Division of Administ, ative fy ass STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATIO; STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, | Date S29. g 0A ~I9O| = AHCA NO: 2003000553 Petitioner, vs. VISTA MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a VISTA MANOR, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against VISTA MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a VISTA MANOR, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Two Thousand Five Hundred Dollars ($2,500), pursuant to Sections 400.23(8) (b) and 400.102(1)(d) Florida Statutes 2. The Respondent was cited for the deficiency during the annual survey conducted on or about January 09, 2003. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Brevard County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28-106.207, F.A.C. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, F.A.C. 6. Respondent is a nursing home located at 1550 Jess Parrish Court, Titusville, Florida 32796. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, F.A.C. COUNT I __RESPONDENT FAILED TO ENSURE EACH RESIDENT'S DRUG REGIMEN MUST BE. FREE FROM UNECESSARY DRUGS VIOLATING Fl. Admin Code R. 59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 25(1) (1) CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. An annual survey was conducted on January 09, 2003. 9. On that date, based on observations, interview, and record review, it was determined that the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs regarding the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 24 sampled residents (#4). 10. A Class II deficiency was cited against Respondent based on the findings below: a. Resident # 4 was admitted to the facility on 7/23/02 with diagnoses of Psychosis, Abnormal gait, Depressive disorder and history of Colon Cancer (presently in remission). The initial Minimum Data Set (MDS) assessment, dated 8/06/02, indicated that the resident had a cognitive status of 2 (moderately impaired), exhibited aggressive and abusive behavior, required supervision with transfers, was ambulatory and wandering throughout the facility, required supervision with dressing, hygiene and bathing, independent with set-up for eating, no range of motion limits, and continent of bowel and usually continent of bladder. The resident's weight at the time of admission was 164 pounds. b. Review of the resident's Quarterly assessment, dated 10/22/02, indicated an extensive decline in activities of daily living (ADL) . The resident's cognitive status remained as moderately impaired, still exhibiting aggressive and abusive behavior, was non-ambulatory, dependent upon staff for locomotion, and required assistance with eating, dressing, hygiene and bathing. The resident's weight on 10/22/02 was tes) 145 pounds, showing a 19 pound weight loss. As of the dates of the survey, 1/06/03 to 1/09/03, the resident was no longer able to feed self and was incontinent of bladder. The facility failed to complete a significant change assessment for this resident. c. Review of the nurses' progress notes and physician orders from 7/23/02 through 9/26/02 revealed the following documentation: 7/24/02 - The resident was transported to the hospital for a psychiatric evaluation following an aggressive outburst. The resident returned to the facility on the same day with orders to increase _Risperdal, an anti-psychotic medication, to 0.5 0 0. milligrams (mg.) each morning and 1 mg. at bedtime, increase Neurontin, an anti-convulsive medication, to 100 mg. each morning, 100 mg. at noon and 200 mg. at night. 7/31/02 - The Risperdal and Neurontin were discontinued and the resident was started on Seroquel, anti-psychotic medication, 25 mg. twice a day. ~g/11/02 - The resident fell and sustained a sprained wrist and was placed in a reclining chair for safety. 8/18/02 - The Seroquel was decreased to 25 mg. once a day. 8/25/02 - The resident fell from the reclining chair with no apparent injury. 9/19/02 - The physician ordered a consultation with the psychiatrist for behavior concerns and modification of medication. 9/26/02 - The resident was seen by the psychiatrist, who ordered Ativan i mg. per mouth, if unable to redirect, Klonopin, an anti-convulsive and anti-panic disorder medication, 1 mg. at night and Depakote, an anti-convulsive medication, 250 mg. three times a day. The Klonopin was discontinued a few days later. d. Review of the Behavior Monitoring Forms indicated the following: 7/23/02 to 7/31/02: Anxiety (Ativan), 7 days of continuous behavior on the evening shift. Delusions (Risperdal), 1 episode on day shift and 6 continuous on evening shift. 8/1/02 to 8/31/02: Aggressive behavior (Seroquel), 1 episode on day shift Panic/Fear (Ativan), 2 episodes on evening shift. 