> O1 ANG 13 PHIZ NG STATE OF FLORIDA, AGENCY FOR oo, HEALTH CARE ADMINISTRATION, pteteshh Gal ae vi Petitioner, vs. ARCA NO; 01-01-0110-NH CROSS CREEK NURSING & CONVALESCENT 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 $11,000.00 upon Cross Creek Nursing & Convalescent Center (“Respondent” or “Cross Creek”). As grounds for the imposition of this administrative fine, the Agency alleges as follows: | L. The Agency has jurisdiction over the Respondent pursuant vo Chapter 400 Part U, Florida Statutes. 2. Respondent, Cross Creek Nursing & Convalescent Center, is icensed by the Agency to operate a nursing home at 10040 Hillview Road, Pensacola, Florida 32514 and is obligated to operate the nursing rome in compliance with Chapter 400 Part Il, Florida Statutes, and Rule 59A-4, Florida Administrative Code. TH AT) RY AU ih aT Tar lia Wr 3 On June 19-21, 2000 a survey;t from the Agency’s Area 1 Office conducted a survey and the following Class [I deficiencies were cited. 3A. F224 | Pursuant to 42 CFR 483.15(a), the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality. This requirement was not met as evidenced by the following observations: ne ree ce (1) Interview with a sampled résident on June 20, 2000 at approximately 10:30 a.m. réyealed that the 1 ident was at thmes required to wait for sta tance after using his/her call bell, resulting in the resi thaving to "wet him/her- self." The resident expressed barrassment over these incontinent episodes. : (2) 10 of 15 residents during. the group interview on June 20, 2000 at 11:00 a.m. revealed call bells are not answered in a timely manner. They related at times they have to wait 45 minutes and the situation is worse on weekends and on the 3 to 11 P.M. shift. (3) During observations of skin care and positioning on June 20, 2000, at 2:10 p.m., resident #3 was observed in bed, covered with a light blanket and a sheet. Two staff members repositioned the resident for observation of skin and positioning devices. The resident's feet and buttocks were the areas of concern, therefore the observation required uncovering the resident from the waist down. The outdoor window curtain was completely open and neither staff member attempted to close the curtain before or during the observation and repositioning. (4) On June 21, 2000, at approximately 7:50 a.m., one unsampled resident was observed lying in bed with only a hospital gown on, clearly visible from the hall outside the room. The gown was up around the resident's waist, exposing the resident from the midriff down. The top sheet was at the foot of the bed, out of the resident's reach. A te SMa Pt ee TM me large, formed bowel mover, oted on the resident's buttocks and bed pad. _m., the resident was uulled up around his/her ‘surveyor, a nurse entered ent, and observed the é nurse then requested (a) At approximate observed with the sheet” hips. At the request of th the room, spoke to th feces still on the bed p assistance from the floor s ¢ (5) On June 20, 2000 at 9:30 a.m., during interview, a sampled resident stated that on June 19, 2000, at Approximately 11:00 p.m., two staff members awakened the sampled resident and the unsampled roommate by entering their room and turning on the overhead light. The resident further stated that the staff members were in the room approximately one hour laughing, talking loudly and using profanity. The residents indicated a lack of understanding as to why the staff members were present and stated that they should have been "in the woods" because of the language that they were using. Both residents were offended by the treatment of the staff members. idual interviews and at the facility violated (6) Based on observations group interview, it was deternt 42? CFR 483.15(aj, Federal Regu and Rule 59A-4.1288, F.A.C., for failing to promote ca an environment which maintains and enbances each’“residents dignity for 4 sampled residents, 2 unsampled “residents and 10 of 15 residents in the group interview. (Tag F241, Original Cite). FLSD 3B. Pursuant to 42 CFR 483.15(h)(2), the facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This requirement was not met as evidenced by the following observations: (1) During the initial tour of the facility on June 19, 2000, at approximately 10:30 a.m., very Strong, offensive odors were noted throughout the 120 hall of the facility. The bathroom in room 122, had a very strong foul odor, the floors of rooms 122, 129, and 126 had large grey streaks and WA Tle HTH Aa lh aT scuff marks, debris of small paper bits, sand and dirt were noted throughout the 120 hall. (2) The bathroom in room 151 had a very strong urine odor and brown splatters on the wall around the sink during tour. (3} Several rooms on the 150 and 120 halls had scrapes on the walls, and were in need of repair or painting. (4) During tour, the bathroom'faucet in 124 had a steady dribble, and the lavatory in 125).contained at least 2-inch deep standing water, A b m plunger was noted standing in the corner in the b (5) During an individual int sampled resident stated that The resident stated that t sweep, but instead uses a_ and uses dirty mop water. (6} Observations on June 21, 2000, at approximately 7:00 a.m., revealed a housekeeper outside the day room of the 120 hall mopping up debris with a damp mop. The mop water in the pail was very muddy and had a strong, dirty odor. Another housekeeper was observed using the same process to clean the floor around the nursing station, at the same time. (7) During an interview with a sampled resident at 3:00 p.m., on June 19, 2000, the .resident complained that his/her room was not clean. The resident stated that the staff did not use a broom to sweep, instead used a mop to sweep up trash, resulting in floors that were not always clean, and at times the room had an odor. (8) On June 19, 2000, during. the life safety tour at 1:30 p-m., it was noted that a wall“in the activities room had severe water damage and was mildewed. Also at 2:15 p.m, it was noted that the wallpaper.ifi-the rehab ladies room was pecling from the wall. (9). During random observatioris throughout the facility on all days of the survey, transient offensive odors were detected. feet pio Seo Meas ot interviews, it was (10) Based on observat: Sl 42 CFR 483.15(h)(2}, determined that the facili Federal Regulations and Ru 4.122(2)(a), F.A.C., for failing to provide housekeeping” and maimtenance