02-3 Nov-26~2001 10:25am From 1-782 P.001/001 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. VANTAGE HEALTHCARE CORP., d/b/a DESTIN HEALTH & REHAB, Respondent. AD. RAT 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 $4,000.00 upen Vantage HealthCare Corp., d/b/a Destin. Health & Rehab ("Destin"). As grounds for the impasition of this administrative fine, the Agency alleges as follows: l. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part 1, Florida Statutes. 2. Respondent, Destin, is licensed by the Agency ro operate a mursing home at 195 Mattie M. Kelly Boulevard, Destin, Florida 32541 and is obligated to operate the nursing home in compliance with Chapter 400 Part I, Florida Statutes, and Rule 59A-4, Florida Administrative Code, F981 wwe a Skok kk rR enn seensienseeeee Nov-25-200] 09:40am From - T-781 P.002/020 Fag 3. On April 3-6, 2000, @ Survey team from the Agency’s Area ] Office conducted a re-certification survey and the following Class It deficiencies were cited, 3A. Pursuant to 42 CFR 483.13(C)(1)(i), the faciliry must develop and implement written Policies and Procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This requirement was not met as evidenced by the following observations: as a result of the employee inaccurately recording the attestation of residency documentation. The employee's employment application indicated employment outside the State of Florida within the past 5 years. (2}. Based on record review and interview, it was determined that the facility violated 42 CFR 483.13(C)(1)qi), and Section 400.2 15(2)}(b), FLORIDA STATUTES, (2000)., for failing ta implement written policies and procedures for ; backgreund seteening for new employees for 1 of 7 personnel records reviewed. (Tag F226) 3B. Pursuant ta 42 CFR 483.20(b), a facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument {RAI} specified by the State. This requirement was not met as evidenced by the fallawing observations: Ql) Resident #15, was admitted ta the facility on January 3, 2000, with multiple medical diagnoses including in part supernuclear palsey. The comprehensive assessment dated January 16, 2000, coded the resident as having a regular bowel pattern with no concems. On March 21, 2000, the resident was disimpacted of a large amount of firm hard eee “ Nov=28~2001 08:40am From T-781 P.003/020 F989 eto stool. Following the disimpaction, the resident developed rectal bleeding requiring transfer ta the hospital emergency department where more stool was expelled and the resident suffered hypotension, bradycardia and a diminished respiratory rate. The resident subsequently was admitted to | intensive 'care prior to returning ta the nursing home on March 27, 2000. On April 3, 2000, a new comprehensive assessment was completed on this resident. The assessment coded the resident as having been constipated, however, there was no coding for fecal impaction within the last 14 days, placing this resident at risk for further fecal impactions. (2) Based on observation, record review and interview, it was determined that the facility vialated 42 CFR 483.20{b), and Rule 59A-4.1288, F.A.C., for failing to make a comprehensive assessment of a resident's needa to include the health care needs for 1 of 25 sampled residents. Additionally, the facility did not provide therapeutic and rehabilitative services consistent with the resident care plan, established and recognized Practice standard within the community, and with rules adopted by the agency, as required by section 400.022, Florida Statutes, (2000). (Tag F272) 3C. Pursuant to 42 CFR 483.25(c), based on the comprehensive assessment of 2 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 Soares receives necessary treatment and services to promote healing, prevent infection and prevent new sores fram developing. This requirement was not met as evidenced by the following observations: (1) During the initial tour of the facility, resident # 4 was identified by facility staff as having terminal cancer, a "Stage IV plus (unstageable pressure sore on her coccyx and was currently under the care of hospice. Review of the resident's clinical record revealed that the resident received antibiotic treatment for infection related to decubitus from February - Nove26=2001 08:40am 3D. that each resident receives adequate supervision and assistance devices From T-781 P.on4/o20 21, 2000 to March 3, 2000. Assessment by facilicy staff and - observations during the Survey revealed that the resident generally left 25% or more of her meal uneaten. Farther review of the resident's clinical recard revealed @ Mhutritional assessment and note by the facility's registered dietitian on December 8, 1999 which read “open area to caccyx" and recommended adding a mult-vitamin/mineral supplement, 500 mg. of Vitamin C twice a day, and 2 ounces of 2Cal HN with medication pass four times a day for the purpose of improving the resident's nutritional status and promoting wound healing. There was no evidence that any of these recommendations had been implemented at the time of the survey. Interview with facility staff revealed that the recommendations were never made to the resident's hospice treatment team or physician and on April 4, 2000, the recommendations were made and orders were received to begin the nutritional supplements in order to aid in the treatment of the pressure sore. (2]}. Through observation, interview and record review, it was determined thar the facility violated 42 CFR © 483.25 (c)(1}(2), and Rule 59A-4.1288, F.A.C., for failing to provide the necessary treatment and services to prevent the develapment of pressure sores and Promote healing and Prevent infection for residents with pressure sores for 1 of 24 sampled residents. Additionally, the facility did not provide therapeutic and rehabilitative services consistent with the resident care plan, established and recognized practice Standard within the community, and with rules adopted by the agency, as required by section 400.022(1}() Florida Statutes, (2000). (Tag F314) Pursuant to 42 CFR 483.25(hi(2), the facility must ensure to prevent accidents. This requirement was not met as evidenced hy the following observations: (1) Resident #16 was admitted to the facility on January 3, 2000 with multiple medical diagnoses, including Exptrapyramidal syndrome, Progressive Supernuclear Palsey, Trans-ishemic attacks, cataracts, and a history of falls with head injuries. The resident was initially assessed as cognitively impaired with dementia, and ag needing F989 assistance with transfers and ambulation. A problem Stated 4 cca ANiiilnstememnadare=— * Nov-26*200) 00:40am From- 7-781 — P.005/020 in the plan of care developed January 18, 2000: “forgets Safety measures to prevent falling, and is at risk for injury related to falling." A goal for this problem was that the resident would cause no harm or injury to self. Interventions included educating the resident of safety measures to use, provide a quiet and unhurried environment, and to orient the resident to various areas in the facility. Record review revealed the resident fell 7 times in January, on the 10%, 11%, 16%, 19%, 234 97% and 28%, 2000, twice sustaining a "lump" on the left forehead. In February, the resident fell 9 times on February 18%, 2000 twice on February 4%, 8th, 15m, 16%, 18, 22nd, and 25t, 2000; once sustaining a "left frontal hematoma’. Eight of the resident's falls occurred in the resident's room. On February 29, 2000, the resident's plan of care was revised ta include the use of a lap buddy due to the resident's inability to perceive safe/unsafe situations. The goal stated was for the resident to have no falls with injury and to replace the lap buddy with a “break away’ lap buddy. Interventions were revised to include encouraging activity and mild exercise daily and to keep him/her under sUpervision at alj times. Record review revealed thar on April 1, 2000, the resident was found on the floor by the bed with a laceration and hematoma to the back of the head. The tabs monitor was attached, but did nor alarm. On the second day of the survey, April +, 2000, after supper, the resident was retuumed to the day room by staff. Shortly after being placed in the. day room, the resident fell forward out of his/her wheelchair, striking the front, left side of his/her head. Interview with staff revealed the resident had been returned to the day room without the lap buddy. Observation of the resident pn April 5 and 6, 2000, revealed a larger purplish and green bruised knot to the left forehead. This resident had fallen eighteen times since admission to the facility in January. (2} Resident #5 was admitted to the facility on February 10, 2000 with diagnoses of malnutrition, diahetes, chronic ischemic heart disease, depression, and chronic liver disease. His initial assessment completed on February 24, 2000 indicated that he had suffered a fall within the past 30 days and the resident was determined to be at risk for falls due to his unsteady gait, decreased cognition, and an inability to always remember safety concerns, Interventions established to help prevent “falls with injury in the next 90 days" included: F-989 Sk it ee a a ea