FILED STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION JUN -& 02 / AGENCY FOR HEALTH CARE OePARTMENT CLERK ADMINISTRATION, Petitioner, oO vs. AHCA NO. 2002029951 ~ se CS MADISON HEALTH INVESTORS L.C., ~ d/b/a LAKE PARK OF MADISON, - = 62-2935 Bil Um Respondent. isp = oO ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against MADISON HEALTH INVESTORS L.C. d/b/a LAKE PARK OF MADISON (hereinafter “Lake Park of Madison”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This ig an action to impose a $10,000 fine against Lake Park of Madison pursuant to Section 400.102(1) (ad) and Section 400.23(8) (b), Florida Statutes (2001), baged on two class II deficiencies, and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. AHCA has jurisdiction pursuant to Chapter 400, Part II, 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 is 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 If, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I LAKE PARK OF MADISON FAILED TO DEVELOP A COMPREHENSIVE CARE PLAN FOR RESIDENT #8 THAT INCLUDED MEASURABLE OBJECTIVES AND TIMETABLES TO MEET THE RESIDENT’S MEDICAL, NURSING, AND MENTAL AND PSYCHOSOCIAL NEEDS. 42 CFR § 483.20(k) (2001) Rule 59A-4.1288 Fla. Admin. Code (2001) Rule 59A-4.109(2) Fla. Admin. Code (2001) CLASS II DEFICIENY ISOLATED 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 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 ll. On or about March 11-14, an AHCA surveyor reviewed Resident #8’s medical record. The resident has a pruritic condition (i.e., frequent scratching at arms, legs and face as a manifestation). The minimum data set dated January 30, 2002 revealed 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. 12. 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 blood from scratching. 13. 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 resident #8’s medical, nursing, and mental and psychosocial needs. 14. Based on all of 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 resident #8’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 15. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing violation is a class II violation because it compromised resident #8’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. 16. Pursuant to Section 400.23(8), Plorida Statutes, the foregoing violation is an “isolated” class II deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or in a very limited number of locations. 17. Pursuant to Section 400.23(8)(b), Florida Statutes, AHCA may impose a $2,500 fine against Lake Park of Madison for an isolated class II deficiency. COUNT IIL LAKE PARK OF MADISON FAILED TO ENSURE THAT RESIDENT #8 RECEIVED THE NECESSARY CARE AND SERIVCES TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING. 42 CFR § 483.25 (2001) Rule 59A-4.1288 Fla. Admin. Code (2001) CLASS II DEFICIENCY ISOLATED 18. 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 19. 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 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 was no prevention and treatment methods for these areas. 20. 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. 21. 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. 22. 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. 23. 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. 24. 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. 25. 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. 26. 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. 27. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing violation is a class II violation because it compromised resident #8’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. 28. Pursuant to Section 400.23(8), Florida Statutes, the foregoing violation is an “isolated” class II deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or in a very limited number of locations. 29. Pursuant to Section 400.23(8)(b), Florida Statutes, AHCA may impose a civil penalty of $2,500 against Lake Park of Madison for an isolated class II deficiency. COUNT III THE FINE AMOUNT FOR EACH CLASS II DEFICIENCY SHALL BE DOUBLED BECAUSE LAKE PARK OF MADISON WAS PREVIOUSLY CITED FOR ONE CLASS II DEFICIENCY AT A SURVEY ON OR ABOUT NOVEMBER 19, 2001. 42 CFR § 483.10(b) (11) (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) Section 400.23(8)(b), Florida Statutes (2001) 30. On or about November 19, 2001 AHCA conducted a survey at Lake Park of Madison. One class II deficiency was cited against Lake Park of Madison based on the findings below involving resident #1. RESIDENT #1 31. On or about November 19, 2001 an AHCA surveyor reviewed resident #1’s medical record. According to the nurses’ notes and hospital discharge summary dated October 31, 2001, respectively, resident #1 was admitted to Lake Park of Madison on October 31, 2001 with a diagnosis of severe closed head injury, respiratory failure, dysphagia, and blunt chest trauma with left pneumothorax and pulmonary contusion. 32. On or about November 19, 2001 an AHCA’ surveyor interviewed a CNA and licensed practical nurse (“LPN”) caring for resident #1 on or about November 2, 2001. The surveyor also reviewed the nurses’ notes dated November 2, 2001. The interviews and the record review revealed the following approximate chain of events on November 2, 2002. > 7:15 a.m.- resident #1 had a body temperature of 105.7 degrees Fahrenheit. > 10:23 a.m.- resident #1 had a body temperature of 105.1 degrees Fahrenheit. > 11:40 a.m.- resident #1 was given 325 milligrams of Tylenol for a body temperature of greater than 101 degrees Fahrenheit as ordered by the resident’s physician. > 11:55 a.m.- resident #1’s physician was paged for consultation. 10 12:30 p.m.- resident #1 had a body temperature of 105.2 degrees Fahrenheit. 3:00 p.m.- resident #1 had a body temperature of 105.1 degrees Fahrenheit. 3:30 p.m.- CNA attended to resident #1. The physician still had not responded to the 11:55 a.m. page. 5:00 p.m.- CNA attended to resident #1. 5:10 p.m.- LPN administered medication to resident #1. 6:15 p.m.- LPN suctioned resident #1. 7:30 p.m.- resident #1 was found by LPN with no respirations or pulse. Cardiopulmonary resuscitation was performed on resident #1. 7:35 p.m.- emergency medical services (“EMS”) called. 7:40 p.m.- EMS arrived at facility and pronounced resident #1 anastolic. 7:55 p.m.- physician responded to the 11:55 a.m. page. Physician said he would sign resident #1’s death certificate for 8:00 p.m. 33. Lake Park of Madison failed to consult immediately resident #1’s physician following a significant change in resident #1’s physical status. 34. Based on the foregoing, Lake Park of Madison violated 42 CFR § 483.10 (b) (11) via Rule 59A-4.1288, Florida Administrative Code, by failing to consult immediately with the resident #1’s physician when there was a significant change in resident #1’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) . 35. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing violation is a class II violation because it compromised resident #1’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. 36. Pursuant to Section 400.23(8)(b), Florida Statutes (2001) the fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. 12 37. Lake Park of Madison’s last annual inspection was on or about January, 18, 2001. 38. Based on all of the foregoing and pursuant to Section 400.23(8) (b), Florida Statutes, AHCA shall impose a total fine amount of $10,000 (($2,500 x 2) + ($2,500 x 2) = $10,000)) against Lake Park of Madison. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1) Make factual and legal findings in favor of AHCA on Counts I, II and III; 2) Impose a $10,000 fine against Lake Park of Madison; 3) Assess costs against Lake Park of Madison 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. 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 Blection 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 Cc. 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 Respectfully submitted on this 17th day of May 2002. dx C. Doane. 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 Sa ERE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9313) to Allyson Burwin, Administrator, Madison Health Investors L.c. d/b/a Lake Park of Madison, 1900 Country Club Drive, Madison, Florida 32340 and via U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 9283) 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 17th day of May, 2002. de ©. ork LORI C. DESNICK, ESQUIRE

Docket for Case No: 02-002532