STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos, 2011004657 (Fines) 2011004658 (Cond.) . GINGER DRIVE HEALTH CARE ASSOCIATES, LLC, d/b/a HERITAGE HEALTH CARE CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Ginger Drive Health Care Associates, LLC, d/b/a Heritage Health Care Center (“the Respondent”), pursuant to sections 120.569 and 120.57 Florida Statutes, and alleges as follows: NATURE OF THE ACTION This is an action to impose an administrative fine-in the amount of $10,000.00 based upon two (2) cited Class II deficiencies pursuant §400.23(8)(b) and assign conditional licensure status commencing April 7, 2011 and ending May 6, 2011 on the Respondent. | PARTIES 1, The Agency is the licensing and regulatory authority that oversees nursing homes and enforces the applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to Chapters 408, Part II, and 400, Part IL, Florida Statutes, and Chapter 59A-4, ‘Florida Administrative Code. Filed July 7, 2011 12:52 PM Division of Administrative Hearings 2. The Respondent was issued a license (License Number 12210961) by the Agency to operate a nursing home located at 3101 Ginger Drive, Tallahassee, Florida 32308, and was at all times material times required to comply with all applicable regulations, statutes and rules. COUNT I (Tag NO072) 3. Under Florida law, 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 completed within 7 days after completion of the resident assessment. Fla. Admin. Code R. S9A- 4.109(2) 4, Under Florida law, “Resident care plan’ means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident; the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being; a listing of services provided within or outside the facility to meet those needs; and an explanation of service goals. The resident care plan must be signed by the director of nursing or another registered nurse employed by the facility to whom institutional responsibilities have been delegated and by the resident, the resident’s designee, or the resident’s legal representative. The facility may not use an agency or temporary registered nurse to satisfy the foregoing requirement and must document the institutional responsibilities that have been delegated to the registered nurse. §400.021(16), "gee Hig? Florida Statutes (2010) 5. That on April’ 7, 2010, the Agency conducted a complaint investigation (CCR#201 1003299) of Respondent’s facility, 6. . That based on observations, interviews, and record reviews the facility failed to ensure the residents care plans were followed and updated so that residents received necessary care and treatment to prevent the development and promote the healing of avoidable pressure ulcers for 5 of 5 sampled residents, (#1, #2, #3, #4, and #5) Resident # 1 7, That a review of the medical record for resident #1 revealed resident #1 has an unstageable pressure ulcer to the coceyx and 3 deep tissue injuries to the left inner, middle, and lateral aspects of the heel, The resident went out to the hospital on 3/1 0/ 11 for an upper respiratory infection and returned on 3/19/11 with the pressure ulcers to her coccyx and left heel, 8. Documentation shows starting 3/28/11 through 4/4/11 that the coccyx wound is draining a moderate amount of serous yellow drainage and states there is no odor. 9. Observation of the wound on 4/7/11 revealed there is a very strong foul smell] coming from the wound. The resident's care plan stated the care plan is to be evaluated every 2 weeks, and the physician should be notified if wound got worse. 10. The care plan also states the resident should be repositioned at least every 2 hts, The medical record contained no communication with the physician of the continued foul smelling drainage. 11. On 4/7/11 at 11:05 a.m. an interview with the wound care nurse was conducted. The nurse stated resident #1 went to the hospital in March with a stage IIT pressure ulcer to the coccyx and returned on 3/19/11 with an unstageable pressure wound to the coccyx anda ‘stage III pressure wound to the heel. 12. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. 13. The surveyor asked the nurse, if the resident is being provided care, why did the wounds continue to get worse after admission on 3/19/11, and why the resident's doctor was not notified. 14, The nurse stated, "I did talk to the hospice nurse about the resident's wounds on 4/S/11 and the hospice nurse said ok so I was going to let hospice handle it." The wound care nurse also stated, "there have been some problems with the residents, who have pressure ’ wounds; not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes." 15. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. 16. ~ On 4/7/11 at 12:30 p.m. an interview was conducted with resident #1 ' s daughter. The daughter is concerned because the wounds are getting worse. The daughter stated she is in the facility 3 times a week for several hrs. and the resident was not turned every hr. 17, On 4/7/11 at 2:00 p.m. observation of the resident's wounds and wound care were made. Wound care was provided as ordered. The wound does appear as measured on 4/4/11. There is a moderate amount of yellow drainage and a strong foul odor coming from the wound. 