STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, D2 Ise AHCA NO. 2002040761 vs. BROOKWOOD-EXTENDED CARE CENTER OF MARIANNA, LLC d/b/a COURTYARD AT THE MILL POND, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against BROOKWOOD-EXTENDED CARE CENTER OF MARIANNA, LLC d/b/a COURTYARD AT THE MILL POND (“Courtyard”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is an action: (a) to assign a conditional licensure status to Courtyard pursuant to Section 400.23(7), Florida Statutes (2001) due to the presence of one class II deficiency at a survey on or about May 13-16, 2002; and (b) to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). The original conditional license effective May 16, 2002 was delivered to Courtyard on or about November 6, 2002. Courtyard’s licensure status was upgraded to standard effective June 24, 2002. JURISDICTION AND VENUE 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 laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Brookwood-Extended Care Center of Marianna, LLC, doing business as Courtyard at the Mill Pond, is a Florida limited liability corporation with a principal address of 803 North Calhoun Street, Tallahassee, Florida 32303. 7. Courtyard is a 120-bed skilled nursing facility located at 2600 Forest Glen Trail, Marianna, Florida 32446 having been issued license number SNF130470975. 8. Courtyard 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. COUNT I EFFECTIVE MAY 16, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO COURTYARD BASED UPON THE DETERMINATION THAT COURTYARD WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF A LEAST ONE CLASS II DEFICIENCY AT THE MOST RECENT SURVEY OF MAY 13-16, 2002. § 400.23(7), Fla. Stat. (2001) 42 CFR § 483.25 (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) _ 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 May 13-16, 2002 AHCA conducted a survey at Courtyard. A class II deficiency was cited against Courtyard based on the findings below involving resident #18. Resident #18 11. On or about May 13-16, 2002 an AHCA surveyor reviewed resident #18’s nurse’s notes and neurological check sheets dated February 24 and 25, 2002. The review revealed that resident #18 returned to Courtyard from the hospital emergency department on February 24, 2002 at about 7:00 p.m. The physician ordered neurological checks every two (2) hours and oxygen by nasal canula at a rate of two (2) liters/minute. 12. During the 3:00 p.m. to 11:00 p.m. shift the neurological checks were not performed every two hours as ordered by the physician. The neurological check was performed only once and there was no time noted as shown below: 3-11 shift Neurological score -15 (no neurological deficit) Temperature 99.6 Blood pressure 125/68 Pulse 78 Pulse quality +2 Respirations 20 Respiration quality normal 13. Neurological checks and vital signs were documented during the 11:00 p.m. to 7:00 a.m. shift at 11:30 p.m., 1:30 a.m., and 3:10 a.m., respectively, as shown below. 11:30 p.m. Neurological score -15 (no neurological deficit) Temperature 97.4 Blood pressure 122/68 Pulse 120 (increased from 78 beats per minute on 3-11 documentation) Pulse quality +3 irregular Respirations 23 Respiration quality deep/labored oxygen applied (this would indicate that resident was having respiratory difficulty) 1:30 a.m. Neurological score -15 (no neurological deficit) Temperature Blood pressure 110/60 (blood pressure is beginning to drop here) Pulse 130 (pulse is more rapid since last documentation) Pulse quality +3 Respirations 32 (this rate indicates respiratory difficulty, along with increased pulse rate indicates that resident was declining rapidly) Respiration quality labored 3:10 a.m, Neurological score -15 (no neurological deficit) Temperature Blood pressure unable to obtain (this would indicate that resident has had a profound decline in physical condition) Pulse 120 Pulse quality regular Respirations 32 Respiration quality labored with accessory muscles 14. On or about May 13-16, 2002 an AHCA surveyor reviewed resident #18’s nurse’s notes. A nurse’s note dated February 25, 2002 at about 12:00 a.m. revealed that resident #18 vomited a small amount of dark brown emesis and respiratory effort was deep and labored. According to the notes; resident #18 had an oxygen saturation level of eighty-nine percent (89%) and oxygen was started via nasal cannula at two (2) liters/minute. 