(99 3L SS STATE OF FLORIDA YO Gen AGENCY FOR HEALTH CARE ADMINISTRATION ; Ta pg, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003002984 Return Receipt Requested: v. 7000 1670 0011 4849 5573 7000 1670 0011 4849 5580 GJS HOLDINGS, INC. d/b/a HALLANDALE 7000 1670 0011 4849 5597 REHABILITATION CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against GJS Holdings, Inc. d/b/a Hallandale Rehabilitation Center (hereinafter “Hallandale Rehabilitation Center”) pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, and herein alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $20,000.00 pursuant to Section 400.23(8) (b), Florida Statutes for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes. 3. venue lies in Broward County pursuant to Section Rule 28.106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Florida Statutes and Chapter 59A-4 Florida Administrative Code. 5. Hallandale Rehabilitation Center operates a 141- bed skilled nursing facility located at 2400 FE. Hallandale Beach Blvd., Hallandale, Florida 33009. Hallandale Rehabilitation Center is licensed as a_ skilled nursing facility under license number SNF 11920961. Hallandale Rehabilitation Center 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 HALLANDALE REHABILITATION CENTER FAILED TO OBTAIN BACKGROUND SCREENING FOR NEW EMPLOYEE. SECTION 400.215(1) (1-b) and (2) (a), FLORIDA STATUTES (STAFF TREATMENT OF RESIDENTS) CLASS IIT 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During a six-month survey cycle re-certification and re-licensure survey conducted between 3/3/03-3/5/03 and based on interview and record review it was determined that two of eight personnel records did not have proof that background screening was performed before allowing the employees to work with residents. The findings include the following. 8. Employee records for employee #6, a respiratory therapist, with a hire date of 12/3/02 did not contain background screening. Neither were there background- screening records for employee #3, a certified nursing assistant, with a hire date of 2/6/03. A staff member from the Human Resources department confirmed on 3/5/03 that the background screening results for those two employees had not been received. The Director of Nursing reported on 3/5/03 that both employees had been assigned to care for residents. The Director of Nursing and Human Resources staff member both reported during their interviews that they thought that as long as the background screening process was initiated, that the employees could work pending the results. Review of the policy and procedure submitted by the facility as their abuse prevention policy, revealed the following: All applicants for employment in the facility shall, at a minimum, have the following screening checks conducted...criminal background check... The facility did not ensure that background screening was performed for 2 employees before allowing them to work with residents. a. The mandated correction date was designated as April 5, 2003. b. Based on the revisit to the 6-month cycle re- certification survey and based on record review and interview, it was determined that the citation remained uncorrected. 9. During the revisit survey on 4/10/03 it was determined that a registered dietician who had commenced employment with the facility on 3/28/03 and who was observed to be interacting with the residents did not have documentation in her file that the required background screening had been completed prior to working with the residents. 10. Based on the foregoing, Hallandale Rehabilitation Center violated Section 400.215 (1) (a-b) and (2) (a), Florida Statutes, herein classified as a Class Ill patterned deficiency, which warrants, an assessed fine of $2,000.00. COUNT II HALLANDALE REHABILITATION CENTER WAS NOT FOLLOWING M.D. ORDERS FOR 7 OF 10 RESIDENTS REVIEWED. 483.20(k) (3) (i), CODE OF FEDERAL REGULATION RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (RESIDENT ASSESSMENT) CLASS III 15. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16. During a six-month survey cycle re-certification and re-licensure survey conducted between 3/3/03-3/5/03 and based on observation, interview and record review, it was determined that the facility failed to provide services that met professional standards of quality in following physician orders and facility policy for 8 of 18 sampled residents. (Residents #2, 3, 4, 6, 9% 10, 13, 18). The findings are as follows. a 17. Resident #13 was observed on 3/3/03 at approximately 10:00 am to have a gastrostomy tube feeding infusing at 50cc/hr via a pump. Resident #13 was again observed on 3/3/03 at approximately 2:00 pm to have a gastrostomy tube feeding infusing at 50cc/hr via a pump. No label was noted on the tube feeding to determine the date or time hung or product infusing. Interview with the staff nurse revealed that she concurred that there was no label and the tube feeding should be labeled with the product name, infusion rate and date and time hung. Review of the clinical record revealed a physician order dated 2/26/03 for Nutrivent 60cc/hr x 23 hours. 