4 Resident #2 18. A record review was conducted on 4/7/11 for resident #2. This record review revealed, resident #2 is a bilateral above the knee amputee and has a stage III pressure ulcer to the coceyx. The resident was re-admitted to the facility with the coccyx wound on 2/17/11. The skin. grid documentation for the resident revealed that on 3/7/11 the resident had a stage ITI pressure ulcer and the measurements were 2.7 cm, in length, 2.1 cm. in width, 2.1 cm. depth, and a surface area of 5.67 cm. the wound bed color is red and there is tunneling at 9:00 of 2.6cm. in length, and undermining at 12:00 of 2.3 cm. in length, there is small amount of serosanguinous pink/red drainage with an odor. 19. On 3/14/11 the wound appears to have gotten worse and documentation stated the wound is still a stage II. 20. On 4/4/11 documentation shows the resident's wound is still a stage III, 2.8 cm. in length, 1.5 om. in width and 2.3 cm, depth, the surface area of the wound is 4.20 cm., the wound bed is red, the undermining is 3.1 cm. in length and tunneling is 2.8 cm. in length and there is a moderate amount of serosanguinous drainage pink/red with odor present (there is no documentation where the undermining and tunneling are). 21. The care plan stated the resident's physician should be notified if wound got worse and the resident should be repositioned every 2 hours. The resident is being seen by the wound care center monthly with the facility providing the care between visits to the wound care center, 22. On 4/7/11 at 11:50 a.m. an interview was conducted with the wound care nurse. The nurse stated resident #2 went to the hospital in February and returned from the hospital with a stage II] pressure ulcer to the coccyx. 23, The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse-stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. 24. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " 25. The wound care nurse stated she found resident #2 soiled yesterday and the dressing was soiled: with feces for quite some time prior to her finding this. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. 26. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. Resident #3 27, On 4/7/11 a record review was conducted for resident #3. This record review revealed the resident is a quadriplegic with an unstageable pressure ulcer to the coccyx, 28. In February the resident 's wound was a stage IT and the most current documentation on 4/4/11 stated the resident 's wound has gotten worse and is now unstageable. This resident was transferred to the hospital for respiratory distress this morning. 29. Review of the skin grids for resident #3 revealed that on 3/8/11 the resident's wound was unstageable and the length of the wound was documented 4.2 em. in length, 4.5 cm. in width, and 0.1 depth, with a surface area of 18.9 cm., there is slough tissue with a yellow wound bed, no tunneling or undermining, and a large amount of serous yellow drainage and no odor. 30. On 3/15/11 the wound is unstageable, 4.5 om. in length, 5.1 cm. width, 0.1 cm. depth, with a surface area of 22.95 cm., slough tissue, yellow wound bed, no tunneling and underminig, small amount of serous yellow drainage without odor. 31. On 3/22/11 the wound is still unstageable, 4.5 em. in length, 5.5 cm. in width, 1 om. in depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, and a small amount of serous yellow drainage. 32. On 3/29/11 the wound is unstageable, 4.5 cm. in length, width is 5.5 cm., 1 om. depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. 33. On 4/4/11 the wound is unstageable, 4.4 cm. in length, 5 cm. in width, 1 cm, depth, with a surface area of 22 cm., there is slough tissue, with red and yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. There is no evidence that when the wound got worse, the doctor was notified as care planned. The care plan stated the resident's wound was still a stage II. 34. On 4/7/11 at 11:50 a.m. the The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. 35. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " . 36. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident 's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. The wound care nurse stated that she felt like the resident's wound got worse due to the resident not being changed when soiled and repositioned as directed at least every 2 hrs. Resident #4 37, On 4/7/11 a record review was done for resident #4. This record review revealed the resident is incontinent of bowel and bladder and is a total assist due to a left above the knee amputation and the resident is confused and does not communicate. 