pivced STATE OF FLORIDA Ww AGENCY FOR HEALTH CARE ADMINISTRATION en "2p a AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, va. Case No. 2002045196 EMERALD SHORES HEALTH CARE ASSOCIATES, LLC d/b/a EMERALD SHORES HEALTH AND REHABILITATION, Respondent. ADMINISTRATIVE COMPLAINT comes NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against EMERALD SHORES HEALTH CARE ASSOCIATES, LLC d/b/a EMERALD SHORES HEALTH AND REHABILITATION (“Respondent”), pursuant to sections 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to upheld Respondent’s conditional licensure status. JURISDICTION AND VENUE 2. This tribunal has jurisdiction pursuant to sections 120.569 and 120.57, Florida Statutes. 3. Venue shall be determined pursuant to Rule 28- 106.207, Florida Administrative Code. LAGB9TL8eS5R8=a1 OSHUOHS GAIVUYANA SAUOHS GQIVUINA SE:aT ZH-So0-s8ea 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, and; Chapter 59A-4 Fla. Admin. Code, respectively. 5. Respondent is a skilled nursing facility in the State of Florida, whose 77-bed nursing home is located at 626 North Tyndall Parkway, Calloway, Florida 32404. Respondent is licensed as a skilled nursing facility license #SNF1292096, certificate number 8823 effective June 6, 2002. Respondent was at all times matexial hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. Count I TYE FACIDITY FAILED TO DEVELOP COMPLETE AND ACCURATE CARE PLANS FOR 6 oF 19 SAMPLED RESIDENTS. 42 CFR 483.20(kK); Section 400.23(7) (B), Fua. STAT. ; SECTION 400.23 (8) (Bs), FLA. STAT.; RuLE S9A-4.106(4) (v), Fua. ApMIN. CODE; RULE 59A-4.109(2), AND; RuLE 59A-4.1288, FLA. ADMIN. CODE 6. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) as if fully set forth herein. bivsed L9SIGTL80SS8=aI OSMUOHS GIVUANA SAUOHS CIVUAHA @e:at 28-58-86 7. BHCA surveyors conducted a survey of Respondent’s facility on June 6, 2002. staff interview, record review and surveyor observation brought to light the following: a. Record review of Resident #3’s record showed the resident went from 133.7 pounds in November of 2001, to 90.2 pounds December 20, 2001. No plan of care for weight loss was developed or implemented despite the resident’s heightened risk. The resident came back from the hospital February 9, 2002 with a gastrostomy tube for feeding. b. Review of the clinical record for Resident #5 indicated a diagnosis that included: 1. Alzneimers 2. legal blindness 3. agitation 4. anxiety, and: 5. constipation. Resident Assessment Instrument dated 11/15/01 reflected severe cognitive impairment, and inability to make needs known or communicate, and total dependence for all care. A fall risk assessment completed 11/5/01, assessed the resident as being his risk for falls. The resident’s bed was observed to be a mattress placed on the floor, with no frame or rails. The interventions stated in the plan of care for this blind and severely impaired resident are 3 virsrad LIG9TLB8eo8=dal OSHUOHS GIVUAWNA SHUCHS CIVUANA Gaizt zZ8-59-80 not appropriate to meet his/her needs. co. Review of the record for Resident #7 indicated the resident suffers from moderate pain @aily. However, this resident’s plan of care did not address the need for pain management through individualized assessment, interventions or goals. d. Record review for Resident #8 showed the resident suffers from less than daily moderate pain. The resident is given Hydrocodone every six hours. However, pain management was not addressed in the care plan dated 3/8/02. The resident was incapable of being interviewed. e, Surveyor record review of Resident #4 revealed resident was continent of bowel and bladder on 9/7/01 but had become incentinent of bowel and bladder by 3/12/02. No evidence could be found indicating that the facility had addressed this problem in this resident’s plan of care. £. Record review of Resident #2 showed the resident uses a wheelchair for all locomotion. Review of the plan of care indicated the resident should be assisted with walking, which does not reflect the current state of the resident. 8. Respondent’s failure to develop complete and accurate care plans for residents is a violation of 42 CFR 483.20(k). 9. Respondent’s failure to develop complete and accurate care plans for residents is a violation of Rule 59A-4.106(4) (v), bissbd L989TL80S8=da1 OSHSUOHS CDIVUANA SAUYOHS GIVUEWNA O2:2T 2A-Ge-se Fla. Admin. Code. 10. Respondent’s failure to develop complete and accurate care plans for residents is a violation of Rule 59A-4.109(2), Fla. Admin. Code. 1L. Respondent’s failure to develop complete and accurate care plans for residents is a violation of Rule 59A-4.1288, Fla. Admin. Code. 12. Respondent’s failure to develop complete and accurate care plans for residents is a class It deficiency as defined in section 400.23(8) (b), Fla. Stat. 12. The above constitutes grounds for the imposition of conditional licensure status, pursuant to section 400.23(7) (b), Fla. Stat. Count It THe FACILITY FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS. 42 CPR 483.25(H) (2); Sucrron 400.23(7) (3), FLA. STAT.7 SeeTron 400.23(8) (B), Fuaa. STAT., AND; Rube 59A-4.1288, Fa. Apmin. CODE 14, AHCA re-alleges and incorporates by reference paragraphs (1) through (13) as if fully set forth herein. 