18/23/2882 15:48 8634535388 DAKS AUON PAGE @2 ae STATE OF FLORIDA —_ Ms ye AGENCY FOR HEALTH CARE ADMINISTRATION ©) f AGENCY FOR HEALTH CARE fy. ADMINISTRATION, OD- U yf of 2 Petitioner, AHCA Case Nos. Vs. 2002046509, 2002045659, KINDRED NURSING CENTERS EAST, 2001051031 L.L.C., d/b/a OAKS AT AVON, & 2001021091 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION [AHCA], by and through its undersigned counsel, and files this Administrative Complaint against KINDRED NURSING CENTERS EAST, L.L.C,, d/b/a OAKS AT AVON [Respondent], pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is multi-count action to assign conditional licensure status to KINDRED NURSING CENTERS EAST, L.L.C., d/b/a OAKS AT AVON, pursuant to Section 400.23(7), Florida Statutes (2001), to impose administrative fines and any applicable survey fee upon Respondent pursuant to Chapter 400, Part H, Florida Statutes (2002) and to assess a mandated additional statutory fine pursuant to Section 400.19(3), Florida Statutes (2001). 18/23/2882 15:48 8634535388 OAKS AUON PAGE JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part I, Florida Statutes (2001). 3. AHCA, and the Division of Administrative Hearings [DOAH] in the event Respondent requests a formal hearing, have jurisdiction pursuant to Sections 120.569 and 120.57, 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 594-4, Florida Administrative Code. 6. The Respondent is Kindred Nursing Centers East, LL.C., a foreign limited liability company with its principal address at 680 South Fourth Street, Louisville, Kentucky 40202, doing business in Florida as Oaks at Avon, 1010 US 27 North, Avon Park, Florida 33825. 7. Oaks at Avon is a 104-bed skilled nursing facility [Facility] located at 1010 US 27 North, Avon Park, Florida 33825. Oaks at Avon currently is licensed by AHCA as 4 skilled nursing facility having been issued conditional license number SNF1557096, certificate number 9033, with an effective date of July 12, 2002, and an expiration date of April 30, 2003. The original license is enclosed herewith and a copy attached hereto as Exhibit “A.” 8. Oaks at Avon is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. @3 10/23/2882 15:48 8634535308 OAKS AUON PAGE COUNTI AHCA Case No. 2002046509 ASSIGNMENT OF CONDITIONAL LICENSURE STATUS TO RESPONDENT’S FACILITY (§ 400.23(7), Florida Statutes] 9, AHCAre-alleges and incorporates herein by reference paragraphs 1-8 asif fully set forth herein. 10. AHCA has the statutory authority, and mandated duty, pursuant to section 400.23(7), Florida Statutes, periodically to evaluate all nursing home facilities and to assign a licensure status of “standard or conditional” to each of its licensees. A conditional licensure status means that a facility, due to the presence of one or more class I or class IT deficiencies, or class Il deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part Il, Florida Statutes, or with rules adopted by the agency. 11. AHCA’s assignment of licensure status to Respondent’s Facility is based upon considerations including but not limited to the agency’s determination that the following hereinafter-specified deficiencies existed upon the date of AHCA’s hereinafter-specified survey and the agency’s determination as to the scope and severity of such deficiencies. Determination of §483.25 Deficiency Related to Providing Residents with Sufficient Fluid Intake to Maintain Proper Hydration and Health 12. The regulatory provisions of the Code of Federal Regulations that are specifically pertinent here to Respondent and to operation of its facility as a long term care facility, which regulations are applied in Florida pursuant to Rule 59A-4.1288, Florida Administrative Code, include, but are not limited to, the following: [42 CFR] § 483.25 Quality of care. a4 10/23/2002 15:48 8634535388 OAKS AUON Fach resident must receive and the facility must 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. * * * (j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. 13. Onor about July 11-12, 2002, AHCA conducted a survey at Respondent’s facility, OAKS AT AVON. AHCA cited Respondent for a §483.25 deficiency, in particular for failure to provide each resident with sufficient fluid intake to maintain proper hydration. Such citation and the existence of the violation alleged herein under §483.25 and subsection (j) thereof in particular, are supported by facts including, but not timited to, the following: 13.1. About 9 P.M. on Tuesday evening, July 9, 2002, one of Respondent’s employees heard a local radio station’s announcement concerning a “water alert” by the City of Avon Park, In response, this employee notified the Facility’s nurse on duty, at that time, as to what she had heard. 