38. Documentation also revealed, the resident has a stage II pressure ulcer to the coccyx and a deep tissue injury pressure ulcer to the right heel, Documentation on the resident's skin grid dated 4/5/11 stated the resident has a deep tissue injury to the right heel that was not present on admission. | 39. On 4/5/11 the length of the wound is 6 cm. the width is 7.3 cm. and the depth is 0, the surface area of the wound is 43.8 cm., there is no undermining or tunneling and no drainage. The skin grid documentation for the pressure ulcer to the coccyx stated the wound is a stage II and is 5 cm. in length, 7cm. in width, 0 depth, with a surface area of 35 cm., there is no tunneling or undermine and no drainage or odor. 40. The weekly skin sweeps stated there are no new skin impairments. Review of the plan of care revealed interventions to evaluate the wounds every 2 weeks, notify the physician if ¢ no improvement noted. use pressure relieving mattress, and to reposition the resident every 2 hours. 41. On 4/7/11 at 11:50 a.m. an interview with the wound care nurse was conducted, The wound care nutse stated there is a protocol that is followed for wound care with pressure ulcers and ifthe treatment is not working and ulcer gets worse then the doctor is notified. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. 42. On 4/7/11 at 5:00 p.m. an interview was conducted with the resident's nurse. The resident's nurse stated that the resident is total care and needs to be turned every 2 hrs. due toa pressure ulcer on her coccyx, 43. At 5:15 p.m. an interview with the aide caring for the resident. The aide stated the resident should be turned every 2 hrs. or sooner because she has a pressure ulcer and she is total assist. 44. On 4/7/11 at 6:00 p.m. an interview was conducted with the resident's daughter. The resident's daughter stated that her mother is not turned on a regular basis. The daughter stated she has stayed all day some days and no one came and turned her mother all day. 45. On 4/7/11 at 4:15 p.m, Observations of resident #4 revealed the resident is not on a pressure relieving mattress. The resident is sitting up in bed at a 40 degree angle on her back. The resident's heels are not floating and are flat on the mattress. 46. On 4/7/11 at 6:10 p.m, resident is still in the same position she was in at 4:15 PM. 47. On 4/7/1 lat 6:30 p.m. resident is still in the same position she was in at 4:15 PM. Resident #5 48. On 4/7/11 a record review for resident #5 was done. This record review revealed the resident was not initially admitted with the pressure ulcer. The resident was sent out to the hospital on 3/25/11 and when the resident came back from the hospital on 3/31/11 the resident had a stage II pressure ulcer to the coccyx. 49. _ Review of skin grid documentation for resident #5 revealed the length of the wound is 2 om. and the width of the wound is 1.5 cm. and the depth is 0, there is no tunneling or undermining and no drainage. The resident's care plan stated the resident should be on a pressure reducing mattress and the resident should be changed and repositioned every 2 hrs. 50. On 4/7/11 at 5:15 p.m. an interview with resident #5 was conducted. During the interview the resident stated the staff do not turn the resident every 2 hrs. "I wish they would turn me every 2 hrs." The resident stated that the resident can't turn and is dependent on staff for care, The resident stated, " I usually wait for 20-30 minutes before someone will change me after I have soiled my diaper. " 51. On 4/7/11 at 11:50 a.m. An interview with the wound care nurse was conducted, The nurse stated that the resident was recently in the hospital and was admitted with the pressure ulcer to the coccyx. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. 52, On 4/7/11 at 5:10 p.m. Observations of resident #5 were made at this time. The resident is not on a pressure relieving mattress and the resident is in bed on her back with a diaper on. 53. On 4/7/11 at 6:30 p.m. observation of the resident at this time revealed the resident is in the same position she was at 5:10 p.m. 10 . a 54. On 4/7/11 at 7:00 p.m. observations of the resident at this time revealed the resident is in the same position she was at 6:30 p.m. 55. The Respondents actions or inactions constituted an isolated Class II deficiency, 56. A.class Il deficiency is a deficiency that the Agency détermines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. § 400.23(8)(b), Fla. Stat. (2010). ‘57. Respondent was previously cited for one Class II deficiency. 58. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $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 class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8)(b), Fla. Stat. (2010). 59. In this instance, the Agency is seeking a fine in the amount of five thousand dollars ($5,000), as a Class II deficiency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $5,000.00, COUNT HI (Tag NO216) 60. The Agency re-alleges and incorporates by reference paragraphs 1 through 5. 