CERTIFIED ARTICLE @:: 7002 2030 0006 g if ‘0 23 yf STATE OF FLORIDA esa pe id & “Ty Ei AGENCY FOR HEALTH CARE ADMINISTRATION ote ee dal 04 JIN 28 PH 4:34 UVIS oa | STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AOMINISTR A HE ARINAS 7% Petitioner, AHCA NO: aoteanuges vs- ?00e 2030 OO0b 4359 5b13 GULF COAST HEALTH CARE ASSOCIATES, LLC, d/b/a/ SEA BREEZE HEALTH CARE, Respondent. ee ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA’), by and through the undersigned counsel, and files this Administrative Complaint, against GULF COAST HEALTH CARE ASSOCIATES, LLC, d/b/a/ SEA BREEZE HEALTH CARE, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose a conditional licensure status effective August 28, 2003 pursuant to §§ 400.23(7)(b) and 400.23(8), Fla. Stat. (2003). AHCA seeks to impose a Conditional Licensure Status effective August 28, 2003, based upon two (2) Class || deficiencies as defined and by § 400.23(8)(b) Fla. Stat. (2003). 2. The Respondent was cited for the deficiencies set forth below as a result of recertification survey conducted on or about August 25-28, 2003. Page 1 of 14 e CERTIFIED ARTICLE @:: 7002 2030 0006 4359 5613 JURISDICTION AND VENUE 3. AHCA has jurisdiction over the Respondent pursuant to Chapter 400, Part Il, Florida Statutes. 4. Venue shall be determined pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 Fla. Admin. Code. PARTIES 5. AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part !I, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a skilled nursing facility located at 1937 Jenks Avenue, Panama City, Florida, 32405-4510. The facility is licensed under Chapter 400, Part Il, Florida Statutes and Chapter 59A-4, Florida Administrative Code. Its license number is 41870961, renewed November 20, 2003, and effective through November 30, 2004. The original conditional license is attached hereto as Exhibit “A”. COUNT |! NSURE THAT A RESIDENT HAVING PRESSURE RY TREATMENT AND SERVICES TO PROMOTE CTION AND PREVENT NEW SORES FROM DEVELOPING. § 400.102(1)(d), § 400.23(7), 400.23(8)(b) FLA. STAT. (2003), FLA. ADMIN. CODE R. 5QA-4.1288 CLASS II DEFICIENCY RESPONDENT FAILED TOE SORES RECEIVED NECESSA HEALING, PREVENT INFE 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. AHCA staff conducted a survey on or about August 25-28, 2003. 9. Based on interviews, medical record reviews, and observations the facility failed to promote healing and prevent infection of a decubitus ulcer as evidenced by not Page 2 of 14 e CERTIFIED ARTICLE @... 7002 2030 0006 4359 5613 following physician orders, not following infection control guidelines, and exposing a continent resident to the risk factor of fecal wound contamination in 1 of 32 residents. (#6) 10. The findings included the following: a. Resident #6 record review revealed two decubitus ulcers, one on the coccyx and one on the right heel. 11. Frequency of wound care vs. physician's orders: Ulcer on coccyx was documented on facility Skin Grid-Pressure sheet: 7/1/03 as a. stage II, 10cm x 15cm x 2cm with no tunneling/undermining and on 8/23/03 stage Ill, 8cm x 8cm x 2cm with 8cm undermining. b. Ulcer on right heel was documented on facility Skin Grid-Pressure sheet: 7/1/03 unstagable, 4cm x 3cm x Ocm and on 8/23/03 stage Il, 1¢m x 2cm x 0.25cm. Cc. An interview was conducted with the Licensed Practical Nurse (LPN)/Treatment Nurse on 8/27/03 at 9:35 A.M. He/she states resident #6 receives wound care every other day. An observation was performed on 8/28/03 at approximately 8:50 A.M. The "treatment administration record” listed wound care to stage II decubitus i. d. e. ulcer right heel to be performed once a day and wound care to stage IV decubitus ulcer to coccyx to be performed once a day. f. The LPN/Treatment Nurse was interviewed at this time concerning his/her statements on 8/27/03, when s/he stated wound care was to be performed every other day. i. The LPN stated the frequency of the wound care listed on the treatment administration record is incorrect. ji. |The LPN showed the surveyor the Wound Care Protocol Book for the facility and stated wound care should be performed every "3-4 days.” The