STATE OF FLORIDA an ie AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ‘; ADMINISTRATION - Petitioner, AHCA No.: 2003003426 Vv. 2003003425 Return Receipt Requested: HEBREW HOME OF SOUTH BEACH, INC., 7002 2410 0001 4236 8130 d/b/a HEBREW HOME OF SOUTH BEACH, 7002 2410 0001 4236 8147 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Hebrew Home of South Beach, Inc., d/b/a Hebrew Home of South Beach (hereinafter “Hebrew Home of South Beach” or the “facility”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2002) (hereinafter “Fla. Stat.”), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose and maintain the Agency’s administrative fine totaling $51,000.00 against Hebrew Home of South Beach; $45,000.00 in administrative fines for deficiencies, pursuant to Sections 400.102, 400.121, and 400.23(8), Fla. Stat., for the protection of the public health, safety and welfare, plus a $6,000.00 survey fee, pursuant to Section 400.19(3), Fla. Stat. 2. This is an action to impose and maintain the Agency’s assignment of a Conditional Licensure status to Hebrew Home of South Beach, for the period of 05/12/2003 tarough 12/31/2003, pursuant to Section 400.23(7) (b), Fla. Stat. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 4. Venue lies in Miami-Dade County, pursuant to Section 400.121(1)(e), Fla. Stat., and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part Il, Fla. Stat. and Chapter 59A-4 Florida Administrative Code. 6. Hebrew Home of South Beach operates a 104-bed skilled nursing facility located at 320 Collins Avenue, Miami, Beach, Florida 33139. Hebrew Home of South Beach is licensed as a skilled nursing facility; license number SNF1351096; certificate number 10134 effective 05/12/2003. Hebrew Home of South beach was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT _I HEBREW HOME OF SOUTH BEACH FAILED TO PROVIDE COMFORTABLE AND SAFE TEMPERATURE LEVELS AND ENSURE THAT THE RESIDENTS WERE NOT BEING EXPOSED TO DANGEROUS TEMPERATURES AND CONDITIONS. 59A-4.122(2) (f) and 59A-4.106(4) (n), FLORIDA ADMINISTRATIVE CODE, and/or Title 42 C.F.R. 483.15(h) (6), CODE OF FEDERAL REGULATIONS, as incorporated by Rule 59A-4.1288 (ENVIRONMENT) CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. Because Hebrew Home of South Beach participates in Title XVIII or XIX, it must follow the certification rules and regulations found in 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, F.A.C. 9. During the complaint investigation conducted by the Agency on 5/12/2003 and based on observation, record review and interview, the Agency found that Hebrew Home Of South Beach failed to provide comfortable and safe temperature levels and ensure that the residents were not being exposed to dangerous temperatures and conditions. The Agency found that at least three resident (identified in the survey as residents #6, #7, and #8) showed signs of distress, with resident #6 passing away, resident #7 being admitted to the hospital with chest pain and resident #8 becoming dehydrated and also requiring admission to the hospital. Findings include the following, to wit: 10. On 5/12/03 at 3:15 pm, the Agency’s surveyor and tae administrator of the facility conducted a tour of the resident areas. There were 94 residents in the facility at the time of the investigation. The temperature on the outside of the building was measured using a calibrated thermometer, with a reading of 88 degrees Fahrenheit (F). The temperature in the 2™ floor activity room was 86 degrees (F), even though the windows were open. The surveyor’s observations of eighteen (18) residents in the activity room at the time of the tour revealed that fluids were placed on a cart on the side of the room, but no residents had a glass of fluid in their hands or close by. ll. The surveyor’s private interview with sampled residents #1, #2, #3, #4 and #5 in the activity room at the time of the initial tour of the facility revealed that the residents were hot, tired and thirsty. The activities assistant, that was in the room with the 5 residents at the time, identified the residents as being interviewable residents. The residents further stated that fluids had not been offered in the 2 days that the air conditioning had been off. The residents stated that they had not been given any fluids recently by the staff. 12. The temperature in the 3% floor resident care area was 85 degrees (F) as indicated by thermometer and thermostat readings, witnessed by the surveyor and the Administrator. The temperature on the 4° floor resident care area was 89 degrees by thermometer and thermostat, as witnessed by the Administrator. There were 10 residents in wheelchairs at the 4°" floor nurses station, and none of the residents had liquids in the vicinity. 