STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ‘ADMINISTRATION, Petitioner, YS, Case Nos. 2010010232 (ine) 2010010233 (Cond.) PENSACOLA SNF LLC, d/b/a SOUTHERN OAKS REHABILITATION AND NURSING CENTER, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Pensacola SNF LLC, d/b/a Southern Oaks Rehabilitation and Nursing Center (hereinafter “Respondent’ , | pursuant to §§120.569 and 120.57 Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00 upon Respondent, pursuant to §§ 4003.022, 400.102 and 400.23(8), Florida Statutes (2010). The imposition of this fine is based on two (2) Class II deficiencies. The Agency also intends to impose a Conditional rating effective September 17, 2010, pursuant to section 400.23(7), Florida Statutes (2010). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2010). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. Filed December 3, 2010 3:30 PM Division of Administrative Hearings ame” PARTIES 3, The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter SOA-4, Florida Administrative Code. 4, Respondent operates a 210-bed nursing home, located at 600 West Gregory Street, Pensacola, Florida 32501, and is licensed as a nursing facility license nuniber 1556096. 5. . Respondent was at all times material hereto; a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT L (Tag N203 RESPONDENT'S FACILITY FAILED TO PROMOTE CARE FOR RESIDENTS INA MANNER AND AN ENVIRONMENT THAT MAINTAINED OR ENHANCED RACH RESIDENT’S DIGNITY AND RESPECT §400.022(1)(n), Florida Statutes (2010) ISOLATED CLASS II DEFICIENCY . 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to §400.022(1)(n), Florida Statutes (2010), Florida law states: 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 following: (n)The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis. 8. That an unannounced re-licensure survey was conducted between 9/13/10 and 9/17/10 in conjunction with CCR # 2010008232 & CCR # 2010008474 & CCR # 2010009565, Complaints were not substantiated, 9. That based on observation, interview with residents and staff the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect for 4 ( #62, #155,#172 and #279) of 23 sampled residents, . Resident # 172 10. That on 9/13/10 resident #172 was observed to lay in his/her own feces from 11:00 A.M. until 11:40 A.M. without staff intervention even though staff was observed to enter the room _ during this observation period. 11, On 9/14/10 at 8:45 A.M. the surveyor knocked on the closed room door of resident #172 and there was no answer from the room. The resident was in bed A with a nursing assistant attending him/her. The curtain was pulled back and the resident's genital area was exposed, The resident's roommate was also in the the room sitting on the side of bed B facing the resident in bed A and was able to observe resident #172 as the nursing assistant attended him/her. A unit nurse observed the surveyor knocking on the door. When the Director of Nurses (DON) was advised of both the above situations on 9/15/10 at 12:55 P.M. she stated neither situation was acceptable, Resident # 62 12. That an interview with resident #62 on 9/15/10 at 2:30 PM revealed comments that he feels degraded by the way he is treated at this facility. The resident stated he came to the facility using condom catheters but "now they put me in diapers". tage?! 13. That he stated his electric wheelchair has been taken away from him "I'm an incomplete Quad and I needed that chair", he states it is much more difficult for him to get around in a standard wheelchair. He reported that staff purposely leave his call light where he cannot reach it “so I won't bother them". The resident stated staff on the night shift go into resident's rooms and just sit and talk on their cell phones and talk to each other rather than respond to call lights _and resident requests for help. The resident said staff do not treat the residents with respect or dignity "there is no such thing as dignity here, it's like being in prison". | 14. When asked whether his concerns had been reported to administration or social services, he stated "yes, several times". He indicated his complaints have not been addressed to his satisfaction and he rarely gets any kind of explanation for the things staff does. 15. That an interview on 9/1610 at 3:00 PM with the corporate nurse revealed several valid reasons for taking the resident's motorized wheelchair. These reasons were related ta the safety’ of other residents. 16. That an interview on 9/17/10 at 11:20 AM with the resident's nurse confirmed the facility no longer uses condom catheters for this resident, the only reason given for this was that the resident is totally incontinent of urine. 17. The resident indicated through his comments that the lack of dignity and respect afforded residents at the facility has resulted in psychological harm and dissatisfaction/unhappiness with his life at this facility. Resident #155 18. That an interview with resident #155 on 9/14/10 at 9:04 AM revealed the statement that Certified Nursing Assistants (CNA's) are not helpful most of the time, he/she has not reported it to anyone. 