~ w STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ied Article Number Arti cle Num 70h ber ADMINISTRATION, 4575 leqy 2049 75,2 Petitioner, SENDERS RECORD vs. Case No. 2002013301 LAKE CARE SYSTEMS INC., 2002003831 D/B/A EDGEWATER AT WATERMAN VILLAGE, Respondent. a ile ADMINISTRATIVE COMPLAINT a COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION go: Wd S7 rar 20 (“AHCA”), by and through the undersigned counsel, and files this Administrative LAKE CARE SYSTEMS INC.,D/B/A EDGEWATER AT WATERMAN VILLAGE INC, hereinafter referred to as EDGEWATER or Respondent, pursuant to Section 120.569, and 120.57, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against EDGEWATER, pursuant to Section 400.102, Florida Statutes, (2001) and assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Fla. Stat. (2001). al wo! JURISDICTION AND VENUE 2. This tribunal has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, (2001). 3. Venue shall be determined pursuant to Rule 28-106.27, Florida Administrative Code. PARTIES 4. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987,Title IV, Subtitle on (as amended); Chapter 400, Part II, Florida Statutes, (2001), and; Chapter 59A-4 Fla. Admin. Code, respectively. 5. EDGEWATER is a nursing facility whose 120-bed nursing home is located at 300 Brookfield Ave, Mount Dora Florida. EDGEWATER is licensed to operate a nursing facility license #1138096 At all relevant times, EDGEWATER was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I EDGEWATER failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care by failing to maintain acceptable parameters of nutritional status. 42 CFR 483.25 Rule 59A-4.1288, Fla. Admin. Code (2001) Section 400.19 Fla.Stat. (2001) Section 400.23 Fla.Stat. (2001) Class I 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. AHCA conducted survey of EDGEWATER on or about September 14, 2001. Investigation revealed a Class I deficiency. Based upon surveyor observations, staff interview and record review it was revealed the facility failed to ensure that 4 of 13 residents received thickened liquids as ordered which resulted in immediate jeopardy for one resident and the potential for harm for those other residents identified as having swallowing problems and/or risk for choking and/or aspiration. Those facts are delineated as follows: Based on observations, record review and staff interviews the facility failed to ensure that 4 of 13 residents (#'s 1, 13, 15, and 18) received thickened liquids as ordered which resulted in Immediate Jeopardy for one resident and the potential for harm for those other residents identified as having swallowing problems and/or at risk for choking and/or aspiration. Finding: ail ww 1. During tour on 9/11/01 at 12:30 PM, and again on 9/12/01 at 12:50 PM, Resident #15 was observed facing the nurse's station in the dining area of the Atlantic Unit, eating lunch. The beverages on the tray included regular consistency milk and water. The resident was attempting to drink the soup from a bowl and each time the resident sipped the soup s/he began to cough and was unable to finish the meal, there were four certified nursing assistants (CNA) present and no one attempted to assist the resident. A CNA eventually came to his assistance by patting him on the back and leaning him forward. Interview with the Unit Manager (RN) at 12:30 PM on 9/11/01, "He always coughs like that", and added, "he has a waiver". The RN explained it was her understanding the resident's family had signed a waiver for the thin liquids instead of the thickened liquids ordered by the doctor. Observations of the resident at 5:25 PM on 9/11/01, during the supper meal revealed that s/he was sitting in the same area as lunch attempting to drink soup from a bowl and milk from a glass, after each attempt the resident would start coughing and could not finish the meal, there were four CNAs present and no one attempted to assist the resident. Review of the resident's dietary card on 9/11/01 revealed that the resident was to receive honey thickened liquids. Interview with the resident's assigned CNA on 9/11/01 at 5:45 PM revealed that she had not thickened the resident's soup and had put only one pack of thickener in an eight ounce glass of milk (directions read 1 pack for every 4 ounces) the interview also revealed that the CNA did not know how to thicken the liquids. The unit manager was present when the resident was coughing and did not assist until after the surveyor requested that she call the dietitian. Interview with the dietitian on 9/11/01 at 5:50 PM (in the presence of the unit manager) revealed that the resident's soup and milk were thin liquids and not honey thickened as ordered the dietitian thickened the milk and the resident drank it without coughing. Review of the resident's Quarterly Minimum Data Set dated 6/27/01 documents the resident as needing extensive assistance with eating. Review of the care plan dated 6/27/01 revealed that the resident was to be provided a diet with honey thickened liquids. Review of the physician’s orders dated 9/1/01 also revealed that the resident's diet order was for honey- thickened liquids. Observations of the resident on 9/12/01 at 9:11 am during breakfast revealed the resident had a glass of milk on the tray without being thickened. Interview with the assigned CNA on 9/12/01 at 9:15 am revealed that she did not put the thickener in the milk because the resident's family had signed a waiver stating that no thickeners were to be added to the liquids (with which the unit manager indicated 4 —— Ne agreement). (Note: This is the