13. Further interviews by the surveyor with the Administrator and the Director of Nurses confirmed that they were not notified over the weekend by the staff that the air conditioning unit was not functioning properly. They further reported that from the time they were notified on Monday morning on 5/12/03, the air conditioning was not functioning properly for approximately 40 hours, placing the residents at risk for dehydration and heat stroke. The Administrator stated on 5/12/03 at 4:00 pm that the temperatures were not monitored and recorded as per policy. Review of the policy revealed that the following tasks should have been performed but were not, including: notifying the County Health Department and the facility's medical director that the residents were at risk for dehydration; adding additional staff to hydrate and monitor the residents at risk; increasing fluids and initiating intake and output records on each resident in affected areas; taking vital signs on each resident in affected areas (No vital signs were taken until 8:00 pm on 5/12/03 after surveyor's inquiry); relocating the residents at risk for dehydration to more comfortable areas or to another facility, if necessary. 14. Interview with the Administrator on 5/12/03 at 3:30 pm revealed that the current air conditioner had been in place for 5 to 6 years with a monthly contract for service. Further interview with the Administrator confirmed that the facility does not maintain any documentation of facility staff maintenance of the air conditioning unit. The only documentation located were the bills/receipts for the monthly service done by the service company. 15. Interview with the Administrator on 5/12/03 at 5:30 pm revealed that none of the residents’ private physicians had been notified about the air conditioning not functioning properly, the residents exposure to high temperature and high humidity, and that the residents were at risk for dehydration. The facility administration was unresponsive to the Agency to identify any steps that the facility had taken to protect residents from lingering adverse effects of heat exposure, especially for high risk residents suffering from vomiting/diarrhea, elevated temperatures, infectious processes, dependence on staff for the provision of fluid intake, use of medications including diuretics, laxatives, and cardiovascular agents, renal disease (dialysis), dysphagia, enteral feedings, oxygen therapy, a history of refusing fluids, limited fluid intake or lacking the sensation of thirst. Complications of dehydration would include fecal impaction, urinary tract infections, weight loss, pressure ulcers and death. 16. Interview with the Social Worker on 5/12/03 at 4:30 pm revealed that the residents were complaining of the heat even with the windows open, but the complaints were not recorded in the log because the facility was trying to resolve the problem. According to the social worker, the complaints that are resolved immediately are not recorded in the complaint log by the social work staff. However, the complaints were not resolved immediately, as evidenced by the detrimental environmental conditions noted during the investigation. 17. Interview with the Activity Assistant on 5/12/03 at 3:30 pm revealed that the air had been off for more than a day, and that the residents were complaining of the heat even though the windows were open. Although a container of juice was in the room, none of the residents had a glass of the juice at the time of the tour nor was staff offering drinks or encouraging the residents to drink fluids. 18. Interview with the Housekeeping and Maintenance Supervisor on 5/12/03 at 4:00 pm revealed that he/she was called on 5/10/03 at 11:00 pm and notified that the air conditioning went off. The Supervisor reported that he came into the facility and reset the air conditioner and called the service company to come to the facility in the morning. On 5/11/03 at 9:00 am the service company arrived and found that the air had gone off again at 8:00 am. The air conditioner was reset and stayed on until 2:30 pm. The service company was called again and was in the facility from 3:00 pm to 5:00 pm. When they left, the air conditioner was working, and the staff was told that someone from the company would be out to check on 5/12/03, early in the morning. The service company arrived at 11:30 am and the staff informed them that the air conditioner had been off for most of the night. 