61. Under Florida 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 intentional or negligent act materially affecting the health or safety of residents of the facility 11 4 : shall be grounds for action by the agency against a licensee. § 400,102(1), Fla. Stat. (2010), 62. Under Florida law, 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: .... (J) The right to receive adequate and appropriate 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 rules as adopted by the Agency. § 400.022(1)(1), Fla. Stat. 63. That on April 7, 2010, the Agency conducted a complaint investigation (CCR#201 1003299) of Respondent’s facility. 64. Based on observations, interviews, and record reviews the facility failed to ensure the residents received necessary care and treatment to prevent the development and promote the healing of an avoidable pressure ulcers for 5 of 5 sampled residents. (#1, #2, #3, #4, and #5) Resident #1 65. A review of the medical record for resident #1 revealed resident #1 has an unstageable pressure ulcer to the coccyx and 3 deep tissue injuries to the left inner; middle, and lateral aspects of the heel. The resident went out to the hospital on 3/10/11 for an upper respiratory infection and returned on 3/19/11 with the pressure ulcers to her coccyx and left heel. Documentation shows starting 3/28/11 through 4/4/11 that the coccyx wound is draining a moderate amount of serous yellow drainage and states there is no odor. Observation of the wound on 4/7/11 revealed there is a very strong foul smell coming from the wound. The medical record contained no communication with the physician of the continued foul smelling drainage. 12 66. Documentation on re-admission from the hospital on 3/19/11 stated resident #1's pressure ulcer to the coccyx was a stage 4 and the measurements were 4 cm. X4em. A review of resident #1's skin grid revealed, on 3/21/11 the wound was documented as unstageable and the measurements were 6.1 cm. in length, 6.5 cm. in width, and 1 cm. deep with a surface area of 39.65 cm. There is no documentation that the resident's doctor was notified the wound was getting worse. On 3/28/11 the wound is still unstageable and is documented to be 6 cm. in length, 7 cm. in width, and 1 cm. deep with a surface area of 42 om. On 4/4/11 the wound is still unstageable with 6 cm. in length, 7.om. width, and 1 cm. deep with surface area of 42 and there is slough tissue around the wound, the wound bed is red with undermining at 12:00 and the length of the undermining is 1.5 cm., no tunneling, a moderate amount of serous yellow drainage, and no odor. 67, The resident's wound to the left heel had red areas but no open areas on admission 3/19/11. A review of resident #1's skin grid of the left heel revealed the resident's wound had gotten worse, The documentation for the wound on the left inner heel stated that on 3/21/11 the wound is a deep tissue injury with measurements of 0.4 cm. in length, 1.3 cm. in width, 0 depth, and surface area of 0.52. On 4/4/11 deep tissue injury, 0.4 cm. in length, 1,3 om. width, 0 depth, and surface area of 0.52 cm. The documentation for the wound on the resident's left middle heel dated 3/21/11 shows deep tissue injury, 1.2 cm. in length, 2.5 cm. width, 0 depth, with a surface area of 3 cm. On 4/4/11 deep tissue injury, 1.2 cm. in length, 2.5 em. width, 0 depth, and surface area of 3 cm. Documentation of the wound to the resident's left lateral heel on 3/21/11 stated deep tissue injury, 1 cm. in Jength, 3.2 cm. in width, 0 depth, and surface area of 3.2cm. On 4/4/11 documentation stated, deep tissue injury, 1 cm. in length, 3.2 cm. width, 0 depth, and surface area of 3.2 cm. Documentation on all the days mentioned above revealed the wounds were purple in color, wound edges are firm, no undermining, tunneling, drainage or odor. The wounds were measured weekly and continued to reveal an increase in wound size and the wound to the coccyx had foul odor with a moderate amount of yellow drainage but there is no documentation noted in resident #1's medical record the doctor was notified the wounds were getting worse. 68. On 4/7/11 at 11:05 a.m. an interview with the wound care nurse was conducted. The nurse stated resident #1 went to the hospital in March with a stage III pressure ulcer to the coccyx and returned on 3/19/11 with an unstageable pressure wound to the coccyx anda stage III pressure wound to the heel. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being tured and repositioned as ordered. The surveyor asked the nurse, if the resident is being provided care, why did the wounds continue to get worse after admission on 3/19/11, and why the resident's doctor was"' not notified. The nurse stated, "I did talk to the hospice nurse about the resident 's wounds on 4/5/11 and the hospice nurse said ok so | was going to let hospice handle it." The wound care nurse also stated, " there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. 