LPN stated this was an error and the facility follows the protocols. iti. The LPN then wrote on the treatment administration record for the wound iv. care to be performed "every (q) 3-4 days and prn." v. The LPN dated the entries as 8/28/03. Page 3 of 14 @ CERTIFIED ARTICLE Oa 7002 2030 0006 4359 5613 g. During observation of the wound care to resident #6 on 8/28/03 at approximately 8:50 A.M. an AHCA surveyor saw a date written on the dressing to the coccyx as 8/26/03 and a date written on the dressing to the right heel as 8/26/03. h. A review of the resident's medical record revealed a physician order dated 7/31/03 for wound care to be performed to the coccyx once a day and to right heel once a day. i. An interview with the facility's corporate Registered Nurse (RN) on 8/28/03 at 10:15 A.M. confirmed the facilities protocol does not supercede the physician's orders. j. The RN stated, "No they should follow the M.D. orders.” j. An interview with the resident on 8/28/03 at 1:30 P.M. confirmed wound care was not performed each day. The resident questioned the surveyor on the appearance of the wound. i. The resident stated "...one says it looks bad, one says it looks good." "I can't Ih. trust them to tell me the truth.” "I just want to get well.” 12. Failure to follow aseptic/sterile technique: During an observation of the wound care to resident #6 on 8/28/03 at approximately 8:50 A.M. The LPN was observed not following aseptic/sterile technique for the packing of a tunneling cavity into an infected wound. During this procedure, the LPN/Treatment Nurse did the following: a. Removed from the treatment cart drawer an open container of calcium i. alginate; ji. | Then took the calcium alginate packing rope out of the container with bare hands; iii. | Cut off a section of the calcium alginate with scissors from his/her pocket. The LPN laid the piece of calcium alginate on a bedside table covered with aluminum foil, which was in the hallway beside the resident's room. The LPN then placed the remaining calcium alginate packing back in the iv. Vv. open package and placed the package in the treatment cart drawer. vi. The calcium alginate remained on the bedside table in the hallway, exposed to air, staff, and residents for approximately 20 minutes. vii. | The LPN then placed on top of the calcium alginate Page 4 of 14 e CERTIFIED anne Meer 7002 2030 0006 4359 5613 1. Non-sterile 4x4 gauze, 2. Non-sterile gloves, and 3. A package of sterile cotton tip applicator. The LPN then wheeled the bedside table containing the supplies into the vill. room and began wound care. ix. |The LPN placed a sterile cotton tip applicator into the open area of tunneling at the top of the decubitus ulcer to the coccyx. x. | The LPN stated the tunneling measures approximately 8 centimeters. xi. | The LPN then packed the tunneling area with the calcium alginate from the bedside table using 1. Non-sterile gloves and 2. A sterile cotton tip applicator. b. The wound had a moderate amount of purulent, foul smelling drainage. Cc. An AHCA surveyor read the calcium alginate package from the treatment cart before the wound care and saw the following statements: i. "Contents 1 dressing" ii. "Sterile in unopened, undamaged package" iii. | CMC/Alginate dressing rope-12 inches.” d. At 11:45 A.M. on 8/28/03, the surveyor telephoned the manufacturer's phone number that was on the front of the calcium alginate package. e. The manufacturer representative confirmed the CMC/Alginate dressing 12-inch rope comes in individual packages and should be used once then discarded, as they are no longer sterile. f. A review of the medical record revealed the resident with a diagnosis of peripheral vascular disease, diabetes, and left above the knee amputation. g. A wound culture was performed on 8/20/03 and revealed "Heavy growth of Klebsiella Pneumoniae.” h. The resident was placed on antibiotics for the wound infection. 