services necessary to maintain a sanitary, orderly and comfortable interior. (Tag F253, Original Cite). a 3C, Pursuant to 42 CFR 483.20(k), the facility must develop a comprehensive care plan for each resident that includes measurable objectives and time-tables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: (i) the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.25; and: (ii) any services that id otherwise be required under §483.25 but are not provided d resident’s exercise of rights under §483.10, including the rig. use treatment under §483.10(b)(4). This requirement was not met as evidenced by the following observations: (1) Resident #4 was observed on June 20, 2000, in her room in bed for breakfast and lunch meals. During breakfast, served at 9:00 a.m., the resident was in bed with her breakfast tray to her left and staff was observed feeding the resident. Staff revealed at that time that the resident could not feed herself. During the noon meal served at 1:45 p.m., staff was again attempting to feed the resident with the resident resisting and refusing. (2) Review of the residents’ current care plan regarding nutrition, revealed it states "To main dining room for breakfast and/or lunch daily. Set up tray for ease of left hand feeding, cue her to eat, repeating as often as needed to promote self-feeding. Feed her remainder of meal praising her accomplishments each meal." (3) Interview with staff on June: 20, 2000 at 3:55 p.m., revealed staff agreed the caré/plan,.did not describe the resident's current nutritional ne r dining. The resident entered the facility obese a ‘pidly lost weight. Some weight loss was desirable, ‘ff verbalized concerns with the resident refusin eel she needs much more assistance at this tim 3-to-he fed. ected that resident #9, 25, 2000 from a local asa result of a head rinary catheter was (4) Review of the clinical was adrnitted to the facility hospital, with a diagnosi injury. At that time an present. (a) Admission Minima ata. Set (MDS) was completed on February 1,°°2000, and the Resident Assessment Protocol (RAP) summary indicated that care planning for the catheter was triggered; however a decision not to proceed with care planning was documented; (b} Care-planning note on February 4, 2000, indicated that because the catheter was present and there was no urinary incontinence, a care plan was not developed; (c) Nursing note on May 14, 2000, at 9:45 a.m., indicated that resident was hot and clammy and had a blood pressure of 112/50, pulse of 150, respirations of 32 and a rectal temperature, of 104.2; (d) Urinalysis ordered at that time reflected high red and white blood cell countsjand many bacteria, {e) The urine cultu ts from this specimen revealed greater than 1 colonies of e-col, (9 The resident was % d to the hospital with a diagnosis of sepsis; (g) Failure to plan for-caré ef the indwelling catheter and potential for urinary tract infection (UTI) could have contributed to this resident's subsequent illness. (5) Through observation, record review and staff interview, it was determined that the facility violated 42 CFR 483.20(k), Federal Regulations: Rule 59A-4.109(1}(2)(3), F.A.C., and Chapter 400.2(3)(1)(1), FS. for failing to develop comprehensive care plans that described the services to be ae eT Om Toe TU Ce TTT ca ate RARER sevmmtarcria it furnished in accordance with'tJ sampled residents. (Tag 279, 3D. Pursuant to 42 CFR 483.20(k 103) ) i), as services provided or arranged by the facility must meet professional standards of quality. Also pursuant to 59A-4.107(5), F.A.C., 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 This requirement was not met as evidenced by the following observations: (1} During observations of resid nt #10, on every. day of the survey, June 19-21, 2000, noted that the resident had a groshong catheter site he dressing dated une 16, 2000, 8:00 p.m. as beity date that the dressing had been changed. The residé confirmed this as the last time of a dressing ch cord-review revealed a physician's order on May 3 © to change groshong- dressing site every 3 days. vo (2) Based on observation, intery and record review, it was determined that the facility violated 42 CFR 483. 20(k)(3)(i), Federal Regulations: and Rule 59A-4.107(5), F.A.C., for failing to. provide services that meet professional © standards of quality for 1 of 25 sampled residents by not following physicians orders. (Tag F281, Original Cite}. 3B. Pursuant to 42 CFR 483. Q5(c aye based on the ‘comprehensive assessment of a resident, the facility must ensure that a— resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates © that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent TH TAI) HERA SI bia Ge saT TMF cm Wwir AGT Ad infection and prevent new sores from developing. This requirement was not met as evidenced by the following observations: comprehensive assessment, the facility mu 3k. . (1) Resident #14 was admitted to the facility on February 3, 2000 after falling at home and breaking her right hip. (a) Her initial assessment determined the resident to be at risk for pressure sore development due to her decreased mobility and weight bearing ability; (b) Facility staff, however!:chose not to develop a care plan at that time for jurpose of prevention of pressure sore developm eause the resident had “no breakdown present: time. Not at high nsk presently"; : ; ; {c) No interventi the resident's skin cc (a) On February her right hip and had:,ta re-alignment of the fract (e} She returned to‘ cility on February 21, 2000, with continued limitation in her mobility and by March 22, 2000, the resident:had developed a Stage I] breakdown on her right heel; blished for monitoring surgical intervention for (f The facility developed a plan of care for the © treatment of the pressure sore after it developed. They did not, however, provide aggressive preventive measures and care to prevent the breakdown from occurring for this resident who was determined by assessment to be at risk for the development of breakdown. : (2). Based on interview and record review, it was determined that the facility violated 42 CFR 483.25(c)(1)(2), Federal Regulations: and Rule 59A-4.1288, F.A.C., for failing to ensure that 1 of 25 sampled. residents who entered the facility without pressure sores did’ not develop a pressure sore, (Tag F314, Original Cite) . aro based on a resident’s Pursuant to 42 CFR 483.251 ensure