18. The facility was not following the physician order for the rate of the feeding nor were they following the facility infection control policy for feeding systems which read under the heading Miscellaneous, #12 "Administration bag and tubing must be marked with the date and changed every 24 hours." 19. In addition, observation during the initial facility tour on 3/3 between 9:30 and 10:30 am revealed sampled residents #6 and #18 to have an unlabeled gastrostomy tube feeding infusing. 20. Review of the clinical record of sampled resident #6 on 3/3/03 at approximately 3:00. pm, revealed a physician's order dated 3/1/03 for a CBC and SMA7 to be done on Monday (3/3/03) and a physician's order dated 3/3/03 for D5W 50cc/hr X 3 days. Observation of the resident at 9:45 am on 3/4/03 revealed no IV infusing. Interview with the staff nurse revealed that she was unaware of the order. Further review and interview with staff revealed that the labs had not been drawn on 3/3/03 as ordered. Please refer to F327 and F502. 21. During a review of the Medication Administration Record for Resident #4 on 3/4/03 at 11:30 AM, a staff nurse requested to view the MAR's in the surveyor's possession as she wanted to know how much coverage to give to the resident as she had just taken his blood sugar. A review of the MAR's revealed no area where accu-check results or amount of insulin to administer was recorded. Further review of the record revealed the resident was readmitted from the hospital on 2/12/03, after a 5-day admission for Pneumonia and Urinary Tract Infection. The resident's original admission date is 1/6/03. Resident #4 is a tracheostomy patient that receives nutrition via a gastrostomy tube. The transfer orders read "Accucheck and sliding scale insulin as prior." The Physician order sheet for the readmission only had the following: "Accucheck" and did not specify the frequency or any sliding scale to follow. However, review of the MAR for February 12, 2003 to February 28 revealed that the accucheck was done every 6 hours. No documentation was noted on the March MAR indicating the resident's blood sugar was not taken for four days in March for a total of 16 scheduled opportunities. During interview with the facility's acting Director of Nursing at 12:30 PM on 3/4/03, she revealed that the order was not accurately transcribed onto the March MAR's, and should have been listed accurately on the admission physician order sheet when the resident was readmitted from the hospital. 22. During the initial tour, at 10:45 AM, and 2:15 PM on 03/03/03, and at 8:10 AM and 9:50 AM on 03/04/03, resident #2 was observed with a Kangaroo type bag attached to a feeding tube, with the bed not elevated, lying on his/her side. A review of the physician's orders determined the resident should have the bed elevated to 45-degree angle while the feeding tube is running. On 03/04/03, the resident's private duty aide came in and elevated the bed, stating, "the bed should be up. I don't know why it wasn't." 23. During the initial tour, at 10:45 AM on 03/03/03, it was observed that resident #2 had a Kangaroo type bag attached to the feeding tube. A review of the bag determined that the bag was not labeled with the following: the day or time the bag had been filled, or what it is filled with or the amount put into the bag. On 03/04/03, at 8:10 AM, a review of the Kangaroo bag noted the time the bag was filled with Probalance at 6:00 AM, but failed to contain how much had been placed in the bag at that time. On 03/05/03 at 2:40 PM, the bag was observed to be unlabeled. A review of an in-service, in regard to infection control & care of tube feeding patients states: All tube feedings must have written orders for formula and rate. Be careful of your feeding label information: Right patient; right formula; right rate; right date and time. As observed the nursing staff is not following the policies for feeding tube patients as they are not properly labeling the feeding tube bags. 24. During the observance of the lunch meal it was observed that resident #2 received a tray of pureed food from dietary. A review of the resident's clinical record revealed that the resident was receiving food for pleasure. However, the record contained a physician's order to discontinue the pleasure foods, dated 02/28/03. 25, On initial tour 3/03/03, at 9:30 am, resident #3 was observed resting comfortably in bed, with an oxygen concentrator at bedside. Interview with the Unit Charge Nurse revealed that the resident used Oxygen "as needed". Review of the clinical record revealed no current order for Oxygen "as needed” on the March 2003 Physician order sheet, nor was there an order for Oxygen "as needed" on the March 2003 daily Medication Administration Record. 