13. contamination. Unnecessarily exposing a pressure sore in the coccyx area to fecal Page 5 of 14 CERTIFIED secre Mecr 7002 2030 0006 4359 5643 a. A review of resident #6 medical record revealed on 6/2/03 the comprehensive assessment/minimum data set (MDS) listed the resident as "usually continent” with bowel incontinence "less than weekly.” b. The resident's care plan dated 6/12/03 stated "assist of 1 for transfer” "initiate elimination pattern.” Cc. The Physical Therapist on 7/24/03 listed the transfer ability of the resident as "max assist" "transfer from bed to wheelchair, stand-pivot technique” and ability to sit for "4-2 hours." d. During observation of the wound care on 8/28/03 at approximately 8:50 A.M. after completion of the wound care to the coccyx, the resident stated he needed to have a bowel movement. The LPN secured a diaper and stated to "go ahead the diaper is on.” e. f. The nurse then proceeded to perform wound care to the right heel. g. Upon completion of the wound care, the LPN left the room. h An interview with the resident was conducted at 9:30 A.M. on 8/28/03. i. The resident stated was told by staff to have bowel movements in a diaper. ii. |The resident states then he/she has to use the call light to call for assistance and "a lot of times I sit for 2 hours in it.” iii. The resident denied being offered a bedpan, a fracture bedpan, or bedside commode by staff. i. Review of the Resident Assessment Protocol (RAP) for 6/1/03 listed "prevent contamination of coccyx wound.” J. The resident has a Foley catheter to prevent contamination of the wound from urine. 14. Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which incorporates the federal standard of § 42 CFR 483.25(c)(2). That standard requires the Respondent to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 15. Rule 59A-4.1288 is promulgated pursuant to § 400.102(1)(d), Florida Statutes Page 6 of 14 @ CERTIFIED ance Mbece 7002 2030 0006 4359 5613 16. The foregoing constitutes a Class II deficiency as defined by § 400.23(8)(b) Fla. Stat. as follows: 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 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 I! 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. The above referenced violation constitutes the grounds for the imposed 17. Class |! 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. 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 I, B. Uphold the issuance of the conditional license attached hereto as Exhibit “py COUNT II RESPONDENT FAILED TO ENSURE THAT A RESIDENT WITH A LIMITED RANGE OF MOTION RECEIVED APPROPRIATE TREATMENT AND SERVICES TO INCREASE RANGE OF MOTION AND/OR TO PREVENT FURTHER DECREASE IN RANGE OF MOTION § 400.102(1)(d), § 400.23(7), 400.23(8)(b) FLA. STAT. (2003), FLA. ADMIN. CODE R. 59A-4.1288 CLASS II DEFICIENCY 18. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. Page 7 of 14 @ CERTIFIED aaricue Meer 7002 2030 0006 4359 5613 19. AHCA staff conducted a survey on or about August 25-28, 2003. 20. Based on medical record review, observation, and interviews the facility failed to provide equipment which was ordered by the physician and recommended by the physical therapist to prevent pain, muscle spasms, and decrease range of motion for 1 of 32 sampled residents. (#6) 21. The findings included the following: Medical records reviewed stated that the diagnoses for the resident (#6) 22. included: a. Left above the knee amputation, b. decubitus ulcer to right heel and coccyx c. Peripheral vascular disease d. and diabetes. 23. Aphysician order dated 7/25/03 stated,” Right knee brace to be worn from 6 P.M. till 10 A.M. daily for contracture management.” 24. A Physical Therapist note dated 7/24/03 stated knee brace needed to "increase range of motion/decrease (muscle) spasm/tightness to right knee hamstring.” 25. During observations the resident complained of pain and muscle spasms to the right hamstring and knee area on the following dates and times: 8/25/03- 1:00 P.M. a. b. 8/26/03- 9:05 A.M. Cc. 8/26/03- 1:45 P.M. d. 8/27/03- 2:30 P.M. e. 8/27/03- 3:45 P.M. f. 8/28/03- 9:30 A.M. 26. An interview was conducted on 8/26/03 at 9:05 A.M. with the resident. a. He/she complained of pain and states pain is in the muscle in the back of the right leg and complains of muscle "tightening.” b. He states Physical Therapy was discontinued until a "brace" is received. Page 8 of 14 @ CERTIFIED ARTICLE @... 