14 69. On 4/7/11 at 12:10 p.m. An interview with the aide caring for the resident was conducted. The aide stated, " the residents are to be tumed at least every 2 hrs. but if the resident has.a bad wound, they were instructed to turn the resident every hr." The aide stated if she noted the dressing was missing, she would notify the nurse caring for the resident or the wound care nurse. 70. On 4/7/11 at 12:30 p.m. an interview was conducted with resident #1's daughter. The daughter is concerned because the wounds are getting worse. The daughter stated she is in the facility 3 times a week for several hrs. and the resident was not turned every hr. 71, On 4/7/11 at 2:00 p.m. observation of the resident's wounds and wound care were made. Wound care was provided as ordered. The wound does appear as measured on 4/4/11, There is a moderate amount of yellow drainage and a strong foul odor coming from the wound. Resident #2 72. — A record review was conducted on 4/7/11 for resident #2. This record review revealed, resident #2 is a bilateral above the knee amputee and has a stage ITI pressure ulcer to the coccyx. The resident was re-admitted to the facility with the coccyx wound on 2/17/11, 73. The skin grid documentation for the resident revealed that on 3/7/11 the resident had a stage III pressure ulcer and the measurements were 2.7 cm. in length, 2.1 em. in width, 2.1 om. depth, and a surface area of 5.67 om. the wound bed color is red and there is tunneling at 9:00 of 2.6cm, in length, and undermining at 12:00 of 2.3 om. in length, there is small amount of serosanguinous pink/red drainage with an odor, 74, On 3/14/11 the wound appears to have gotten worse and documentation stated the wound is still a stage II], is 3 cm. in length, 1.6 cm. in width, 2.6 cm. in depth, with a surface 15 area of 4.8 om. the wound bed is red, there is undermining at 12:00 of 3 cm. in length and tunneling at 9:00 of 3.2 cm. in length, the drainage is serosanguinous pink/red with odor. . 75. On 3/21/11 the wound is still a stage ITI, 2.6 cm. in length, 2 cm. in width, and 2.5 cm. in depth, with a surface area of 5.2, the wound bed is red, the drainage is serosan. guinous small amount of pink/red drainage with odor, there is undermining of 3cm. in length, and tunneling of 2.8 cm. in length (no documentation as to exactly where the tunneling and undermining is). 76. On 3/28/11 the wound is stage III, 2.8 cm. in length, 2.8 em. in width, 2.1 em. depth, and the surface area is 7.84 cm. the wound bed is red, again the documentation is missing for exactly where the undermining and tunneling are at, but the undermining length is 2.6 cm, and the tunneling length is 2.8 cm. 77. On 4/4/11 documentation shows the resident's wound is still a stage [iI, 2.8 om. in length, 1.5 em. in width and 2.3 cm. depth, the surface area of the wound is 4.20 cm., the wound bed is red, the undermining is 3.1 cm. in length and tunneling is 2.8 cm. in length and there is a moderate amount of serosanguinous drainage pink/red with odor present ( again there is no documentation where the undermining and tunneling are). The wound was cultured on 2/8/11 and showed no growth for bacteria, The resident is being seen by the wound care center monthly with the facility providing the care between visits to the wound care center. 78. On 4/7/11 at 11:50 a.m. an interview was conducted with the wound care nurse. The nurse stated resident #2 went to the hospital in February and returned from the hospital with a stage III pressure ulcer to the coccyx. 79. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and ifthe treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. 80. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " 81. The wound care nurse stated she found resident #2 soiled yesterday and the dressing was soiled with feces for quite some time prior to her finding this. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. ‘The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily, 82. On4/7/L1 at 2:40 p.m. an interview was conducted with the nurse caring for the resident. This interview revealed that the resident has been found wet from incontinence. The nurse stated, "the resident uses the urinal and will spill some occasionally " The nurse stated she has talked to the aides about making sure the resident is turned frequently and is not wet. 83. On 4/7/11 at 5:10 p.m. an interview with the CNA caring for the resident was conducted. The aide stated that the resident should be turned every 2 hrs. or sooner if needed, 84. On 4/7/11 at 5:30 p.m. an interview with the resident's daughter was conducted. The daughter stated she was here all day on Sunday and the resident was left sitting up in his chair all day. The daughter stated no one came in to change or re-position the resident the entire time she was in the facility. 85. On 4/7/11 at 2:30 p.m. observations were made of the resident sitting in his wheelchair. 86. On4/7/11 at 3:30 p.m.observations of the resident revealed the resident was in bed on his left side facing the door. . 