13.2. Jn immediate response thereto on Tuesday evening, during the 3-1] pm. shift, Respondent’s staff removed residents’ bedside water, stopped consumption of city water by residents and posted signs warning staff not to use the water or ice in the two nursing pantries. 13.3. On Wednesday morning, July 10, 2002, with an understanding by Respondent’s Certified Dietary Manager [CDM] that there was a need to boil the city water before consumption, Respondent stopped use of the juice dispenser, which required use of city water, bringing to a halt consumption by residents of juices . 13.4. For the then-immediate future, Respondent embarked on 4 Course of conduct that included boiling city water and purchasing bottled water and ice to meet the 10/23/2002 15:48 8634535388 OAKS AUON PAGE needs of the 99 residents at the facility at that time. The Facility’s receipts for purchase of bottled water and ice show that on Wednesday, July 10, 2002, Respondent purchased 14 gallons of water and 10 (ten) 5-pound bags of ice, and that on Thursday, July 11, 2002, Respondent purchased 16 gallons of water and another 10 (ten) 5-pound bags of ice. 13.5. On Thursday, July 11, 2002, AHCA staff visited Respondent’s Facility, observed physical facts pertinent to the situation, interviewed staff and residents and made observations regarding Respondent’s actions subsequent to staff hearing about the water alert on Tuesday evening. 13.6. At approximately 11:30 a.m. on that Thursday morning, AHCA staff toured the residents’ rooms in the 400 and 600 wings of the facility and observed that there was no water or other fluids at the bedsides of residents in those wings. 13.7. Thereafter, AHCA staff interviewed a number of residents, confirming in resident interviews that the response of Respondent to the water alert resulted in serious and widespread limitations on fluid intake of residents (water and juices) beginning Tuesday evening (July 9, 2002) and extending to the time of the Thursday visit by AHCA staff. Resident interviews were conducted on Thursday, with additional resident interviews being conducted on Friday (July 12, 2002). 13.8. Reportedly and by observation, during the subject period from Tuesday evening through the Thursday afternoon visit by AHCA staff, water generally was given to residents only for medications, or if residents expressly asked for water. 13.9, On Thursday morning, in interviews with the Facility’s Director of Nursing [DON], its CDM, and certain of its CNAs, AHCA staff confirmed Respondent's 10/23/2082 15:48 8634535308 OAKS AUON PAGE 87 response to the “water alert” as alleged above regarding ceasing use of city water, with the Facility then bringing in bagged ice and bottled water, and boiling city water. 13.10. Respondent’s CDM confirmed to AHCA staff on the Thursday visit that the juice dispenser was not being used at that time and bad not been in use since Wednesday moming. 13.11. AHCA staff observed the general noon meal on that Thursday at all three of the facility’s dining rooms. AHCA staff noted that approximately 80% to 85% of the residents had either iced tea, coffee or hot tea (with caffeine) for a beverage, and that no juice was available. Milk was not on the noon menu and very few meal trays were observed with milk. 13.12. Shortly after observations of the noon meat on Thursday, AHCA staff toured the facility specifically to determine how much water was in the Facility for resident consumption. There was a total of 14% gallons of water at various locations within the Facility, available fora reported population of 99 residents prior to the 2 p.m. medication pass. There were 8% bags of ice in the freezer. There also were eight (8) five- gallon bottles of bottled Spring water stored outside. Interviews with the CDM, DON and Administrator revealed that no one knew how long those bottles had been there and no attempt had been made to use the water in those bottles. 13.13. Before 2 p.m. on that Thursday, AHCA staff interviewed a certified nursing assistant (CNA) who stated that when she arrived for work on Wednesday for her 3 p.m. to 11 p.m. shift she was told by a licensed nurse that the water was not drinkable, was contaminated and that there was bottled water at the nursing station for residents. This CNA stated that she gave 3 or 4 residents about two ounces of water each during her 18/23/2882 15:48 8634535388 OAKS AUON PAGE 8 eight hour shift because those residents asked for water. She stated that to her knowledge residents received no other water on her shift 13.14. AHCA staff informed the Administrator that the water supply was insufficient. Interviews with the CDM and Administrator revealed that the Facility had a contract with a vendor for supplying water if there was a loss of normal water supply. However, Respondent had not contacted the vendor as of the time of those interviews. Shortly after 2 p.m. on that Thursday, the Administrator told AHCA staff that the vendor had been contacted and that Respondent had ordered 500 gallons of bottled water which would be delivered the next moming, Friday, July 12, 2002. 