7002 2030 0006 4359 5613 i. He states he is "afraid" leg will contracture before brace is received. Cc. An interview was conducted on 8/26/03 at 2:17 P.M. with the Physical Therapist. i. He/she confirms the brace was ordered by the facility in July 2003 but never received by the facility due to the facilities concerns with the expense of the equipment. ii. The therapist tried to use a temporary brace but "it was not adequate.” ii. The therapist states the resident needs the brace to "use at night to prevent contracture of the muscle." iv. The therapist also ordered a sliding board with rollers because the regular sliding board was painful to the resident's wound on the coccyx area. v. The sliding board would ease transfers. vi. The therapist stated he/she has spoken with the supply manager and the facilities administrator concerning the need of the resident for the equipment. The physical therapist stated was told on the day of the interview (8/26/03) by the supply manager that the equipment vii. was ordered. vii. The physical therapist confirmed therapy services were discontinued until the equipment arrived. d. An interview was conducted on 8/26/03 at 3:10 P.M. with the supply manager. i. The supply manager confirmed the equipment was ordered in July 2003 but the first equipment requisition was coded wrong. A second attempt to order the equipment was made on a requisition that contained equipment for other residents. iii. The supply manager states “corporate office kicked it out because the total cost was over $500." Page 9 of 14 @ CERTIFIED ARTICLE @.:. 7002 2030 0006 4359 5613 iv.He/she confirmed no further efforts to obtain the equipment had been made until today when the surveyor enquired about the equipment. v.The equipment was ordered on the day of the interview with the supply manager (8/26/03) and should be "overnighted." e. An interview was conducted with the resident on 8/28/03 at 9:30 A.M. The resident questioned where the brace is for his/her leg. The resident stated, "My leg hurts so bad, | can feel the muscles i. ii. bunching up.” iii, | He/She further states "} don't want to lose my leg like | lost the other leg.” f. An interview was conducted on 8/28/03 at 9:45 A.M. with the supply manager. g. He/she stated he/she has called the equipment supplier this morning after the Physical Therapist requested the brace. h. | The supply manager states the equipment should be in today. i. As of 3:00 P.M. on 8/28/03, the resident had not received the knee brace or sliding board with rollers. 27. Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which incorporates the federal standard of § 42 CFR 483.25(e)(2). That standard requires the Respondent to ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 28. Rule 59A-4.1288 is promulgated pursuant to § 400.102(1)(d), Florida Statutes 29. 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 Il 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 Page 10 of 14 e CERTIFIED ARTICLE @... 7002 2030 0006 4359 5613 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. The above referenced violation constitutes the grounds for the imposed 30. 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. 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 Il, 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. (2003), 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). All requests for hearing shall be made to the attention of Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #8, Tallahassee, FL 32308. Page 11 of 14 @ CERTIFIED ARTICLE @.... 7002 2030 0006 4359 5613 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted on vecember//? 2003 -~Joanna Daniels FL Bar #0118321 Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, FL 32308 (850) 922-5873 Fax (850) 921-0158 cy NL | HEREBY CERTIFY that a copy hereof has been furnished to ADMINISTRATOR SEA BREEZE HEALTH CARE 1937 JENKS AVE PANAMA CITY FL 32405-4510 . 