“igs? STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ‘STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, Case Nos. 2010013138 (Fines) _ 2010013139 (Cond.) SOUTH DAYTONA HEALTH CARE ASSOCIATES, LLC d/b/a OAKTREE HEALTHCARE, 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 South Daytona Health Care Associates, LLC, d/b/a Oaktree Healthcare (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 $1,000.00 upon, Respondent, pursuant to Section 400.23(8), Florida Statutes (2010). The imposition of this fine ig based on one uncorrected Class III deficiency. The Agency also intends to impose a Conditional rating effective October 14, 2010 and ending December 16, 2010 pursuant to § 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 February 25, 2011 9:56 AM Division of Administrative Hearings ‘gag ae PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code, 4, Respondent operates a 65-bed nursing home, located at 650 Reed Canal Road, South Daytona, Florida 32119, and is licensed as a skilled nursing facility license number 1122096 . 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 I (Tag N71) RESPONDENT’S FACILITY FAILED TO REVISE THE CARE PLAN OF A RESIDENT TO ENSURE THAT HE/SHE WAS FED ACCORDING TO HIS/HER NEEDS IN ORDER TO MAINTAIN HIS/HER PRESENT NURITIONAL NEEDS FOR AS LONG AS POSSIBLE Fla. Admin. Code R. 59A-4,109(1) UNCORRECTED 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 Fla. Admin, Code R. 59A-4.109(1), Florida law states: 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, Roe sy completed on admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter, The assessment shall be: 1. Reviewed no less than once every 3 months, 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. That from May 3, 2010 through May 7, 2010, the Agency conducted an unannounced licensure survey at the Respondent’s facility. 9. Based on observations, resident record review, and staff and resident interview, the facility failed to completely and accurately assess and reassess 2 of 36 sampled residents, Resident #17 and Resident #2 for repeated incidents that involved the residents' mood, behavior patterns and mental disease diagnosis that threatened the physical and mental well-being of at least 6 other facility residents, Residents #10, #45, #75, #80, #70 and #58. Resident # 17 10. During an initial interview with Resident #17 on 5/3/10 at 1:20 PM, the resident revealed that an incident had occurred on 4/29/10 between he/she and a staff member. The resident further revealed that he/she felt he/she was talked to in a rude manner by the staff person during the incident. The resident further stated the police were called and he/she felt threatened by the police, 11, A review of Resident #17's clinical record revealed the resident was admitted to the facility on 10/14/09 due to a stroke. The resident was discharged to the hospital on 10/25/09 for “S a being over sedated with Lortab and Xanax that was not provided by the facility. Resident #1 7 returned to the facility on 10/27/09 from the hospital with hospital information stating the resident had a history of bipolar disorder and schizophrenia, 12, Farther review of the clinical record revealed a nurses note dated 4/29/10 revealing the resident had been gone from the facility and when he/she returned around 6:45 PM the resident became angry upon noticing that the television in his/her Toom was removed. The note further stated the resident was yelling in the hallway and went into the main dining room and angrily confronted a CNA, "verbally assaulting her and not letting up." The nurse intervened and "finally" got Resident #17 to return to his/her room. The note further states that a police officer arrived, spoke to the nurse and to the resident and left. The note concludes with the Director of Nursing (DON) being called and informed of the incident. 13. An interview on 5/4/10 at 3:13 PM with the CNA involved in the incident on 4/29/10 revealed Resident #17 was cursing and yelling and "got i in my face" calling her names and pointing at her The CNA further stated the nurse on duty was aware of Resident #17 yelling at her and did nothing at first. The CNA stated after yelling at her, Resident #17 started yelling at Resident #70 who shared a room with Resident #17. The CNA stated as she feared for her safety and no one was helping her, she called the police, 14, An interview on 5/4/10 at 3:28 PM with the nurse on duty on 4/29/10, revealed he observed Resident #17 verbally threatening the CNA, He further stated he did not witness Resident #17 yelling at or threatening Resident #70, The nurse stated he had informed the DON that night what had happened. He further stated no one ever asked him anything about the incident after it occurred. 