teal STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CERTIFIED Return Receipt Req we 7000-0600-0026-7844-8927,,/ STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, abweGiy wi’ mane. oo LEGAL Der. vs. AHCA NO: “Oo SI 060-. seer ; HERITAGE HEALTH CARE CENTER, Petitioner, 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 $3,000.00 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 II, Florida Statutes (1999). 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 Statutes, and Rule 59A-4, Florida Administrative Code. 3. On May 1-4, 2000, a survey team from the Agency's Area 2 Office conducted a recertification survey and the following Class II deficiencies were cited. Be age ar IS 3A. Pursuant to 42 CFR 483.25(h)(1), the facility must ensure that the resident environment remains as free of accident hagards as possible. This requirement was not met as evidenced by the following ofservations a | . ose (1) Based on surveyor observation while on initial tour of the 200 hall on May 1, 2000 at 9:30 a.m., the following was ~ noted. missing 3 or 4 screws. Based on resident and family interview, it was confirmed that 'the ceiling vent had been hanging loose for “at least 2 weeks.” - (b) The side rail outside of room #210 was loose and moved freely up and down. 2) Based on observation and interview, it was determined ( that the facility violated Rule 59A-4.106(3)(cc}, F.A.C., for failing to ensure that the resident environment remains free of accident hazards. 3B. Pursuant to 42 CFR 483.35(h)(2), the facility must store, prepare, distribute, and serve food under sanitary conditions. This — requirement was not met as evidenced by the following observations: (1) During 2 days of observation at different times of the» day, freezer temperatures in the kitchen were consistently above acceptable levels. On May 2, 2000, the temperature was 16 degrees °F at 9:50 a.m. and 8 degrees °F at 4:10 p.m. On May 3, 2000, freezer temperature was 6 degree °F at 10:10 a.m. and at 3:00 p.m. At all times the freezer door observed to close, but not shut properly. (a) Room #209 — The bathroom ceiling vent was hanging loose from the ceiling and appeared. to be. . 3C. (2) On May 2, 2000, 10 large, shallow, rectangular baking pans, 5 square pans, 1 large and 4 small deep baking pans, 1 large mixing bowl, 3 ladles, 1 mixer beater, 1 knife and the meat slicer were found to be dirty with particles of foods or grease coating areas on the surfaces. Likewise, on May 3, 2000, 11 dessert bowls and 1 saucer showed traces of encrusted food on food-contact surfaces. In addition, stacks of plate covers were observed to be stored wet, as were most of the baking pans. (3) One carton of Lactaid ‘and 1 carton of Half and Half. ~ were found open and undated in the. milk cooler on May 1, 2000. In the same cooler were 2 cartons at 1 /2 gal each, of buttermilk with sell-by-date of April 29, 2000. In the main * refrigerator, a plastic container of applesauce with no label or date, was observed on May 2, 2000. ° (4) Kitchen staff repeatedly obtained a higher concentration of sanitizing solution than desired when asked, on May 1, 2000 and May 3, 2000, to demonstrate the. preparation and testing of the sanitizing solution. It was further learned, in speaking with staff, that the preparation of the sanitizing solution was not in accordance with the manufacturer recommended proportions of sanitizer to water. Staff were also not able to show the proper use of the ‘test strips to measure the concentration of the sanitizing solution. (5). Based on observation and staff interview, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for failing to ensure proper freezer temperature, food storage and effective sanitization and cleaning of utensils and food preparation equipment to prevent food-borne illness. Pursuant to 42 CFR 483.75(1)(}, 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 not met as evidenced by the following observations: ap (1) Review of clinical records showed that the consultant psychiatrist recommended Depakote for resident #20 in November 1999 to address her manic and psychotic . behavior, but was never implemented by the facility, as confirmed by the staff. Progress notes written by the psychiatrist from December 1999 to April 2000 indicate, however, that the resident has been taking Depakote, and recommend for present medications to continue. (2) Based on record review and staff interview, it was determined that the facility violated 59A-4.1288, F.A.C., for failing to ensure accurate clinical information for 1 of 27 sampled residents. : 4. On June 13, 2000 a survey team from the Agency’s Area 2 Office conducted a follow-up survey and the following uncorrected Class Ill deficiencies were cited. 