26. The mandated correction date was designated as April 5, 2003. 27. Based on the revisit to the 6-month cycle re- certification survey and based on observation, interviews review and record review it was determined that’ the facility failed to provide professional standards of quality for 7 of 10 sampled residents (resident #1, #3, #4, #7, #8, #9, #10), by not following physician orders. This is an uncorrected tag. The findings include the following. 28. Review of the clinical record documentation for resident #8 on 04/10/03, revealed that the resident was readmitted to the facility on 03/14/03 with diagnoses that include azotemia, respiratory failure, ventilator, dysphagia and tracheostomy. Further review of the clinical record documentation revealed a physician's order dated 04/05/03 for intravenous fluids, dextrose in water with 0.45% normal saline at 50 cc {cubic centimeters) per hour. Continued review of the clinical record documentation revealed a physician's order dated 04/08/03 to continue 10 intravenous fluids 3 more days. Observation of resident #8, in the resident's room, on 04/10/03 at 9:15 a.m. accompanied by the staff nurse, revealed the resident, in bed, no IV (intravenous) fluids being administered to the resident. Further review of the documentation in the MAR (medication administration record) revealed no evidence that the order for the additional 3 days of IV fluids had been transcribed to the MAR. The staff nurse acknowledged that the I. V. fluids should have continued until 04/11/03 29. Review of the clinical record documentation for resident #4 on 04/10/03 revealed that the resident was admitted to the facility on 04/01/03 with diagnoses that include respiratory failure, wounds bilateral lower extremities, left hip, ventilator and PEG (percutaneous enterostomal gastrostomy) tube. Observation in the resident's room, accompanied by the staff nurse, on 04/10/03 between 9:00 a.m. and 9:15 a.m., revealed a tube feeding of Nutren 1.0, 1000 cc, being delivered via a pump at 50 cc per hour to the resident via a PEG tube. There is approximately 200 cc left in the bag. There is no time or date on the bag to indicate the time the bag was hung. The staff nurse acknowledged that there was no time or date on the bag during an interview on 04/10/03 between 9:00 a.m. and 9:15 a.m., and stated, "I don't know (the time or date) ." 30. Further review of the clinical record documentation revealed a physician's order dated 04/02/03 for daily wound care to the resident's wounds. Continued review of the documentation in the TAR (treatment administration record) revealed no evidence that the wound care had been done as ordered on 04/05/03 and 04/06/03. The staff nurse acknowledged that there was no evidence that the wound care had been done as ordered on 04/05/03 and 04/06/03 (weekend) during an interview on 04/10/03 at 11:45 a.m., and stated, "The nurses on the weekend should have initialed that the treatment was done.” 31. Review of the clinical record documentation for resident #10 on 04/10/03 revealed that the resident was admitted to the facility on 03/15/03 with diagnoses that included respiratory failure, ventilator and dysphagia. Observation of resident #10, in the resident's room, on 04/10/03 at 9:30 a.m. accompanied by the staff nurse, revealed a tube feeding of Nutrivent, 1000 cc, being delivered by a pump to the resident via a PEG tube. The date on the bag is 04/10/03. There is no time on the bag to indicate the time when the bag was hung. The staff nurse acknowledged that the bag had no time on it during an 12 interview on 04/10/03 at 9:30 a.m. and stated, "I don't know (the time it was hung)". 32. Review of the clinical record documentation for resident #9 on 04/10/03 revealed that the resident was admitted to the facility on 03/20/03 with diagnoses that included respiratory failure, ventilator, pneumonia and sepsis. Observation of resident #9, in the resident's room, on 04/10/03 at 9:20 a.m. accompanied by the staff nurse, revealed the resident in bed with bilateral hand mittens on that are tied to the bed rails. Further review of the clinical record documentation revealed a physician's order dated 03/20/03 which states, in part, "Hand mittens to bilateral hands....Check every 30 minutes. Release every 2 hours for 10 minutes for skin checks, repositioning and toileting." Continued review of the clinical record revealed no evidence of documentation that the hand mittens had been released as ordered. The staff nurse acknowledged this during an interview on 04/10/03 at 3:00 p.m., and stated", I would have written it on the MAR." 33. A review of the clinical record for resident #1 noted the physician had ordered a left knee immobilizer to be worn by the resident. Further review of the record determined the care plans indicated "apply splints as ordered, pt to tolerate at least 2 hours a day and apply 13 splints as ordered-remove for ADL care". Observation of the resident from 8:30 AM, while resident was receiving ADL care, through-out the day, up to 4:00 PM, determined the resident did not have the left knee splint on. It was observed on the bedside table during these hours and was not put on the resident until an inquiry was made of the floor nurse, in regard to it's use. 34. Resident #3 had a physician's order for "bunny boots for off loading heels". The resident has several pressure ulcers on the heels that are being treated by the wound care nurse. Observation of resident #3 during the tour of the facility, at approximately 9:05 AM and several times during the course of the day noted the resident had both heels wrapped in gauze and was wearing white socks. The resident did not have bunny boots on at all through 4:15 PM. 35. Resident #1 had a physician's order, dated 03/30/03, for the following lab work to be done in the AM: CBC, UA and C & S. A review of the resident's record, on 04/10/03, noted the lab results were not in the resident's record. An interview with the floor nurse revealed the lab log book did not contain documentation that the labs were done. Further review by nursing staff determined they did not have the labs ordered by the physician done. i4 36. Review of the clinical record of sampled resident #7 on 4/10/03 revealed that the resident was admitted to the facility on 4/2/03 with physician's orders for a no concentrated sweets, low sodium, pureed diet as well as a tube feeding of Glytrol at 60cc/hour for 23 hours per day. Further review of the clinical record of sampled resident #7 revealed a physician's order dated 4/3/03 for speech therapy evaluation; however, no documentation that the resident had received the speech therapy evaluation could be found on the record. Interview with staff at approximately 2:00 p.m. on 4/10/03 revealed that the speech therapist had been in the facility on 4/9/03 and "she must have fallen through the cracks". The resident was noted in a dietary evaluation dated 4/4/03 to be "unable to tolerate food by mouth...chipmunks pureed food in mouth.... unable to swallow solids even in pureed consistency...at risk of aspiration". The p.o. diet was discontinued on 4/3/03. 37. Based on the foregoing, Hallandale Rehabilitation Center violated 483.20(k) (3) (i), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class III violation, which warrants, an assessed fine of $4,000.00. COUNT IIT HALLANDALE REHABILITATION CENTER FAILED TO INFORM M. D. OF LAB VALUES PROMPTLY. 483.75(j) (2) (ii), CODE OF FEDERAL REGULATION SECTION 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (ADMINISTRATION) CLASS III 38. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 39. During a six-month survey cycle re-certification and re-licensure survey conducted between 3/3/03-3/5/03 and based on record review it was determined the facility staff failed to promptly notify the attending physician of laboratory findings for 1 of 18 sampled residents (#2) and one random resident (#24). The findings include the following: 40. A review of the clinical record for resident #2, noted on 02/24/03, the physician ordered a CBC & SMAT, digoxin level, T Protein & Albumin levels. The lab book indicated the labs were drawn on that day. Further review revealed that by 03/03/03, at 3:45 PM, the facility had not obtained the results and therefore had not notified the physician of any abnormals. 41. During a review of the clinical record for resident #24, to determine if the resident had been determined capable to self-administer medications/ 16 biologicals, it was noted that the physician, on 02/25/03, had ordered the following lab tests: CBC, SMA and U/A. The lab book noted the labs were drawn on 02/26/03. As of 03/05/03 the facility staff had not obtained the results of these tests and therefore could not have notified the physician on a timely basis. 42. The mandated correction date was designated as April 5, 2003. 43. Based on the revisit to the 6-month cycle re- certification survey and based on record review and interview it was determined that the facility failed to promptly notify the physician of laboratory results for four residents on 2 West. This is an uncorrected tag. The findings are as follows. 44, Resident #3 had an order for lab work, dated 03/24/03. These test were preformed on 03/26/03 and the lab notified the facility of the results on the same day. As of 04/10/03 the facility staff had not notified the physician of the results. 45, Resident #15 had labs preformed on 03/26/03. The facility received the results on the same day. As of 04/10/03 the physician has not been notified of the results. 