15, An interview with Resident #70 on 5/5/10 at 9:31 AM revealed he/she had shared a room with Resident #17 and 2 other residents since being admitted on 4/8/10. Resident #70 stated that Resident #17 would watch pornographic movies at night and that disturbed Resident #70. Resident #70 further stated that he/she had approached Resident #17 about the pornographic movies and that he/she didn't want to listen to them and would Resident #17 tum them off. Resident #17 refused and one time came at him/her with a fist in his/chest and threatened him/her, Resident #70 stated he/she reported this to his/her nurse and the DON. Resident #70 further stated he/she went to a nurse and asked to be put in another room. A review of the nurse's notes for Resident #70, revealed the resident asked to be moved on 4l 12/10. The resident stated that he/she again asked to be moved on 4/27/10 at his/her care plan meeting, Resident #70 further stated that on 4/29/10 Resident #17 came into the room in the evening and "threatened to harm (the resident)" and blamed him/her for the removal of the television. Resident #70 said the nurse on duty was aware of Resident #17 threatening him/her on 4/29/10. Resident #70 algo stated that he/she had been threatened with harm by Resident #17 on numerous occasions and the facility was aware of it. Resident #70 was removed from the room shared with Resident #1 7on 5/1/10. 16. Further review of Resident #17's nurses’ notes revealed on 4/6/10 the resident became agitated and began yelling down hallways and slamming doors. A nurse’s note dated 4/14/10 revealed the resident was watching pornographic movies at 2:00 AM very loudly and when - asked by the nurse to turn it down he/she became agitated and started yelling at the nurse. A nurse’s note dated 4/24/10 at 6:30 AM revealed the resident spoke loudly and in an aggressive manner.towards a CNA. The note further stated Resident #17 yelled (he/she) couldn't stand Resident #70 and was "going to bug the hell out of (him/her) every time I can." 17, A review of Resident #17's clinical record revealed a Minimum Data Set Quarterly assessment tool dated 4/29/10 which revealed the resident was not coded for having any behaviors. A review of Resident #17's Care Plan dated 11/12/09 revealed no plan or interventions for any inappropriate behaviors. The facility's admitting diagnosis dated 10/14/09 for Resident #17 included Bipolar disorder and Schizophrenia, paranoid type. | Resident #2 18. An interview with Resident #10 on 5/6/10 at 8:50 AM revealed that the resident was afraid of Resident #2, as the resident threatened others and was angry. 19. An interview with Resident #75 on 5/6/10 at 4:05 PM revealed Resident #2 had "threatened me with a cane on numerous occasions." The resident further stated that he/she had talked to the DON about the threats and was told the DON "would take care of it." Resident #75 stated Resident #2 still threatened the resident from time to time. Resident #75 further stated that ~ Resident #2 was "backing (the resident) into a corner and I don't know what to do." Resident #75 lives next door to Resident #2. 20. . An interview with Resident #80 on 5/6/10 at 4:09 PM revealed he/she had heard Resident #2 threaten Resident #75 and Resident #2 had threatened him /her also. The resident had a room 2 doors away and across the hall from Resident #2. The resident also stated that the facility was aware of Resident #2's behavior. 21. A review of the clinical record of Resident #2 revealed the resident's admit date to the facility was 12/4/09. The resident's quarterly MDS dated 3/7/10 coded the resident as having ~ short term memory concern, modified independence for daily decision making, persistent anger, repetitive anxious complaints, and unpleasant mood in morning. The resident had a care plan for Se Se? Bipolar Disorder with persistent anger with staff and other residents dated 12/24/09 with the following interventions: a. administer antidepressant medication, b. monitor for side effects, c. use gentle touch, d. encourage (the resident) to ventilate (his/her) feelings and frustrations in a calm. manner, e. if(the resident) continues to yell separate from stressful situation, f. refer to social service for concerns that (the resident) may have, g. refer to psych service, psych to follow per routine for dose reduction. 22. Resident #2 had a Care Plan for behavior management with the following interventions, on 1/22/10; Inappropriate "Bold " sexual behaviors: respond with patience and understanding, respond calmly and firmly, adm antipsychotic med. The resident was also care planned for delusions as of 12/5/09 and aggression 12/4/09, The care plan did not address interventions to prevent aggression or to protect others from his/her aggression. 23. Further review of the clinical record revealed the resident received Risperdal 1 mg am and 2 mg bedtime. Resident #2 was seen and counseled by the facility psychiatrist on 1/25/10 for inappropriate sexual behavior and was ordered Risperdal 0.5mg qid, Risperdal increased to 1 mg am and 2 mg hs for psychosis. 