that a resident receives a therapeutic diet when there is a nutritional problem. This requirement was not met as evidenced by the following observations: LTTE Kc CTR moo 8 sthe resident re-injured- eT TT a tes Pee RMS ee a Sed ald 3G. (1) Record review of resident #4 revealed a diet order of 4 gram Sodium with chopped meat.” , (a) Observations .at the,.noon meal on June 21, 2000, as well as interview With the resident, revealed that the facility served chopped ham to the resident for lunch; (b) The resident was complaining of how “salty” the ham was; (c} Review of the facility menu for that meal revealed that the 2-gram Sodium and No Added Salt (4-5 gram Sodium) diets were to receive Roast Pork, a much lower sodium content entree, for the noon meal; (a) Review with dietary staff revealed that the pork had been substituted. with:.chicken and that the appropriate item to be served to this resident would have been chopped chicken; it the resident received ‘noon meal on June (2) ‘The facility did not the appropriate therape 21, 2000. w, and record review, it ted 42 CFR 483.25(i}(2), 1288, F.A.C., for failing dered. (Tag F326, (3) Based on observation was determined that the fac Federal Regulations: and R to provide a therapeutic d Original Cite). Fe! Pursuant to 42 CFR 483.65(a)(1-3),° the facility must establish an infection control program under which it investigates, , controls, and prevents infections in the facility; decides what procedures, such as isolation, should be. applied to an individual resident; and maintains a record of incidents and corrective actions related to infections. This requirement was not met as evidenced by the following observations: on June 19, 2000, at 2:00 -.10:45 am., revealed a edside table completely (1) Observations of resident # p.m., and on June 20, 200 respiratory suction catheter 1 uncovered and attached to the suction machine. This resident breathes through a tracheotomy, is totally dependent on staff for all care; and has had numerous upper respiratory infections, including an admission to the hospital on May 29, 2000, with pneumonia. . (2) During the initial tour at approximately 9:45.. t observations were made. ility on June 10, 2000, a.im., the following (a) Toothbrushes: 4 labeled on backs of toilets in rooms 125: (b) A bedpan and in 126; ° (c) Wet, soiled wa bathroom in 125; (d) An open urinal s room 131; . (e) A contaminated urinary catheter bag with tubing draped over the handrail of the bathroom in room 109; (f A half-full urinal standing on the bedside table of one unsampled resident on the 200 hall. on the bathroom floor “on the floor of the ing on the bedside table in (3) Based on observations, it. was determined that the facility violated 42 CFR 483.65(a){1-3), Federal Regulations: and Rule 59A-4.106(3)(4)(I), F-A.C.,.for failing to provide and follow care procedures to prevent infections for 1 of 25 sampled residents, and 5 unsampled residents. {Tag F441, Original Cite). 4. On March 5-8, 2001 a survey rom the Agency’s Area 1 Office conducted a re-certification and lic survey and the following repeat Class III deficiencies were cited, alor th one Class Il deficiency (previously consicered Class IT). ces 4A. Pursuant to 42 CFR 483.15(a); the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or 10 SpTomR OTe cet STH Tae LTD TL eT following observations: 2001, revealed resident #C one hour, from 2:40 p.m. please help me - I'm just sased Practical Nurse) was ie without assisting or nt was not assisted until other staff member, at tank you." (1) Observations on March. standing at Nursing Station to 3:40 p.m. crying off and gonna sit on this floor.” A LP sitting at the desk the, addressing the resident. J the surveyor got the atte which time the resident ¢ (2) On March 6, 2001 at m., a Certified Nursing Assistant (CNA) was observ ring down resident A#'s pants checking for incontinence'in the middle of the main hallway near the Crosswalk Dining room, (3) On March 6, 2001, at 2:30 p.m., and again on March 7, 2001, at 10:30 a.m., CNA's were observed entering the rooms of residents #9 & #17 without knocking on the door before entering. (4) Based on observation, it was determined that the facility violated 42 CFR 483.15(a), Federal Regulations and Rule 59A-4.1288, F.A.C., for failing to promote care for 2 of 25 (#9, 17) sampled residents and 3 unsampled residents (#A, B, C) in a manner and environment that maintained the resident's dignity. (Tag F241, Repeat). a? the facility must provide 4B. Pursuant to 42 CFR 483.15(5 housekeeping and maintenance services. necessary to maintain a sanitary, orderly, and comfortable interior.. This requirement was not met as evidenced by the following observations: (1) Observations during the initial tour on March 5, 2001, beginning at 9:50 a.m., revealed the following: {a) Bathroom in room 124 had a leaking faucet in the sink, which could not be turned off, OTe TT mem es Te ce ST Tr ec Te TRH) Ii erat “—, (b) Positioning devices (arm bolsters) in. a wheelchair in room 122 were dirty and covered with dried food/liquid. Also dirty, stained hand splints were sitting on the bedside table of the resident in the "B" bed. (2) On March 5, 2001, at 3:30 p.m., observation revealed the commode in room 101 not anchored to the floor. Upon pushing on the commode it moved away from the wall. (3) On March 6, 2001, at 4:45 p.m., observations in the clean utility room on Hall B revealed the water running continuously from the faucet in, the sink when it was turned off. The clean utility room ‘o: all A revealed equipment stuffed into the area includini oxygen concentrators, 8 oxygen tanks, 3 of:which were. safely secured in a,stand., this room and thé this equipment. to. accommodate all of (4) On March 7, 2001, ‘at 2: 45°pam., observations in room 120A revealed a bed with no ge ch to raise and lower the bed. The 120B bed did have a: raising and lowering gatch, however, it was very difficult to.turn and did not work. Resident room 126B had no string or line attached to pull the over bed light in order to turn it on. . (5) On March 5, 2001, at 8:30 a.m., surveyor observed the baseboard molding missing in the dirty utility room. Room 106 had a leaking hot water faucet, which could not be turned off. (6) On March 5, 2001, at 9:15 a.m., on March 6, 2001, at “12:45 p.m., and on March 7, 2001 at 8:15 a.m., the toilet in Room 107 was noted to be continuously