46. Resident #17 labs were preformed on 03/17/03. The results were available on 03/20/03. As of 04/10/03 the physician had not been notified of the results. 47. Resident #16 had labs preformed on 04/03/03. As of 04/10/03 the physician has not been notified of the results. 48. An interview with the floor nurse indicated the lab results were kept in a folder to be signed by the doctor when they come in. 49. Based on the foregoing, Hallandale Rehabilitation Center violated 483.75(4) (2) (ii), Code of Federal Regulation as incorporated by Rule 59A~-4.1288, Florida Administrative Code, herein classified as a Class III violation, which warrants, an assessed fine of $2,000.00. cOuNT_IV HALLANDALE REHABILITATION CENTER’S EXIT CORRIDORS WERE NOT CLEAR AND UNOBSTRUCTED. RULE 59A-4.130, FLORIDA ADMINISTRATIVE CODE (LIFE SAFETY CODE STANDARD) CLASS III 50. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 51. The annual Life Safety survey for state licensure and federal re-certification (Medicare and Medicaid) was conducted on March 3, 2003. Based on the findings of this survey, the following Life Safety Code deficiencies were cited: 52, Exit corridors were not clear and unobstructed. Various items were left in exit corridors while not in use. 53. During the Life Safety survey conducted on March 3, 2003, the following was observed while touring the facility with a member of the Administrative staff: 54. Clean linen carts and miscellaneous other items were left, umattended, in exit corridors; or were left on both sides of an exit corridor, creating a bottleneck. Therefore, in an emergency situation, the items left in the corridors would hinder the evacuation of residents. 55. For example, at 12:30 pm on the second floor next to the West Wing Nurse Station, a treatment cart was noted sitting in the exit corridor between Rooms 216 and 217. Directly opposite it, at the Nurse Desk, was a med cart. This created a bottleneck in the exit corridor and reduced the corridor width to about three feet. 56. A second bottleneck example was noted nearby at 12:35 pm. A wheelchair was left in the exit corridor at Room 212. It sat perpendicular to the wall. Opposite the 19 wheelchair was a food tray delivery cart. The viable exit corridor width was reduced to about two feet. 57. A staff person in the area was advised of the bottleneck and the wheelchair was removed. Several minutes later as this surveyor passed the area again, a rolling bed tray had been placed in the exit corridor where the wheelchair previously sat. This recreated the exit corridor bottleneck. 58, On the second floor East Wing, a Clean Linen cart was positioned in the exit corridor opposite Room 239. Observations were recorded at 2:30 pm, 4:10 pm and again at 4:40 pm. At no time did the cart appear to be in use by any staff personnel. 59. At 4:25 pm, a bottleneck was noted on the first floor in the East Wing. A Crash Cart with respiratory supplies sat in the exit corridor at Room 147. Directly opposite it, in front of Room 141 was a Clean Linen cart. The exit corridor was reduced to approximately three feet in width. 60. Corridors cannot be used as storage areas. It is required that exit corridors be kept clear and unobstructed. While in use, carts can be placed in exit corridors. As soon as the carts' usage is completed (no 20 more than 20 minutes should be allowed), the carts must be repositioned or removed from the corridors. 61. When several carts are in use in an area at the game time, these carts must be kept to one side of the exit corridor so as to eliminate any such bottleneck situations. 62. The mandated correction date was designated as April 5, 2003. 63. A Life Safety survey revisit was conducted on April 14, 2003 as a follow-up to the survey, which took place on March 3, 2003. The findings are as follows. 64. Exit corridors were not clear and unobstructed. Various items were still left in exit corridors while not in use. The findings are as follows. 65. During the Life Safety survey revisit conducted on April 14, 2003, the following was observed while touring the facility with a member of the Administrative staff and a Maintenance staff person. 66. Clean linen carts and miscellaneous other items were still left, unattended, in exit corridors for extended periods of time; or were left on both sides of an exit corridor, creating a bottleneck. 67. On the second floor East Wing, for example, a clean linen cart was noted sitting in the middle of the exit corridor in front of Room 241. This was at 11:58 am. 21 The cart was repositioned against the corridor wall at Room 241. Nearly two (2) hours later (1:50 pm) the cart was still in the same position. 