Jun-22-2000 °02:39pm = From= ; 7-858 = P.015/021 F777 VY UY STATE OF FLORIDA ae EN AGENCY FOR HEALTH CARE ADMINISTRATIO 00 STATE OF FLORIDA, AGENCY FOR JUL 20 AM to: 39 HEALTH CARE ADMINISTRATION, bIVISion 0 ADMINIS TeativE Petitioner, H Vs. HERITAGE HEALTH CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of $2,000.00 upon Heritage Health Care Center. As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part JI, Florida Statutes. 2. Respondent, Heritage Health Care Center, is licensed by the Agency to operate a nursing home at 1815 Ginger Drive, Tallahassee, Florida 32308 and is obligated to operate the nursing home in compliance with Chapter 400 Part II, Florida Srarutes, and Rule 59A-4, Florida Administrative Code. 3. On July 2, 1999 a survey team fram the Apency’s Area 2 Office conducted a survey and the following Class Ill deficiency was cited. AHCA NO: 02-00-054-NH ood amb Jun-22#2000 °02:39pm = From- T-858 = P.01G/021 «-F-777 W 3a. Pursuant tq 42 CFR 483.70(h)(4), the Sthity must maintain an effective pest control program so that the facility is free of pests and rodents. This requirement was not met as evidenced by the following observations: (1) On June 29, 1999 at 7:50 a.m. during an observation of the kitchen (dry storage area], live roaches were seen in the dry food storage area. (2) On July 1, 1999 at 7:50 a.m., a survey team member observed live roaches in the dry food storage area. i i i ' i | i t (3) On duly 1, 1999 at approximately 12:15 p.m., a survey team member observed a staff member kill a roach in the 100 hall area adjacent to the laundry room. (4) On June 29, 1999 a resident reported seeing a mouse in the room. (5) On July 2, 1999 at approximately 9:00 a.m., mice droppings were abserved on the floor behind the resident’s nightstand. Facility staff confirmed these observations. (6) Based on resident interview, surveyor observation and staff confirmation, it was determined that the facility violated Rule 59A-4.106(4), F.A.C., for failing to ensure that the facility is free of pests and rodents. 4. On December 23, 1999 a survey team from the Agency’s Area 2 Office conducted a survey and the following Class I] deficiency was cited. 4A. Pursuant to 42 CFR 483.75(1)fl), the facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. This requirement was nat met as evidenced by the following observations: 2 dun-22+2000 © 02:40pm = From- T-858 = P.O17/021—F-777 WU 7] (1) Review of resident #1’s clinical record revealed that the resident had diagnosis and treatment of C-diff. Review of the BM tracking form only indicated “L”, “M” or “8” without a description of the characteristics of the stools, which is pertinent for a diagnosis of C-diff. (2) Based on clinical record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for failing to ensure that one out of three sampled resident’s clinical records were completely and accurately documented. 5. Qn May 4, 2000 a survey team from the Agency’s Area 2 Office conducted a survey and the following uncorrected Class Il deficiencies were cited. SA. Pursuant to 42 CFR 483.70(h)(4), the facility must maintain an effective pest contro] program so that the facility is free of pests and rodents. This requirement was not met as evidenced by the following abservations: (1) During the initia] inspection of the kitchen on May 1, 2000, dead bugs were observed in the tray containing adaptive eating utensils as well as in a blue flour bin in a | rolling cart. | (a) On May 2, 2000, a small roach was seen moving across the empty space underneath the milk cooler behind the cooking area. This space was observed to be dirty and greasy, littered with crumbs and other food particles. | {b) Immediately outside the kitchen, in the main dining room, a large roach was seen moving rapidly i toward the kitchen door, und! a kitchen aide lalled it with her shoe. (2) _ Based on observation, it was determined that the facility violated Rule 59A-4.106(4), F.A.C., for failing to | ensure that the facility is free of pests and rodents. dun-22+2000 °02:40om = From- T-858 P.018/021 F777 5B. pursieat to 42 CFR 483.75(1)(l), the Teility must maintain clinical records on cach resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. This requirement was not met as evidenced by the following observations: (1) Review of clinical records showed that the consultant psychiatrist recommended Depakate for resident #20 in Navernber 1999 to address her manic and psychotic behavior, but was never implemented by the facility, as confirmed hy the staff. (a) Progress notes written by the psychiatrist from December 1999 to April 2000 indicate, hawever, that the resident has been taking Depakote, and recommended for present medications to continue. (2} Based on record review and staff interview, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for failing to ensure accurate clinical information about 1 of 27 sampled residents. 6. Based on the foregoing, Heritage Health Care Center has violated the folowing: a) Tag F469 incorporates 42 CFR 483.70(h)(4) and Rule 59A- 4.106(4), F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. b} Tag F514 incorporates 42 CFR 483.75(1)() and Rule 59A- 4.1288, FAC. The administrative fine imposed for this uncorrected violation is $1,000.00. 7. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.23(9)(c), Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation dun-22-2000 02:41pm = Fram- T-858 = P.019/021 -F-777 YW wy) of the minimum standards, rules, and regulations for the operation of a Nursing Home. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense), ta take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: Sam Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. All payment of fines should be sent to the Agency for Health Care Jun-23-2900 ° 02:41 pm From T-858 = P.020/02) F777 UW Administration, Attention: Christine T. Messana, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308-5403. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY TRE AGENCY. OR ey of uae 2000. Issued this \ onah Heiberg Field Office Manger, Area #2 Agency for Health Care Administration Health Quality Assurance 2639 N. Monroe Street, Suite 208 Tallahassee, Florida 32303 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrator, Heritage Health Care Center, 1815 Ginger Drive, Tallahassee, Florida 32308 on this (Stay of ~\ crue , 2000. Christine T. Messana, Esquire Office of the General Counsel

Docket for Case No: 00-002967