STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION JUN -L 02 AHCA AGENCY FOR HEALTH CARE DEPARTMENT CLERK ADMINISTRATION, Petitioner, eo _ rm vs. AHCA NO. 2002026191 «: MADISON HEALTH INVESTORS L.C., d/b/a LAKE PARK OF MADISON, Respondent. 2-3s3)e B 0D mB / ‘ s ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “AHCA”), by and through its undersigned counsel, and files this Administrative Compl aint against MADISON HEALTH INVESTORS L.C. d/b/a LAKE PARK OF MADISON (hereinafter “Lake Park of Madison”), pursuant to Section 120.569, Florida Statutes (2001), an and 120.57, d alleges: NATURE OF THE ACTION 1. This is an action to assign a conditional license to Lake Park of Madison pursuant to Section 400.23({7), Florida Statutes (2001), and to assess costs investigation and prosecution of this ca 400.121(10), related to the ge pursuant to Section Florida Statutes (2001). The original conditional license is attached hereto as Exhibit wat JURISDICTION AND VENUE 2. Thig Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. AHCA has jurisdiction pursuant to Chapter 400, Part Il, Florida Statutes (2001). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES 5. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Madison Health Investors L.C., doing business as Lake Park of Madison, is a Florida limited liability company with a principal address of 75 South Church Street, Suite 650, Pittsfield, Maine 01201. 7. Lake Park of Madison is a 120-bed skilled nursing facility located at 1900 Country Club Drive, Madison, Florida 32340. Lake Park of Madison ig licensed by AHCA as a skilled nursing facility having been issued license number SNF16360961, certificate number 8499, with an effective date of March 14, 2002 and an expiration date of August 31, 2002. 8. Lake Park of Madison is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I EFFECTIVE MARCH 14, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO LAKE PARK OF MADISON BASED UPON THE DETERMINATION THAT LAKE PARK OF MADISON WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE OR MORE CLASS Il DEFICIENCIES AT THE MOST RECENT SURVEY OF MARCH 11-14, 2002. § 400.23(7), Fla. Stat. (2001) 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. On or about March 41-14, 2002 AHCA conducted a survey at Lake Park of Madison and found two class II deficiencies. FIRST CLASS IT DEFICIENCY 11. On or about March 11-14, 2002 one class II deficiency was cited against Lake Park of Madison based upon the findings below involving resident #8. Resident_#8 12. On or about March 11-14, an AHCA surveyor reviewed Resident #8's medical record. The resident has history of a pruritic condition (1.¢€., frequent scratching at arms, legs and face as a manifestation) . The minimum data set dated January 30, 2002 yevealed that the resident had areas of broken skin and was to receive skin treatments to alleviate the condition. The current care plan, however, failed to address the prurigo areas. The care plan did not contain any prevention or treatment methods for these areas. 13. On or about March 11-14, 2002, an AHCA surveyor observed resident #8 lying in bed. The resident had a gerisleeve on one arm and kling gauze around one elbow. The surveyor observed multiple open areas on the resident’s arms, including skin tears with scabs, round scab areas (prurigo), and scars from both the prurigo and skin tears. The surveyor further observed that the linens were dotted with a dark, blood- like substance, which a nurse said was old blood from scratching. 14. Lake Park of Madison failed to develop an accurate comprehensive care plan for resident #8 by failing to include in the care plan measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. 15. Based on all the foregoing, Lake Park of Madison violated: (a) 42 CFR § 483.20(k) via Rule 59A-4.1288, Florida administrative Code, by failing to develop a comprehensive care plan for resident #8 that includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; and (b) Rule 59A-4.109(2), Florida Administrative Code, by failing to develop a comprehensive care plan for resident #8 that includes measurable objectives and timetables to meet the resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. 16. Pursuant to Section 400.23 (8) (b), Florida Statutes, the foregoing violation is a class II violation because it compromised resident #8'Ss ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well- being. SECOND CLASS II DEFICIENCY 17. On or about March 11-14, 2002, AHCA conducted a survey at Lake Park of Madison. One class II deficiency was cited against Lake Park of Madison based upon the findings below involving resident #8. Resident #8 18. On or about March 11-14, 2002 an AHCA surveyor reviewed Resident #8’s medical record. Resident #8 was admitted to Lake Park of Madison on March 11, 1997 with a history of a pruritic condition (i.e., frequent scratching at arms, legs and face as a manifestation) . A review of the minimum data set dated January 20, 2002 revealed that the resident had areas of broken skin and was to receive skin treatments to alleviate the condition. The current care plan did not address the frequent prurigo areas. There wags no prevention and treatment methods for these areas. 19. On or about March 11-14, 2002, the surveyor observed resident #8 lying in bed. The resident had a gerisleeve on one arm and kling gauze around one elbow. The surveyor observed the open areas on the resident’s arms. There were fresh scabs and healed skin tears and old scratch areas. There were also stains of dark blood-like substance on the bed linens. 