STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2014012192 2600 HIGHLANDS BOULEVARD NORTH LLC d/b/a BAY TREE 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 2600 Highlands Boulevard North LLC d/b/a Bay Tree Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2014), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing October 24, 2014, and to impose administrative fines in the amount of one thousand dollars ($1,000.00), based upon Respondent being cited for one (1) isolated uncorrected State Class IIT deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2014). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. 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), Chapters 400, Part II, and.408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a one hundred twenty (120) bed nursing home, located at 2600 Highlands Boulevard North, Palm Harbor, Florida 34684, and is licensed as a skilled nursing facility license number 10390964. 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 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Florida law, all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift. Rule 59A-4.107(5), Florida Administrative Code. 8. That on August 22, 2014, the Agency completed a complaint survey of the Respondent facility. 9. That based upon the review of records, observation, and interview, Respondent failed to ensure all physician orders shall be followed as prescribed, and-if not followed, the reason shall be recorded on the resident’s medical record during that shift, for one (1) sampled resident, including medications related to medication administration and diabetic treatment, the same being contrary to the requirements of law. 10. That Petitioner’s representative reviewed Respondent’s records related to resident number two (2) during the survey and noted as follows: a. b. The resident was admitted to the facility on August 15, 2014. Diagnoses which included COPD (Chronic Obstructive Pulmonary Disease), Shortness of Breath, Congestive Heart Failure, and Diabetes Type II. A physician’s order for August 2014, dated August 16, 2014, prescribed Prednisone tablet 20 mg - Give 1 tablet by mouth one time a day for SOB (Shortness of Breath). This Prednisone was programmed on the August 2014 Medication Administration Record to be given at 9: 00 a.m. each day. The resident's History and Physical, dated August 18, 2014, contained the following entry: "COPD- taper Prednisone by 5 mg every 3 days." A physician's order dated August 18, 2014, read "Please taper Prednisone by 5 mg every 3 days - start 15 mg tomorrow and taper every 3 days until discontinued." The resident’s August 2014 Medication Administration Record documented the prescribed Prednisone 15 mg was programmed to be given at 9:00 a.m. on August 19, 2014 through August 21, 2014, and Prednisone 10 mg was programmed to be given at 9:00 a.m. starting on August 22, 2014. The resident’s August 2014 Medication Administration Record reflected that the prescribed Prednisone 20 mg and the Prednisone 15 mg were both documented as given on August 19, 20, and 21, 2014 at 9:00 a.m., and the Prednisone 20 mg and Prednisone 10 mg were both documented as given on August 22, 104 at 9:00 a.m. A physician order, dated August 15, 2014, prescribed "Insulin Lispro Solution, inject as per sliding scale subcutaneous before meals and at bedtime for DM: 150-199 1 unit, 200 -249- 3 units, 250-299- 5 units, 300- 349- 7 units, greater than 350 give 8 units and notify MD." j. The resident’s August 2014 Medication Administration Record reflected as follows: a. There was no documentation that blood sugars were performed on August 19, 2014 at 11:30 a.m. or on August 21, 2014 at 11:30 am. b. On August 20, 2014 at 9:00 p.m., a blood sugar level of four hundred forty-six (446) was recorded. c. Eight (8) Units of Insulin was documented as administered, but there was no documentation in the resident's record that the physician was notified of the blood sugar level of four hundred forty-six (446). d. On August 21, 2014 at 9:00 p.m., a blood sugar of four hundred forty-two (442) was recorded. e. Eight (8) Units of Insulin was documented as administered, but there was no documentation in the resident's record that the physician was notified of the blood sugar level of four hundred forty-two (442). k. Absent from the record was any indication of “monitoring” of the resident after the resident experienced elevated blood glucose levels. 1. A physician order dated August 15, 2014, prescribed "Tessalon Perles Capsule 100 mg, give 1 capsule by mouth three times a day for cough." m. This prescription for Tessalon Perles was documented as discontinued on August 21, 2014: "D/C Tessalon Pearles 8/21." n. The resident’s August 2014 Medication Administration Record documented that the resident was administered doses of the discontinued Tessalon Perles at 9:00 a.m. and 1:00 p.m. on August 22, 2014. 11. That Petitioner’s representative interviewed Respondent’s director of nursing regarding resident number two (2) on August 22, 2014 at 7:34 p.m., and the director indicated that he spoke with the nurse who documented the administration of the resident’s Prednisone 20 mg on August 19, 20, 21, and 22, 2014, and she reported that she had given the correct tapered dose but accidentally documented for both medication orders. 12. That Petitioner’s representative interviewed Respondent’s nurse, who had documented the above described blood sugar levels of resident number two (2), on August 22, 2014 at 5:40 p.m., who indicated as follows: a. She contacted the physician assistant on both August 21 and 22, 2014, and informed her of the blood sugars. b. The physician’s assistant told her just to monitor the resident. c. She did not document the notification to the physician time, stating “T was rushed and I was late. I was planning on doing a late entry, but didn't yet." 13. That Respondent’s director of nursing provided Respondent’s policy and procedure entitled "Medication Administration: General," with a revision date of January 2, 2014, and a policy and procedure entitled "Medication Administration: Injectable (IM, SubQ, Z track),” dated with an effective date of January 1, 2004, and a revision date of January 2, 2014. 14, That Respondent’s director of nursing stated, on August 22, 2014 at 8:20 p.m., that the facility had no policy and procedure specific to Insulin administration and sliding scale coverage. 