9/1/02 to 9/30/02: Panic/Fear (Ativan), 1 episode on day shift and 8 shifts with no documentation. Aggressive Behavior (Seroquel), 11 episodes on 4 day shifts, 5 episodes on 3 evening shifts and 6 shifts with no documentation. e. For the months of August and September, Seroquel was being given for aggressive behavior, but no defined behaviors were documented. f. At.the request of the family, the resident was transferred to the services of another physician on 9/29/02. At this time, the resident was placed on the following medications: Paxil, 25 mg. 1 each day, Depakote. Sprinkles 125 mg. twice a day,.. Duragesic. _ Patch, a controlled substance schedule II analgesic, 50 micrograms (mcg.) every 72 hours, Ativan 0.5 mg. (1 or 2 pills) 4 times a day as needed, Ativan 2 mg. IM every 4 hours as needed, and Zyprexa 5 mg. every day for 3 days, then Zyprexa 10 mg. every day for 3 days, at night. On 10/14/02, Zyprexa Zydis 5 mg. each morning was added. Between 10/14/02 and 10/23/02, the Zypréxa being given at night was changed to Zyprexa Zydis and increased to 15 mg. daily. g. Review of the dietician's progress notes, dated 10/14/02, confirmed that the resident had sustained a 20.6 pound weight loss since 9/4/02. The dietician documented: the "resident is not eating as [he/she] has had medication changes and is lethargic." h. On 10/23/02, the consultant pharmacist communicated three (3) written recommendations to the resident's physician: 1) Recommend discontinuing: the IM PRN order for Ativan. The use of this medication is usually reserved for situations where there is imminent threat to life (self or others), 2) "This resident was observed to be experiencing somnolence _and is receiving Zyprexa Zydis 5 mg..po gam and. 15mg. po ghs." "Somnolence is a common treatment-emergent event as reported in the Zyprexa package insert." "Risperdal has been shown to be effective for behaviors or psychosis associated with dementia in numerous studies. Risperdal has a low incidence of sommolence." "Please consider a cross-taper to Risperdal, the formulary-preferred atypical antipsychotic at this facility." "The maximum recommended daily geriatric dose per OBRA guidelines is 10mg per day. Please DOCUMENT the need to continue this medication outside the OBRA guidelines." 3) "This resident is receiving Depakote without current lab work on the chart. Please order Ammonia level on next lab day to monitor current therapy." i. The resident's physician responded to the pharmacist's recommendations on 10/28/02 and made the choice not to change the medications. The physician did order an Ammonia level on 10/30/02 and the result was 20.6 (normal is 9 to 33). The Ammonia level was repeated on 12/06/02 and the result was an elevated level of 47.2 and again on 12/20/02, with an elevated level of 39.6. The Depakote dosage was not changed. j. Review of the physician orders from 11/29/02 through the date of survey, 1/09/03, revealed five’ (5) dosage changes to the Zyprexa order, all of which were above the OBRA recommendation of 10 mg. per day, with no documentation as to the benefit to the resident for the higher dosage. As of the last day of survey (1/09/03), review of the Medication Administration Record (MAR) for January, 2003, indicated the resident was receiving Zyprexa 2.5 mg. in the morning, Zyprexa Zydis 10 mg. in the morning and Zyprexa Zydis 5 mg. at night, a total of 17.5 milligrams per day. Further review of the Behavior Management forms from 10/1/02 through 12/31/02 indicated the following documentation: k. 10/1/02 to 10/31/02: Aggressive behavior (Zyprexa) 18 episodes on 5 day shifts and 2 episodes on evening shift with 7 shifts of no documentation. These episodes all occurred from 10/1 to 10/10, one day after beginning the..Zyprexa. Panic/Fear (Ativan), 1 episode on evening shift and 7 shifts with no documentation. 1. 11/1/02 to 11/30/02: Aggressive behavior (Zyprexa), 7 episodes on 2 day shifts, 1 episode on evening shift and 19 shifts with no documentation. Panic/Fear (Ativan), 7 episodes on 2 day shifts, 1 episode on evening shift and 20 shifts with no documentation. m. 12/1/02 to 12/31/02: Fighting, striking out (Zyprexa) 3 episodes on 3 day shifts and 7 shifts with no documentation. Fear (Ativan), no episodes. Zyprexa Zydis, no documentation of behavior monitoring for the month. n. On 11/29/02, there was a physician order to "use tray table while OOB in recliner chair due to increase in falls and decrease in safety awareness. Check Q 30 min and release Q 2 hr. times 10 minutes for exercise, toileting and repositioning.” oo. On 1/06/03, from 2:00 PM until 4:45 PM, the resident was observed in the geri-chair with lap tray sitting by the Apollo I nurses' station. He/she was very somnolent and lethargic, leaning over the left arm of