15. AHCA surveyors conducted a survey of Respondent’s facility on June 6, 2002. Staff interview, record review and surveyor observation brought to light the following: a. Record review of Resident #5's record revealed the 5 vi7ged 29090 T280S8=a1 OSSUOHS GIVUANA SAUOHS AIVUANA Gaiat z26-S98-880 resident to be a high risk for falls. The initial Resident assessment Instrument reveals the resident to be severely cognitively impaired, unable to understand or make self understood, severely impaired visually, and totally dependent on staff for all activities of daily living. The original written plan of care for resident #5 states the resident has a problem of “constantly sitting up and falling {their selves} back” and “patient was found banging his/her head on the rails and padded wall.” Facility records dated 1/9/02, 2/3/02, and 5/21/02, show recommendations for a safety helmet to prevent injury. Review of the clinical record on 6/5/02 revealed no order for a helmet. On 2/15/02, Resident #5 fell out of the wheelchair and went to the emergency room with a large hematoma on the head, a skin tear and moderate bleeding. The resident was to agitated for a CT scan. There was no order for a safety helmet. 16. Respondent’s failure to ensure that each resident receives adequate supervision and assistance devices to prevent accidents is a violation of 42 CFR 483.25(#) (2); 17. Respondent’s failure to ensure that each resident receives adequate supervision and assistance devices to prevent accidents ig a violation of Rule 59A-4.1288, Fla. Admin.’ Code. 18. Respondent’s failure to ensure that each resident receives adequate supervision and assistance devices to prevent pivddd 4A989TL80S58=al OSHUOHS CIVYENA SAUOHS CIVUANA 62:21 ca-SA-gs8 accidents is a class II deficiency as defined in section 490.23(8) (pb), Fla. Stat. 19. The above constitutes grounds for the imposition of conditional licensure status, pursuant to section 400.23(7) (b), Fla. Stat. CounT IIL THE FACILITY FAILED TO ENSURE THAT RESIDENTS MAINTAIN ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS, SUCH AS BODY WEIGHT AND PROTEIN LEVELS, UNLESS THE RESIDENT’S CLINICAL CONDITION DEMONSTRATES THAT THIS I$ NOT POSSIBLE. 42 CFR 483.25(1) (L)7 Section 400.23(7) (p), FLA. STAT.; Sacrron 400,.23(8) (Bs), Fha. STAT., AND; Rutt 59A-4.1288, FLA, ApmMin. CODE 20. AHCA re-alleges and incorporates by reference paragraphs (1) through (19) as 4£ fully set forth herein. 21. AHCA surveyors conducted a survey of Respondent's facility on June 6, 2002. Staff interview, record review and surveyor observation brought to light the following: a. Record review of Resident #3’s clinical record show the following weights: 1. 4/18/01 - 141.2 pounds 2. 8/10/01 - 133.4 pounds 3. 1/01 - 133.7 pounds 4. 12/01 ~ 90.2 pounds 5. 1/9/02 - 96 pounds 6. 2/4/02 - 98 pounds viv eid 29e9T48058=a1 OSHZUOHS GDIVUSNA SAUOHS TIVUANA 98:21 2H-Ge-86 7. 2/19/02 - 108.6 pounds 8. 3/2/02 ~ 102.4 pounds 9. 4/1/02 - 98.8 pounds Lo. 5/2/02 - 100.6 pounds LL. 6/4/02 ~ 107.4 pounds There were no interventions to prevent the resident’s weight loss. The resident came back from the hospital February 9, 2002 with a gastrostomy tube for feeding. 22. Respondent’s failure to ensure that vesidents maintain acceptable parameters of nutritional status is a violation of 42 CFR 483.25(1) (Lu); 23. Respondent’s failure to ensure that residents maintain acceptable parameters of nutritional status is a violation of Rule 59A-4.1288, Fla. Admin. Code. 24, Respondent’s failure to ensure that residents maintain acceptable parameters of nutritional status is a class IT deficiency as defined in section 400.23(8) (b), Fla. Stat. 25. The above constitutes grounds for the imposition of conditional licensure status, pursuant to section 400.23(7) (b), Fla. Stat. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1). Factual and legal findings in favor of the Agency on Count I through IIT; 2). Uphold the imposition of the conditional license. 8 pT /68d 2989T2Z80S8-=daI OSAUOHS CIVYUANE SHHYOHS CIVUANA 8S:2T 20-S8H-86 Respondent is notified that it nas a right to request an administyvative hearing pursuant to gection 120.569 and 120.57, 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 the Agency for Health Care Administration, Building 3, mse #3, 2727 Mahan Drive, Tallahassee, Florida, 32308; Christine Thorson Messana, Senior Attorney. DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, the Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. RESPONDENT 1S FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted. biIretd 29sgTZeese-=dal OSAUOHS GIVUBNA GSAYOHS AIVUANA Ge:cTt Ze-sSe-ss pated this @&uday of daly 2002, vA - hag nee ¢ y Le Ez Ven Christine T. Messana Pla. Bar. No. 0153818 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#H3 2727 Mahan Drive Tallahassee, FL 32308 (850) 922-5873 (office) (850) 413-9313 (fax) ce: Blizabeth Dudek CERTIFICATE OF SERVICE { HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail on this Lane day of «J ( /, 2002 to: EMERALD SHORES HEALTH AND REHABILITATION 626 North Tyndall Parkway, Calloway, Florida 32404. Christine T. 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Docket for Case No: 02-003401