19, That a further interview with this resident on 9/17/10 at 9:35 AM revealed comments that there are ongoing problems with some staff just treating him/her and other residents like they don't care and can't be bothered. The resident stated he/she will ask for something (ice, sugar packets, etc.) and they just keep walking and ignore him/her when he/she knows they heard, or ” they will say they'll get it and never come back. 20. That he/she stated the treatment isn't really abuse or neglect, it is just not being treated like everyone deserves to be treated. "Some of us are very dependent on staff, we can't just get up and get what we want" indicating if staff doesn't do for them, they have to do without. He/she indicated it is hard to feel like you ate always a burden and to be treated with no di gnity or. respect as a person, The resident stated past incidents (within the past 3 months) when he/she was in another room on the same floor when night/evening shift staff would sit in his/her room and make extended personal calls on their cell phones rather than responding to call lights or helping residents. 21. | When asked whether any of these problems have been reported to facility administrative or social services staff, the resident replied "some of it, but I quit because it doesn't do any good". This resident's comments indicate he has suffered psychological harm due to disrespectful treatment by facility staff. 22. That on 9/13/10 at 2:20 PM during stage 1 resident interview the resident stated, "Some CNA's come into my room to talk on the cell phone. Sometimes I ask for some ice and they tell me, 'Ask her.’ The next one says the same thing. Once it took me an hour and a half to get some ice.” 23. The above constitutes a violation of §400.022(1), Florida Statutes (2010), and constitutes an isolated class II deficiency. pursuant to section 400.23(8)(b), Florida Statutes (2010). ‘omg’ WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida. COUNT. DI (Tag N216) RESPONDENT’S FACILITY FAILED TO PREVENT THE DEVELOPMENT OFA PRESSURE ULCER §400,102(1), Florida Statutes (2010) ISOLATED CLASS II DEFICIENCY 24. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 25. That pursuant to §400.102(1), Florida Statutes (2010), Florida law states: 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 materially affecting the health or safety of residents of the facility; 26. That an unannounced re-licensure survey was conducted between 9/13/10 and 9/17/10 in conjunction with CCR # 2010008232 & CCR # 2010008474 & CCR # 2010009565. Complaints were not substantiated. 27, That based on observation, interview with staff and record review the facility failed to prevent the development of a pressure ulcer for 1 (#172) of 4 sampled residents. 28. That observation of resident #172 revealed the resident lying in bed in their room on 9/13/10 from 11:00 A.M. until 11:40 A.M. During this entire time there was a strong odor of feces noted in the room and there was a brown stain noted on the sheet covering the resident that grew in size as the time passed. The resident was also observed to have his hand under the sheet and appeared to be digging at his genital area. During these forty minutes staff did go inthe resident's room but did not attend the resident. Seis” 29, That on 9/16/10 at 11:50 AM resident #172 was observed during incontinent check by his -- nursing assistant (CNA) and wound care nurse accompanied by the Director of Nursing (DON) The resident was observed to have a broken wound to the R (right) gluteal fold measuring approximately 1.5 cm (centimeters) X 0.7 cm. Treatment was applied to wound by CNA, 30. That an interview with the resident's nursing assistant on 9/15/10 at 12:50 p.m. revealed the resident is totally dependent for activities of daily living and the resident is incontinent of bowel and bladder. 31. That an interview with the Director of Nurses (DON) on 9/15/10 at 12:55 p.m. revealed the DON stated that having a resident go unattended and lay in their own feces for forty minutes was unacceptable. DON stated it was not acceptable for any staff, much less the Unit Manager, to go in the resident's room and not attend the resident's needs. 32. That an interview with the Wound Care Nurse, a Licensed Practical Nurse (LPN) on 9/16/10 at 11:30 A.M. revealed him to say he was informed on 9/15/10 that resident #172 has breakdown on his right buttocks, He stated the area is a Stage IT and further stated he is notified and treats all House acquired pressure sores. He also stated that laying in feces could "most definitely be a contributing factor" to the development of a pressure area. He stated he treats all Stage III and IV pressure areas but he is notified of all house acquired pressure areas and said he was notified on 9/15/10 of the new pressure area for resident #172. 33. That a record review revealed the resident's most recent Braden Scale for Predicting Pressure Sore-Risk was dated 8/3/10. The resident's score was an 18 with a score of 15-18 placing the resident at risk for developing an ulcer. 34. That the resident's most recent Minimum Data Set (MDS) for a quarterly review had an assessment date of 8/1/10. At that time the resident was assessed as having no pressure ulcers. 35.. That the care plan (with an onset date of 2/4/10 and review date of 8/10/10) addresses q problem of Urinary/Skin/Pressure: Resident is at risk for impaired skin integrity/skin breakdown/pressure ulcer development secondary to bowel and bladder incontinence, use of pads and briefs, impaired bed mobility and a Diagnosis of Diabetes Mellitus IL. 36. That the goals included: be clean and dry with prompt incontinence care; have no skin breakdown related to incontinence; have no pressure ulcer development. 