19. Interview with the Administrator, Director of Nurses, Director of Food Services and the Corporate Director of Clinical Services on 5/12/03 at 8:25 pm revealed that 17 residents out of 94 had an increase in body temperature over the norm of 98.6 F. The temperatures of the residents ranged from 98.9 to 99.5 F. Increase in body temperature, without providing appropriate care and services such as providing fluids, places the residents at higher risk for harm and even death. 20. Review of the clinical record of sampled resident #6 revealed that the resident was returned to the facility from the hospital on 5/12/03 at 1:45 pm and then expired at 3:55 pm. The readmission note gave a description of the resident diminished condition and reported that, "The resident awake and able to identify self, is hard of hearing. Mouth and lips very dry, with slight vomitus around the mouth- loose bowel movement is seen in the sheets when carried by the ambulance staff to the bed. B_eeding noted on the buttocks, which has a skin abrasion and tnere is peeling skin around the sacral area." Additional records from the hospital revealed that the resident had been in the hospital since 4/26/03. On 5/9/03 the resident's electrolytes were abnormal. The sodium was 130 (norm is 136-148), chloride was 82 (norm is 95-110), blood, urea & nitrogen (BUN) was 109 (norm is 7-26). The resident’s medical history is documented in the record by the physician and is significant for congestive heart failure, kidney failure, pleural effusion, anemia and hypertension. This resident's medical condition and electrolyte/fluid imbalance upon admission to the nursing home placed him/her at risk for dehydration and should have been closely monitored by facility staff, particularly under the detrimental hot and humid environmental conditions existing at the facility at that time. 21. Review of the clinical record of sampled resident #7 revealed that the resident complained of palpitations on 5/11/03 at midnight and the physician was called. The resident was transferred to the hospital at 4:30 pm with chest pain and no vital signs had been documented in the record. 22. Review of the clinical record of sampled resident #8 revealed that the resident was found semi-conscious with labored breathing on 5/11/03 at 3:00 pm. The physician was called and the resident was transferred to the hospital at 5:20 pm. Additional information from the hospital revealed that the resident was transferred to the hospital with the diagnosis of dehydration and altered mental status, after having arrived in an unresponsive state, by ambulance. The 10 resident's temperature was 100 degrees F (norm is 98.6 degrees F) and the heart rate was elevated, at 98 beats per minute (norm is 60-80). 23. Hebrew Home Of South Beach’s failure to provide comfortable and safe temperature levels and ensure that the residents were not being exposed to dangerous temperatures and conditions caused or was likely to cause serious harm, impairment or death to the residents; with three residents requiring hospitalization, and one resident dying. Based on the foregoing, Hebrew Home of South Beach violated 59A- 4,122(2)(f) and 59A-4.106(4)(n), Florida Administrative Code, and/or Title 42, Section 483.15(h)(6), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, herein classified as a Class I deficiency, pursuant to Section 400.23(8) (a), Fla. Stat., which carries an assessed fine of $15,000. This deficiency (alone or in conjunction with the other deficiencies cited in this Administrative Complaint) gives rise to a conditional licensure status, for the period of 05/12/2003 through 12/31/2003, pursuant to Section 400.23(7) (b). COUNT II HEBREW HOME OF SOUTH BEACH FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SERVICES FOR RESIDENTS, TO ENSURE THAT EACH RESIDENT RECEIVES SUFFICIENT FLUID INTAKE, TO MAINTAIN PROPER HYDRATION AND HEALTH. 11 400.022(1) (L), and (3), Fla. Stat., and/or Title 42 483.25(j), CODE OF FEDERAL REGULATIONS, as incorporated by Rule 59A-4.1288, Florida Administrative Code. (QUALITY OF CARE) CLASS I DEFICIENCY 24, AHCA re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 25. During the complaint investigation conducted by tne Agency on 5/12/2003 and based on observation, residents’ clinical record review and interview with staff, the Agency found that the facility failed to provide adequate and appropriate services for residents, to ensure that each resident receives sufficient fluid intake to maintain proper hydration and health, as evidenced by not ensuring the health and safety of the residents when the air conditioning failed to work properly for at least forty (40) hours, and exposing 94 of 94 residents to dangerous temperatures and conditions, with the potential for serious injury or death, with at least one resident becoming dehydrated and requiring