87, On 4/7/11 at 5:30 p.m. resident was observed in the same position he was in at 3:30 p.m. 88. On 4/7/11 at 6:30 p.m. resident was observed in the same position he was in at 5:30 p.m. 89. On 4/7/11 at 6:45 p.m. observation of wound care for resident #2.. The resident's diaper was wet when the nurse went to provide wound care. The resident's bandage was soiled and coming off. There was a foul odor noted during dressing change. The resident was pre- medicated with pain medication about an hour prior to the dressing change, but still complained of pain during the dressing change. The nurse followed infection control measures during dressing change. Resident # 3 90. On 4/7/11 a record review was conducted for resident #3. This record review revealed the resident is a quadriplegic with an unstageable pressure ulcer to the coccyx. In February the resident ' s wound was a stage II and the most current documentation on 4/4/11 stated the resident 's wound has gotten worse and is now unstageable. This resident was transferred to the hospital for respiratory distress this morning. 91. Review of the skin grids for resident #3 revealed that on 3/8/11 the resident's wound was unstageable and the length of the wound was documented 4.2 cm. in length, 4.5 om, in width, and 0.1 depth, with a surface area of 18.9 cm., there is slough tissue with a yellow wound bed, no tunneling or undermining, and a large amount of serous yellow drainage and no odor. 18 92. On 3/15/11 the wound is Unstageable, 4.5 cm. in length, 5.1 cm. width, 0.1 cm, depth, with a surface area of 22.95 cm., slough tissue, yellow wound bed, no tunneling and undermining, small amount of serous yellow drainage without odor. 93. On 3/22/11 the wound is still unstageable, 4.5 cm. in length, 5.5 cm. in width, 1 em, in depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, and a small amount of serous yellow drainage. 94. On 3/29/11 the wound is unstageable, 4.5 cm. in length, width is 5.5 cm., 1 cm. depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. 95. On 4/4/11 the wound is unstageable, 4.4 cm. in length, 5 cm. in width, 1 om, depth, with a surface area of 22 cm., there is slough tissue, with red and yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. There is no evidence that when the wound got worse, the doctor was notified as care planned. The care plan stated the resident 's wound was still a stage IL. 96. — On 4/7/11 at 11:50 a.m. the The wound care nurse stated she is providing wound care daily to resident #3. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. 97. The wound care nurse stated, "again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes." The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. 98. The wound care nurse stated she started checking the residents with wounds " more often and changed their dressing changes to daily. The wound care nurse stated that she felt like the resident's wound got worse due to the resident not being changed when soiled and repositioned as directed at least every 2 hrs. Resident #4 99. On 4/7/11 a record review was done for resident #4. This record review revealed the resident is incontinent of bowel and bladder and is a total assist due to a left above the knee amputation. and the resident is confused and does not communicate. Documentation also revealed, the resident has a stage IJ pressure ulcer to the coccyx and a deep tissue injury pressure ulcer to the right heel. Documentation on the resident's skin grid dated 4/5/11 stated the resident has a deep tissue injury to the right heel that was not present on admission. 100. On 4/5/11 the length of the wound is 6 cm. the width is 7.3 cm. and the depth is 0, the surface area of the wound is 43.8 cm., there is no undermining or tunneling and no drainage. The skin grid documentation for the pressure ulcer to the coccyx stated the wound is a stage II and is 5 cm. in length, 7em. in width, 0 depth, with a surface area of 35 cm., there is no tunneling or undermine and no drainage or odor. The weekly skin sweeps stated there are no new skin impairments, 101. On 4/7/11 at 11:50 a.m. an interview with the wound care nurse was conducted, The wound care nurse stated that resident #4 was getting a bath and on 4/5/11 and the aide and nurse caring for the resident called her in to look at the wound to the resident's coccyx (stage ID. The wound care nurse stated she then did a skin sweep to check the resident for any additional skin changes and found another stage II pressure wound on the resident's right heel. The wound 20 2 E care nurse stated the wound is considered an inhouse wound which means the resident acquired the wound while staying in the facility. 102. The resident's wound care is done every 3 days or as needed. The wound care nurse is not sure about the resident being left incontinent too long because she had no contact with the resident prior to 4/5/11. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. 