68. On the first floor, West Wing, two (2) recliner- type chairs were seen in the exit corridor near Room 110 and a clean linen cart at Room 105; both at about 12:15 pm. Over an hour and a half later (1:55 pm) the items still were where they had previously been seen. 69. Between Rooms 219 and 220 on the second floor, West Wing, a night table and rolling bed tray were observed on one side of the exit corridor at 1:30 pm. Opposite those items, between Rooms 219 and 221, was a clean linen cart. This created a bottleneck with a viable exit width of only three (3) feet. 70. Corridors cannot be used as storage areas. It is required that exit corridors be kept clear and unobstructed. While in use, carts can be placed in exit corridors. As soon as the carts' usage is completed (no more than 20 minutes should be allowed), the carts must be repositioned or removed from the corridors. 71. When several carts are in use in an area at the same time, these carts must be kept to one side of the exit corridor so as to eliminate any such bottleneck situations. 22 72. (If exit corridors are not maintained clear and unobstructed, in an emergency situation, the evacuation of residents would be hindered by the items left in the corridors. 73. The facility's Plan of Correction stated, "Ail staff members were in-serviced on the importance of keeping exit corridors clear and unobstructed...". It further stated, “in-services have begun and will continue with Maintenance, Housekeeping, Laundry, Dietary and Nursing personnel explaining the importance of clear and unobstructed exit corridors...." 74. The facility's correction date on the Plan of Correction was 4/05/03. Based on the aforementioned observations, this plan was not met. 75. This is an uncorrected deficiency from the survey which took place on March 3, 2003. 76. Based on the foregoing, Hallandale Rehabilitation Center violated Rule 59A-4.130, Florida Administrative Code, herein classified as a Class III violation, which warrants, an assessed fine of $2,000.00. COUNT V HALLANDALE REHABILITATION CENTER’S PERSONNEL NOT SUFFICIENTLY TRAINED IN SAFETY PROCEDURES. RULE 59A-4.130, FLORIDA ADMINISTRATIVE CODE 23 {LIFE SAFETY CODE STANDARD) CLASS III 77. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 78. The annual Life Safety survey for state licensure and federal re-certification (Medicare and Medicaid) was conducted on March 3, 2003. Based on the findings of this survey, the following Life Safety Code deficiencies were cited: 79. Newly hired staff personnel were not trained in fire safety or fire drill procedures. The findings are as follows. 80. During the Life Safety survey conducted on March 3, 2003, a member of the Administrative staff was asked whether newly hired staff members received any training related to fire safety; and how many newly hired staff members there were since the last survey. 81. When requested by this surveyor, no records were offered as the number of recently hired staff members. However, an Administrative staff person estimated that there were approximately 20 new hires since the last Life Safety survey revisit on October 23, 2002. 24 82. Further, neither the Administrator, the Administrative staff person accompanying this surveyor nor a Maintenance staff member were aware of any such training. No In-Service signature records were available to verify that this training took place. 83. All staff persons should receive fire safety training before being allowed to begin working in an assigned area. They should be taught procedures for fire alarms, fire drills, types of fire extinguishers and extinguishing systems within the facility, special code phrases, disaster preparedness, etc. 84. Lack of such training could jeopardize the safety of residents in the event of a fire or other evacuation- necessary emergency. 85. The mandated correction date was designated as April 5, 2003. 86. A Life Safety survey revisit was conducted on April 14, 2003 as a follow-up to the survey, which took place on March 3, 2003. The findings are as follows. 87. Newly hired staff personnel were still not sufficiently trained in fire safety procedures. There was not sufficient adherence to procedures during a fire alarm activation. The findings are as follows. 88. During the Life Safety survey revisit conducted on April 14, 2003, the following was observed while touring the facility with a member of the Administrative staff and a Maintenance staff person: 89. Two staff personnel did not respond to a fire alarm activation. 90. In order to verify the proper functioning of one of the facility's smoke dampers (see deficiency K104), it was necessary to activate the fire alarm system. It was decided to activate a pull station opposite the first floor West Wing Nurse Station. 