ewe ww STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE Certified Article Number ADMINISTRATION, 7106 4575 Le% 2050 LSbb SENDERS RECORD vs. 6 d-4Y/0 Case No. 2002045097 MARIANNA CONVALESCENT CENTER, Cevtificate™ Mole 4619 12.94 2DeD 1 Sul ian) re Petitioner, Respondent. ADMINISTRATIVE COMPLAINT -3 COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION co ne (“AHCA”), by and through the undersigned counsel, and files this administrative Complaint against MARIANNA CONVALESCENT CENTER, pursuant to Sections 120.569, and 120.57, Florida Statutes., and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $80,000 against Respondent, pursuant to Section 400.102, Florida Statutes, and assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Fla. Stat. JURISDICTION AND VENUE 2. This tribunal has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. ww nd 3. Venue shall be determined pursuant to Rule 28- 106.207, 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 Cc (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 180-bed nursing home is located at 4295 Fifth Avenue, Marianna, Florida 32446. Respondent is licensed as a skilled nursing facility license #SNF1322096, Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. Count I THE FACILITY FAILED TO DEVELOP COMPLETE AND ACCURATE CARE PLANS FOR EACH FACILITY RESIDENT BASED ON THE RESIDENTS’ COMPREHENSIVE ASSESSMENTS ‘ 42 CFR 483.20(k); Section 400.102(a) & (d), Florida Statutes; Section 400.23(8) (b), Florida Statutes; Section 400.121(10), Florida Statutes; Rule 59A-4.109(2), Fla. Admin. Code; Rule 59A-4.1288, Fla. Admin. Code 6. AHCA re-alleges and incorporates by reference ww _ . paragraphs (1) through (5) as if fully set forth herein. 7. AHCA surveyors conducted a survey of Respondent’s facility on June 24-27, 2002. Staff interview, record review and surveyor observation brought to light the following: a. Record review of Resident #18’s interdisciplinary care plan dated 6/14/02 did not address contractures or range of motion issues as identified in the resident’s ) comprehensive assessment. b. Record review of Resident #19’s interdisciplinary care plan dated 4/24/02 did not address contractures or range of motion issues as identified in the resident’s comprehensive assessment. c. Record review of Resident #4’s interdisciplinary care plan dated 6/21/02 did not address cognition problems as identified in the resident’s comprehensive assessment. d. Record review of Resident #15’s interdisciplinary care plan dated 2/8/02 did not address cognition problems as identified in the resident’s comprehensive assessment. e. Record review of Resident #17’s interdisciplinary care plan dated 6/3/99-8/6/02 did not address contractures or range of motion issues as identified in the resident’s comprehensive assessment. f. Resident #20’s comprehensive assessment calls for assistance with all activities of daily living. The resident’s care plan has not been updated since 1998, is 3 Sal vague, containing neither s — pecifics, nor measurable objectives and goals for this 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-4.109(2), Fla. Admin. Code. 10. Respondent’s failure to develop complete and accurate care plans for residents is a violation of Rule S59A-4.1288, Fla. Admin. Code. 11. Respondent’s failure to develop complete and accurate care plans for residents is a class II deficiency as defined in section 400.23(8) (b), Florida Statutes. Respondent was previously cited for one or more class I or class If deficiencies on the survey conducted 8/15/2001. 12. Respondent’s failure to develop complete and accurate care plans for residents constitutes grounds for the imposition of an administrative fine of $10,000 pursuant to section 400.102(a) and (d), Florida Statutes. 13. The Agency may assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Florida Statutes. Coun 12 THE FACILITY FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS. 42 CFR 483.25(h) (2); 4 7" — Section 400.102(a) & (d), Florida Statutes; Section 400.23(8) (b), Florida Statutes; Section 400.121(10), Florida Statutes; and Rule 59A-4.1288, Fla. Admin. Code 14. AHCA re-alleges and incorporates by reference paragraphs (1) through (13) as if fully set forth herein. 