103. On 4/7/11 at 5:00 p.m. an interview was conducted with the resident's nurse. The resident's nurse stated that the resident is total care and needs to be turned every 2 hrs. due toa pressure ulcer on her coccyx. 104. On anni 11 at 5:15 p.m. an interview with the aide caring for the resident. ‘The aide stated the resident should be turned every 2 hrs, or sooner because she has a pressure ulcer and she is total assist. 105. On 4/7/11 at 6:00 p.m. an interview was conducted with the resident's daughter. The resident's daughter stated that her mother is not turned on a regular basis. The daughter stated she has stayed all day some days and no one came and turned her mother all day. 106. On4/7/11 at 4:15 p.m. Observations of resident #4 revealed the resident is not on a pressure relieving mattress. The resident is sitting up in bed at a 40 degree angle on her back. The resident's heels are not floating and are flat on the mattress. 107. On4/7/ r at 6:10 p.m. resident is still in the same position she was in at 4:15 p.m, 108. On 4/7/1 lat 6:30 p.m. resident is still in the same position she was in at 4:15 p.m. 21 Seaspst” 109. On 4/7/11 at 6:30 p.m. observations of wound care were made and the care was given as ordered. The wound is as documented on 4/5/11. Resident #5 110. On 4/7/11 a record review for resident #5 was done. This record review revealed the resident was not initially admitted with the pressure ulcer. The resident was sent out to the hospital on 3/25/11 and when the resident came back from the hospital on 3/31/11 the resident had a stage II pressure ulcer to the Coccyx. Review of skin grid documentation for resident #5 revealed the length of the wound is 2 cm. and the width of the wound is 1.5 cm. and the depth is 0, there is no tunneling or undermining and no drainage. 111. On 4/7/11 at 5:15 p.m. an interview with resident #5 was conducted. During the interview the resident stated the staff do not turn the resident every 2 hrs, "I wish they would turn me every 2 his." The resident stated that the resident can't turn and is dependent on staff for care, The resident stated, " I usually wait for 20-30 minutes before someone will change me after I have soiled my diaper. " 112, On 4/7/11 at 11:50 a.m. an interview with the wound care nurse was conducted, The nurse stated that the resident was recently in the hospital and was admitted with the pressure ulcer to the coccyx. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. 113. On 4/7/11 at 5:20 p.m. an interview was conducted with the nurse caring for the resident. The nurse stated the resident is total care and needs to be turned every 2 hours. 22 wae” 114. On 4/7/11 at 5:25 p.m. an interview with the aide caring for resident #5 revealed the aide is aware the resident is total caré and needs to be turned every 2 hrs. 115. On 4/7/11 at 5:10 p.m. Observations of resident #5 were made at this time. The resident is not on a pressure relieving mattress and the resident is in bed on her back with a diaper on. _ 116. On 4/7/11 at 6:30 p.m. observation of the resident at this time revealed the resident is in the same position she was at 5:10 p.m. 117. On 4/7/11 at 7:00 p.m. observations of the resident at this time revealed the resident is in the same position she was at 6:30 p.m. ‘118. The Respondent’s actions and/or inactions constituted a violation of the above- referenced provision of law and amount to a pattern Class II deficiency. 119.. 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 well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services, § 400.23(8)(b), Fla. Stat. (2010). 120, Respondent was previously cited for a Class IT deficiency. 121. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $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 " class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8)(b), Fla. Stat. (2010). 122. In this instance, the Agency is seeking a fine in the amount of five thousand 23 a hundred dollars ($5,000), a Class II deficiency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $5,000.00. COUNT Il 123. The Agency re-alleges and incorporates by reference Count J and Count IT. 124. Based upon the above cited state class II deficiencies, the Respondent was not in substantial compliance with criteria established under Chapter 400, Part Il, Florida Statutes, or the rules adopted by the Agency, subjecting the Respondent to assignment of a conditional licensure status under Section 400.23(7)(b), Florida Statutes. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assign conditional licensure status to Respondent commencing April 7, 2011 and ending May 6, 2011. | CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1. Makes factual and legal findings in favor of the Agency. 