admission to the hospital. At least three resident (#6, #7, and #8) showed signs of distress, with resident #6 passing away, resident #7 being admitted to the hospital with chest pain and resident 48 becoming dehydrated and also requiring admission to the hespital. Findings include the following, to wit: 26. The surveyor and the administrator of the facility conducted a tour of the resident areas on 5/12/03 at 3:15 pm. There were 94 residents in the facility at the time of the investigation. The temperature on the outside of the building was measured using a calibrated thermometer with a reading of 88 degrees Fahrenheit (F). The temperature in the 2™ floor activity room was 86 degrees (F) even though the windows were open. Observations of eighteen (18) residents in this activity room at the time of the tour revealed that fluids were placed on a cart on the side of the room, but no residents had a glass of fluid in their hands or close by. 27. Private interview with sampled residents #1, #2, #3, #4 and #5 in the activity room at the time of the initial tour of the facility revealed that the residents were hot, tired and thirsty. The activities assistant that was in the room with the 5 residents at the time identified the residents as being interviewable residents. The residerts further stated that fluids had not been offered in the 2 days that the air conditioning had been off. The residents also stated that they had not been given any fluids recently by the staff. 28. The temperature in the 3% floor resident care area was 85 degrees (F) as indicated by thermometer and 13 thermostat readings, witnessed by the surveyor and the Administrator. Rooms 301, 302, 304, 308, 312, 315, 317, 318, 319 and 321 had residents in them, lying in bed, who were observed to be functionally impaired and required assistance from direct care staff with activities of daily living, which include providing fluids, and there were no liquids at the bedside. There were 12 residents in waeelchairs at the 3% floor nurses station, and none of the residents had liquids in the vicinity. The temperature on the 4'® floor resident care area was 89 degrees by thermometer and thermostat, as witnessed by the Administrator. There were 10 residents in wheelchairs at the 4" floor nurses station, and none of the residents had liquids in the vicinity. 29. Further interviews with the Administrator and the Director of Nurses confirmed that from the time they were notified on the morning of 5/12/03, the air conditioning was not functioning properly for approximately 40 hours, placing the residents at risk for dehydration and heat stroke. The Administrator stated on 5/12/03 at 4:00 pm that the temperatures were not monitored and recorded as per policy. Review of the policy revealed that the following tasks should have been performed but were not, including: notifying the County Health Department and the facility's 14 medical director that the residents were at risk for dehydration; adding additional staff to hydrate and monitor the residents at risk; increasing fluids and initiating intake and output records on each resident in affected areas; taking vital signs on each resident in affected areas (No vital signs were taken until 8:00 pm on 5/12/03 after surveyor's inquiry); relocating the residents at risk for dehydration to more comfortable areas or to another facility, if necessary. 30. Interview with the Administrator on 5/12/03 at 3:30 pm revealed that the current air conditioner had been in place for 5 to 6 years with a monthly contract for service. Interview with the Administrator confirmed that the facility does not maintain any documentation of facility staff maintenance of the air conditioning unit. The only documentation located were the bills/receipts for the monthly service done by the service company. 32. Interview with the Administrator on 5/12/03 at 5:30 pm revealed that none of the residents' private physicians had been notified about the air conditioning not functioning properly and that the residents were at risk for dehydration. The facility administration was unresponsive to identify any steps taken to protect residents from lingering adverse effects of heat exposure, 15 especially for high risk residents suffering from vomiting/diarrhea, elevated temperatures, infectious processes, dependence on staff for the provision of fluid intake, use of medications including diuretics, laxatives, and cardiovascular agents, renal disease (dialysis), dysphagia, enteral feedings, oxygen therapy, a history of refusing fluids, limited fluid intake or lacking the sensation of thirst. Complications of dehydration would include fecal impaction, urinary tract infections, weight loss, pressure ulcers and death. 