37. That the approaches included: assist resident with incontinent care every two hours and PRN (as needed); provide with adult briefs/pull ups/pads and change; monitor skin per facility protocol and during Activity of Daily Living (ADL) care; notify Nurse/MD of any abnormalities noted; pressure relieving mattress to bed, 38. . That arecord review revealed documentation on a nursing assistant Shower Sheet dated 9/10/10 on the body check of the back of the resident had a circle around the left buttocks, 39. Thata review of a Nurse Report Sheet dated for the 7-3 shift on 9/12/10 indicated "bottom breaking".There is no indication these two incidents were reported or acted upon or interventions changed. 40, That at 12:12 P.M. on 9/16/10 the wound care nurse brought for surveyor review his Weekly Pressure Ulcer Record dated 9/15/10. The form notes the resident to have a Stage IT pressure ulcer affecting the R buttock. 41. The above constitutes a violation of §400.102(1), Florida Statutes (2010), and constitutes an isolated class II deficiency pursuant to section 400.23(8)(b), Florida Statutes (2010). COUNT DI 42. The Agency re-alleges and incorporates paragraph one (1) through five (5) and Count I and Count II of this Complaint as if fully set forth herein. 43. Based upon Respondent’s cited two State Class II deficiencies, it was not in substantia] compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditiona) licensure status under § 400.23(7)(b), Florida Statutes (2010), WHEREFORE, the Agency intends to assign a conditional licensuré status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2010) commencing September 17, 2010. 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 through III; (B) Recommend administrative fines against Respondent in the amount of $5,000 for Count I and II; (C) Impose a conditional license commencing September 17, 2010. (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. ) If you want to hire an attorney, you have the right to be represented by an attomey in this ‘asp 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 4 of November, 2010 . Carlton Enfinger, Fla. Bar. No. 793450 Agency for Health Gare Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 412-3640 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7001 0360 0003 3808 3499 to Facility Administrator Paul J. Prybylski, Southem Oaks Rehabilitation and Nursing Center, 600 West Gregory Street, Pensacola, Florida 32501 and via U.S. Mail to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301-2525 on November E soo D. Carlton Enfinger, II Copy furnished to: Barbara Alford, F OM 10 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST . ELIZABETH DUDEK GOVERNOR : INTERIM SECRETARY October 26, 2010 SOUTHERN OAKS REHABILITATION AND NURSING CENTER 600 WEST GREGORY STREET - PENSACOLA, FL 32501 Dear Administrator: The attached license with Certificate #16494 i is being issued for the operation of your facility, Please review it thoroughly to ensure that rmation is correct and consisten records. If errors or omissions are noted, please make corrections on a copy and mail Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for Status Change. Sincerely, SPO! Tracey Weatherspoon Agency for Health Care Administration. Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management LORIDA COM Pe Re SG Re Visit AHCA online at Health Caro in the Sunshine ahca.myflotida.com 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 www.FloridaCompareCare.gov TIOC/OE/Cl -ALVC NOILVUIdXa OLOZ/L 1/60 -FLVG FAILOS AAT FONVHDO SNLVLS | SCH OI “TVIOL : 10SZE Td “WIOOVSNAd | JAFALS AYODAAD LSA 009 : UALNAO ONISUAN GNV NOILVIITIGVHAE SYVO NYFHLNOS -Burmoyfoy amy ayerado 0} poztoyyne SI sasusol] ay} se pur ‘sayraeis eplopy ‘TT ued ‘OOr JoydeyD ul pezuoyine ‘uonensiunupy ered yyyeeaH 10.J Agua8y ‘epuoyy Jo arerg om Aq paydope suowejnder pue seqns ayy yim porduos sey DTT ANS WIOOVSNAd 7y} WFO 0} SI STL i TVNOILIGNOD j HINOH ONISAIN AONVAASSV ALITVNO HITVdH AO NOISIAIG NOILVYLSININGY FaVO HLTVWAH YO AONADV BPLIO[ JO 938} ete Sores REE ES Voto LidbK & CONIM Page 1 of 1 Ea. UNITED STATE: POSTALSERVICE® — Track & Confirm Search Results Labei/Receipt Number: 7001 0360 0003 3808 3499 Service(s): Certified Mall™ : : Status: Arrival at Unit Enter Label/Receipt Number. Your item arrived at 7:33 am on November 06, 2010 in PENSACOLA, FL 32501. Information, if available, is updated periodically throughout the (80 > day. Please check again {ater. ero Notification Options Track & Confirm by email Get current event information or updates for your item sent to you or others by email. (Ge ED) Site Map Customer Service Forms Gov't Services Careers Privacy: Polley Tenns of Use Business Customer Gateway & UG hd hayevodians IQUOROSSorare, Beverdeg te turk 7 Voanedigy biden ly Copyright® 2010 USPS, All Rights Reserved. No FEAR Act EEO Data FOIA http://Arkenfrm1 -Smi.usps.com/PTSInternet Web/InterLabelinquiry. do 12/02/2010 IFIED MAIL RECEIPT Postage Certified Fae Postmark Return Receipt Feo Here (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Feos Tivyosgtadat stg Actan da, S : < o-listirance. Coverage Provided). i

Docket for Case No: 10-010484