ee + Nov-26+2001 08:41am Frome - T-781 -P.006/020 F989 encouraging resident to call for assistance before a. transferring; b. non-skid soles for his shoes: c. | have call light available and answer promptly; ad. keep bed in low pasition; e. keep pathways clear of chatter and well lit; f. tehab for evaluation of unsteady gait: g. assist resident to walk daily at least after each meal; and h. the red dot fall prevention Program, a means of identifying to staff those residents that are at risk of falling. (3) Review of facility accident log revealed that from February 10, 2000 through March 17, 2000, the resident experienced eleven falls, occurring in his bedroom, bathroom, the nursing station, hallway, and unit day room some resulting in skin tears and hematoma of the head. Purther review of facility records revealed that the resident was assessed by physical therapy on March 6, 2000 and PT services were provided from March 6-19, 2000, at which time the resident no longer agreed to Participate in therapy or a functional maintenance plan for strengthening in ambulation, There was no evidence that the interventions established for this resident had been re-assessed or modified during the time that he was experiencing numerous falls. Review of the minutes of the Risk Meeting held on March 30, 2000, indicated that a TABS monitor had been placed on the resident when in bed and wheelchair in order to prevent him fram continuing ta fall. Observations on April 3-5, 2000 revealed that the resident was taken to and from meals in the restorative dining room in his wheelchair and Spent a large part of the day in his room in bed sleeping or watching TV with no TABS monitor in place. (4) Based on observation and record review, it was determined that the facility violated 42 CFR 483.25(h)(2}, and Rule 59A-4.1288, FA.C., for failing to provide adequate supervision and assistive devices ta prevent accidents for two of 24 sampled residents. Additionally, the facility did not provide therapeutic and rehabilitative services consistent with the resident care plan, established and recognized practice standard within the community, and with rules adopted by the agency, as required by section 400.022(1}{1), Florida Statutes, (2000). (Tag F324) , Nov-26¢2001 O8:4)am = From- - 1-781 P.007/020 4. On February 19-22, 2001, a survey team from the Agency’s Area 1 Office conducted a re-certification survey and the following repeat Class III deficiencies were cited, and two repeat Class I! deficiencies that were classified as Class [II the year prior (Tags F314 & F324, see paragraphs 4C & 4D}: 4A. Pursuant to 42 CFR 483.13(C)(1)(i), the facility must develop and implement written policies and precedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This requirement was not met as evidenced by the follawing observations: (1) Review of facility policy on February 22, 2001, regarding the screening of employees prior to employment for possible abuse related offenses revealed the following procedures: a. A thorough investigation of the potential employee's past history through a check of all Telerences to make a reasonable effort to uncover information about past criminal prosecutions. b. A criminal background check will be completed on all associates. {2} Furthermore, a “Background Investigation Policy" . pertaining to Level 1 and Level 2 Screening stated the following: a. For Level 2 Screening: 1. "Fingerprints will be required of employees who have not resided in the State of Florida for the past five years. The fingerprint card will be given to the employee at the time of drug screening and will be sent to AHCA within 5 days of hire date. Copies and results will be retained in personnel file." April, 2000 F-988 SRE Pre emer re tee a he 4B. a . Nov-26-2001 08:42am From * 7-781 = P.008/020 (3) On February 22, 2001, review of the personnel files of six randomly selected employees listed as new hires by facility staff revealed the following: a. An employee hired on July 28, 2000 requiring a Level 2 background screen did not have the fingerprints and request for Level 2 screening submitted to AHCA until September 14, 2000, 49 days following employment. b. An employee’ hired on October 9, 2000 had evidence of a potentially disqualifying offense on the FDLE backgraund = screen completed prior tao employment (October 2, 2000). Record review and interview with facility staff on February 22, 2001 revealed no evidence corporate personnel had made an effort to investigate the full nature of the criminal eharge in order to determine the employee's eligibility for hire. (4) Based on