32. Interview with the Social Worker on 5/12/03 at 4:30 pm revealed that the residents were complaining of the heat even with the windows open, but the complaints were not recorded in the log because the facility was trying to resolve the problem. According to the social worker, the complaints that are resolved immediately are not recorded in the complaint log by the social work staff. However, the complaints were not resolved immediately as evidenced by the detrimental hot environmental conditions noted during the investigation. 33. Interview with the Activity Assistant on 5/12/03 at 3:30 pm revealed that the air had been off for more than a day, and that the residents were complaining of the heat even though the windows were open. Although a container of 16 juice was in the room, none of the residents had a glass of the juice at the time of the tour nor was staff offering drinks or encouraging the residents to drink fluids, placing them at risk for dehydration. 34. Interview with the Housekeeping and Maintenance Supervisor on 5/12/03 at 4:00 pm revealed that he/she was called on 5/10/03 at 11:00 pm that the air conditioning went off. The Supervisor reported that he came into the facility and reset the air conditioner and called the service company to come to the facility in the morning. On 5/11/03 at 9:00 am the service company arrived and found that the air had gone off again at 8:00 am. The air conditioner was reset and stayed on until 2:30 pm. The service company was called again and was in the facility from 3:00 pm to 5:00 pm. When they left the air conditioner was working, and the staff was told that someone from the company would be out to check on 5/12/03 early in the morning. The service company arrived at 11:30 am and the staff informed them that the air conditioner had been off for most of the night. 35. Interview with the Administrator, Director of Nurses, Director of Food Services and the Corporate Director of Clinical Services on 5/12/03 at 8:25 pm revealed that 17 residents out of 94 had an increase in 7 body temperature over the norm of 98.6 F. The temperatures of the residents ranged from 98.9 to 99.5 FP. Increase in body temperature increased fluid loss and need for increased ingestion of fluids. 36. Review of the clinical record of sampled resident #65 revealed that the resident was returned to the facility from the hospital on 5/12/03 at 1:45 pm and expired at 3:55 pm. The readmission note gave a description of the resident diminished condition and reported that, "The resident awake and able to identify self, is hard of hearing. Mouth and lips very dry with slight vomitus around the mouth- loose bowel movement is seen in the sheets when carried by the ambulance staff to the bed. Bleeding noted on the buttocks, which has a skin abrasion and there is peeling skin around the sacral area." Additional records from the hospital revealed that the resident had been in the hospital since 4/26/03. On 5/9/03 the resident's electrolytes were abnormal. The sodium was 130 (norm is 136-148), chloride was 82 (norm is 95-110), blood, urea & nitrogen (BUN) was 109 (norm is 7-26). The medical history is documented in the record by the physician and is significant for congestive heart failure, kidney failure, pleural effusion, aremia and hypertension. This resident's medical condition and electrolyte/fluid imbalance upon admission to the 18 nursing home placed him/her at risk for dehydration and should have been closely monitored by facility staff, particularly under the detrimental hot environmental conditions at that time. 37. Review of the clinical record of sampled resident #7 revealed that the resident complained of palpitations on 5/11/03 at midnight and the physician was called. The resident was transferred to the hospital at 4:30 pm with chest pain and no vital signs had been documented in the record. 38. Review of the clinical record of sampled resident #8 revealed that the resident was found semi-conscious with labored breathing on 5/11/03 at 3:00 pm. The physician was called and the resident was transferred to the hospital at 5:20 pm. Additional information from the hospital revealed that the resident was transferred to the hospital with the diagnosis of dehydration and altered mental status, after having arrived in an unresponsive state, by ambulance. The resident's temperature was 100 degrees F (norm is 98.6 degrees F) and the heart rate was elevated at 98 beats per minute (norm is 60-80). 