2. Imposes the relief set forth above. Respectfully submitted on this 9".day of June, 2011. qlee D. Carlton Enfinger, Esquire, pl-Bar No. 793450 Office of the General Coun, Agency for Health Care 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 3238/5407 Telephone: 850-412-3640 24 NOTICE The Respondent has the right to request a hearing 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 within the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, 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, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE ] 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 3987 to Anthony J. Pileggi, Administrator, Heritage Health Care Center, 3101 Ginger Drive, Tallahassee, Florida 32308, and by U.S. Mail to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301, and via email to Anna Gay Small, Esquire, Broad and Cassel, 215 South Monroe Street, Suite 400, Tallahassee, Florida 32301 on this 9" day of June, 2011: a aoe D. Carlton Enfinger, Esquir Florida Bar No. 793450 Office of the General Coynse Tallahassee, Florida 32308-5407 Telephone: 850-412-3640 Copy: Donah Heiberg, FOM 25 Sau FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT GOVERNOR May 5, 2011 HERITAGE HEALTHCARE CENTER 3101 GINGER DRIVE TALLAHASSEE, FL 32308 Dear Administrator: ELIZABETH DUDEK SECRETARY The attached license with Certificate #16753 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, Sudeathirspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure cc: Medicaid Contract Management 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 Health Care In the Sunshine ZY www.FloridaCompareCare.gov Visit ABCA online at ahca.myflorida.com TIOC/OE/TI “ALVC NOLLValdx 4a TI0Z/L0/00 “ALVC FALLOg dar ADNVHO SNLVLS Sddd 08st *TVLOL SO0€TE Td “AASSVHVTIVL FATA UAONID OTE UALNAO TAVOHLITVEH FOV LiddH :SULMOTIOF Oy} a1eI0do 01 peZLIOYINe SI desuedT] au} Se pur ‘sameyS ePOTy ‘T] Ved ‘OOp JerdeYD Ul pozLioyne “‘UoneNsTUTUpY ered YeeH JOT Aouad y ‘eproyj Jo aris emp Aq paidope suonepBes pue som aT yim pordutos sey OTT ‘SALVIOOSSV TAVO HLTVIH AAIIG WAONIO 2H wUUOd O1 St SME AINOH DNISMAN AONVANSSV ALITVNO HITVH JO NOISIAIG NOILVULSININGYV daVO HLTVaH dOd AONADV BPLIOL] JO IVIS I9601ZZIANS °# ASNAOYI . eSL9l -# ALVOWILYAO FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT ELIZABETH DUDEK GOVERNOR SECRETARY June 9, 2011 HERITAGE HEALTHCARE CENTER 3101 GINGER DRIVE TALLAHASSEE, FL 32308 Dear Administrator: The attached license with Certificate #16831 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 exrors 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, Jduathorseco Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 Visit AHCA online at ahca.myflorida.com anes Andeq TIOC/OE/Tt “ALVG NOILVUdxe TIOC/L0/S0 ‘ALVG FALLOS ATA FONVHO SALVLS Saad 081 *TVLOL SOETE Td ‘AASSVHVTIVL FAATIG YADNID LOTE YALNAO TAUVOHLTIVGH FOV IGS :SuIMmoTpO} ou} eqeredo 0] pezLoyMeE SI sesueor] sojdeyQ ul pezuoyne ‘uonensHTUpy arel Wpeey JOd Aouesy “eptzopy Jo a1e1g om Aq paidope suonensel pue soni ou} tas perfduios sey OTT ‘SALVIOOSSY TAVO HLTVGH FARIC UFONIO Hy UAIFUOS 0} ST STU], ayy se pue ‘somners EpuOoly ‘Tl Ved “Or CAVANVLS HINOH ONISHIN AONVUNSSV ALITVNO HLTVIH AO NOISIAIC NOLLVULSININGY FUVO HLTVEH wot AONHDV | BPLIOpy JO 931 TO960IZZIANS “# ASNAOIT Tesol # ALVOILYAO STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: GINGER DRIVE HEALTH CARE ASSOCIATES, LLC, d/b/a HERITAGE HEALTH CARE CENTER. CASENO = 2011004657 2011004658 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Noti¢e of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter!20, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) T admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)_____—I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Stattes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choos’ }OPTION THREE (3), by itself, i OT sufficient to obtain a formal hearing. You also must file a written petition in order to odtain a formal hearing before the Division of Administrative Hearings under Section 120,57(1), Florida Statutes. Tt must be received by the Agency Clerk at the address above within 21 days of your receipt of this Proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none, Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. ; License type: \ (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC Postage | $ Postmark Return Recelpt Fee re (Endorsement Required) | He Restricted Delivery Fee (Endorsement Requlred) Total Postage & Fees isi SSA ny 7BD49 OF60 oo00 3708 35787 ™ Complete items 1, 2, and 3, Also complete A 4 : item 4 if Restricted Delivery is desired. Le Cheon ® Print your name and address on the reverse Z CD Addressee | S0 that we can return the card to you. j'@ Attach this card to the back of the mailpiece, or on the front If space Permits, eee, ( 2 S20} ag D. Is delivery address different from item1? LI Yes ‘y Atlcle Addressed to: 'f YES, enter delivery address below: © No 3. ree ertiied Mail 7) Express Mail Ci Registered © Return Recelpt for Merchandlsa VOvevahane RB WIQ O Insured Mall 61.0.0, ‘ 4. Restricted Delivery? (Extra Fee) O Yes 7009 o540 (O000 37p8 35787 Jianore sens on | PS Form 3811, February 2004 Domestic Return Receipt 102695-02-M-1640 5

Docket for Case No: 11-003354