13.15. Respondent commenced an aggressive hydration program for its residents at approximately 3:30 p.m. on Thursday, July 11, 2002. 13.16. AHCA staff conducted further interviews with Respondent’s staff and residents on Friday, July 12, 2002. Among other things, staff CNAs reported that there . was one gallon jug of water and one five-pound bag of ice, per shift, for each hall on the South Unit (for 16 to 22 residents per hall) for both days of the water alert (Wednesday and Thursday), with one CNA reporting that she did not furnish any water to residents on one of her shifts. In summary, Respondent appears to have focused on having enough water for medication passes, but otherwise severely restricted fluid intake by its residents. 13.17. AHCA staff also reviewed the records of fluid intake and output of four residents (Residents #1, #2, #3 and #5) who had indwelling catheters. For the period from July 9-11, 2002, for all four of these residents, the records when compared to individually assessed hydration needs, showed that Respondent did not meet the hydration needs of these four residents. 10/23/2082 15:48 8634535388 OAKS AUON rear 13.18. AHCA staff reviewed the medical records of these four residents and found no review of the individual intake and output for them and no report of a failure to meet the hydration needs of any of them. 14. Based on facts as alleged herein, Respondent violated 42 CFR §483.25 and subsection (j) thereof in particular, by failing to provide residents the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, specifically as this pertains to the failure of Respondent to provide each resident with sufficient fluid intake to maintain proper hydration and health. Determination of §483.75(m)(1) Deficiency Upon Facility’s Response to Water Alert and Failure to Implement Disaster Preparedness Plan 15, Theregulatory provisions of the Code of Federal Regulations that are specifically pertinent here to Respondent and to operation of its facility as a long term care facility, which regulations are applied in Florida pursuant to Rule 59A-4,1288, Florida Administrative Code, also include the following: {42 CFR] Sec. 483 75 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. x *# * (m) Disaster and emergency preparedness. (1) The facility must have detailed written plans and procedures to mect all potential emergencies and disasters, such as fire, severe weather, and missing residents. 16. Upon conducting the above-referenced survey on July 11-12, 2002, AHCA cited Respondent for a deficiency for failure to administer the Facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, us 18/23/2882 15:48 8634535388 OAKS AUON PAGE mental and psychosocial well-being of each resident. This additional citation was based on the following additional findings to those previously alleged above. 17. The Facility has a Disaster Preparedness Pian (Plan] that was approved by the county on December 27, 2001. The Plan was established as required by the above-referenced regulatory provision to enable the Facility “to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each of its residents” specifically as that mandate applies to “all potential emergencies and disasters.” 18. The Plan, among other things, specifically and expressly states jn its introductory paragraph of its section (7.0) on “Emergency Water Supply” that “It is Kindred’s policy to ensure emergency water supply for residents and staff in the event ofa disruption in the water supply.” The Plan indicates that the water supply for residents in an emergency should be one and one-half gallons of water per day per resident. 19. Respondent’s response to the water alert, as previously alleged above, failed to implement the Plan to meet the loss of normal water supply that occurred July 9 — 11, 2002. Respondent failed to furnish sufficient water to its residents as contemplated by the policy stated in its Plan. 20. Respondent severely restricted fluid intake of residents for approximately 40 hours without determining and verifying with the City the nature, extent and degree of the problems with the city’s water. 21. Respondent chose not to contact any vendor for supplying water in the event of a loss in normal water supply, until after AHCA staff visited the Facility. 