20. Resident #8’s medical record contained a physician's order for Derma-Smoothe FS 0.01% Oil to be applied to affected areas every day after a bath, and a physician’s order for Temovate Emollient Cream 0.05% to be applied to spots twice daily as needed. The February and March, 2002 treatment administration records revealed that neither the Derma-Smoothe nor the Temovate Emollient Cream had been applied to the resident at all in February. As of the date of the surveyor, March 11-14, 2002, the Derma-Smoothe had only been applied to the resident’s affected areas once in March. The oil and cream is used to soothe affected areas and prevent further breakouts of "itchy" areas. 21. The nurses’ notes revealed multiple instances of observations of scratching or complaints of itching on February 10, 14, 20, 26 and March 6 and 13, 2002. The only intervention noted was the administration of Atarax. There was no documentation of topical treatments being applied to the resident’s skin for soothing. 22. On or about March 11-14, 2002 an AHCA_ surveyor interviewed Lake Park of Madison’s Certified Nursing Assistant (“CNA”). The CNA was unaware of the need to apply oil and cream to the resident’s skin. The CNA had never seen either being used on the resident. 23. On or about March 11-14, 2002 an AHCA surveyor interviewed Lake Park of Madison’s registered nurse (“RN”). The RN said she believed that the treatment nurse was to apply the oil. The RN did not know that resident #8 was not receiving the necessary skin treatment. 24. Lake Park of Madison failed to provide necessary care and services to attain or maintain resident 8's highest practicable physical, mental and psychosocial well-being. 25. Based on all of the foregoing, Lake Park of Madison violated Title 42 CFR § 483.25 via Rule 59A-4.1288, Florida Administrative Code, by failing to ensure that resident #8 received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being. 26. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing violation is a class II violation because it compromised each resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care and provision of services. 27. Pursuant to Section 400.23(7), Florida Statutes, AHCA assigned a conditional licensure status to the Lake Park of Madison based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the presence of one or more class II deficiencies at the most recent survey on or about March 14, 2002. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1) Make factual and legal findings in favor of AHCA on Count I; 2) Uphold the issuance of the conditional license, attached hereto as Exhibit “A”; 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001); and 4) Grant any other legal and equitable relief as deemed necessary in the furtherance of justice. DISPLAY OF LICENSE Pursuant to Sections 400.062(5) and 400.23(7) (e), Florida Statutes, Lake Park of Madison shall post the license ina prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE Lake Park of Madison hereby is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Lori C. Desnick, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. LAKE PARK OF MADISON IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY ACHA. 10 Respectfully submitted on this WHELAN day of May 2002. Aine C Deavncel Lori C. Desnick Fla. Bar. No. 0129542 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and the original conditional license attached thereto as Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9290) to Allyson Burwin, Administrator, Madison Health Investors L.C. d/b/a Lake Park of Madison, 1900 Country Club Drive, Madison, Florida 32340 and that a true and correct copy of the Administrative Complaint and Exhibit “A” has been. sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9306) to C.T. Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324, Registered Agent for Madison Health Investors L.C. d/b/a Lake Park of Madison, on this 17™ day of May, ee Qerrete LORI C. DESNICK, ESQUIRE CERTIFICATE #: 8499 LICENSE #: _SNF16360961 : State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY SKILLED NURSING FACILITY CONDITIONAL This is to confirm that_ MADISON HEALTH INVESTORS LLC_has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: LAKE PARK OF MADISON 1900 COUNTRY CLUB DRIVE MADISON, FL 32340 with 120 beds. Change In Status ACTION EFFECTIVE DATE: 03/14/2002 LICENSE EXPIRATION DATE: _08/31/2002 Deputy Secretary, Exhibit “A” CONDITIONAL LICENSE License # SNF16360961; Certificate #8499 Effective Date: 3/14/2002 Expiration Date: 8/31/2002 12 State of Florida Division of Administrative Hearings Sharyn L. Smith The DeSoto Building Director and Chief Judge 1230 Aplalachee Parkway Ann Cole Tallahassee, Florida Clerk of the Division 32399-3060 Cecil Howard, General Counsel Florida Commission on Human Relations 2009 Apalachee Parkway, Suite 100 Tallahassee, Florida 32301 Re: MARGIE R. ISRAEL vs. WAL-MART STORES, INC., DOAH Case No. 01-2818 Dear Mr. Howard: Enclosed is my Recommended Order in the referenced case. Also enclosed is the two volume transcript, together with the Petitioner's Exhibits numbered 1, and 3, which were admitted into evidence, and Exhibits 2, 4, 5, and 6, which were not admitted, and the Respondent's Exhibits numbered 1-5. Copies of this letter will serve to notify the parties that my Recommended Order and the hearing record have been transmitted this date. As required by Subsection 120.57 (1) (k), Florida Statutes, you are requested to furnish the Division of Administrative Hearings with a copy of the Final Order within 15 days of its rendition. Sincerely, \ y { scan HARRY L. HOOPER Administrative Law Judge HLH/cdl Enclosures ec: Denise Crawford, Agency Clerk Margie R. Israel John A. Unzicker, Jr., Esquire (850) 488-9675 + SUNCOM 278-9675 ° Fax Filing (850) 921-6847 * Fax SUNCOM 291-6847 www.doah.state.flus + E-mail Ann_Cole@doah.state.fl.us

Docket for Case No: 02-002531