interview with staff and record Teview, it was determined that the facility violated 42 CFR 483.13(C}(1)(i), and Section 400.215(2)(b), Florida Statutes, (2000), and Chapter 435.03, 435.04, Florida Statutes, {2000)., for again failing to implement facility policies regarding pre- employment background screening for 2 of 6 personne} records reviewed. (Tag F226, Repeat) Pursuant to 42 CFR 483.20(b), a facility must make a comprehensive assessment of a residents needs, using the resident assessment instrument (RAI) specified by the State. This requirement was not met as evidenced by the following observations: (1) Observation of resident #14 an February 21, 2001 ar 3:00 p.m. and on February 22, 2001 at 9:20 am. revealed an alert resident making choices about daily life, ambulating around the facility and caring for her personal needs. Interview with staff at 8:45 a.m. on February 22, 2001 revealed the resident was independent with toileting during the day but chose to wear an adult diaper during the day for dignity due to stress incontinence. Staff said the resident was occasionally incontinent at night. Nursing notes dating back to early January describe the resident as “usually” F988 — OER NT FORT TEE ET RT RE RE wom oe evans nsessaanashtenesanuemnee— ‘Nov~26+2001 08:42am = From- T-781 = P.009/020 continent or continent but dribbles during the day and wears depends. (2) The most recent resident minimum data set (assess: t toal) dated February 2, 2001, assessed the resident as incontinent. The lack of a comprehensive assessment for continence resulted in a care Plan that did not address all needs of the resident. (3) Observations of resident #7 on February 19-22, 2001, revealed the resident to be up in a wheelchair, independently arranging personal items anid feeding herself without assistance. When interviewed, the resident was appropriate and pleasant. Review of the clinical recerd revealed minimum data sets from May 22, 2000 through January 8, 2001, which indicated an assessment of the resident ag being totally continent of bowel and bladder at all times. Nursing notes were found to address episodes of incontinence on many occasions during the day as well as at night, with incontinence care provided by staff. A “Problem Summary” found in the medical record included a statement with an “original date" of January 3, 2001, which read: “The resident is at risk for UTI and skin breakdown due to frequent urinary incontinence during the night’. {4) The incontinence needs of the resident were added to the resident's plan of care on January 3, 2001, 5 days prior to the mast recent minimum data set assessment indicating the resident to be totally continent. (5) Resident #17 was admitted to the facility on December 12, 2000 and had Minimum Data Set (MDS) assessments completed on December 20, 2000 and January 30, 2001. Review of these assessments on February 21, 2001 revealed documentation regarding the resident's sleep habits indicating no problems with insomnia or changes in sleep pattern over the previous 30 days. Facility staff, however, obtained an order on January 23, 2000 for the PRN {as needed) use. of Ambien, 5-10 mgs each evening. Review af documentation by the facility psychiatrist on January 31, 2001 revealed the resident had a “chronic Insomnia disarder, noted on admission”. At the time of the survey, use of this sleep aid was documented on the resident's Medication Administration Record as having been given all but one evening between January 23, 2001 and February 20, 200]. Further review of the clinical record revealed no additional F989 ee 4c. ee “Nov-26=2001 08:42am rom T-781 P.o10/020 evidence of an accurate assessment of the resident's sleep habits. (6) Based observation, interview with staff and record review, it was determined that the facility violated 42 CFR 483,20(b), and Rule 59A-4.109(1)(c}, F.A.C., for again failing te make a comprehensive accurate assessment to address a resident's necds using the State Resident Assessment Instrument (RAI) for 3 (#7, #14, #17) of 22 sampled residents. Additionally, the facility did not provide therapeutic and rehabilitative services consistent with the resident care plan, established and recagnized practice standards within the community, and with rules adopted the agency, as required by section 400.022(1)(l), Florida Statutes, (2000). (Tag F272, Repeat) Pursuant to 42 CFR 483.25(c), 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 rece@ives necessary treatment and services to promote healing, prevent infection and prevent new sares fram developing. This requirement was not met as