same unit manager that was present during earlier observations and the interview with the facility dietician on 9/11/01.) Interview with a family member of Resident #15 on 9/12/01 at 11:00 PM revealed that they had not signed a waiver to deny the resident thickened liquids and that they were aware of the diet order for honey thickened liquids. Review of the resident's record and a request for documentation of the signed waiver did not result in the location of the document. Interview with the administrator on 9/13/01 revealed that he was informed by staff that the resident refused to drink thickened coffee and liquids. Observations of Resident #15 on 9/14/01 from 7:55-8:10 am revealed that the resident was sitting in the TV room watching the news and drinking honey thickened coffee without coughing. During the interview with the resident, the resident commented that the coffee tasted good (CNA present). 2. Review of Resident #18 therapy evaluation dated 1/10/01 revealed that the resident had swallowing difficulty and chokes on liquids and solids. Review of resident's MDS dated 7/6/01 revealed the resident triggered in nutrition and care planned on 7/12/01 for a diet that consisted of nectar thick liquids Observations of the resident on 9/12/01 at 4:50 PM during the supper meal revealed that the resident was sitting in the dining area with 16 residents and two CNAs present while s/he was eating a bowl of soup that had crackers in it. Interview with one CNA revealed that she had thickened the resident's soup with the crackers. The second CNA stated that they used thickeners, but when asked where were the thickeners the CNA had to search through the cabinets before she could locate them in a box on the top shelf. Both CNAs were interviewed together in the secured unit at 4:50 PM on 90/12/01. The interview revealed that they were aware of the resident's order for thickened liquids. The interview also revealed that they were responsible for thickening the resident's meals and had not been trained. Observations of the juice that the CNA thickened after the interview revealed that the consistency was pudding thick. During the interview with the unit manager on 9/12/01 at 5:00 PM she stated that the pudding thick liquid was OK because it would thin out when left standing. Interview with the survey team dietitian on 9/13/01 at 8:30 revealed that once the liquid melts the top portion would be considered thin liquids and that the liquids the resident received were inappropriate, placing the resident at more risk for aspiration and choking. ww ww” 3. Record review for resident #13 revealed that the resident was readmitted on 1/18/01. A Speech Therapy note dated 2/5/01 indicated that the resident was to receive "Honey- thickened liquids" as part of the restorative dining program. The resident's Care Plan dated 4/20/01 indicated that the resident was at risk for weight loss due to leaving 25% or more of meals at each meal. One intervention states, "Provide Mechanical soft diet with honey thick liquids, fortified foods once per day. Diet as ordered by M.D." The last dietary change in the resident's record (undated) indicates that the resident is to receive a regular diet, honey thickened liquids and Italian Ice to all trays, alternate bites between food and Ice. The last Speech Therapy note dated 8/29/01 indicates that the resident has profound dysphagia, feeding tube declined by family. The last dietary progress note dated 9/10/01 indicates that the diet will be continued, pureed diet, honey thick liquids continued, 2 Cal with medication passes. Suggest fortified foods twice per day along with Carnation Instant Breakfast twice a day with meals. Observation of this resident at the noon and evening meals on 9/12/01 and breakfast on 9/13/01 revealed that the resident received regular consistency Carnation Instant Breakfast. The resident's voice after drinking the unthickened liquids sounded wet and "gurgle." Interview with the CNA who served the resident's meal indicated that the resident did not want the liquids thickened. Interview with the resident's physician revealed that the physician, who had ordered the honey thickened liquids, did not know the resident's liquids were not being thickened and that the resident was not capable of making decisions about his/her care and well-being. Failure to follow the physician's orders to thicken the resident's liquids produces the increased risk of choking and aspiration while drinking. 4, Observation of Resident #1 during the noon meal on 9/11/01 revealed the resident's diet card called for Nectar-thickened liquids. Observation of the resident's tray revealed that the liquids were thickened to almost a honey consistency and that the CNA was feeding the resident the liquids with a spoon. Interview with the CNA who was feeding the resident revealed that she had followed the directions on the packet of thickener, but had not received any specific instructions in thickening liquids. The facility's failure to insure that the staff were trained and knowledgeable about how to thicken the liquids increased the potential for aspiration.and choking by residents with difficulty swallowing. 