Corea ® _ “Oe 45751994 3009 Ben OR- AOR AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO. GINGER DRIVE HEALTH CARE ASSOCIATES, INC. d/b/a HERITAGE HEALTHCARE CENTER, Respondent. / ADMINISTRATIVE COMPLAINT =e ALN COMES NOW the AGENCY’ FOR HEALTH CARE ADMINISTRATION (“AHCA”’), by and through its undersigned counsel, and files this Administrative Complaint against GINGER DRIVE HEALTH CARE ASSOCIATES, INC d/b/a HERITAGE HEALTHCARE CENTER (“Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION Se AS LON 1. This is an action to assign a conditional license to Respondent, pursuant to Section 400.23(7), Florida Statutes (2001), and to assess costs related to the investigation and prosecution of this case Pursuant to Section 400.121(10), Florida Statutes (2001). A copy of the original conditional license is attached hereto as Exhibit “A” and incorporated herein by reference. JURISDICTION AND VENUE — Oe 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 S9A-4, Florida Administrative Code. 6. Respondent is a Florida limited liability company with a principal address of 1815 Ginger Drive, Tallahassee, Florida 32308. 7. Respondent is a 180-bed skilled nursing facility located at 1815 Ginger Drive, Tallahassee, Florida. Respondent is licensed by AHCA as a skilled nursing facility having been issued license number SNF12210961, certificate number 8605, with an effective date of February 01, 2002 and an expiration date of November 30, 2002. 8. Respondent 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 EFFECTIVE FEBRUARY 1, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO RESPONDENT BASED UPON THE DETERMINATION THAT RESPONDENT WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF A CLASS II DEFICIENCY DURING THE SURVEY OF FEBRUARY 1, 2002. $ 400.23(7), Fla. Stat. 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 January 28, 2002 - February 1, 2002, AHCA conducted a survey at Respondent’s facility. A class II deficiency was cited against Respondent based on the findings below: Based on record review, interview and observation, the facility failed to provide appropriate care and services to treat a probable urinary tract infection for one of thirty- four sampled residents. (Resident #21) Findings include: Resident #21 was readmitted to the facility 1/2/02 after a right above the knee amputation. Surveyor observation 1/28/02 during the initial tour at approximately 6:00 p.m. revealed the resident lying in bed, with a Foley bag hanging at the bedside. The urine in the bag was very dark, with approximately twelve inches of whitish, granular sediment completely filling the tubing. Observations throughout the day on 1/30/02, 1/31/02 and 2/1/02 revealed the Foley bag continuing to contain very dark amber urine with sediment. Record review of the physician's notes dated 1/17/02 revealed notes under Assessment/Plan: 1) Low grade fever? Secondary to UTI (urinary tract infection). Check UA (urinalysis), urine culture. Review of lab results and physician's orders since 1/17/02 did not reveal a urinalysis was obtained. The intake and output log was reviewed for January. Of all dates reviewed, no day had the total intake or output filled out. The nurse or surveyor would be unable to ascertain whether the resident had received enough fluids to ensure adequate hydration. No documentation was found to show that the facility acted on the plan from the doctor. Interview with the facility staff and the attending physician 1/31/02 at 5:30 p.m. did not reveal whether the physician gave a direct order to the nurse at that time. Review of the nurse’s notes from 1/17/02 to current revealed ongoing documentation regarding rust, cloudy or amber urine. On 1/25/02, the nurse’s notes state "Foley cath intact, draining amber urine with sediment.” Noted on 1/26/02 nurses notes was "Foley catheter draining amber urine with sediment without problems." Dark amber urine with sediment was also noted 1/27/02 and 1/28/02. A urinalysis was reordered by the physician on 1/30/02 after the surveyor brought the situation to the staff. Preliminary results 2/1/02 revealed red blood cells and white blood cells noted in the urine, and the resident was started on the antibiotic Levaquin. ll. Based on all of the foregoing, Respondent violated 42 CFR § 483.25(d)(2) via Rule 59A-4.1288, Florida Administrative Code, by failing to provide appropriate treatment and services to a Resident who was incontinent, in order to prevent a urinary tract infection. 12. Pursuant to Section 400.23 (8) (b), Florida Statutes, the foregoing is a class II deficiency because it 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. 13. AHCA assigned a conditional licensure Status to CLAIM FOR RELIEF EL EF WHEREFORE, the Agency respectfully requests the following relief; a) Make actual and legal findings in favor of AHCA on Count I. b) Uphold the issuance of the conditional license with an effective date of 02/01/02, a copy of which is attached hereto as Exhibit “a”; and c) Assess costs related to the investigation and Prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). DISPLAY OF LICENSE a in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE Respondent, Ginger Drive Healthcare Associates, LLC d/b/a Heritage Healthcare Center 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 Jodi oc, Page, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Respectfully submitted on this inl day of July 2002. C. Page Fla. Bar. No, 0174629 2727 Mahan Drive, Ms#3 Tallahassee, Florida 32308 (850) 921-6362 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE KE DERVICE I HEREBY CERTIFY that the original Administrative Complaint and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt #7106 4575 1294 2049 8804) to Ginger Drive Health Care Associates, LLC a/b/a Heritage Healthcare Center, 1815 Ginger Drive, Tallahassee, Plorida 32308, on the 11% day of July, 2002. AGENCY FOR HEALTH CARE ADMINISTRATION DLT Ie, JODI \C? PAGE, ESQUERE Fla. Bar. No. 0174629 2727 Mahan Drive, Ms#3 Tallahassee, Florida 32308 (850) 921-6362 (office) (850) 921-0158 (fax) COPIES To: Elizabeth Dudek Deputy Secretary Managed Care and Health Quality Assurance Agency for Health Care Administration 2727 Mahan Drive, M.S. #9 Tallahassee, Florida 32308 (via interoffice mail) Exhibit “a” ame At CONDITIONAL LICENSE License # SNF12210961; Certificate #8605 Effective Date: 2/01/02 Expiration Date: 11/30/02 DIVISION OF MANAGED C Change In Status ACTION EFFECTIVE DATE: 02/01/2002 sSNA LICENSE EXPIRATION DATE: 11/30/2002 EI CONDITIONAL 1815 GINGER DRIVE TALLAHASSEE, FL 32308 with 180 beds. Deputy Secretary, CARE ADMINISTRATION ARE AND HEALTH QUALITY SKILLED NURSIN G FACILITY LICENSE #: SNF12210961 ee AOL of Managed Care and Health Quality

Docket for Case No: 02-003262