1S. AHCA surveyors conducted a survey of Respondent’s facility on June 24-27, 2002. Staff interview, record review and surveyor observation brought to light the following: a. Resident #16 was not assessed for the appropriateness of the change from a regular wheelchair to a high-back wheelchair with a seat belt. The resident flipped him/herself out of the high-back wheelchair and fractured a hip. The seat belt remained intact and was clearly inadequate to prevent the resident’s accident. b. A note to Resident#1’s care plan dated 11/28/01 included observe closely when sitting up in a chair, a low bed and seat belt when sitting up ina chair. The plan was revised on 5/21/2002 to add a mat on the floor to prevent injury in case of falls. From March through June of 2002, the resident fell four times, with one fall resulting in facial injuries requiring transfer to the emergency room. Surveyor observation revealed a significantly impaired, completely dependent resident sitting up in the chair without a seatbelt and no staff in attendance. _ —_ 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(h) (2); 17. Respondent’s failure to ensure that each resident receives adequate supervision and assistance devices to prevent accidents is 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 accidents is a class II deficiency as defined in section 400.23(8) (b), Florida Statutes. Respondent was previously cited for one or more class I or class II deficiencies on the survey conducted 8/15/2001. 19. Respondent’s failure to ensure that each resident receives adequate supervision and assistance devices to prevent accidents constitutes grounds for the imposition of an administrative fine of $5,000 pursuant to section 400.102(a) and (d), Florida Statutes. 20. The Agency may assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Florida Statutes. Count 111 THE FACILITY FAILED TO ENSURE THAT THE RESIDENT ENVIRONMENT REMAINS AS FREE FROM ACCIDENT HAZARDS AS POSSIBLE. 42 CFR 483.25(h) (1); Section 400.102(a) & (d), Florida Statutes; Section 400.121(10), Florida Statutes; Section 400.23(8) (a), Florida Statutes., and; Rule 59A-4.1288, Fla. Admin. Code 6 ws — 21. AHCA re-alleges and incorporates by reference paragraphs (1) through (20) as if fully set forth herein. 22, AHCA surveyors conducted a survey of Respondent’s facility on June 24-27, 2002. Staff interview, record review and surveyor observation brought to light the following: a. A Hydrocollator used for heating hot packs with hot water, metal racks and canvas packs inside of it was located in a room on the main hallway, 20 feet from the main dining room. b. Residents can, and do, access this room unsupervised. During the survey the area was unsupervised during dinner. c. Staff stated the water was heated to 160-180 degrees and left on all the time. Surveyors measured the water temperature at 168 degrees farenheit. d. Coffee measured at 173 degrees farenheit was in an urn used by residents on a frequent basis, whether supervised or unsupervised. e. Tap water temperature at 140 degrees takes five seconds or less to cause a serious burn. Temperatures at 160-180 degrees may result in almost instantaneous burns that may require surgery to heal. f£. This facility has cognitively impaired residents who are known to wander the facility. ~~ ind 23. Respondent’s failure to ensure that to ensure that the resident is a violation of 42 CFR 483.25(h) (1). 24. Respondent’s failure to ensure that the resident environment remains as free from accident hazards as possible is a violation of Rule 59A-4.1288, Fla. Admin. Code. 25. Respondent’s failure to ensure that the resident environment remains as free from accident hazards as possible is a class I deficiency as defined in section 400.23(8) (a), Florida Statutes and constitutes grounds for the imposition of an administrative fine of $30,000 pursuant to section 400.102 (a) and (dad), Florida Statutes. Respondent was previously cited for one or more class I or class II deficiencies on the survey conducted 8/15/2001. 26. The Agency may assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Florida Statutes. COUNT IV THE FACILITY FAILED TO ENSURE THAT A RESIDENT WHO ENTERED THE FACILITY WITHOUT PRESSURE SORES DID NOT DEVELOP PRESSURE SORES. 42 CFR 483.25(c; Section 400.102(a) & (da), Florida Statutes; Section 400.23(8) (b), Florida Statutes; Section 400.121(10), Florida Statutes, and; Rule 59A-4.1288, Fla. Admin. Code 27. AHCA re-alleges and incorporates by reference paragraphs (1) through (26) as if fully set forth herein. 