22. AKCA staff observed the lack of sufficient water being supplied to residents, inventoried available water at the Facility as of Thursday aftemoon July 11, 2002, and informed 1 a 18/23/2802 15:48 8634535388 OAKS AUON Paar the Facility’s administrative staff of this at that time. Thereupon, but not until then, the Facility commenced an aggressive hydration program. , | 23. Respondent's actions and omissions as alleged herein violated 42 CFR § 483.75, in that Respondent failed to administer the Facility in the manner requixed by its own Plan for using its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each of its residents, in this instance as the Plan specifically relates to a Joss in normal water supply. Facility “Not in Substantial Compliance” & Conditional Licensure Status Assigned 24, AHCA determined that the above and foregoing facts evidenced the presence of one or more class I or class Il deficiencies, meaning as set forth in section 400.23(7), Florida Statutes [quoted above] that upon the above-referenced survey of the Facility, Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part Il, Florida Statutes, or with rules adopted by the agency. 25. AS required by law, AHCA determined the scope and severity of the two above- referenced deficiencies and classified both deficiencies as class I violations existing on July 11, 2002. . 26. In accordance with the requirements of section 400.23(7), the aforementioned facts and the determination by the agency 4s to scope and severity of the violations, AHCA assigned conditional licensure status to Respondent’s Facility, effective as of the date of the aforementioned survey. 2 A 10/23/2082 15:48 8634535388 GAKS AUON PAGE 14 COUNT AHCA Case No. 2002045659 Fine for Class I §483,25 Deficiency Related to Providing Residents with Sufficient Fluid Intake to Maintain Proper Hydration and Health [42 CER § 483 .25Q)) 27, AHCA re-alleges and incorporates herein by reference paragraphs 1-8and 12-14 as if fully set forth herein. 28. §400.23(8)(), Florida Statutes, provides the definition of a class I deficiency and the civil penalty for such deficiency, as follows: (8)a) Aciass I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, OF death to a resident receiving care ina facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class Lor class I deficiencies during the last annual inspection or any inspection or complaint investi gation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 29. AHCA determined both (a) that the subject deficiency of this count constituted a class I violation, in that the facts presented a situation in which jmmediate corrective action was necessary and because the facility's noncompliance caused, or was likely to cause, serious injury. harm, impaimnent, or death to a resident receiving care in a facility; and (b) that the deficiency was widespread, in that the problems causing the deficiency were pervasive in the facility or represented a systemic failure that affected or had the potential of affecting a large portion of the facility’s residents. 30. In accordance with the above-stated facts and applicable jaw, AHCA. determined that the subject violation warrants a fine of $15,000.00. il £5 ee 10/23/2082 15:48 8634535308 DAKS AUON PAGE 13 COUNT UI ABCA Case No, 2002045659 Fine for Class I §483.75(n)(1) Violation for Failure to Effectively and Efficiently Administer Facility’s Response to Water Alert in order to Maintain Highest Practical Well-Being of Residents [42 CFR 483. 75] 31. AHCA re-alleges and incorporates herein by reference paragraphs 1 - 8 and 15 - 23 as if fully set forth herein. 32. §400.23(8)(a), Florida Statutes, provides the definition of a class 1 deficiency and the civil penalty for such deficiency, as follows: (8)a) A class I deficiency is a deficiency that the agency determines presents a situation ja which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, hart, impairment, or death to a resident receiving care ina facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $1 5,000 fora widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the Jast annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 33. AHICA determined both (a) that the subject deficiency of this count constituted a class ] violation, in that the facts presented a situation in which immediate corrective action Was necessary and because the facility's noncompliance caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in @ facility; and (b) that the deficiency was widespread, in that the problems causing the deficiency were pervasive in the facility or represented a systemic failure that affected or had the potential of affecting a large portion of the facility’s residents. 34. Jn accordance with the above-stated facts and applicable law, AHCA determined that the subject violation warrants 4 fine of $15,000.00. 10/23/2082 15:48 8634535388 OAKS AUON PAGE COUNT IV AHCA Case No. 200105103! Fine for Class I §483.13(c) Violation Related to Implementation of Facility Abuse Prevention Policy [42 CFR 383.13(¢)} 35, AHCA repeats, re-alleges, and incorporates herein by reference paragraphs one da through eight (8) as if fully set forth herein. 