15. The nurse’s notes dated February 25, 2002 at about 3:20 a.m. revealed that resident #18 was lying in bed alert and responsive. This note is in direct conflict with the inability to obtain or palpate a blood pressure as documented in the notes abovet Resident #18’s skin was documented as pale and clammy with respirations labored with the use of accessory muscles. 16. The nurse’s notes dated February 25, 2002 at about 3:25 a.m. indicated nursing staff called resident #18’s physician and notified him/her of the resident’s change in condition. Nursing staff notified Resident #18's family of the change in condition at about 3:36 a.m. At about 3:45 a.m. resident #18 was transported to the hospital via ambulance. 17. On or about May 15, 2002 at about 10:00 a.m. an AHCA surveyor interviewed Courtyard’s Director of Nursing (“DON”). The DON said Courtyard failed to follow the physician's order for neurological checks every two (2) hours. The DON further stated that there was no documentation on February 24, 2002, showing that oxygen was given to resident #18 as ordered by the physician. Courtyard failed to administer oxygen to resident #18 as ordered by the physician. 18. On or about May 15, 2002 at approximately 10:40 a.m. an AHCA surveyor interviewed resident #18’s physician. During the interview, the physician said he was unaware that resident #18 did not have oxygen started upon return to Courtyard on February 24, 2002. 19. Courtyard failed to notify resident #18’s physician when the resident's condition began to deteriorate at about 11:30 p.m. on February 24, 2002. At that time, resident #18’s oxygen saturation level dropped and his/her pulse increased by forty-two (42) beats per minute. 20. Courtyard failed to notify resident #18’s physician at about 1:30 a.m. on February 25, 2002 when resident #18's heart rate became more rapid and his/her respiratory effort more labored. 21. Based on all of the foregoing, Courtyard violated Rule S9A-4.1288, Florida Administrative Code (2001), which incorporates by reference Title 42 CFR § 483.25(k), by failing to ensure that resident #18 received proper treatment and care for special services. 22. Pursuant to Section 400.23(8)(b), Florida Statutes, (2001) the foregoing is a class II deficiency because it compromised resident #18’s ability to maintain or reach his or her highest practicable physical, mental, or psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 23. Pursuant to Section 400.23(7), Florida Statutes, the presence of one class II deficiency warrants the assignment of a conditional licensure status to Evans Health Care. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1) Make factual and legal findings in favor of AHCA on Count I; 2) Uphold the assignment of a conditional licensure status to Courtyard for the time period May 16, 2002 to June 23, 2002. The license was upgraded to standard on June 24, 2002; and 3) Assess costs related to the investigation and prosecution of the case. NOTICE Courtyard 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 (two pages) 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 Lori Cc. Desnick, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. COURTYARD 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. THE REQUEST FOR HEARIING MUST BE RECEIVED BY AHCA WITHTIN TWENTY-ONE (21) DAYS FOLLOWING COURTYARD’S RECEIPT OF THIS ADMINISTRATIVE COMPLAINT. Respectfully submitted on this 18th day of March 2003. /} WAN Duane Lori C. Desnick, Senior Attorney Fla. Bar. No. 0129542 Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-8854 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that one original Administrative Complaint has been sent by U.S. Certified Mail, Return Receipt Requested, (return receipt # 7104 4575, 1a94+ BOS 0 4.22 ex )} to Annette B. Jansenius, Administrator, Brookwood- Extended Care Center of Marianna, LLC d/b/a Courtyard at the Mill Pond, 803 North Calhoun Street, Tallahassee, Florida 32303, and via facsimile (222-1691) to Theodore Mack, Registered Agent, 803 North Calhoun Street, Tallahassee, Florida 32303, Brookwood- Extended Care Center of Marianna, LLC d/b/a Courtyard at the Mill Pond on this 18th day of March 2003. LORI C. DESNICK, ESQUIRE

Docket for Case No: 03-001548