running. (7) A crash cart stored in the clean utility room on the A hall was first observed as dirty and in need of cleaning on March 5, 2001, at approximately 11:00 a.m.. There was no evidence of it being cleaned throughout the remainder of the survey, March 6-8, 2001. Labs (8} Resident #8's foot splint was first observed soiled and dirty on March 5, 2001, at 9:00. a.m., and again on March 6, 2001, at 8:15 a.m., on March 7, 2001 at 1:15 p.m., and on March 8, 2001, at 4:40 p.m. 12 a stérmined that the éderal Regulations and (9) Based on observations: facility violated: 42.,CFR 483.19 Rule S9A-4,122(2)(a), FACS ain” failing to provide housekeeping and mainterfance, Services. necessary to maintain a sanitary, orderly and comfortable interior, in that it failed to assure resident care equipment was maintained in sanitary and safe working conditions. (Tag F253, Repeat). et 4C. Pursuant to 42 CFR 483.20(k); the facility must develop a comprehensive care plan for each resident that includes measurable objectives and time-tables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: (i) the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.25; and: (ii) any services that would otherwise be required under §483.25 but are not provided du sident’s exercise of rights under §483.10, including the right to, refuse treatment under §483.10(b)(4). This requirement was not met as evidenced by the following observations: (1) Review of the clinical record of resident #10 revealed the resident was readmitted to the facility in January of 2000 with a stage III pressure sore to the left heel. Orders for treatrment were obtained and a care plan was developed for this resident placing him/her at risk for the development of skin breakdown. The resident was non-ambulatory, incontinent and had limited mobility in bed. (a) On November 7, 2000, an update to the care plan was made indicating that the breakdown to the heel was now resolved and the resident currently had a stage Il pressure sore to the coccyx. At that time, the goals developed regarding further development of skin 13 OH AH HITHAH MM) IACI Bayt TEI OE breakdown stated the resident "will have no further breakdown higher than a Stage Il by the next review date." : (2) Resident #11 was assessed by facility staff as being at risk for the development of urinary tract infections due to the use of an indwelling Foley catheter used to aid in wound healing. cs a ‘goal was developed for than two urinary tract January 5, 2001).” ssed as being 4 breakdown the hospital (a) On October 6, 2000 the resident to “have nom infections by the next revi (b) This same residei at risk for. the de following readmissig with a stage Il] pressul (c) The goal develope stated that the residen wound infections % decrease by .5 cm by ne 2001). db “interdisciplinary teara more than two the coccyx will te (January 5, (3) Resident #12 was admitted to the facility on September 14, 2000, and was assessed as being at risk for falls on September 26, 2000 due to previous falls, resulting in head injury. (a) The goals developed for this resident by the facility interdisciplinary staff were that the resident would "have no more than two falls by the next review date." (4) Resident #25 was admitted to the facility on October 6, 2000, with skin intact; however, he/she was assessed by an interdisciplinary team on October 25, 2000, as being at risk for skin breakdown due to "incantinence and immobility while up in wheelchair and in bed. (a) The goals developed for the resident related to the prevention of skin breakdown stated the resident , would "have no greater than a stage Il {pressure sore) by the next review. (S) Review of the interdisciplinary care plan for resident #16 revealed that established goals were not met at the time of the care plan review, the goals were down graded rather than implementing care plan revision with :"n interventions. The resident's care plan for the prevention of weight loss due to poor appetite revealed the following goals and revisions: : os (a) October 9, 2000 Goal: "Resident will not lose below ideal body weight (IBW) of 137's, will rermain within 2-3 #'s of IBW." ; - ; On January 17;.°2001 documentatio 1. ri of 130-135 #5 by the : No new interventions are. liste (c) On February 28, 2001, documentation notes stated: 7 . 1. "goal not met resident declining,” new goal: "keep resident cornfortable." The care plan does reflect new interventions for February 25, 92001 of "total assist for all meals" and February 28, 2001 of “weekly weights and speech therapist to evaluate." (d) The resident expired on March 1, 2001. (6) Medical record review for resident #8 revealed a. physician's order for aspiration precautions on January 30, 2001. The resident's interdisciplinary plan of care was reviewed and revised on January 30, 2001 i March 8, 2001, with no evidence. of interventions to prevent aspiration. A plan of care wa ‘.developed om, Se 2000 due to the resident's risk, omplications due to use of indwelling Foley catheter. T these complications was that thy more than two UTI's (urinary tract infections date." The resident had 4 UTI's diagnosed between September 17, 2000 and January 9, 2001. There was no fee eT TW OPA TI ‘motion of the arm, hand evidence that the care since being written /on'S (7) Review of medical, revealed no care plan relating to’ as following. a physician's order. Observations f the resident during meals on all days of the survey revealed the resident eating alone in his/her room with no safety precautions used to prevent aspiration. The resident also had. a physician's order from June of 2000 to ambulate daily with a cane. “There was no evidence that daily ambulation had been addressed in his/her plan of care. ; : (8) Resident #4 was assessed as having limited range of motion of the arm, hand, leg and foot, with most of ‘the limitation on his/her right side. He/she was observed’ on March 5, 2001 at 12:50 p.m., and noted to have a severely contracted right hand with no supportive device. Although the assessment noted the problem, the facility did mot develop a care plan to address: the medical needs of this resident so that staff could:,assure his/her highest practicable physical well-being could be main ined. 9) Resident #22 was: shave ! E. Qbsenvation of the resident on March 8, 2001 beginning to develop contracture of the le he. and no supportive device. The plan only addressed passive range of motion to the resident's upper and lower extremities. There was no plan of care to prevent further contracture or to maintain the resident's highest practicable - physical well-being. (10) Based on observation and record review, it was determined that the facility violated 42 CFR 483.20(), Federal Regulations: Rule 59A-4.109(1}(2)(3), F-A.C., and Chapter 400.2(3)(1)(1), F.S., for again failing to develop comprehensive care plans that described the services to be furnished in accordance with the resident's needs, in that it failed to develop resident care plans for the prevention of avoidable decline with goals and objectives which reflect current standards of practice and which would enable the residents to attain their highest level of well being for 9 of 25 sampled residents (#4, 8, 9, 10, 11, 12, 16, 22, and 25). (Tag F279, Repeat) ee oe ee eS mma eS $98! 