STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION We [e p uv Pit fit “OP AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. . AHCA NO: 2002049451 SV/JUPITER PROPERTIES, INC., , ; d/bla PENSACOLA HEALTH CARE OD D5 FACILITY, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against S/V JUPITER PROPERTIES, INC., d/b/a PENSACOLA HEALTH CARE FACILITY, [hereinafter “Respondent”] NATURE OF THE ACTION 1. This is an action to assign a conditional license to PENSACOLA HEALTH CARE FACILITY, pursuant to Section 400.23(7)(b), Florida Statutes (2002), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). A copy of the original conditional license is attached hereto as Exhibit “A” and incorporated herein by reference. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 3. AHCA has jurisdiction pursuant to Chapter 400, Part Il, Florida Statutes (2002). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2002). 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 Il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. SV/JUPITER PROPERTIES, INC., d/b/a PENSACOLA HEALTH CARE FACILITY is a Florida corporation with a principal address of Stratford Point Building, 110 South Stratford Road, Fifth Floor, Winston-Salem, North Carolina 27104. 7. PENSACOLA HEALTH CARE FACILITY is a 118-bed skilled nursing facility located at 1717 West Avery Street, Pensacola, Florida 32501. PENSACOLA HEALTH CARE FACILITY is licensed by AHCA as a skilled nursing facility having been issued license number SNF 1434096, certificate number 10086, with an effective date of March 18, 2003 and an expiration date of December 31, 2003. 8. PENSACOLA HEALTH CARE FACILITY is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part Il, Florida Statutes and Chapter 59A-4, Florida Administrative Code, respectively. COUNT I EFFECTIVE MARCH 18, 2003, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO PENSACOLA HEALTH CARE FACILITY BASED UPON THE DETERMINATION THAT PENSACOLA HEALTH CARE FACILITY WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) REPEAT CLASS I] DEFICIENCY AT THE MOST RECENT ANNUAL HEALTH LICENSURE AND RECERTIFICATION SURVEY OF MARCH 18, 2003. § 400.23(7)(b) and (8)(a) and 400.022(1) Florida Statutes Rule 59A-4.1288; Rule 59-A4.123(1) and Rule 59A-109(2), F.A.C., 42 CFR 483.13(c)(1)(i) and 483.25(j) 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. and Florida Administrative Code that are pertinent to these alleged violations read as follows: 400.23 Rules, evaluation and deficiencies; licensure status. — (7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shail assign a licensure status of standard or conditional to each nursing home. (b) A conditional licensure status means that a facility, due to the presence of one or more class | or class Ii deficiencies, or class III 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 this part or with rules adopted by the agency. If the facility has no class |, class I! or class II! deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of the deficiencies as follows: (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 II deficiency is subject to a civil penalty of $2,500 for an \._._.____ igolated_deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one of more class | or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shalt be levied notwithstanding the correction of the deficiency. 400,022 Residents’ Rights. (1) All licensees of nursing home facilities shall adopt and make public a statement of the tights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: (17) Notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and services to treat the condition. 483.13 Resident behavior and facility practices. (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. (1) The facility must-- (i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. § 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. wu (j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. 59A-4.1288 Exception. Nursing homes that participate in Title XVIH or XIX must follow certification rules and regulations found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. Non-certified facilities must follow the contents of this rule and the standards contained in the Conditions of Participation found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies. CLASS II DEFICIENCY 41. On or about March 18, 2003, AHCA conducted a complaint survey at PENSACOLA HEALTH CARE FACILITY. On or about March 18, 2003, based upon observation, interview and record review the AHCA survey team determined that the facility jeopardized the health, life and safety of 2 of 4 sampled residents [Residents #2 and #3] by its failure to provide adequate fluids to maintain proper hydration and health. On that basis, the AHCA survey team cited PENSACOLA HEALTH CARE FACILITY with a Class II deficiency, supported by the following findings: _.... .4,___Review_of the clinical record for resident #2 revealed an initial admission __ date of 6-30-00, with multiple medical diagnoses to include in part: hypothyroidism, hypertension, depression, congestive obstructive pulmonary disease, edema, and a history of congestive heart failure. Review of the resident assessment protocol summary (raps) dated 1-6-03, and generated by the comprehensive resident assessment (minimum data set - mds) completed 12-28-02, after readmission to the facility from a hospitalization for urosepsis, revealed under the raps problem area the resident triggered as being at risk for dehydration/fluid maintenance concerns. The care plan decision column indicated the facility staff determined not to proceed to put a plan of care in place to prevent dehydration of the resident due to the opinion that the dehydration was suggested as being related to a urinary tract infection. The approach of using IV fluids was stated as the intervention to prevent dehydration. The resident's factors which may impede correct fluid balance are listed on the raps = aS moderate to severely impaired decision making ability, comprehension/communication problem, swallowing problem, body control concerns. Further, the resident assessment reflected the resident as being unable to make his/her needs known, disoriented, having a poor appetite - leaving more that 25 % of meals, unable to feed his/herself, fed in room by staff, and