4A. Pursuant to 42 CFR 483.25(h)(1), the facility must ensure that the resident environment remains as free of accident hazards as possible. This requirement was not met as evidenced by the following observations: (1) Surveyor observation on June 12, 2000 at 10:14 a'm. revealed that the hallway siderail between rooms 208 and 210 was loose and moved freely up and down. (2) Based on observations, it was determined the facility violated Rule 59A-4.106(3)(cc}, F.A.C.,. for again failing to ensure that the resident environment remains free of accident hazards. 4B. Pursuant to 42 CFR 483.35(h)(2), the facility must store, prepare, distribute, and serve. food under sanitary conditions. This requirement was not met as evidenced by the following observations: a i (1) Surveyor observation on June 12, 2000 at 3:45 p.m. revealed an external freezer thermometer reading of 9 degrees Fahrenheit and an internal freezer thermometer reading of 22 degrees Fahrenheit. (2) Surveyor observation on June 13, 2000 at 1:58 p.m. revealed refrigerator temperatures of 45 degrees Fahrenheit and 48 degrees Fahrenheit at 3:08 p.m.. On both of these occasions, the surveyor observed that the refrigerator door had not been securely closed and latched. (3) on June 12, 2000 at 9:40 a. m., , Surveyor observed an open, uncovered / undated box of oats on a shelf in the main. food preparation area. On June 12, 2000 at 9:43 a.m., the surveyor observed boxes of food sitting directly on the floor while being stored in the refrigerator/freezer area. The - dietary manager confirmed that these boxes had recently been delivered to the facility and contained meat and vegetables. (4) On June 12, 2000 at 9:55 a.m., the surveyor observed 2 loaves of bread on the bread rack that had a green mold covering over areas of each loaf. On June 12, 2000 at 9:58 a.m., the surveyor observed 1 container of a red soupy substance that was unlabeled and undated. (5) On June 13, 2000 at 9:15 a.m., the surveyor observed 1 bottle of water undated and 1 opened, undated container of lemon juice. On June 13, 2000 at 3:08 p.m., the surveyor observed 1 large bowl of onions and separately stored pieces of cantaloupe not securely covered by plastic wrap. (6) On June 12, 2000 at 1:48 p.m., the surveyor requested that dietary staff demonstrate proper use of the 3 sink sanitation procedure. One dietary aide stated that the sanitizing solution had been improperly poured into the rinse sink. During this same demonstration, surveyor observation revealed that the dietary aide did not follow manufacturer’s instructions to immerse the test strip in the sanitizer/water solution for 10 seconds. wt 4c. ._ main kitchen were encrusted with food (7) On June 12, 2000 at 9:50 a.m., the surveyor observed that the meat slicer was dirty with particles of food or grease coating areas of the slicer. During an interview with the dietary manager at 9:51 a.m., he/she was unable to specify when the meat slicer was last used and explained that the debris found on the meat slicer was the result of someone laying a white plastic garbage bag on top of the slicer. (8) On June 12, 2000 at 10:00 a.m., the surveyor observed that the control knobs of the regular greasy substances. On June 12, 2000 at 1:48 p.m., the surveyor observed that the floor space underneath the milk cooler was dirty, greasy and lined with debris. On June 12, 2000 at” 9:50 a.m., the surveyor observed approximately one dozen flat pans and desert bowls had been stored wet. On June 13, 2000 at 2:04 p.m., the surveyor observed that multiple oo plate lids were stacked. wet. An interview with a dietary aide . at 9:53 on June 12, 2000 confirmed that these same plate . lids were in a storage location. This deficient practice would not prevent the growth of microorganisms. mos (2) Based on surveyor observations and staff interviews, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for again failing to ensure maintenance of proper freezer temperature, maintenance