4D. Pursuant to 42 CFR 483.20(k)(3)(i), the services provided or arranged by the facility must meet professional standards of quality. Also pursuant to S9A-4.107{5), FAG, followed as prescribed, and if not followed on the resident’s medical record dur ing. that-s) not mel as evidenced by the followin (1) Observations of resident #10 >< 12:20 p.m., and again on’March 82001, at 8:00 a.m., while the resident was being assisted with.meals revealed a pureed diet served to him/her. (a) The current diet order in the resident's clinical record was for a Mechanical Soft, No Added Salt Diet; (b} Interview with the resident on March 7, 2001, revealed the resident was unaware of why his/her diet had been changed and was having no difficulties with chewing or mouth pain; (c) The resident also stated that he/she did not care for the pureed diet and was certain the food would be tastier if it were not pureed; (d) During interview with the dietary manager on . March 8, 2001, information was provided indicating the resident's diet had been changed to puree by a unit nurse on December: 18, 2000. ("due to sore mouth and missing teeth."); (e) There was no evidence: that a physician's order had been obtained changing:the resident's diet. Review of the resident's weight history revealed an eleven- pound weight loss since January |, 2001; (f) Documentation by the dietary manager and the facility dietitian on March 2, 2001 stated the resident was on an Mechanical Soft, No Added Salt Diet, however, at the time of the survey, the resident was continuing to receive a Pureed diet. (2) Review of the clinical record of resident #10 revealed an order for a Foley catheter. Observation of the resident and interview with facility staff during the initial tour 7 OH SAR HITHAH a4 4AM TAT TAIN revealed the catheter had been removed on February 27, 2001. There was no evidence of a physician order to remove the catheter. Facility staff interviewed on March 5, 2001 at approximately 3:00 p.m. revealed that an order had not been obtained from the resident's health care provider prior to removing the catheter, (3} Based on observation, interview and record review, it was determined that the facility violated:'42 CFR 483.20(k)(3)(), Federal Regulations» and Rule F.A.C., for again failing to provide services: ‘that meet professional standards of quality for 2 of residents (#10, 19) by not following physicians {Tag F281, Repeat). 4E. Pursuant to 42 CFR 483 13 ehensive assessment of a resident, the facility ent who . enters the facility without pressure sores. unless the individual’s clinical conditioz they were unavoidable; and a resident having pressure sores receives-necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This requirement was not met as evidenced by the following observations: (1) Observation of resident #4-0n March 7, 2001 at 2:00 p.m. revealed the resident lying in bed, There was a skin tear on the right inner ankle and a blood blister, approximately .Sem in size, on the lower right leg. He/she had stage II and Ill pressure sores on the right outer ankle. Record review revealed the resident had stage IJ pressure areas on the right heel and outer calf, which were healed when observed by a nurse surveyor. Interview with facility staff during the initial tour on March S, 2001 at 10:30 a.m., revealed facility staff did not really feel these were préssure areas as the resident moved around so much in the bed and moved his/her legs back and forth. Observations of the resident on March 5, 2001 at 12:50 p.m. and March 6, 2001 at 6:30 p.m. revealed 18 CH Aa HRA A ANAS POI ies cn egpea the resident, lying in beds wi (4) “Based on observations resident #8 was lyin ““his/hér left side on the following date and at the follo - limes: (5) On March 7, 2001, while touring with a staff nur ‘Pésident #8 Was observed to have stage | pressure areas on supportive devices or er legs or feet. The blems and was totally there “was no clinical essure’ sores were preventive mea resident had: dependent 6 condition dermonst unavoidable and the faci ihe sites of the pressure i lying in bed on March 7, a stage II pressure sore on pressure area on. his/her (2) Resident #3 was observ 2001 at 2:15 p.m. He/she h his/her right ankle andi left outer coccyx... Th for all care and had a daily. Interview with facility ‘st; p-m. revealed facility staff were not aware the reside pressure sores. There was ho evidence to support th that the pressure’sores weré unavoidable. This resides not identified as having pressure areas on the { Pressure Sore Report at the time of the survey. (3) Record review of resident #8 revealed th September 5, 2000, he/she was assessed as being at ris skin breakdown related to bowel incontinence and dependence on staff for turning. Interventions develop help prevent the development of pressure areas include: {a} turn and reposition every two hours; a (b) document on weekly skin reports, out of bed daily in Geri chair fonspositioning; : (c) (a) March 6, 2001 at 8:00 am. 8:45 am. a.m., 10:30 a.m., 12:45 p.m., 1:05 p.m p.m., 4:30 p.m., 5:30 p.m., and 6:25 p.m.; the right foot, ankle and heel. The resident did not have positioning pillows or heel protectors. Review of the facility Weekly Skin Report did not show documentation of these pressure areas. Nurse’s notes on March 7, 2001 and March 19 4F. reas, The resident was O01 and March 7, 2001. sistant revealed they did -because there were "not 8, 2001 did not doer also observed in bed on | Interview with. a Certified’ not get the resident out