requiring total care of the staff for all activities of daily living. Review of physician orders revealed an order dated 12/26/02, to flush the picc _.......line (IV port access) before and after meds. Monthly nursing assessments of the resident dated 1/19/03 and 2/19/03, reveal no evidence of documentation of the resident” — receiving IV fluids. Review of intake and output records for the resident also reflect no documentation of IV fluid administration for hydration. Daily medicare charting of 2/03, for the resident also reflected no evidence the resident received IV fluids for hydration. Review of the intake and output records for the resident reveal very sporadic, incomplete documentation, with over 30 blanks for the two months, and no totals for any 24 hour periods. Nutritional Progress note of 1-17-03 reveals dietician recommendation of 1900 cc's of fluid daily. No evidence of the use of IV hydration is contained in the dietician's notes. Review of medication administration records reveal simply an order to flush the IV access site. On 3-2-03, a nursing note states the access was discontinued. On 3-3- 03 an order was written to offer water often. Nursing notes reflect that on 3-6-03, the resident was lethargic with a temperature of 99.9, pulse of 110 and respirations of 32 and a blood pressure of 102/62 and was sent to the hospital, for abnormal respirations. interview with nursing department management staff on 3-17-03, revealed no further evidence of fluid maintenance documentation and monitoring. The hospital physician progress notes dated 3-7-03, and the admission history and physical examination, state the resident was found to be dehydrated, malnourished, have early pneumonia, and a urinary tract infection. The resident's admission blood urea nitrogen (bun) was 73 (normal range 7-23), his/her sodium level was 162 (normal range 133-146). Review of additional hospital records (discharge summary of 3-17-02) state the resident was admitted from the nursing home with blood urea nitrogen level of 73 which quickly dropped to 37 with fluid replacement (IV fluids were immediately started at” 90 cc's per hour) and his/her creatinine level reached a normal level. The resident's high sodium level dropped more than 20 points and the resident became more alert with the fluid replacement, attempting to respond and answer questions when addressed. At the time of discharge on 3-17-03, the resident's bun was 12 and sodium was 135. 2. Review of the clinical record for resident #3 revealed 2 transfers from the facility to the hospital dated 1-26-03 and 3-5-03. The physician's order on 1-26-03, states the transfer out to the hospital is due to dehydration. The facility re-admission nursing assessment for the resident on 1-31-03, states a diagnosis of volume depletion, renal failure and urinary infection. While in the hospital, a feeding tube had been placed for nutrition, and readmission orders into the facility reveal an order for 2 Cal HN at 40 cc an hour continuously with an order for flushes of 25 cc of water every shift, and 30 cc of water before and after medications. Review of the resident's intake and output records for the month of February 2003, reveals 18 days of tube feeding "TF" (no amount) being entered in the day shift’s intake record, only 3 intake entries on 3-11 shift, 6 no entries on 11-7 shift with 3 entries of "TF." Nursing department management staff was unable to provide further evidence of fluid monitoring during interview on 3-17-03 and 3-18-03. On 3-5-03, according to a transfer sheet the resident was transferred out to the hospital again, for “CHF and renal failure", and was readmitted. The physician's hospital” admission assessment documents the resident's elevated creatinine and blood urea ion. The physician's progress note of 3-6-03 states the bun within normal limits of 0.7 to 1.5) at admission likely due to dehydration and the plan is to administer IVF (IV fluids) and free water to the feeding tube continuously to gently rehydrate the resident, along with IV antibiotics use for treatment of urinary tract infection. nitrogen suggest dehydrati 66, and creatinine of 1.2 ( 12. Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property, including physical abuse. That rule incorporates by reference 42 CFR § 483.13 (c)(1)(i). 13. The foregoing also constitutes a violation of § 400.022, Fla. Stat., which requires the Respondent to ensure the residents’ right to receive adequate and appropriate health care and protective and support services. 14. The foregoing also constitutes an intentional or negligent act materially affecting the health or safety of residents of the facility as defined by § 400.102 (1)(a), Fla. Stat. and is ~————"gubject to a fine under § 400-124 Fla- Stat —————-— ee ne 15. The foregoing constitutes a Class II deficiency as defined by § 400.23(8)(b) Fla. Stat. as follows: A class Il 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 II 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. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class | or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 16. The above referenced violation constitutes the grounds for the imposed Class Il deficiency and for which the imposition of a conditional license is authorized pursuant to § 400.102(1)(d), and-400:23(7)(b) Fla-Stat—. a CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of AHCA on Count |, B. Uphold the issuance of the conditional license attached hereto as Exhibit “A”. DISPLAY OF LICENSE Pursuant to §§ 400.062(5) and 400.23(7)(e), Fla. Stat., Respondent shall post its current 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 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). Ail requests for hearing shall be made to the attention of AGENCY CLERK, AGENCY FOR _._.___ HEALTH._CARE ADMINISTRATION, 2727 MAHAN DRIVE, MAIL STOP #3, TALLAHASSEE, FL 32308. SV/JUPITER PRPOERTIES, INC. d/b/a PENSACOLA HEALTH CARE FACILITY 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 submit 4 fo ‘ DONNA RISELL*’ Fla. Bar. No. 325821 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 a see om ~~ (850) 921-9313 (fax) (850) 921-5873 (office) EXHIBIT LIST Exhibit “A” CONDITIONAL LICENSE License #SNF 130471008; Certificate #9091 Effective Date: 07/25/2002 Expiration Date: 11/11/2002

Docket for Case No: 03-002566