evidenced by the following observations: (1) Observation of resident #5, during the initial tour af the facility ar 10:45 a.m., on February 19, 2001, revealed the resident to be in bed, lying on the lefr side, clothed in a hospital gown. and an E-Z boot on the left foot. The resident's skin appeared pale with slightly dry skin on the forearms only, but with good turgor. A foley catheter . Attached to bedside drainage was in place. The nurse stated that the resident had a stage IV decubitis to her coccyx and @ stage I to her left foot. She also stated that the resident “eats like a little pig”. Observation at that time revealed a Jarge dressing to the coccyx, the left heel was covered by a dressing and E-Z boot, and the right heel was bright pink and mushy to touch. Observation on February 19, 2001, at approximately 2:00 p.m., during dressing change ta the caccyx revealed a very deep open wound surrounded by 19 F089 SET RE Te ron or ee oe ed otas “Wov-26-2001 08:42am Frome TT eeeerennenehetmhietemnetec- T-781 P.O1/o20 Fege9 bright pink tissue. The Opening was at least 2 1/2 to 3 inches around and with depth enough to expose beefy-red deep muscle tissue. The dressing included packing the area with several 4X4 gauze pads before covering the area. {2} Review of the resident's clinical record Tevealed thar at the time of admission on Seprember 8, 2000, the resident had intact skin, with only bruises on one hand. Admitting diagnoses inchided in part, Alzheimer’s, incontinence and Possible concussion. The resident was decumented as being alert and requiring moderate assist of one person for transfers. The resident's original assessment on September 20, 2000, identified her as being at risk for pressure sores. Qn November 4, 2000, bilateral heel blisters were identified, and the approach documented to Prevent further hreakdown Was to pro 8, 2000, Pp the heels on a pillow. Nurses notes of November reveal a 4.8 om x 4.1 cm Stage I decuhitis to the ' corcyk, The center of the area contained al om-x 1 cm area that was yellow and spongy. On November 10, 2000, the area is documented as increased in size with an papen center 2.4 cm x* 2.7 cm, yellowish Weeping drainage. New orders were obtained for the resident to be up in the wheeichair for short times, EZ boots and a fcley catheter. The facility decuhbitis report of February 21, 2001, states the decubitus To be a Stage II ta the coccyx, 6.2 em x 4.7cem x 1.3 em. deep, and as being originally identified on November 22, 2000. (8) The original plan of care dated September 21, 2000, included interventions of: a b. . ec keep the bed clean and dry; routine skin inspections; ; perineal skin inspected with each incontinence check; Protective barrier cream used to prevent any breakdown in perineal area: tam and reposition every two hours and as needed; to promote good nutrition and adequate fluid intake; encourage resident to be up and out of bed in wheelchair throughout the day = with repasitioning to change pressure points when in wheelchair. 1 PIE rag george coe ee REET Petree “Nove26"2001 08:49am Frome (4) nsession 1-781 P.012/020 F888 The current plan of care in the record included new interventions of: following physician's orders for wound care; documenting changes and reporting to the physician; measure changes; EZ boots; heels floated; hospice referral; and air mattress. op mop ap (5) No date of the addition of the new approaches was contained in the medical record at the beginning of record review. After being interviewed by the surveyor on February 20, 2001, the RN Supervisor added dates to the care plan. (6) During all three-meal Observations, supper an February 19, 2001, breakfast on February 20, 2001, and hinch on February 20, 2001, the resident was in bed and fed by staff. The resident ate 80 ta 100% of all three meais. During medication pass observation on February 21, 2001, at 8:45 am., the resident drank 2 cups of water, with the nurée stating “She loves to drink water’... (7) Interview with nursing management staff on February 20, 2001, revealed that the facility staff “had no idea” why this resident developed Stage Il and Stage IV decubiti, (8) Review of the clinical record for resident #13 revealed that the resident wag re-admitted to the facility on October 24, 2000 following a brief hospitalization for a fractured hip. In addition to the Fractured Femur, Tibia/Fibula, his/her diagnoses: inchided Osteoarthritis, Senile Psychotic Condition and Peripheral Vascular Disease. Prior to transfer to the hospital on October 16, 2000, the resident had been assessed as being at risk for skin breakdown