36. The regulatory provisions of the Code of Federal Regulations that are specifically pertinent here to Respondent and to operation of its facility as a long term care facility, which regulations are applied in Florida pursuant to Rule 59A-4.1288, Florida Administrative Code, include, but are not limited to, the following: [42 CFR] §483.13 Resident behavior and facility practices. * # OF 13. * * * (c) Staff treatment of residents. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 37. Respondent developed pertinent written policies and procedures to comply with the above regulation. Among other things, Respondent's promulgated its “RESIDENT SAFTETY POLICY AND PROCEDURE” which states: Policy It is the policy of The Oaks at Avon to maintain a work and living environment that is professional and free from threat and or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. : Providing a safe environment for the resident is one of the most basic and essential duties of the The Oaks at Avon. Employees have a unique position of trust with vulnerable residents. * * Py Residents must not be subjected to abuse by anyone. . - 14 ee 19/23/2882 15:48 8634535388 GBAKS AUON 38. On or about August 8, 2001, AHCA conducted a survey at the Respondent’s facility. ABCA cited the Respondent for a deficiency, that the facility did not implement its policies and procedures to prevent mistreatment, neglect and abuse of one of jts residents, a woman diagnosed with Parkinson's Disease, Dementia and Congestive Heart Failure. This cited deficiency is based upon facts including but not limited to the following: Based on review of the facility abuse prevention policy, record review, and interviews with staff, it was determined that, although the facility had initiated a written policy regarding how it will prohibit mistreatment, neglect and abuse of their residents, the policy had not been implemented with a thorough understanding from the staff. The facility staff failed to protect 1 of 3 sampled residents (Resident #1) by not providing 4 safe environment for the resident during a major dental procedure. A dentist entered the facility and went to Resident #1's room without nursing being notified and proceeded to extract teeth and then, when a CNA (Certified Nursing Assistant) became aware of the presence of the dentist and reported this to Jicensed nurses, no one went to assist or assure continued care for approximately 30 minutes (after the dentist had left). The facility allowed a dentist to perform extractions on 4 confused resident without staff oversight to ensure that resident comfort and safety were provided. This oversight and Jack of responding to the resident's needs caused actual harm to the resident. 39. Pursuant to §400.23(8)0); Florida. Statutes, the agency determined that the subject deficiency herein constitutes an isolated Class I deficiency under the criteria of the statute, which warrants a fine of $2,500.00. That statute reads: (b) A class Ii deficiency is a deficiency that the agency determines has compromised the resident's 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 I deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency.* * * COUNT V. AHCA Case No. 200102109 1 Fine for Uncorrected Class YW §483.25 Violation Related to Ensuring Appropriate Treatment and Services to Resident Fed by Gastrostomy Tube [42 CFR] § 483.25 (2)(2)] 13d a 18/23/2082 15:48 8634535308 GAKS ALON PAGE 40, AHCA re-alleges and incorporates herein by reference paragraphs one (1) through eight (8) as if fully set forth herein. : 41, The regulatory provisions of the Code of Federal Regulations that are specifically pertinent here to Respondent and to operation of its facility as a long term care facility, which regulations are applied in Florida pursuant to Rule 59A-4.1288, Florida Administrative Code, include, but are not {imited to, the following: (42 CFR] § 483.25 Quality of care. Each resident must receive and the facility must 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. * * * (g) Naso-gastric tubes. Based on the comprehensive assessment of a resident, the facility must ensure that- x * F (2) Aresident who is fed by 4 naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. 