91. Intentionally, no announcement was made that the fire alarm was being tested so that this surveyor could observe the staff's reactions in the area. 92. Upon activation of that pull station, the system went into alarm. This surveyor stood in the exit corridor near the pull station and noted that two staff persons who were sitting at the Nurse Station did not move. They continued sitting and made no attempt to respond to the alarm. 93. This surveyor approached the Nurse Station and asked the Nursing staff member whether she had specific duties to perform during a fire alarm activation. It was noted that a housekeeping cart and clean linen cart, which 26 sat in the exit corridor at Room 118, and a treatment cart which sat opposite the Nurse Station, were not removed from the exit corridor. Nor were the residents’ room doors closed. 94. Her response was that it looked as though the fire alarm was being tested so she thought she didn't have to do anything. This surveyor's response was that no announcement was made referring to testing the fire alarm; and any activation of the fire alarm should be treated as a real fire emergency. 95. This surveyor then checked with a member of the Administrative staff as to how long those two (2) "non- responders" have been employed by the facility. Both had been hired "within the last two and a half to three months". Therefore, they were within the group of 20 or so newly-hired personnel referred to in the annual survey's deficiency as not having received any training related to fire safety. 96. It is imperative that every staff person knows the specifics of fire emergency procedures. This includes the actions necessary to ensure the safety of and, if necessary, orderly evacuation of all facility occupants in case of an emergency. All staff persons should have received fire safety training and demonstrated such 27 knowledge before being allowed to work in an assigned area. Lack of such training could jeopardize the safety of residents in the event of a fire or other evacuation- necessary emergency. 97. The facility's Plan of Correction stated, "newly hired staff members received in-service training in the fire safety or fire drill procedures". The correction date on the Plan of Correction was 4/05/03. Based on the aforementioned observation, this plan was not met. 98. This is an uncorrected deficiency from the Life Safety survey conducted on March 3,2003. 99. Based on the foregoing, Hallandale Rehabilitation Center violated Rule 59A-4.130, Florida Administrative Code, herein classified as a Class III violation, which warrants, an assessed fine of $6,000.00. COUNT VI HALLANDALE REHABILITATION CENTER’S SMOKE BARRIERS WALL PENETRATIONS NOT PROPERLY PROTECTED. RULE 59A-4.130, FLORIDA ADMINISTRATIVE CODE (LIFE SAFETY CODE STANDARD) CLASS III 100. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 28 101. The annual Life Safety survey for state licensure and federal re-certification (Medicare and Medicaid) was conducted on March 3, 2003. Based on the findings of this survey, the following Life Safety Code deficiencies were cited: 102. Air conditioning duct and air return penetrations of smoke barrier walls were not properly protected. Smoke dampers were not tested; and not all fire dampers were inspected. The findings are as follows. 103. During the Life Safety survey conducted on March 3, 2003, it was observed, while touring the facility with a member of the Administrative staff, that... 104. Smoke dampers were not being properly maintained and tested, as required. 105. For example, on the first floor, the smoke barrier wall dividing the East and West Wings had two air conditioning ducts penetrating the wall above the dropped ceiling level. 106. The ducts contained smoke dampers within them, as required when an air conditioning duct penetrates a smoke wall. This damper is a mechanical device within which one or two plates rotate 90 degrees from the normal open (horizontal) position to close off the duct (vertical 29 position) and prevent smoke and air flow during a fire alarm activation. 107. Each smoke damper was tested (with a test switch). Neither one closed completely to seal the duct, as required, nor opened completely when the switch was shut off. Further, there was no indication (electrical wiring attached to the outer mechanism of the smoke damper) that the dampers were connected to the fire alarm system. 108. This means that in the event of a fire emergency, the duct could not be relied upon to close and prevent smoke from traveling from one smoke compartment to the adjacent one. Thus, the safety of the occupants in that area of the building would be jeopardized. 109. Not all of the fire dampers in air conditioning and exhaust vents were being inspected and maintained. 