que to “howel incontinence and dependence on staff for bed mobility’. Interventions developed to help prevent skin breakdown included: scheduled toileting every two hours, call light within reach, incontinence Care as needed, observe for UTI (urinary tract infection}, monitor skin for Signs and symptams of breakdown, turn every two hours, pillows for wedges, and use of non-drying soap. Documentation in the Nursing Progress Notes revealed that on October 28, 2000, four days after re-admission, a “large broken blister noted to left heel” and on November 1, 2000, “new blister identified, to R (right) heel 5cem X 3 em, intact, tx (treatment 12 RRR IOUN mae MRO FRET ee are ee ve ee Nov-26<2001 08:43am = From: T-781 -P.013/020 F~989- started...5tarted E-Z Boats for protection”. A Minimum Data Set (MDS) assessment completed on the resident on February 8, 2001 indicated that the resident had two Stage Hf pressure sores on the left and right heels. Even though the resident had been assessed as being at risk for skin breakdown, peripheral vascular disease was never addressed as @ potential cause and ageressive/appropriate preventive measures and care specific to the vascular insufficiency was hat provided until after pressure sores developed on both heels. (8) Based on observation of 22 sampled residents, clinical record reviews and interviews with staff and caregivers, it was determined that the facility violated 42 CFR 483.25(c)(1)(2), and Rule 59A-4.1288, F.A.C., for again failing to ensure that 2 residents who entered the facility without pressure sores (residents #5 and #13), did not develop’ pressure sores. Additionally, the facility did nor provide therapeutic and rehabilitative services consistent with the. resident care pian, established and recognized practice Standards within the community, and with rules adopted by the agency, as required by section 400,022{1)(l), Florida Statutes, (2000). (Tag F314, Repeat) 4D. Pursuant to 42 CFR 483.25(h){2), the facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This requirement was not met as evidenced by the following observations: {1} Review of the clinical record for resident #13 revealed the resident sustained a fall on October 16, 2000 resulting in a fractured right hip. The current plan of care for thia resident identified him/her as being at risk for falls as far back as April 18, 2000 due to “decreased cognition and impetuosity, history of falls, and no safety awareness”. The following preventive measures were developed: Red Dot fall prevention program: TABS monitor; bed in lowest position; call bell within reach; and observe reaction to psychaactives, PRP orp LALLA - Nov-26*2001 08:43am From, T*7Bl P.014/020 F989 (2) Available documentation at the time of the survey regarding details of the resident's fall revealed he/ahe fell from a wheelchair and was found by facility staff on the floor of the small dining room, located in the Tear of the facility. The fall was not witnessed by anyone. There was no evidence thar facility staff were supervising residents in the small dining room at the time of the fall or that the resident had a TABS monitor attached which would have alerted staff to the resident's attempt to stand. (3) Resident #9 was originally admirted to the facility on August 25, 1995. Included in the admission diagnoses were Alzheimer’s Dementia and Presenile Organic Psychotic Conditions. The resident is currently assessed as severely impaired cognitively and totally dependent on staff for all areas of care. The current record reveals the resident to be assessed as high risk for falls due ta taking Risperdal and Remeron, poor sitting halance and seizure disorder, and poor cognitive status. Approaches in the plan of care to prevent falls include to observe the resident closely and to follow the facility red dat fall prevention program, with the last revision dated January 29, 2001. Observation of the resident on February 22, 2001, revealed the Tesident to have a large Taised area to the right side of the forehead with discoloration surrounding it and extending down the right side of the face to the neck. Interview with staff and record review revealed. that the resident was found on the floor in the dayraom at 11:59 a.m. on February 12, 2001, and at the time no injuries were apparent. The documentation regarding the fall states the resident “apparently fell forward out of her wheelchair’. Upon further review, it was ‘determined the resident experienced a fall forward out of her - wheelchair in the day roam on September 13, 2000 ar 5:13 p.m. The resident sustained injuries