28. AHCA surveyors conducted a survey of Respondent’s facility on June 24-27, 2002. Staff interview, record review 8 ww — and surveyor observation brought to light the following: 29, a. Resident #1 was admitted to the facility with skin intact and independent ambulation. b. The resident developed a stage II pressure ulcer, greenish yellow in appearance with a narrow band of Yaw area surrounding a large center with slight swelling around the ankle and reddened skin. c. Physician order states the resident is to keep the leg elevated and use compression stockings. d. The resident was observed on seven occasions throughout the survey with the leg not elevated as per physician’s order, €. There was nothing in the resident’s clinical record to show that the pressure sore was unavoidable. Respondent’s failure to ensure that residents did not develop pressure sores is a violation of 42 CFR 3.25(c; 30. Respondent’s failure to ensure that residents did not develop pressure sores is a violation of Rule 59A-4.1288, Fla. Admin. Code. 31. Respondent’s failure to ensure that residents did not develop pressure sores is a class IL deficiency as defined in section 400.23(8) (b), Florida Statutes and constitutes grounds for the imposition of an administrative fine of $5,000 pursuant to section 400.102(a) and (d), Florida Statutes. Respondent was previously cited for one or more class I or class II ww — deficiencies on the survey conducted g/15/2001. 32. The Agency may assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Florida Statutes. CouNT Vv THE FACILITY WAS NOT ADMINISTERED IN A MANNER THAT ALLOWED IT TO USE ITS RESOURCES EFFECTIVELY AND EFFICIENTLY TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND EMOTIONAL WELL-BEING OF EACH RESIDENT 42 CFR 483.75; Section 400.102(a) & (D), FLORIDA STATUTES; Section 400.121(10), FLORIDA STATUTES; Section 400.23(8) (A), FLORIDA STATUTES., AND; RuLE 59A-4.1288, FLA. ADMIN. CODE 33. AHCA re-alleges and incorporates by reference paragraphs (1) through (32) as if fully set forth herein. 34. AHCA surveyors conducted a survey of Respondent's facility on June 24-27, 2002. Staff interview, record review and surveyor observation brought to light the following: a. The facility did not implement systems and practices to provide a safe environment for all residents. b. The facility failed to formulate accurate and specific care plans for facility residents. c. The facility failed to adequately assess residents at risk for falls, plan their care and implement procedures to prevent accidents. da. The facility failed to maintain an infection control program that identified infections and 10 ww ll followed through to resolutions. e. The facility failed to maintain a Quality Assurance and Assessment program that identified the problem areas. 35. Respondent’s failure to administer the facility ina manner that allowed it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and emotional well-being of each resident is a violation of 42 CFR 483.75; 36. Respondent's failure to administer the facility ina manner that allowed it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and emotional well-being of each resident is a violation of Rule 59A-4.1288, Fla. Admin. Code. 37. Respondent’s failure to administer the facility in a manner that allowed it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and emotional well-being of each resident isa class I deficiency as defined in section 400.23(8) (a), Florida Statutes and constitutes grounds for the imposition of an administrative fine of $30,000 pursuant to section 400.102 (a) and (d), Florida Statutes. Respondent was previously cited for one or more class I or class II deficiencies on the survey conducted 8/15/2001. w we 38. The Agency may assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1). Factual and legal findings in favor of the Agency on Counts I through v; and 2). Imposition of $80,000 in administrative fines 3). Uphold the imposition of costs. related to the investigation and prosecution of this case, pursuant to section 400.121(10), Florida Statutes. Respondent is notified that it has a right to request an administrative hearing pursuant to section 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, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308; Christine Thorgon Messana, Senior Attorney. we — RESPONDENT IS 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, Dated thisyy/ ti day of Ssplee ten , 2002. i. . ae Christine T. Messana Fla. Bar. No. 0153818 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSCH3 2727 Mahan Drive Tallahassee, FL 32308 (850) 922-5873 (office) (850) 413-9313 (fax) cc: Elizabeth Dudek CERTIFICATE OF SERVICE Sa EE BERNESE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail on this oh, day of S » 2002 to: MARIANNA CONVALESCENT CENTER, 4295 Fifth OM RG 32446. © Christine T. Messana

Docket for Case No: 02-004410