39, The facility’s failure to provide adequate and appropriate services for residents, to ensure that each resident receives sufficient fluid intake to maintain 19 proper hydration and health, caused or was likely to cause serious harm, impairment or death to the residents. Based on the foregoing, Hebrew Home of South Beach violated Section 400.022(1)(L), and (3), Fla. Stat., and/or Title 42, Section 483.25(}), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class I deficiency pursuant to Section 400.23(8) (a), Fla. Stat., which carries an assessed fine of $15,000. This deficiency (alone or in conjunction with the other deficiencies cited in this Administrative Complaint) gives rise to a conditional licensure status, for the period of 05/12/2003 through 12/31/2003, pursuant to Section 400.23(7) (b). COUNT III HEBREW HOME OF SOUTH BEACH FAILED TO PROPERLY ADMINISTER THE FACILITY AND ENSURE THAT IT’S POLICY ON THE PREVENTION OF HEAT STROKE WAS IMPLEMENTED AFTER THE AIR CONDITION SYSTEM MALFUNCTIONED FOR AT LEAST 40 HOURS, EXPOSING 94 OF 94 RESIDENTS TO DANGEROUS TEMPERATURES AND HUMIDITY. 400.147(2) Fla. Stat., and/or Title 42, Section 483.75, CODE OF FEDERAL REGULATIONS, as incorporated by Rule 59A-4.1288, F.A.c. (ADMINISTRATION) CLASS II DEFICIENCY 40. AHCA re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 41. During the complaint investigation conducted on 5/12/2003 and based on observation, interview and record 20 review, the Agency found that Hebrew Home Of South Beach failed to properly administer the facility and ensure that it’s policy on the prevention of heat stroke was implemented after the air condition system malfunctioned for at least 40 hours, exposing 94 of 94 residents to dangerous temperatures and humidity, after the facility’s air conditioning system malfunctioned for at least 40 hours starting on Saturday 5/10/02, with the potential for serious injury or death to residents, with at least one resident becoming dehydrated and requiring admission to the hospital. At least three resident (#6, #7, and #8) showed signs of distress, with resident #6 passing away, resident #7 being admitted to the hospital with chest pain and resident #8 becoming dehydrated and also requiring admission to the hospital. Findings include the following, to wit: 42. On 5/12/03 at 3:15 pm, the Agency’s surveyor and the administrator of the facility conducted a tour of the resident areas. There were 94 residents in the facility at the time of the investigation. The temperature on the outside of the building was measured using a calibrated thermometer with a reading of 88 degrees Fahrenheit (F). The temperature in the 2™ floor activity room was 86 degrees (F}) even though the windows were open. Observations 21 of eighteen (18) residents in this activity room at the time of the tour revealed that fluids were placed on a cart on the side of the room, but no residents had a glass of fluid in their hands or close by. 43. Private interview with sampled residents #1, #2, #3, #4 and #5 in the activity room at the time of the initial tour of the facility revealed that the residents were hot, tired and thirsty. The activities assistant that was in the room with the 5 residents at the time identified the residents as being interviewable residents. The residents further stated that fluids had not been offered in the 2 days that the air conditioning had been off. The residents also stated that they had not been given any fluids recently by the staff. 44, The temperature in the 3'% floor resident care area was 85 degrees (F) as indicated by thermometer and thermostat readings, witnessed by the surveyor and the Administrator. Rooms 301, 302, 304, 308, 312, 315, 317, 318, 319 and 321 had functionally declined residents in them, lying in bed and were not relocated to a more comfortable area. There were 12 residents in wheelchairs at the 3°? floor nurses station, and none of the residents had liquids in the vicinity. The temperature on the 4° floor resident care area was 89 degrees by thermometer and 22 thermostat, as witnessed by the Administrator. There were 10 residents in wheelchairs at the 4‘ floor nurses station, and none of the residents had liquids in the vicinity. 45, Further interviews with the Administrator and the Director of Nurses confirmed that they were not notified over the weekend by the staff that the air conditioning unit was not functioning properly. They further reported tnat from the time they were notified on Monday morning on 5/12/03, the air conditioning was not functioning properly for approximately 40 hours, placing the residents at risk for dehydration and heat stroke. The Administrator stated on 5/12/03 at 4:00 pm that the temperatures were not monitored and recorded as per policy. The intent of the policy as described was "planning and prevention of and reaction to hyperpyrexia or heat stroke”. 