enough gerichairs" avail (6) Based on observation, intérview and record review, it was determined that the, facility violated 42 CFR 483.25(c)(1)(2}, Federal Regulations» and Rule S9A-4.1288, F.A.C., for again failing to ensure that residents who entered the facility without pressure sores did not develop a pressure sore, in that it failed to ensure that 3 of 25 sampled residents (#3, 4, and 8) did not develop pressure sores. (Last year in ‘2000’, this tag was a Class III, this year it is a Class Il; Tag F314, Repeat}, Lio Pursuant to 42 CFR 483.25(i}(2), based on a resident’s comprehensive assessment, the facility must ensure that a resident receives a therapeutic diet when there is a nutritional. problem. This requirement was not met as evidenced by the following observations: (1} Review of the clinical ‘of resident #2 revealed he/she was currently receiving hemodialysis treatments three times a week and was on a Renal diet. (a) During interview on March 5, 2001 at approximately 3:30 p.m., the dietary manager stated a Renal diet ‘included modifications in protein (increased), sodium (reduced), and potassium (reduced); (b} On the morning of March 6, 2001 at 8:40 a.m., the resident was observed sitting in his/her wheelchair - in the lobby awaiting transportation to the dialysis center. He/she was noted to have a sack lunch prepared by the dietary department consisting of a tuna sandwich, graham crackers, and diet soda. Review of the facility menu for the evening meal on March 5, 2001 revealed renal diets were to receive a SF (salt free) Tuna Salad Sandwich; (c) During kitchen observations of the dry storage area later that same morning, there was no evidence of a supply of salt free tuna; 20 FTA Sa AE ATR TIC mR staff revealed the tuna nehes for resident's on a egular tuna was all that and dietary staff would paring the tuna salad. f resident #10 revealed a er documentation in the s allergic to caffeine. 2:30 p.m., during the tray being set up by facility staff. ~ resident's tray stated he/she was ona y Caffeine. Included as part of the resident's meal was a glass of iced tea, a beverage containing caffeine. : noon meal, (3) A significant change assessment dated January 4, 2001, revealed resident #1 was experiencing weight loss and the resident's plan of care was revised to include an order for a "Pureed diet with a 206 shake" to be provided with all meals. Observations of the resident were made on March 5, 2001 at lunch, March 6, 2001 at dinner, and again on March 7-8, 2001 at breakfast revealing no shake being provided with meals. Review of the diet card used to serve the meals did not list the "206 shake" as ordered. (4) Resident #14 was admitted on December 12, 2000 with diagnoses of diabetes, urmary tract infection and below the knee amputation on the right. She was assessed as being at nutritional risk and was care planned with a diet order of Mechanical Soft No :Céncentrated Sweets, Low Potassium diet, No Milk Products (lactose intolerance), along — “with further interventions of weekly weights, and provide No Concentrated Sweets snacks. Interview with the resident on . March 6, 2001 at 3:20 p.m. revealed he/she is not provided ~ with snacks of any kind. The resident indicated a desire to receive snacks, as he/she is often hungry. Observation of snacks delivered after hinch each day to the nurses’ station | revealed no snacks labeled with resident #14's name. (5) Based on observation, interview, and record review, it was determined that the facility violated 42 CFR 483.25(i)(2), Federal Regulations: and Rule S9A-4.1288, F.A.C., for again failing to provide a therapeutic diet as ordered, in that it failed to provide for 4 of 25 (#1, 2, 10, and 14) sampled residents, (Tag F326, Repeat). 21 mee a ree et TI k E see ca 4G. Pursuant to 42 CFR 483. 65(a a1 3), the facility must establish an infection control program ynder which it investigates, controls, and prevents infections in the acy: decides what procedures, such as isolation, should be: applied to “an ‘individual resident; and maintains a record of incidents and ‘ ive actions related to infections. This requireme: idenced by the following observations: (1) Observatioris madé, throughout the survey revealed the following: (a) March’ 6; 2001" at 5 am. - soiled linen 3 hamper not covered and overflowing with soiled linen : a in the hallway of the 100 hall. are (b)} March 6, 2001 at 8:00 a.m. — Hall-A shower room had resident's personal items present; soiled linen was left on the shower room floor; the same observations were again made on March 7-8, 2001. (c) March S, 2001 at 11:00 a.m. = the facility crash cart was dirty and a clean suction machine was stored uncovered in the clean utility room off Hall-A. (dl) March 6, 2001 at 8:00 a.m. and again on March 7, 2001 ~ Hall-A nourishment pantry microwave was dirty with dried food; the refrigerator was dirty with open food containers. (e) March 7, 2001 at 12:40 p.m. — CNA (Certified Nursing Assistant) was observed taking a soiled linen hamper into a resident's room (116). (f March 7, 2001 at 10:30 a.m. ~ Rooms 117 and 108 had soiled water pitchers. (g) During the initial tour on March 5S, 2001, beginning at 9:50 a.m., Rooms 105 and 131 had urinals at bedside full of urine and without a lid. 22 FTSR CLP ASS TH Dee LES rar Boat Tan Lona Room 106 had a soiled bedpan sitting on closet. — rn a oo (h) March §, 2001 - Rooms 105, 107, and 116 soiled over-bed tables. 7 cs () During the initial tour on March 5, 2001, beginning at 9:50 a.m. — foam heel protector marked with resident R's name were being worn by resident #9. ‘50 a.m. +-an oxygen cannula was i the floor in'Room 110. 7 () ; | “p.m. and again on March 6, 201 Resident #8 was observed with his/ eter bag. lying.on the floor in his/her (1) March 5, 2001: at 00 am. - Clean utility room on Hall-A had a soilédrazor present; On same day and again on March 6, 2001, the shower room also had soiled razors presen te (2) Resident #12 was observed during the initial tour of the facility lying in a low bed with a protective mat on the floor beside the bed due to his/her high risk of falls and a previous hip fracture. Additional observations at the time revealed a staff nurse walk over and across the mat to attend and re-adjust the resident in bed with no means of protective covering for his/her shoes or the mat. (3) Based on observations, it was determined that the facility violated 42 CFR 483.65(a}(1-3), Federal Regulations» and Rule 59A-4.106(3)(4)(I), F.A.C., for again failing to provide and follow care procedures to prevent infections and to maintain an infection control program which would deliver care in a sanitary manner for 3 of 25 sarnpled residents (# 8, 9, & 12) and | unsampled residents (R) and provide a - a sanitary environment for all residents. (Tag F441, Repeat). 