15. That Respondent's policy and procedure entitled "Medication Administration: General" provides as follows: a. "Policy: A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed. Medications will not be borrowed from another patient. . b. “Purpose: To provide a safe, effective medication administration process. c. “Practice Standards: a. “5. Administer medication. i. “5.1 Assist patient as needed. ii. “5.2 Remain with patient until administration is complete. b. “9, Document: i. “9.1 Administration of medication on Medication Administration Record (MAR). ii, “9.2 Patient's response to medication. iii. “9.2.1 Notification of physician/mid-level provider, if applicable.” 16. That above reflects Respondent’s failure to ensure all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift related to prescribe medicinal. 17. That the Agency determined that this deficient practice 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 and cited Respondent for an isolated State Class III deficiency. 18. That Florida law provides that cited deficient practice shall be corrected by the provider within thirty (30) days, Section 408.811 Florida Statutes (2014). 19. That on October 24, 2014, the Agency completed a re-visit to the complaint survey of the Respondent facility. © 20. That based upon the review of records, observation, and interview, Respondent failed to ensure all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift, for one (1) sampled residents related to oxygen administration, the same being contrary to the requirements of law. 21. That Petitioner’s representative observed and interacted with resident number one hundred eighty-seven (187) and others in the resident’s room on October 21, 2014 at 1:58 p.m. and noted as follows: | a. The resident was clean and well groomed, seated in a wheelchair with oxygen on via nasal cannula. b. The resident was observed to have a capped tracheostomy and a family member was seated at the resident’s side. c. A family interview was being conducted with the resident's family member when Respondent’s employee “A,” a registered nurse, entered the room and stated he needed to re-start the resident's g-tube feeding in order to be compliant with doctor's orders, d. The surveyor excused herself so care could be rendered. 22. That Petitioner’s representative again observed and interacted with resident number one hundred eighty-seven (187) and others in the resident’s room on October 21, 2014 at 2:22 p.m. and noted as follows: a. The resident was observed in bed with eyes closed. b. A tube feeding was running and the head of the bed was elevated. c. The resident's family member pointed out that staff had hooked up the tube feeding and put the resident to bed, but they did not put the resident’s oxygen back on. d. The family member stated this happens often and the family member usually puts the oxygen backs on, however on this day, the family member wanted the staff to - be aware, so the family member pushed the call light. e. A certified nursing assistant (CNA) answered the light within one minute and was informed that the resident's oxygen was not on. f. The certified nursing assistant immediately informed Respondent’s employee “A> g. Employee “A” entered the room, placed the nasal cannula on the resident, and turned the oxygen concentrator on to 2 liters/min. 23. That Petitioner’s representative reviewed Respondent’s records related to resident number one hundred eighty-seven (187) during the survey and noted as follows; a. An admission record face sheet documented that this sixty-two (62) year old resident was admitted to the facility on October 2, 2014. b. Relevant diagnoses include acute respiratory failure, tracheostomy, and intracerebral hemorrhage. c. A physician's order dated October 16, 2014, prescribed “Continuous Oxygen via mask at 2 liters/min.” d. A respiratory therapy progress note dated October 16, 2014 at 12:45 p.m. documented the following relevant information: “..Oxygen at 2 Liters via nasal cannula applied...” 24. That Petitioner’s representative interviewed Respondent’s south wing unit manager on October 23, 2014 at 11:57 a.m. regarding resident number one hundred eighty-seven (187) and the manager indicated as follows: a. He confirmed that the resident was to receive oxygen at all times. b. He had written the order on October 16, 2014 for oxygen using a mask because he thought the resident had been using this. ¢. He verified that the resident was using a nasal cannula at this time and stated this was appropriate. d. He would call the doctor right away to get the order changed to indicate nasal cannula instead of a mask. 25. That above reflects Respondent’s failure to ensure all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift, related to prescribed diets. 26. That the Agency determined that this deficient practice 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 and cited Respondent for an isolated State Class III deficiency. 27. That the same constitutes an uncorrected deficiency as defined by law. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Florida Statutes (2014). COUNT II 28. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 29. . Based upon Respondent’s State uncorrected Class III 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)(a), Florida Statutes (2014). 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 (2014) commencing October 24, 2014. Respectfully submitted this [/ day of February, 2015. f hy F fy Thognas’J. Walsh II, Esquire Fla. Bar. No. 566365 “Agency for Health Care Admin. $25 Mirror Lake Drive, 330G. St. Petersburg, FL 33701 727.552.1947 (office) walsht@ahca.myflorida.com DISPLAY OF LICENSE Pursuant to § 400.23(7){e), Fla. Stat. (2014), Respondent shall post the most current license in a - prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg. #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7007 0220 0001 1585 4813, to Tracy Lynn Johnson, Administrator, 2600 Highlands Boulevard North LLC d/b/a Bay Tree Center, 2600 Highlands Boulevard North, Palm Harbor, Florida 34684, and by Regular U.S. Mail to Corporation Service Company, Registered Agent for 2600 Highlands Boulevard North LLC, 1201 Hays Street, Tallahassee, Florida 32301-2525, this na day of “Ty 2015. “pf, The 66 i Walsh I, Esquire Fla‘ Bar. No. 566365 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) walsht@ahca.myflorida.com Copy furnished to: Patricia R. Caufman Field Office Manager Agency for Health Care Admin. } } STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: 2600 Highlands Boulevard North LLC CASE No. 2014012192 d/b/a Bay Tree Center 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, Notice 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 wiil 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 Chapter120, 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)___—iI 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 Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. ) PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It 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

Docket for Case No: 15-002462