46. Review of the policy revealed a description of the procedure that should be followed in the event of a malfunction of the air condition system, and revealed that the following tasks should have been performed but were not, including: notifying the County Health Department and the facility's medical director that the residents were at risk for dehydration; adding additional staff to hydrate and monitor the residents at risk; increasing fluids and initiating intake and output records on each resident in 23 affected areas; taking vital signs on each resident in affected areas (No vital signs were taken until 8:00 pm on 5/12/03 after surveyor's inquiry); relocating the residents at risk for dehydration to more comfortable areas or to another facility, if necessary. Interview with the Administrator on 5/12/03 at 3:30 pm revealed that the current air conditioner had been in place for 5 to 6 years with a monthly contract for service. Further interview with the Administrator confirmed that the facility does not maintain any documentation of facility staff maintenance of the air conditioning unit. The only documentation located were the bills/receipts for the monthly service done by the service company. 47, Interview with the Administrator on 5/12/03 at 5:30 pm revealed that none of the residents' private physicians had been notified about the air conditioning not functioning properly and that the residents were at risk for dehydration. The facility administration was unresponsive to identify any steps taken to protect residents from lingering adverse effects of heat exposure, especially for high risk residents suffering from vomiting/diarrhea, elevated temperatures, infectious processes, dependence on staff for the provision of fluid intake, use of medications including diuretics, laxatives, 24 and cardiovascular agents, renal disease (dialysis), dysphagia, enteral feedings, oxygen therapy, a history of refusing fluids, limited fluid intake or lacking the sensation of thirst. Complications of dehydration would include fecal impaction, urinary tract infections, weight loss, pressure ulcers and death. 48. Interview with the Social Worker on 5/12/03 at 4:30 pm revealed that the residents were complaining of the heat even with the windows open, but the complaints were not recorded in the log because the facility was trying to resolve the problem. According to the social worker, the complaints that are resolved immediately are not recorded in the complaint log by the social work staff. However, the complaints were not resolved immediately as evidenced by the detrimental environmental conditions noted during the investigation. 49. Interview with the Activity Assistant on 5/12/03 at 3:30 pm revealed that the air had been off for more than a day, and that the residents were complaining of the heat even though the windows were open. Although a container of juice was in the room, none of the residents had a glass of the juice at the time of the tour nor was staff offering drinks or encouraging the residents to drink fluids. 50. Interview with the Housekeeping and Maintenance Supervisor on 5/12/03 at 4:00 pm revealed that he/she was called on 5/10/03 at 11:00 pm that the air conditioning went off. The Supervisor reported that he came into the facility and reset the air conditioner and called the service company to come to the facility in the morning. On 5/11/03 at 9:00 am the service company arrived and found that the air had gone off again at 8:00 am. The air conditioner was reset and stayed on until 2:30 pm. The service company was called again and was in the facility from 3:00 pm to 5:00 pm. When they left the air conditioner was working, and the staff was told that someone from the company would be out to check on 5/12/03 early in the morning. The service company arrived at 11:30 am and the staff informed them that the air conditioner had been off for most of the night. Sl. Interview with the Administrator, Director of Nurses, Director of Food Services and the Corporate Director of Clinical Services on 5/12/03 at 8:25 pm revealed that 17 residents out of 94 had an increase in body temperature over the norm of 98.6 F. The temperatures of the residents ranged from 98.9 to 99.5 F. Increase in body temperature without providing appropriate care and 26 services such, as providing fluid, places the residents at higher risk for harm and even death. 