24. — A review of the social services notes dated 2/5/10 revealed 2 residents (Resident #75 and #80) went to her to inform her they are afraid of Resident #2 saying they "feel threatened because of the things he/she says to them and the way that he/she looks at all of them." They stated he/she threatened them by telling them he/she was going to "kill them and knock off their heads." The social service person stated in notes that she had witnessed Resident #2's behavior on the back porch with him/her threatening to "kill her and knock her head off". Interview with P i the Social Services person on 5/6/10 at 10:06 AM revealed she went to the DON regarding Resident #7 5's and #80's complaint and was told it would be handled internally. 25, Class “I” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. §429.19(2)(a), Florida Statutes 26. Class “I” violations are those conditions or occurrences related to the operation and. maintenance of a provider or to the care of clients which the agency determines present an. imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. . 27. The Agency gave a mandatory correction date of this deficiency of June 7, 2010. . 28. That from October 11, 2010 through October 14, 2010, the Agency conducted a revisit to the unannounced licensure survey at the Respondent’s facility. 29. That based on observation, staff interview and record review, the facility failed to revise the care plan for 1 of 27 sampled residents to ensure Resident #30 was fed according to his/her needs in order to maintain their present nutritional needs for as long as possible. 30. That an observation of Resident #30 on 10/11/10 at 12:20 PM revealed a CNA attempting to feed Resident #30 their lunch. 31. That the observation revealed the CNA was unable to successfully put food in the resident's mouth due to the tongue thrusting of the resident. The resident's food was observed on the resident's clothing protector and on the resident's face but not in the resident's mouth sufficiently to swallow. 32. That an observation on 10/13/10 at 12:35 PM in the locked unit dining room revealed another CNA was observed appropriate feeding the resident despite the resident's thrusting tongue, ensuring the resident was able to swallow the pureed foods. 33. That an interview with the CNA on 10/13/10 at 12:36 PM revealed that when she feeds Resident #30 breakfast and lunch, the resident usually ate all of his/her food. 34. — Resident #30's quarterly assessment dated 4/18/2010 indicated a diagnosis of Huntington's Chorea and was a Hospice resident with a diagnosis of Failure to Thrive (adult), 35, The quarterly MDS dated 7/20/10 revealed that the resident had an end-stage disease with 6 or fewer months to live, chewing and swallowing problems, weight loss of 5% in the last 30 days or 10% in the last 180 days and was on a planned weight change program. 36. A review of the care plan for nutrition dated 11/5/09 revealed a concern for significant weight loss, leaves 25% or more of foods uneaten at most meals of puree with fortified foods and pudding liquids as ordered. 37, ‘The care plan goal was for the resident to consume 75 to 100% of their meals. The care plan approaches stated staff are to offer three in between meals snacks and provide nutritional supplement as ordered. It also stated "When you place food in (the resident) mouth gently close mouth by placing fingers on chin as needed." 38. No evidence could be found in the care plan that the facility addressed the successful technique used by the CNA so other CNA's could also be successful feeding Resident #30 due to tongue thrusting. | age? 39, Although the care plan stated the concern for nutrition due to the resident leaving 25% or more foods uneaten, and the goal was for the resident to consume 75 to 100% of their meals, no evidence could be found the amount of food consumed by the resident was monitored or documented. 40. That an interview with the corporate nurse on 10/14/10 at 11:00 AM revealed their corporate policy was not to tecord resident intake. 41. Aclass III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise 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. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned 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 licensure inspection or any inspection or complaint investigation since the last licensure inspection, A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. Ifa class III deficiency is corrected within the time specified, a civil penalty may not be imposed 42, The Agency gave a mandatory correction date of this deficiency of November 14, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§, and 429.19(2)(c), Florida Statutes (2010). COUNT II 43. The Agency re-alleges and incorporates paragraph one (1) through five (5) of this Complaint as if fully set forth herein. 