23 ree ec le Oe Bo TT Office conducted a re-certi n - survey and the following i> | : ] . . i : 6 jancorrected Class lll deficiencies were cited: . snacrcemnnvvenne Pursuant to 42 CFR 483.20(k)(3)(i),’ i Qenices pro the services provided or arranged by the facility must be provided by qualified persons in accordance with each resident’s written plan of care. This requirement was not met as evidenced by the following observations: 6 RRR RARE 1) Record review revealed resident #22 had a care plan addressing the care of his/her Peg site (tube feeding . the resident through her stomach.). ‘The care plan outlined how staff should clean the site andsto notify M.D. of any S/S signs and symptoms) of irrita ‘trauma. Observation of the Peg sit »March 7, 2 revealed the site to be infected. .In same time revealed this had not bee 's physician. use Geri Arm and Geri 3 the resident from skin fears. Observation of the resident on March 5, 2001 at 12:30 p.m., at 1:05 p.m., and again on March 6, 2001 at 4:00 p.m. revealed the resident to have on a long sleeved shirt and long pants but not the Geri devices. The resident had numerous skin tears and bruises. (3) Resident #19 was assessed by facility staff on as being "at nutritional risk related to his/her dependence on others for meals." The resident had Rheumatoid arthritis with severely contracted hands. Interventions developed by the multidisciplinary team to prevent decline in the resident's nutritional status included: "Provide diet per MD order." Observations of the resident on March 7, 2001 and again on “March 8, 2001 during meals revealed the resident receiving a Pureed diet. The resident's current diet order in his/her clinical record, however, ‘was for a Mechanical Soft, No “Added Salt diet. The resident was questioned regarding the change of his/her diet order and replied that he/she was unsure why he/she was receiving a pureed diet rather than the diet ordered by his/her physician. Further review of the ‘tevealed no 206. “sh e changing | from the top of the G _was sitting. Additional obsé 5 ap Re = resident! , loss since Je (4) “.Review:of 9, 2000 and Jan diet 1 a Observations ith all meals. dining room pureed meals on March 5, 2001 hinch, March’ 2001 breakfast. Review of the d rd used to serve the meals did not list the 206 shake as ordered. (5) A-care plan for resident 494 written on October 3, 2000 for alteration in activity of daily living (ADL) included an intervention for mouth care to be done daily. Observations by the surveyor on all days of survey found the resident's teeth unbrushed with food particles noted on his/her teeth. (6) A care plan dated September 5, 2000 was written for resident #8 and included interventions of. "Keeping Foley catheter bag below bladder level" and “use ‘privacy bag for Foley catheter drainage bag." Observations. by the surveyor on March 7, 2001 at 12:45 p ed.the catheter bag h the resident surveyor were made on March 5, 2001 at 8:0 rch'6, 2001 at 1:00 p.m., and March 7, 2001 at 3: -m. ing the catheter bag uncovered. The same care plan dated September 5 5, 2000 included instructions for getting’ the resident out of bed daily. Based on surveyor’s observations, at various times throughout the day, the resident was left in bed on March 5, 2001 and March 6, 2001. When the surveyor asked staff why _..the resident was not out of bed daily, a Certified Nursing «Assistant (CNA) stated the facility "did not have enough Geri- ‘chairs for resident use." A care plan dated October 2, 2000 .dnclided interventions for padding of side rails in the resident's bed. Based on surveyor observation throughout the survey, the bed rails were not padded. (7) Based on observation, interview and record review for _. 6 (#1,3, 8, 9, 19 and 22) of 25. sampled residents, it was ““determined that the facility violated 42 CFR 483.20(k}(3)(ii), Federal Regulations: and Rule 59A-4.1288, F.A.C., for failing to provide services for each resident in accordance with the plan of care. (Tag F282, Original Cite). 25 Oe TAIT) HPWH AI NASH Sa 2aT jeer cate tee ge 8 e abo big, 5B. Pursuant to 4 provide services in com local laws, regulation standards and principles thi (1) Review of the personnel. ree hired within the past six months {a) Employee hired February '8, Level II background screen’ requirements did not have a r submitted by March 7, 2001; (b) Employee hired January 29, Level U1 background screen “requirements did not have a submitted by March 7, 2001; (c) Employee hired October 19, Level I] backgrourid’ ‘screen requirements did not have a request submitted by March 7, 2001; no evidence of a Le March 7, 2001. (2) Based on ‘record — review. of facility personnel hired within the last six months, it w: j violated 42 CFR’ 483.75(b), “Federal Regulations: Rule 59A- ; 4.1288, F.A.C., and Chapters 400.215(2}(b) & 435.04(1), : F.S., for failing to follow state laws regarding background screening for 4 of the 7 records reviewed. (Tag F492, Original Cite). 6. On April 10-12, 2001 a survey tear from the Agency's Area 1 Office conducted a follow- -up to re-certification survey and the following uncorrected Class lI deficiencies were cited. ia 6A. Pursuant to 42 CFR 483.20(k), the facility must develop a comprehensive care plan for each resident that includes m asurable objectives and time-tables to meet a resident’s medical, n mental and psychosocial needs that are identified in the co : assessment. This requirément was not,met 2 observations: (1) Revie 2001 reveale (April 6, to have a resident w incidence of causing Calcitab, and Dufagesic include severe Rheumatoi have decreased mobility adding to resident's h risk for constipation as well as on a 1,000cc per 2 restriction. Review of the resident's record r vealed no documentation where facility had developed a care plan for _the prevention of constipation thereby leading to high risks of fecal impaction. om (2) Resident #3 was admitted to the facility on November 19, 1998. Review of the clinical record on April 11, 2001 revealed the resident had a Foley catheter until March 19, 2001. Review of the care plan dated Januaryeof 2001 revealed the facility failed to develop a care ) resident's incontinence. No assessment wi address the now incontinent resident. (3} Resident #13 was admitted,to the facility; January 6, 2000. This resident has a history of chronic infections, with physician notes: and laborat documenting infections January 12000, January 30, 2001, and March 13, 2001. This resident has a Foley catheter for renal failure and urinary retention. Review of the care plans revealed the facility had developed a care plan to address the “Bley Catheter in January 2000, but had discontinued the care plan in April 2000. There were no care plan problems with specific goals and approaches to address _ chronic urinary tract infections. 