5. Random observation of the Atlantic dining area at 5:30 PM on 9/12/01 revealed the CNA thickening a glass of milk for a resident whose diet card required Nectar thickened liquids. The CNA had to ask 6 wT ~~ another CNA how muck thickener to use. While the CNA was involved thickening the milk, the resident picked up the unthickened glass of water and began drinking. The resident did not choke or cough at that time, but the resident was at risk for choking and aspiration. During this incident, the facility CDM and Speech Therapist were present in the dining room. 6. ‘Interview with the Certified Dietary Manager (CDM) on 9/12/01 at 3:10 PM revealed that thickened liquids are prepared by CNAs. "Thicken liquids are on the diet slip, the aide who serves the tray makes up the beverage." The CDM explained that the thicken liquids are made by adding packets of thickener to the beverages; for nectar consistency, 3/4 of the packet is added to 4 ounces of liquid, and 1 whole packet is added to 4 ounces of liquid for honey thickened consistency. Packets are available for nursing to provide thickening to the bedside water. The CDM stated that an in-service was held on 9/12/01 in the morning addressing thickener use. No documentation was provided to show that in-services prior to 9/12/01 had been given regarding thickener use and residents identified as needing them. The Immediate Jeopardy was removed during the survey when the facility changed the procedures for thickening liquids. 8. Pursuant to Section 400.23(8), Florida Statutes, the foregoing is a pattern” class I deficiency because more than a very limited number of residents were affected, more than a very limited number of staff were involved, the situation occurred in several locations, or the same resident or residents were affected by repeated occurrences of the same deficient practice but the effect of the deficient practice was not pervasive throughout the facility. 9. EDGEWATER failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care by failing to maintain acceptable ~~ rT parameters of nutritional status in contravention of 42 CFR 483.25., as delineated hereinabove. 10. That pursuant to Chapter 400.19 Fla.Stat. (2001) EDGEWATER is subject to assessment for a six (6) month survey cycle having been cited for a Class I deficiency. As a result a fine in the amount of $6000 is to be assessed one-half to be paid at the completion of each survey. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief:. a. Enter actual and legal findings in favor of AHCA b. Impose a $12,500 civil penalty against EDGEWATER. c. Assess the amount of $6000 is to be assessed one-half to be paid at the completion of each survey as defined by Chapter 400.19 Fla.Stat.(2001). d. Grant any other general and equitable relief as appropriate COUNT IIT EDGEWATER failed to ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in : range of motion. 42 CFR 483.25(e) Rule 59A-4.1288, Fla. Admin. Code Rule 59A-4.107(5) Fla. Admin. Code Section 400.19 Fla.Stat. (2001) Section 400.23 Fla.Stat (2001) 11. AHCA re-atleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. AHCA conducted survey of EDGEWATER on or about October 30, 2001. Investigation revealed a Class III deficiency. Based upon surveyor observations, staff interview and record review it was revealed the facility failed to follow orders for the use of a splint, increasing the risk of further loss of joint motion. The findings are delineated as follows: Observation and record review for 1 of 20 residents in the survey sample (#1) revealed that-the facility failed to follow the orders for the use of a splint, increasing the risk for further loss of joint motion. Findings: Review of the records for resident #1 revealed an order on the Physician's Order Sheet to place a splint on the resident's left wrist in the mornings and remove in the evening. The order was dated 3/2000. Observation of the resident on 9/11/01 at Noon and 4 PM; 9/12/01 at 8:30 AM, 10 AM, 4:30 PM and 6 PM; and 9/13/01 at 8 AM and 11 AM revealed that the resident was not wearing the splint. Interview with staff revealed that the resident kept removing the splint and causing scratches and skin tears on his/her arms by trying to remove the splint. The staff indicated that a discussion took place with "therapy" about not using the splint any longer, however the staff was unable to 9 — — remember when the discussion took place or provide any documentation regarding discontinuing the splint. Interview with therapy staff revealed no knowledge of the splint or it's use or discontinuation. As a result, the resident is placed at increased risk of further contractions and decline in joint motion. 13. AHCA provided to EDGEWATER a correction date of October 14, 2001, in accordance with Section 400.23(8)(c), Florida Statutes. EDGEWATER, however, failed to correct the class III deficiency by the mandated correction date and the same deficiency was discovered at the survey conducted EDGEWATER was cited for an uncorrected class III deficiency. 14, Pursuant to Section 400.23(8), Florida Statutes, the foregoing is an “isolated” class III deficiency because one or a very limited number of residents were affected, or one or a very limited number of staff were involved, or the situation occurred occasionally or in a very limited of locations. 15. That Edgewater was cited on or about date of September 14, 2001, with a Class I violation and such citing occurred subsequent to or during the last annual inspection thereby requiring that the fine be doubled pursuant to Section 400.23(8)(c)Fla.Stat. (2001). This citation constitutes a repeat violation. 16. EDGEWATER failed to provide the necessary care and services to ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 10 New ~~” acceptable parameters of nutritional status in contravention of 42 CFR 483.25 -CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: a. Enter actual and legal findings in favor of AHCA b. Impose a $1000 civil penalty against EDGEWATER. c. Impose an additional fine of $1000 pursuant to authority of Section 400.23 (8)(c)Fla.Stat.