LA -AFO3 — ww ' STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Certified Article Number 7306 4575 1294 2049 7951 SENDERS RECORD AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2002038731 LAKE CARE SYSTEMS INC., D/B/A EDGEWATER AT WATERMAN VILLAGE, Respondent. a oa / © un ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“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 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 RESPONDENT, 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). New" ~w 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 C (as amended); Chapter 400, Part II, Florida Statutes, (2001), and; Chapter 59A-4 Fla. Admin. Code, respectively. 5. RESPONDENT is a nursing facility whose 120-bed nursing home is located at 300 Brookfield Ave, Mount Dora Florida. RESPONDENT is licensed to operate a nursing facility license #SNF1138096 At all relevant times, RESPONDENT was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I RESPONDENT FAILED TO PROVIDE ASSESSMENT CARE AND SERVICES TO PREVENT THE DEVELOPMENT OF AN AVOIDABLE PRESSURE SORE. 42 CFR 482.25 Rule 59A-4.1288, Fla. Admin. Code (2001) Section 400.23 Fla.Stat. (2001) 6. AHCA re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. AHCA conducted survey of RESPONDENT on or about September 14, 2001. Investigation revealed a Class II deficiency. 8. Pursuant to that survey the following facts were determined, to wit: Based on observation, and clinical records review, the facility failed to provide assessment, care and services to prevent the development of an avoidable pressure sore in one (resident #5) of 20 residents reviewed. As a result, the resident is at increased risk for infection due to his/her already compromised physical condition. Findings: Review of Resident #5 medical record revealed resident was readmitted to the facility on 8/28/01 with diagnoses of Common Bile Duct Obstruction with Cholycystostomy Tube, Anasaria, Enteritis, GI Bleed, and Endometrial Cancer. The nursing home's admission assessment, dated that day, identified the resident as having "No pressure ulcers" present, continent of bowel and bladder, using pads/briefs. Review of the MDS (Minimum Data Set) dated 9/3/01 reveals resident was coded as frequently incontinent of bowel and usually continent of bladder. The RAP Summary dated 9/6/01 reveals resident "currently has episodes of incontinence”, "resident triggers for pressure ulcer r/t to poor bed mobility”, and "resident was admitted with small stage I pressure sore on coccyx and stage I's on her heels,” although the nurse's notes dated 9/6/01 at 4:10 PM described the resident's coccyx as "pink with flaky skin, " and at 9 PM as "with a small area of excoriation.” Both notes indicated that Baza ointment was applied. On 9/7/01 at 9 PM, nurse’s notes documented the coccyx as "red with two tiny open areas.” ed — Interdisciplinary Progress Notes, dated 9/8/01, 4:45 PM, dietary states, "Duoderm to coccyx. Suggest 1 scoop Pro-Powder/day. There was no documentation of toliow-up to this by nursing. On 9/8/Olat 9 PM, "DuoDerm intact to coccyx." There was no documentation of a physician's order found for the Duoderm. Observation of the resident on 9/11/01 at 11:40 AM and 1:55 PM revealed the resident lying on his/her back in the bad. Surveyor viewed the resident's pressure area at 1:25 PM on 9/11/01 revealing an open area approximately 0.5cm in diameter. Nurse's notes at 9 PM on 9/11/01 documented the area as reddened with a small (0.5cm) opening. The note states that Baza cream was again applied. The facility staff did not accurately document the development of the pressure area, possibly delaying effective treatment and increasing the risk of infection for this resident. 9, RESPONDENT failed to provide an assessment, care and services to prevent the development of an avoidable pressure sore ina Resident in contravention of 42 CFR 483.25 as delineated hereinabove. 10. Pursuant to Section 400.23(8), Florida Statutes, the foregoing is an ISOLATED ” class II deficiency because such compromises the residents 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. A class II deficiency is subjected to a civil penalty $2500 for an isolated deficiency, $5,000 for a pattern deficiency and $7500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or II deficiencies during the last annual inspection or complaints investigated since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. all wt 11. Respondent was provided with a mandated date of Correction of October 14, 2001. 12. Said violation constitutes an isolated Class II and warrants imposition of the fine of $2500. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: a. Enter actual and legal findings in favor of AHCA b. Impose a $2,500 civil penalty against RESPONDENT. c. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001); and d. Grant any other general and equitable relief as appropriate. Dated: June 18, 2002 Agency for Health Care Administration Ke 0 (phi— Richarddoseph 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) 922-5865 (office) (850) 921-0158 (fax) NOTICE 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. Dated: June 18, 2002 Agency for Health Care Administration Vo. ad (A= Richard 4dseph 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) 922-5865 (office) (850) 921-0158 (fax) ee” we 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 7951) to LAKE CARE SYSTEMS, INC, D/B/A EDGEWATER AT WATERMAN VILLIAGE, 115 Hart Street, Niceville, Florida 32578, this June 18, 2002. Agency for Health Care Administration (TEN RichardAoseph 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) 922-5865 (office) (850) 921-0158 (fax) STATE OF FLORIDA re, AGENCY FOR HEALTH CARE ADMINISTRATION, : ’ WG a wes “¢ EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES (To be used in conjunction with Election of Rights form — attached) In response to the allegations set forth in the Administrative Complaint issued by AHCA for Health Care Administration (“AHCA” or “Agency”), you must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION 2. If you do not dispute any materia! fact alleged in the Administrative Complaint (you admit each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes (2001) before AHCA. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 2 on the Election of Rights form. OPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes (2001). To obtain a formal hearing, select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28- 106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. IN ORDER TO PRESERVE YOUR RIGHT TO A HEARING, YOUR ELECTION OF RIGHTS IN THIS MATTER MUST BE DIRECTED TO AHCA BY FILING WITHIN TWENTY-ONE (21) DAYS FROM THE DATE YOU RECEIVE THE ADMINISTRATIVE COMPLAINT. IF YOU DO NOT RESPOND AT ALL WITHIN TWENTY-ONE (21) DAYS FROM RECEIPT OF THE ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ISSUED FINDING YOU GUILTY OF THE VIOLATIONS CHARGED AND IMPOSING THE PENALTY SOUGHT IN THE ADMINISTRATIVE COMPLAINT. “ ; STATE OF FLORIDA % OP AGENCY FOR HEALTH CARE ADMINISTRATION . ay RE: CASE NAME Lake Care Systems Inc., d/b/a Edgewater at wateman Village? > CASE NO. 2002038731 ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 0 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) 8 ! do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) 8 1 do dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If you choose OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. 'f you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please aiso mark this block. 8 Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT NOW -— REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address.) Respondent (Licensee) Address: License. No. and facility type: : Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Richard Saliba, Esquire, GENERAL COUNSEL OFFICE, Agency for Health Care Administration, 2727 Mahan Drive MS#3, Tallahassee, FL. 32308. Telephone Number: 850-922-5873; FAX 850-413-9313; TDD 1-800-955-8771.

Docket for Case No: 02-002903