of lacerations ar that time which required application of steri Strips, dressing and ice packs for swelling. Record review and interview with staff revealed no evidence that the facility was providing close supervision of this resident at the time of either documented fall. (4) Based on observation and record review, it was determined that the facility violated 42 CFR 483.25{h)(2), and Rule 59A-4.1288, F.A.C., for failing to pravide adequate supervision and assistive devices ta Prevent accidents for twa of 24 sampled residents. Additionally, the faciliry did not Provide therapeutic and rehahilitative services. consistent with the resident care plan, established and recognized 1g Sali dB a a ak a ae * Nov-26-2001 09:44am Fron T-781 —-P.015/020 practice standards within the community, and with rules adopted by the agency, as required by section 400.022(1}(}), Florida Statutes, (2000). (Tag F324, Repeat) 5. Based on the foregoing, Destin has violated the following: a) b) c) a) Tag F226 incorporates 42 CFR 483.13(C}{1)(ij, section 400.215(4)(b}, Florida Statutes, (2000) section 435.03, 435.04, Florida Starutes, (2000), and rule 89A-4.1288, Pla. Admin. Code. The administrative fine imposed for this repeat violation is $1,000.00; Tag F272 incorporates 42 CFR 483.20(h) and rules 59A-4.109(1)(c) and S9A-4.1288, Fla. Admin. Code, The administrative fine imposed for this repeat viglation is $1,000.00; Tag F314 incorporates 42 CFR 483.13(C)(1)(i), section 400.022(1){)), Florida Statutes, (2000).section 435.03, 435.04, Florida Starutes, (2000) and mile 59A-4.1288, Fla. Admin, Code. The Administrative fine impased for this repeat violation is $1,000.00; and Tag F324 incorporates 42 CFR 483.25(h}(2), section 400.022(1)(l), Florida Statutes, (2000), and Rule 59A- 4.1288, FAC, The Administrative fine imposed for this repeat violation is $1,000.00. for the abovementioned violations. 6. The above referenced violations constitute grounds to levy this civil penalty for repeated violations pursuant to section 400.23(8)(c), Florida Statutes, (2001). Under rule 5S9A-4.1288, Florida Administrative Cede, the above referenced conduct of Respondent constirutes a violation of the minimum standards, miles, and regulations for the Operation of a Nursing Home. Further, pursuant section 400.102(d), Flarida Statutes, (2000), Respondent’s conduct constitutes a violation of the provisions of this part, or rules adopted under this part. 15 F088 COREE RE REET RE PRR ere “Nov-26-2001 08:44am = From T-781 = P.O16/020 «= F~989 OTIC: Respondent is notified that it has a right to request an administrative hearing pursuant to sections 120.57 and 120.569 Florida Statutes, to be represented by counsel (at its expense}, to 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. tn order to obtain a formal proceeding under Section 120.57(1), i Florida Statutes, Respondent’s: request must state which issues of material fact are disputed. Failure to dispute material issues of fact in Saree Ce weer the request for a hearing, may be treated by the Agency as an election by Respondent for an informal praceeding under Section 120.57(2), Florida F Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: Diane Grubbs, Agency Clerk, Office of the General Counsel, 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 paymenr of fines should be sent to the Agency for Health Care Administration, Attention: Gloria Collins, Finance & Accounting, 2727 Mahan Drive, Mail Stop #14, Tallahassee, Florida 32308. 16 Steyr pee epee pee ‘Nov-26-2001 08:45am = From T-781 P.o17/020 F-S88 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 THE AGENCY. Issued thigZOtday of A) oueuslae,2001. _ Christine T. Messana, Esquire Senior Attorney Agency for Health Care Administration General Counsel’s Office 2727 Mahan Drive, MS#3 Tallahassec, Florida 32308 CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that the original complaint was sent by Certified U.S, Mail, Return Receipt Requested, to: Administrator, Destin Health & Rehab, 195 Mattie M. Kelly Boulevard, Destin, Florida 32541 on this¥a¢uday of KT asse oa bo im, 2001. Christine T. Megsana, Esquire Office of the General Counsel Copies furnished to: Elizabeth Dudek, Acting Deputy Secretary. Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403 17 ‘Nov-26-2001 09:48am © Frome # « Donah Heiberg Field Office Manger, Area #1 Agency for Health Care Administration Health Quality Assurance 2727 Mahan Drive, Bldg. 2, MS#46 Tallahassee, Florida 32308 Gloria Collins, Finance & Accounting Long Term Care Unit rte T-781 P.018/020 F-989 epee oe

Docket for Case No: 02-000048