42, On or about February 1, 2001, AHCA conducted a survey at the Respondent’s facility. AHCA cited the Respondent for a §483.25 deficiency, in particular for failure of the facility to ensure that each resident with a gastrostomy tube received appropriate treatment and services, Such citation and the existence of the violation alleged herein under §483.25 and subsection (g)(2) thereof in particular, are supported by facts including, but not limited to, the following: Resident #5 was first admitted to the facility in August, 2000. The resident had a permanent gastrostomy feeding tube in place upon admission. Resident was transferred to the hospital on 1/8/01, treated for Pneumonia and readmitted to the facility on 1/26/01. Review of the active clinical record, observation and staff interview revealed there were no clear physician orders for the volume, rate of flow , flush solution and amounts, hang time, resident positioning oF how/when 15 1 18/23/2882 15:48 8634535388 OAKS AUON PAGE to check for tube placement. The new admission physician orders stated: Tube feeding - Pulmocare every A hours. The only other orders were for medications. 43, For this deficiency, AHCA provided the Respondent 3 mandated correction date of February 21, 2001. 44, On or about March 14, 2001, AHCA conducted a re-visit survey at the Respondent’s facility and made findings that include put are not limited to the following: Ciinical record review, observation an interview revealed that two of two (#5 and 9) sampled residents reviewed with a gastrostomy feeding tube did not receive appropriate treatment and services for the tube feedings. Flushes were either omitted or not as ordered by the physician putting residents at risk for dehydration and/or a non-functional tube. Findings include: 1, Resident #5 was admitted to the facility on March 8, 2001. The resident had a permanent gastrostomy feeding tube in place upon admission. Review of the active clinical record, observation and staff interview revealed there were no physician orders for the feeding tube flushes, amount or frequency. Physician orders stated: Tube feeding - Pulmocare at 55cc per hour. Upon review of the medication administration record (MAR) on 03/13/01 at 3:00 p.m. there was no documentation that indicated the resident had received any flushes since admission. Review of the nurses notes revealed one notation made on 03/12/01 between 7:00 am. and 11:00 p.m. of flushing the tube with 100cc of water. Interview and discussion with the Director of Nursing (DON) revealed the facility policy was to flush the feeding tube every 4 hours "with the appropriate amount of water", before and after each medication pass, and to document the procedure on the resident's medical record, as per facility policy. Upon review of the clinical record on 03/14/01 at 10:30 a.m., there was a physician order to flush the feeding tube with 20ce warm water every 4 hours and to flush the tube with 10cc of water before and after each medication pass and to flush with 5cc of water between each medication. Further review of the MAR revealed these flushes were initiated at 5:30 p.m. on 03/13/01, after the resident was in the facility 5 days. 2. Resident #9 was readmitted 08/22/00 following an above the knee amputation of the (L) leg due to Peripheral Vascular disease. During the hospitalization the resident also had a gastrostomy tube (GT) inserted dus to swallowing problems. Observation of the medication pass on 03/14/01 at 9:40 a.m. revealed the nurse hung 240ce of Jevity Plus to run through the GT via gravity after administering Aciphex 20 mg. crushed and mixed with approximately 60ce of water and flushed with about 30cc of water. Observation following the bolus administration of the tube feeding at 11:00 a.m. revealed the nurse administered 20cc of warm water before administering Sec of liquid yitamin/mineral solution. She then flushed the 12/23/2082 15:48 8634535388 OAKS AUON PAGE GT with 120ce water as ordered by the physician. Interview with the licensed nurse administering the medication revealed her routine was to flush with at least 20cc of warm water prior to administering medication, flush with Sec of water between medication and flush with the physician ordered amount following the medication. Reconciliation of the medications administered with the physician's orders revealed there were orders for water flushes after only two of the feedings (120¢ce at 9:00 am. and 160ce at 1:00 p.m.) which were documented as being completed. Further review of Resident's clinical record revealed that on admission (08/22) the physician ordered GT flushes of 120ce of water following bolus tube feedings every 4 hours (6 feedings/flushes x 120c¢ = 720ce/24 hours). On 02/07/01, the physician ordered lab work, which revealed an elevated Sodium Na), Blood Urea Nitrogen (BUN) and Creatinine levels (clinical indicators of dehydration). On 02/09/01, the physician ordered additional water flushes of 120 co at 9:00 a.m. and 160ce at 1:00 p.m. The flushes were documented as completed on the February Medication Administration Record (MAR). The pharmacy had not printed the 120cc water flushes following the every 4 hour bolus tube feedings on the March MAR and the nurses had not noticed the omission. The MAR did address the physician's order for a needed daily water intake of 1000cc, Documentation of meeting the 1000cc/day flushes was absent from 03/01/01 to 03/14/01. The licensed nurses could not describe how they tracked the resident's fluid intake. 