the resident's desire to be toxleted atter lunch, instead the plan stated "check for toileting needs Q2-3 hours as needed, toalet prior to meals, activities, therapies and as he/she requests The resident 1s also assessed as beg contment of bowel 103. Interview with the A- Wing Umit Manager on 7/16/09 at 9.40 A M. revealed her to say she knew nothing about the resident wanting to be tusleted after lunch or to have her door always opened Interview with the resident's nursing assistant on the same day at 9°45 AM. revealed Mar 3 2010 16:36 43/03/2818 16:27 8569218158 PAGE 22/38 her to say she was not aware the resident wanted io be toileted after lunch or to have her door always open 104, The above findings reflect Respondent’s failure to Protect a resident from abuse to include feeling scared at times, thus the Respondent’s actions constituled a Class II deficiency, pursuant of § 400 023(8)(b), Flonda Statutes(2008) 105, The Agency provided Respondent with the mandatory correction date for this deficient practice of August 18, 2009 WHEREFORE, the Agency intends to unpose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400 102, Flonda Statutes (2008) COUNT IV 106. The Agency re-alleges and yncorporates paragraphs one (1) through five (5), and Count J, II and III of this Complaint as if fully set forth heremn. 107. Based upon Respondent's cited State Class Il deficiencies, it was not in substantial comphiance at the time of the survey with critena established under Part II of Flonda Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional hcensure status under § 400 23(7)(b), Flonda Statutes (2008). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent. a nursing faciity in the State of Flonda, pursuant to § 400 23(7), Flonda Statutes (2008) commeneing July 18, 2009 COUNTY. 108 The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count J, U, 1 and IV of this Complaint as if fully set forth herein Mar 3 2010 16:36 @3/83/2818 16:27 8509218158 PAGE 23/38 10S = That the Agency may revoke any iscense under § 400 121(2)(a) 110. That the Respondent bas been cited with tinee (3) Class I deficiencies pursuant to §§ 400 102(1), 400 022(1)(n), 415 102 and 400 23(8)(a), Flonda Statutes (2008) 111. That based thereon, the Agency seeks the revocation of the Respondent's hecuse WIIEREFORE, the Agency intends to revole the license of the Respondent to operate a nursing home facility in the State of Flonda, pursuant to §§ 400 121(1)(a) and 400 121(3)(d), Florida Statutes (2008). § 400 121(3)(d), F S , authonzes the Agency to revoke the license of a nursing 2f the nursing home 1s cited for lwo Class I deficiencies amsing from separate surveys or investigations within a 30-month perind Approximately six and a half months ago, or within a 30-month time period, on or about June 25, 2008, the Agency issued an Admunistrative Complaint (Agency Case Nos 2008007399 and 200800400) which cited the Respondent with a Class J deficiency based on a survey separate from the survey at issue on this Admunistrauve Complaint Therefore, based on §§ 400 121(4)(a) and 400 121(3)(d), F S , the Agency has proper statutory authonty to revoke the Respondent’s license because the Respondent violated appheable rulcs and has been cited for two Class I deficiencies ansing from separate surveys within a 30-month time penod 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, HL, I, IV and V, (B) Recommend an administrative fine against Respondent in the amount of $15,000, (C) Assign a conditional hcensure status commencing July 18, 2009, Mar 3 2010 16:36 83/83/2018 16:27 9589218158 PAGE 24/38 (D) Assess attomey’s fees and costs, and (E) Grant the revocation of Respondent’s license, (F) Grant all other general and equitable relief allowed by ‘aw. Respondent is notified that it has a nght to request an admimistralive hearing pursuant to Section 120 569, Flonda Statutes. Specific options for admimistrauve action are set out in the attached Rlection 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 Dnve, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to bare an attomey, you have the nght to be represented by an attomey in this matter. RESPONDENT IS FURTHER NOTIFIED THAT THE FAQLURE 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 December 3 , 2009 Te D Carlton Enfin Fla Bar 0793450 Agency for Health Care Admin 2727 Mahan Dnve, MS #3 Tallahassee, Flonda 32308 850 922 $873 (office) 850 92) O158 (fax) CERTIFICATE OF SERVICE IT HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US Certified Mail, Retum Receipt No 7004 2890 0000 $526 4161 to. Facility Administrator Thomas J. McDaruel, Capita] Healthcare Center, 3333 Capital Medical Blvd , Tallahassee, Florida 32308, by U.S Certified Mail, Retum Receipt No 7004 2890 0000 $526 4178 to. Owner Mar 3 2010 16:36 @3/83/2818 16:27 8589218158 PAGE 25/30 Capital Health Care Associates. LLC, d/b/a Capital Heastheare Center, 102.0 Highland Manor Drive, Suite 250, Tam pa, Florida 33610, and by US Cerufied Mail, Retum Receipt No. 7004 2890 0000 5526 4185 to Registered Agent Corporation Sernice Company, 1201 Hays Street, Tallahassee, Flonda 32301 on December 4, 2909 Copy furnished to. Barbara Alford, FOM

Docket for Case No: 10-001124