27 a--- oe on ee ee ee ea eS IT. SMS accordance was not met (4y Based on ecord review, it was. determined that the facility ated 42 CFR 483. Federal Regulations» and Rule S9A- 4,109(1)(2}(3), RA, c again failing to develop resident care plans for the preven of avoidable decline with goals and objectives which reflect current standards of practice and which enable the residents to attain their highest level of well being for 3 of 16 sampled residents (#2, 3, and 13). (Tag F279, Uncorrected from March 5-8, 2001 Survey). Pursuant to 42 CFR 483. 200949 3\(ii), the services da problem ‘related to saches for maintaining an upright: position while _ fe device to keep neck uprig 2001 confirms the need to pad the neck with towe to maintain alignment. Observation of the resident on April 11, 2001 at 12:30 p.m. revealed the resident being fed lunch with no towels or pads to maintain alignment. Observation over the next thirty minutes revealed no padding :was ever placed between the neck and wheelchair to correct the severe head tilt. (2) Resident #1 was admitted to the facility August 23, 2000. This resident had a history of pressure ulcers on the heels. Observation of the resident's heels on Apri at 10:15 a.m. revealed the resident had an alm Stage | ulcer on the left heel, measuring approximy centimeters. The right heel, 3 blanchable. Observation of the 9: 1S am, and again at 2:35 acm., “9:30 a.m., and at 10:;00'’a.m. on April» revealed the resident lying in bed with both heels flat on the bed, creating pressure on both.heels. Review of the care plan originally dated Septemb 900 and revised March 28 ee a 6c. ity violated 42 CFR 483. 20(k)(3)(ii}, Pec 3 3 and Rule 59A-4.1288, F.A.C., for failing’ to follow w mn care plans for two: of sixteen sampled residents (#1, 6). (Tag F282, Uncorrected) om Pursuant to 42 CFR 483.75(0 he facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. This requirement was not*met. as evidenced by the following observations: - (Florida Department rse with the hire date mber had a history of ry) dated February 1, . nd-screening unit on April 11, 2001 revealed this is 61 a disqualifying event if the victim is a minor. Review ofthe record and interview with the Administrator failed to show the facility had investigated the offense to find out the age of the victim. A note on the record stated: “cleared from corporate", but did ‘not show the facility, nor did the corporate office further investigate the offense. The nurse had been working ‘unsupervised in the facility without a letter of exemption or farther explanation of the charges. The nurse was removed “from the building on April 11, 2001 at 4:15 p.m. by the facility staff, pending further investigation. (2) Based on record review of facility personnel hired from March 8, 2001 to present, it was determined that the facility violated 42 CFR 483.75(b), Federal Regulations: Rule S9A- 4.1288, F.A.C., and Chapters 400.215(2}(b) & 435.04(1), F.S., for failing to follow state laws regarding background screening for one of four records reviewed. (Tag F492, Uncorrected). : : 483.15(h)}(2} and Ru trative fine imposed for a 59A- 4,122(2){a), F.A.¢ this repeat violation is : c) Tag. F279 incorporates 42 CFR 483. 3,20(k) and Rule 59A-4.106(2), F.A.C. The administrative fine imposed for this repeat and uncorrected violation is $2,000.00; dj Tag F281 incorporates 42 CFR 483.20(k)(3)() and Rul 59A-4.107(5), F.A.C. The administrative fine imposed for this repeat violation is $1,000.00, _ oO e) Tag F314 incorporates 42° CFR 483.25(c) and Rule 59A-4.1288, F.A.C. The administrative fine imposed for this repeat violation is $2,000.00; 483,25(i}(2) and Rule ve finé imposed for this f) S9A-4. 1288, F.A.C. The adininist repeat violation is $1,000.00; g) Tag F441 incorporates 42 R 483.65(a)(1-3) and Rule 59A-4.106(3)(4)(), F.A.C. The administrative fine imposed for this repeat violation is $1, 000. 99; h) Tag F282 incorporates 42 ‘CER 483.20(k}(3) Hii) and Rule 59A-4.1288, F.A.C. The administrative fine imposed for this uncorrected violation is $1,000.00; and i) Tag F492 incorporates 42 CFR 483.75(b), Rule S9A- 4.1288, F.A.C., §400.215(2)(b), F.S. and §435.04(1), F.S. The administrative fine imposed for this uncorrected violation is $1,000.00. 8. 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 cor ee ie a bbc aaa ee: ie RE eS . Attorney, 2 a7 27 awed i of the minimum standards, rules, and regulations for the operation of a Nursing Home, NOTICE gg Teht to request an Respondent is) notilie be represented by counsel a cross-examine witnesses, to 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 2 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 allahassee, Florida 32308. All ¢ Saymen of fines should ‘be inade 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 i number and facility name that is referenced on page l of this complaint. othe Agency for: Health Care All payment of fines should b 31 orrweme ~ # & + t Deo ® 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 TH ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER i BY THE AGENCY. Issued this day of | nah Heiberg. Field Office Manger, Area #1 Agency for Health Care Administration Health Quality Assurance 2639 N. Monroe Street, Suite 208 Tallahassee, Florida 32303 CERTIFICATE OF SERVICE | HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrator, Cross Creek Nursing & Convalescent Center, 10040 Hillview Road, Pensacola, Florida 32514 on this Sxday of | re In Np 2001. (Least § Ia Christine T. Messana, Esquire - Office of the General Counsel rv] nm em em mar ahd

Docket for Case No: 01-003137