45. As of March 14, 2002, Respondent had failed to correct the violation alleged herein under §483.25 and subsection (g)(2) thereof in particular. 46. Pursuant to §400.23(8)(¢), Florida Statutes (2000), the agency determined that the subject deficiency herein constitutes a Class Ili deficiency under the criteria of the statute, which warrants a fine of $2,500.00. That statute reads: (c) Class IIL deficiencies are those which the agency determines to have an indirect or potential relationship to the health, safety or security of the nursing home facility residents, other than class Lor class II deficiencies. A class I deficiency shall be subject to a civil penalty of not less than $500 and not exceeding $2,500 for each and every deficiency. A citation for a class la deficiency shall specify the time within which the deficiency is required to be corrected. Ifa class III deficiency is corrected within the time specified, no civil penalty shall be imposed, unless it is a repeated offense. 17 18/23/2082 15:48 8634535388 OAKS AUON PAGE COUNT V1 Mandated Fine for Facility Subject to 6-Month Survey Cycle {§ 400.19(3), Florida Statutes] 47, ATCA re-alleges and incorporates herein by reference paragraphs one (1) through eight (8) as if fully set forth herein. 48. Upon certain hereinafter-described circumstances, §400.19(3), Florida Statutes, mandates that AH'CA conduct an unannounced inspection survey every 6 months to determine compliance with applicable regulations. Under those circumstances, the “agency shal] assess a fine for each facility that is subject to the 6-month survey cycle” which fine is “in addition to any other fees or fines in this part.” 49, The required factual basis for the mandatory assessment of such fine are: a. the facility “has been cited for a class I deficiency, has been cited for two or more class II deficiencies arising from separate surveys OT investigations within a 60-day period, or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class 1 or class II deficiency” and b. such fine is “in addition to any other fees or fines in this part.” 50. Onor about July 12, 2002, AHCA conducted a survey at Respondent’s facility, OAKS AT AVON and cited Respondent, not for one, but for two class I deficiencies. 51. ABCA is required by law to assess the “additional” $6,000 fine for the 6-month survey cycle to which the facility is now subject, in the event an administrative fine is imposed on Respondent for either of the two above-referenced citations in this Administrative Complaint. 19 18/23/2082 15:48 8634535308 OAKS AUON PAGE 21 and delivered to Tom R. Moore, Senior Attorney, Agency for Mealth Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. OAKS AT AVON 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. Respectfully submitted on this 46" day of October 2002. To’ . Moore Fla. Bar. No. 0097383 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) 20 19/23/2682 15:48 8634535388 OAKS AUON PAGE CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make actual and legal findings in favor of AHCA as to all counts; 2) As to Count I, uphold the assignment of conditional licensure status and issuance of the conditional license with an effective date of July 12, 2002, a copy of which is attached hereto as Exhibit “A”; 3) As to counts I and V, impose fines as follows ‘for each violation: Count IL - $15,000.00 Count I - $15,000.00 Count IV - $2,500.00 Count V - $2,500.00 For a total of $35,000 in fines for violations; 4) As to Count VJ, assess a $6,000 fine for mandatory implementation of a6- month survey cycle pursuant to §400.19(3), Florida Statutes (2001). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(€). Florida Statutes, the Facility shall post the assigned conditional 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. NOTICE | Respondent 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 Blection of Rights (two pages) and explained in the attached Explanation of Rights, All requests for hearing shall be made to the Agency for Health Care Administration, 10/23/2082 15:48 8634535388 OAKS AUON PAGE CERTIFICATE OF SERVICE pat MESS We el I HEREBY CERTIFY that the original Conditional License and the original of this Administrative Complaint, with a copy of the Conditional License attached thereto as Exhibit “A” thereto, has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7106 4575 1294 2050 3225) to: Carolyn Antone, Administrator, Kindred Nursing Centers East, LL.C., d/b/a Oaks at Avon, 1010 US 27 North, Avon Park, Florida 33825. TOM R. MOORE, Esq. Counsel for Petitioner 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) 21 22

Docket for Case No: 02-004443