of proper refrigerator temperature, proper food storage, consistent implementation of effective sanitation procedures and effective cleaning of food preparation equipment to prevent food-borne illness. Pursuant to 42 CFR 483.75(1}(), 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 not met as evidenced by the following observations: © (1) Record review of resident #1 revealed that resident #1’s treatment record contained a May 2000 and June 2000 treatment entries for which there were no physician’s orders. Additionally, these 2 treatment entries specify different treatments for the same right heel wound condition. en.in the... 5. (2) Record review of the physician’s orders for resident #1 reflect a third different treatment for resident #1’s right heel even though this third treatment was indicated as discontinued effective May 30, 2000 on resident #1’s May 2000 treatment record. (3) Record review of resident #5 and #14 revealed that these residents were missing quarterly Minimum. Data Sets (MDS). During surveyor interview, the Director of Nursing (DON) indicated that the MDSs for these residents had been coded incorrectly. . re (4) Chart review of residents #5 and “#12 revealed quarterly MDS not on chart. DON unable to produce the’ missing MDS quarterly reports for these residents. (5) ‘In an interview with the DON on June 13, 2000 at 3:30 p.m., the DON stated that quarterly MDS is the same as 90 day billing MDS. DON told that MDS must be coded for quarterly as well as coded for billing. (5) Based on record review and interview, it was determined that the facility violated Rule 59A-4. 1288, F.A.C., for again failing to ensure that maintenance of clinical records on each resident is in accordance with accepted: professional standards and practices. Based on the foregoing, Heritage Health Care has violated the following: 6. a) Tag F323 incorporates 42 CFR 483.25(h)(1) and Rule S9A-4.106(3}(cc), F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. wes b) Tag F371 incorporates 42 CFR 483.35(h)(2) and Rule 59A-4.1288, F.A.C. The administrative fine imposed for this uncorrected violation is. $1,000.00. , c) Tag F514 incorporates 42: CFR 483.75(1)() and Rule - 59A-4.1288, F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.23(9}{¢), Florida Statutes, in 7 “that the above referenced conduct of Respondent ¢ constitutes a violation i “of the minimum standards, rules, and regulations | for the operation of a wae ee aba ase at ‘NOTICE ‘administrative hearing pursuant to Section 120. 87, Florida Statutes, to 4 eh i all ii in ea al al il ‘ ee 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’ Ss request must State which issues of ‘material fact are disputed. Failure to dispute material i 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. Al 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. Al payment of fines should be sent to the Agency for Health Care Respondent ‘is notified ‘that ‘it. has a Tight to “request an” ARE ibe represented by counsel (at its expense), to take testimony, to call or Administration, Attention: Christine T. Messana, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308-5403. : _RESPONDENT Is FURTHER NOTIFIED AHAL THE ; ; ‘comPLanne WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ; ENTRY OF A FINAL L ORDER : Soe elas ; seep BYTHE AGENCY. )— 3 (re Issued this day ofdanuary, 2001. . : Donah Heiberg SOS fcberg 7 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 0 on this& letday of March , 2001. <_ T. Messana, a Office of the General Counsel - EQUEST A “HEARING WITHIN 21 DAYS OF RECEIPT OF THIS ny formal administrative hearing be held pursuant to Section 120.57(1), Florida Statutes and that an URGE ON ee ee tenner tb ed lismissing the Administrative Complaint. Reweetily Submited, : : pant Stine _ DONNA H. STINSON ... Florida Bar No. 0181261 BROAD and CASSEL =~ 215 S. Monroe St., Ste. 400". P.O. Drawer 11300 : Tallahassee, FL 32302, (850) 681 -6810 ~~. ‘CERTIFICATE OF SERVICE Thereby certify that a true and correct copy of the foregoing instrument has been furnished via first class mail to Christine Messana, Agency for Health Care Administration, 2727 Mahan Drive, Ft. Knox Bldg. 3, Tallahassee, Florida 32308, this Me of April, 2001. Darna Kn . She So Attorney 3 TLHA\HEALTH\43277.1° 10967/0291 DMA dma 4/10/01

Docket for Case No: 01-001980