the chair. The resident was not checked or repositioned.during this observation time of 2.75 hours. Pp. On 1/07/03 at 8:10 AM, the resident was observed sitting in the geri-chair with lap tray at the nurses' station. He/she was somnolent and leaning over the right arm of the chair and drooling. The resident: sat_ at the nurses' station until 12:30 PM, at which time, he/she was taken to the dining room for lunch. At 1:00 PM in the main dining room, the nursing assistant was observed trying to wake the resident to be fed. After approximately five (5) minutes, the resident was alert enough to be fed and began eating. q. On 1/06/03 at 2:00 PM, during an interview with the resident's physician regarding the resident's lethargy and being placed in a geri-chair with a lap tray, the physician stated: "I prefer [he/she] be in the chair so [he/she] will be predictable." 10 On 1/08/03 at 10:30 AM, the care plan team met with 3 surveyors to discuss 3 residents. Regarding this resident, the team was asked why the obvious decline of this resident since admission was not addressed. The director of nursing (DON) indicated that they were aware of the decline and that the physician was also aware of.their concerns about the medications. When asked if they had involved their medical director, the DON replied: "Yes, [he/she] has spoken to [him/her] on several occasions, but [he/she] will not change." 11. These observations were cited as an isolated, State Class II deficiency and were to be corrected by January 31,_ 2003. 12. The above actions or inactions constitute a violation of 59A-4.1288 incorporating by reference 42 CFR 483.25(1) (1) requires each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. 13. The above referenced violation constitutes the grounds 11 for the imposed uncorrected Class II deficiency and for which a fine of Two Thousand Five Hundred Dollars ($2,500) is authorized pursuant to Sections 400.102(1) (a,d), 400.121(1), and 400.23(8) (b), Florida Statutes CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A Make factual and legal findings in favor of: the Agency on Count I; B. Recommend that the administrative fine of Two Thousand Five Hundred Dollars ($2,500) be upheld; and Cc. Assess costs related to the investigation and Fl. Stat. (2002) D All other general and equitable relief allowed by law. The Respondent 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 Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. 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. y submitted, Garcia, Esquire Senior Attorney ar No. 504149 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (Fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof was sent by U.S. Mail, to C T Corporation System, Registered Agent for Vista Manor, 1200 South Pine Island Road, Plantation, Florida 33324 and by U.S. Certified Mail, Return Receipt No.7002 2030 0007 8499 6829 to Administrator, Vista Manor, 1550 Jess Parri 2 Court, Titusville, Florida 32796, by U.S. Mail on April , 2003. ‘Hara Garcia, Esq. 13 Copies furnished to: C T Corporation System Registered Agent for Vista Manor 1200 South Pine Island Road Plantation, Florida 33324 (U.S. Certified Mail) Administrator Vista Manor 1550 Jess Parrish Court Titusville, Florida 32796 (U.S. Mail) Eileen O'Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330D St. Petersburg, Fl 33701 (Interoffice) 14 215 SOUTH MONROE STREET Suite 400 PO Drawer 11300 TALLAHASSEE, FLORIDA 32301 TELEPHONE: 850.681.6810 BROAD AND CASSEL FACSIMILE: 850.681.9792 www.broadandcassel.com ATTORNEYS AT LAW DONNA HOLSHOUSER STINSON D1rECT FACSIMILE: 850-521-1449 EMAIL: dstinson@broadandcassel.com May 12, 2003 Mr. Patrick Duplantis President and Chief Executive Officer SeaCrest Health Care Management 10210 Highland Manor Drive, Ste. 410 Tampa, FL 33610 Dear Patrick, First, thank you for taking time to meet with me a few weeks ago. It was good to see you and to review the matters we have pending for SeaCrest facilities. We received payment from various facilities on a number of outstanding invoices last month, and also-appreciate that, of course: Somehow, however, some of the older invoices seem: to have been overlooked. Attached is a chart which shows outstanding balances in the 0-30, 31- 60, 61-90, and 91+ day categories. As you can see, there are very few outstanding amounts in the O7 30 —3+-60 and 61-90 day columns, but numerous ones under the 91+ headingS =z {-60 and We would certainly appreciate your attention to bringing these invoices current, and if you have any questions, please do not hesitate to call. Yours truly, Donna Holshouser Stinson Boca RATON ® FT. LAUDERDALE # MIAM! # ORLANDO #® TALLAHASSEE # TAMPA @ WEST PALM BEACH TLHI\HEALTH\63926.1 29367/0001 DHS 5/9/03

Docket for Case No: 03-002011