110. The determination was made by reviewing a list of the fire dampers, which the Maintenance staff had generated. While touring the facility, it became apparent that there were more fire dampers than were indicated on the Maintenance list. lil. Fire dampers are held open and in place by a metal fusible link. The damper is designed to activate when exposed to excessive heat. They close and thereby seal the vent, preventing smoke and flames from traveling through 30 it. Lack of maintenance could prevent the curtain from closing completely, thus allowing smoke to enter a room or an exit corridor. 112. For example, in the second floor West Wing air handler room opposite Room 215, two fire dampers were seen. They were not numbered as were the fire dampers on the Maintenance list; and were dust-laden--an indication that they were not being inspected or maintained. 113. Similarly, in the East Wing's air handler room opposite Room 239, three unnumbered (and dusty) fire dampers were noted. 114. On the first floor's West Wing, the air handler room opposite Room 115, there were two unnumbered (and dusty) fire dampers noted. 115. The East Wing's air handler room opposite Room 239 also contained two dusty, unnumbered fire dampers. 116. Additional, unnumbered fire dampers were seen as follows. a. 2 West Soiled Utility Room, b. 2 East Soiled Utility Room and Kitchen. 117. Lack of knowledge as to where these fire dampers are within the facility and lack of inspecting and maintaining them could jeopardize the safety of occupants within a building in a fire emergency. 31 118. The mandated correction date was designated as April 4, 2003. 119. A Life Safety survey revisit was conducted on April 14, 2003 as a follow-up to the survey, which took place on March 3, 2003. The findings are as follows. 120. Air conditioning duct and air return penetrations of smoke barrier walls were not properly protected. Some smoke dampers did not function properly. The findings are as follows. 121. During the Life Safety survey revisit conducted on April 14, 2003, it was observed, while touring the facility with a member of the Administrative staff and a Maintenance staff person, that: 122. Some smoke dampers still were not being properly maintained and tested to ensure proper operation. 123. For example, on the first floor, the smoke barrier wall dividing the East and West Wings had two air conditioning ducts penetrating the wall above the dropped ceiling level. 124. During the annual survey, each smoke damper was tested (with a test switch). Neither one closed completely to seal the duct, as required, nor opened completely when the switch was shut off. When tested during the revisit, 32 one of the devices (damper #4) did not close fully as required. 125. Also, one of the smoke dampers in the smoke barrier wall at Room 115 (first floor West Wing) did not close completely when retested. 126. This means that in the event of a fire emergency, those ducts could not be sealed to prevent smoke from traveling from one smoke compartment to the adjacent one. Thus, the safety of the occupants in that area of the building would be jeopardized. 127. The facility must test each and every smoke damper to ensure that it functions as required to seal the air conditioning duct within which it is installed and thereby protect that smoke compartment in the event of a fire emergency. 128. The facility's Plan of Correction indicated that all smoke dampers were inspected to ensure that they are working. The correction date on the Plan of Correction was 4/05/03. Based on the aforementioned observations, this plan was not met. 129, This is an uncorrected deficiency from the Life Safety survey conducted on March 3,2003. 130. Based on the foregoing, Hallandale Rehabilitation Center violated Rule 59A~4.130, Florida Administrative 33 Code, herein classified as a Class III violation, which warrants, an assessed fine of $4,000.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Hallandale Rehabilitation Center on Counts I though VI. 2. Assess against Hallandale Rehabilitation Center an administrative fine of $20,000.00 on Counts I through VI for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable 4. Grant such other relief as the court deems is just and proper on Counts I through VI. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 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 34 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. _f Alba M. Rodrigue ! Assistant General Counsel Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 35 Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE T HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Dennis Sarcauga, Administrator, Hallandale Rehabilitation Center 2400 E. Hallandale Beach Blvd., Hallandale, Florida 33009; G.J.S. Holdings, Inc., 3370 N. W. 47 Terrace, Lauderdale Lakes, Florida 33319; Garson L. Lambert, 3370 N. W. 47 Terrace, Lauderdale Lakes, cetto a . Florida 33319 on this _ /S5 day of Chasagtat , 2003. ~ ny . LALbO) 71). WS otag J Alba M. Rodriguez 4 , 36

Docket for Case No: 03-003845