52. Review of the clinical record of sampled resident #6 revealed that the resident was returned to the facility from the hospital on 5/12/03 at 1:45 pm and expired at 3:55 pm. The readmission note gave a description of the resident diminished condition and reported that, "The resident awake and able to identify self, is hard of hearing. Mouth and lips very dry with slight vomitus around the mouth- loose bowel movement is seen in the sheets when carried by the ambulance staff to the bed. Bleeding noted on the buttocks, which has a skin abrasion and there is peeling skin around the sacral area." Additional records from the hospital revealed that the resident had been in the hospital since 4/26/03. On 5/9/03 the resident's electrolytes were abnormal. The sodium was 130 (norm is 136-148), chloride was 82 (norm is 95-110), blood, urea & nitrogen (BUN) was 109 (norm is 7-26). The medical history is documented in the record by the physician and is significant for congestive heart failure, kidney failure, pleural effusion, anemia and hypertension. This resident's medical condition and electrolyte/fluid imbalance upon admission to the nursing home placed him/her at risk for dehydration and should have been closely monitored by facility staff, 27 particularly under the detrimental hot environmental conditions at that time. 53. Review of the clinical record of sampled resident #7 revealed that the resident complained of palpitations on 5/11/03 at midnight and the physician was called. The resident was transferred to the hospital at 4:30 pm with chest pain and no vital signs had been documented in the record. 54. Review of the clinical record of sampled resident #8 revealed that the resident was found semi-conscious with labored breathing on 5/11/03 at 3:00 pm. The physician was called and the resident was transferred to the hospital at 5:20 pm. Additional information from the hospital revealed that the resident was transferred to the hospital with the diagnosis of dehydration and altered mental status, after having arrived in an unresponsive state, by ambulance. The resident's temperature was 100 degrees F (norm is 98.6 degrees F) and the heart rate was elevated at 98 beats per minute (norm is 60-80). 55. Hebrew Home Of South Beach’s failure to properly administer the facility in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, and to ensure that it’s policy 28 on the prevention of heat stroke was implemented, caused or was likely to cause serious harm, impairment or death to the residents. Based on the foregoing, Hebrew Home of South Beach violated Section 400.147(2), Fla. Stat., and/or Title 42, Section 483.75, Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class I deficiency pursuant to Section 400.23(8) (b), Fla. Stat., which carries an assessed fine of $15,000. This deficiency (alone or in conjunction with the other deficiencies cited in this Administrative Complaint) gives rise to a conditional licensure status, for the period of 05/12/2003 through 12/31/2003 pursuant to Section 400.23(7) (b). SURVEY FEE 44, Based on the deficiencies described in Counts I through III, and pursuant to Section 400.19(3), Fla. Stat., the Agency assessed a 6-month survey cycle fee of $6,000.00 against Hebrew home of South Beach, to cover the costs of surveys. DISPLAY OF LICENSE 45, Pursuant to Section 400.23(7), Florida Statutes, Hebrew Home of South Beach shall post the license in a prominent place that is in clear and unobstructed public 29 view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit MAY CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A, Make factual and legal findings in favor of the Agency on Counts I through III. B. Assess and maintain the Agency’s administrative fine totaling $51,000 against Hebrew Home of South Beach on counts I through III, for the deficiencies ard the survey fee, pursuant to Sections 400.23(8) (a) and 400.19(3), Fla. Stat. Cc. Assess and maintain the Agency’s assignment of a conditional license status to Hebrew Home of South Beach, for the period of 05/12/2003 through 12/31/2003, pursuant to Section 400.23(7) (b), Fla. Stat. D. Award the Agency for Health Care Administration costs related to the investigation and prosecution of this case, in accordance with Section 400.121(10), Fla. Stat. E. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE REQUEST A FOR 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, Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 N. W. 53 Street Miami, Florida 33166 (305) 499-2165 32 Copies furnished to: Diane Lopez-Castillo Field Office Manager Agency for Health Care Administration 8355 NW 53°° Street Miami, Florida 33166 (Interoffice mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Znteroffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 32 EXHIBIT “A” Conditional License License No. SNF1351096; Certificate No. Effective date: 05/12/2003 Expiration date: 12/31/2003 33 10134

Docket for Case No: 03-002570