(2001) d. Assess costs related to the investigation and. .. prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001); and c. Grant any other general and equitable relief as appropriate. COUNT III EDGEWATER FAILED TO STORE, PREPARE, DISTRIBUTE AND SERVE FOOD UNDER SANITARY CONDITIONS. 42 CFR 483.35(h) Rule 59A-4.1288, Fla. Admin. Code (2001) Section 400.19 Fla.Stat. (2001) 17. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 18. AHCA conducted a survey of EDGEWATER on or about October 30, 2001. Investigation revealed a Class III deficiency. Based upon surveyor observations, staff interview and record review it was — ww revealed the facility failed to store, prepare, distribute and store food under sanitary conditions. The facts are delineated as follows: Based on observation, the facility failed to store and serve food under sanitary conditions, which may increase the risk of food borne illness. Findings: Observation on 9/11/01 at 11:20 am of the main kitchen, which cooks and supplies the food for Edgewater at Waterman, revealed the following: a.) Frozen food items stored on the floor in the freezer, and boxes within 2 inches of the ceiling of the freezer. b.) Walk in refrigerator had a 30 dozen case box of raw eggs in the shell stored in the shelf above five boxes of table ready individual . margarine cups. c.) The electric slicer, stated by the kitchen staff as being clean, still had small particles of white debris on the blade edge and deck of the slicer. d.) The ice machine had spots of black mildew type stains on the inside upper plastic molding. On top of the ice machine were two ice scoops, laid directly on the surface of the top of the machine. One the scoops was cracked and chipped from the handle area to the edge of the scoop. e.) An employees purse was found in the salad preparation area anda book with personal papers stuffed in the outside pocket was found above the clean utensil area of the cook line. f.) A cutting board stored in the rack of the clean dish area was heavily stained and had dried food adhered to it. g.) Utensils used in food preparation and serving were found stored in plastic bins. These plastic containers were filled with various scoops, tongs, spatulas, etc..., and 11 out of 11 bins held dirty, brown water residue in the bottom of each bin. h.) The dry store room had open food products with numerous flour type beetles living in a 5 pound bag of tempura batter and in a 22 pound bag of flour. The pests were found crawling in the products and dead beetles were fond on top of canisters of baking powder and on the floor. A container of cinnamon with a broken lid was found open. i.) Four large dry ingredient bins on wheels were found in the kitchen area with dried brown substances on and inside the lid and inside and outside of the bins. All four bins had scoops directly in the food products, one had a stainless steel bowl in the cornstarch and the rice had a scoop encrusted with a white powdery substance. 12 Failure to store and serve food in a sanitary manner may increase the risk of food borne illness. 19. AHCA provided to EDGEWATER a correction date of October 14, 2001, in accordance with Section 400.23(8)(c), Florida Statutes. EDGEWATER, however, failed to correct the class III deficiency by the mandated correction date and the same deficiency was discovered at the survey conducted EDGEWATER was cited for an uncorrected class III deficiency. 20. Pursuant to Section 400.23(8), Florida Statutes, the foregoing is a “widespread” class III deficiency because the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility’s residents. 21. That Edgewater was cited on or about date of September 14, 2001, with a Class I violation and such citing occurred during the last annual inspection thereby requiring that the sum doubled pursuant to Section 400.23(8)(c)Fla.Stat. (2001). 22. EDGEWATER, as a result of failing to store, prepare, distribute and store food under sanitary conditions is in violation of 42 CFR 483.35 (h). CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: a. Enter actual and legal findings in favor of AHCA b. Impose a $1000 civil penalty against EDGEWATER. c. Impose an additional fine of $1000 pursuant to authority of Section 400.23 (8)(c)Fla.Stat.(2001) d. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001); and e. Grant any other general and equitable relief as. appropriate. Dated MAY 31 “Voor Agency for Health Care Administration Ri d Jdseph Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 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) 14 LAKE CARE SYSTEMS INC.,D/B/A EDGEWATER AT WATERMAN VILLAGE 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 Richard Joseph Saliba, Esquire, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. LAKE CARE SYSTEMS INC., D/B/A EDGEWATER AT WATERMAN VILLAGE 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. Age “Ges y for cot Pe Care Administration eph Saliba, Tae _ Senior Attorney Fla. Bar. No. 0240389 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) — nd CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Administrative Complaint has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2049 7562) to LAKE CARE SYSTEMS, INC, D/B/A EDGEWATER AT WATERMAN VILLIAGE, 115 Hart Street, Niceville, Florida 32578, this 31st day of May, 2002 Agency for Health Care Administration Yad Bbon Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 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) 16

Docket for Case No: 02-002688