44. The Agency re-alleges and incorporates Count I of this Complaint as if fully set forth herein. 45, Based upon Respondent’s cited uncorrected State Class Ill deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2010). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2010) commencing October 14, 2010 and ending October , 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; (B) Recommend an administrative fine against Respondent in the amount of $1,000; (C) Impose a conditional license commencing October 14, 2010 and ending December 16, 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; M8 #3, Tallahassee, Florida 32308, (850) 922-5873. | If you want to hire an attorney, you have the right to be represented by an attorney in this matter, RESPONDENT 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 EN'TRY OF A FINAL ORDER BY THE AGENCY. aim Respectfully submitted this day of January, 2011 Yiex Meh 444Ou (OLD. Carlton Enfinger, II, Esq. "Fla. Bar. No, 793450 Agency for Health Care 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. 7009 0960 0000 3708 3031 to: Facility Administrator Gus Murphy, Oaktree Healthcare, 650 Reed Canal Road, Dayton Beach, Florida 32119 and by U.S. Mail to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301-2525 on JanuaryZ4!o11; awe Asher Fey D- Carlton Enfinger, II Copy furnished to: Rob Dickson, FOM FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT GOVERNOR January 19, 2011 OAKTREE HEALTHCARE 650 REED CANAL ROAD SOUTH DAYTONA, FL 32119 Dear Administrator: ELIZABETH DUDEK INTERIM SECRETARY The attached license with Certificate #16616 is being 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 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 Drive, Building 3 Tallahassee, Florida 32308 Issued for status change to Standard. Sincerely, Sidiathurspoor Tracey Weatherspooon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management - LORIDA 2727 Mahan Drive, MS#33 s i ie Tallahassee, Florida 32308 e COMEARE BARE Health Care in the Sunshine Y www.FloridaCompareGare.gov Visit AHCA online at ahca.myflotida.com TLOC/Oe/TI “ALVG NOILVUdXa O1OC/LV/CI ‘ALVG FAILOTAIA AONVHD SALVLS Saga s9 “IVLOL 611ZE Td “WNOLAVG HLINOS avOw IVNVO daaa 0s9 HFaVOHLTVaH FaAaLAVO :Butmoyyo} oy) ayeredo 0} pezLIOYyINE St sesuedl] 24} se pue ‘semmeig epuoLs ‘TI wed ‘OOr JerdeyD wr pezuoyme ‘uonensturpy ered tnyeay 10,j AoueSy “epuiopy Jo arerg am fq pordope suonenZer pur sayni oy} wim perdwoo sey OTT ‘SALVIOOSSV TUVO HLIVAH VWNOLAVG HLNOS tp uno 0} st STE AHINOH ONISUIN FONVUNSSV ALITWNO HLTVGH AO NOISIAIG NOILVULSININGY Fav) HLIVEH YOA AONADV BpLIO[yy Jo 960CTTIANS ‘# ASNAOIT Ee FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST . GOVERNOR December 20, 2010 OAKTREE HEALTHCARE 650 REED CANAL ROAD SOUTH DAYTONA, FL 32119 Dear Administrator: Sogo” ELIZABETH DUDEK - INTERIM SECRETARY The attached license with Certificate #16571 is being 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 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 Drive, Building 3 Tallahassee, Florida 32308 Issued for Status Change to Conditional. Sincerely, dideathorgocn Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management La RIDA COMPARE CLARE Health Care in the Sunshine 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 www.FlorigaCompareCare. gov Visit AHCA online at ahca.myflorida.com LLOC/OL/TI “ALVG NOILVUIdXxa O10Z/PI/Ol -ALVd SJALLOgsIa AONVHO SNLVIS sda 69 “IVLOL 6LIZE TA “VWNOLAWG HLNOS avVOuw TVWNVO Gada 0S9 FUAVOHLIVEH FFALAVO SUIMOTIOF 2u3 oyerodo 0} paztoyne st sesusoT] Sy} se pur ‘sommeig epuory ‘TI ued ‘Op JodeyD ut pazuoyne ‘uonENstUTpy aeD Wea} 10,5 Sousdy ‘epuoyy Jo arerg amp Aq pardope suonjernBar pue sens ayy ym porjdusos sey OT] ‘SALWIOOSSV TUVO HLIVAH VWNOLAV HLNOS Rup uUOD 0} st SIL TVNOWIGNOD AINOH ONISUIN AONVUENSSV ALITVNO HLTVaH AO NOISIAIG NOILLVULSININGV AuvV) HLIVEH YOd AONADV VPLIO],] JO 9183S 9O0CTITANS “# TSNSOIT Postage Cottified Fee Return Recelpt Feo (Endorsement Requlred) Fesirictsd Delivery Fee (Endorsement Requived) ‘Total Postage & Feas Galileo Wes apex aes Aca SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 3. Also complete item 4 If Restricted Delivery is desired, ™ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front If space permits. 1. Article Addressed to: A. Signature XDalu Posen B, Recelved by (Printed Name) Ble Perkias D. Is delivery address different from item 12 [2 Yes 'f YES, enter delivery address below: [0 No C1 Agent : > © Addressee | C. Date of Detivery | 3. wee Type Certified Mall (Ct Express Malt im) Registered 0 Return Receipt for Merchandise ° Cl insured Mati =F c.0.b. [4 Restricted Delivery? (Extra Fea) D Yes 102595-02-M-1540 t = wee es | PS Form 3811, February 2004 Domestic Return Recalpt

Docket for Case No: 11-001017