4 , 2003. -) Zh. ap We Mir ) va) J) : Mio LE. _ eS —_—— — -c=Joanna Daniels Assistant General Counsel y U.S. Certified Mail (ARTICLE NUMBER 7002 2030 0006 4359 5613), on December Copies furnished to: Wendy Adams (interoffice mail) Page 12 of 14 PRINTED: 09/04/2003 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 23567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER /SUPPLIER/CLIA 02) MULTIPLE CONSTRUCTION (3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: = “ new COMPLETED A BUILDING ane es 7 3B. WING Ppa kn he 105391 ; a _ 08/28/2003 4 NAME OF PROVIDER OR SUPPLIER STREET ADDRES. CUANSIZE: BHEcwE 3L 1937 JENKS AVENUE SEA BREEZE HEALTH CARE PANAMA CIT Pit S24 ND SUMMARY STATEMENT OF DEFICIENCIES D AGENT SLR di conkecrion a PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (ACH i CORRAL TYE GION SHOULD BS COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS: NCED TO THE APPROPRIATE DATE DEFICIENCY) | nee 7 F 154 | 483.10(b)(3) NOTICE OF RIGHTS AND F154 8S=D | SERVICES This Plan of Correction does not The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. This REQUIREMENT is not met as evidenced by: This requirement was not met as evidenced by: Based on observation, record review, and interview, the facility failed to inform the resident and the resident's family the resident's condition and the consequences of his/her choice of refusing medications for 1 of 32 sampled residents. (#11) The findings are: 1. While interviewing resident #11 lying in bed on | 8-26-03 at approximately 10:15 a.m., the resident stated to this surveyor, "my leg hurts” and was rubbing | his/her right leg. This surveyor notified the staff nurse. This surveyor and staff nurse went into the resident's room. The staff nurse asked the resident if his/her right leg was painful. The resident stated, "yes, I hurt". The staff nurse asked, "will you take a pain pill if I bring you one". The resident stated, "no, I take no pill". The staffnurse stated, "ok” and left the room. The staff nurse stated to this surveyor, "resident refuses medication all the time that is why the doctor discontinued medications". The staff nurse failed to determine why she was in pain and why resident refused the medication. 2. Record review revealed resident #11 is refusing her medication for the last 3 months. The medical doctor on 6-11-03 ordered "all PO (by mouth) medications de (discontinue). There is no constitute admission or agreement by the Provider of the truth of the facts alleged or conclusions set forth in this Statement of Deficiencies. This Plan of Correction is prepared solely because it is required by state and Federal law. F 154 Resident #11 will be interviewed in English and in her native language via her family to determine reasons for non-compliance with medications and her physician will be notified of her answers. Social Worker will review all residents to determine if there are any others who may have language barrier. Licensed nurses will be inserviced on the importance of making sure residents can communicate their needs via family interpreters or in the event that resident does not speak English and family is not available to translate, community resources that can be contacted. LABORATORY DIRECTOR'S OR PR QO fie S SIGNATURE TITLE Op) DA: e@— LC Co ADM NIST RATOK, Gli /eF t - - t Any deficiency statement ending with an asterisk{*) denotes a deficiency which may be excused from correction providing it is determined that other sateguards provide sufficient protection to the patients, The findingS stated above are disclosable whether or not a plan of correction is provided. The findings are disclosable within 14 days after such information is made available to the facility. If deficiencies are cited, an approved plan of correction is Tequisite to continued program participation. 12000 EventID: OSNS11 CMS-2567L Facility ID: 20302 Ifcontinustion sheet 1 of 55 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L = F E = SSTRT a (83) DATE SURVEY UND PLEN OF CORRECHON en ocror tla e2) MULTIPLE CONSTRUCTION peas OMS A BUILDING i 105391 BING yy es f NAME OF PROVIDER OR SUPPLIER STREET nopress shear . 1937 JENKS AVENUE) ), 0)... SEA BREEZE HEALTH CARE PANAMA CITY, WH) eh £: oO — Sako: | GACHDEMICENCY MUST HE PRECEDED Be FULL PEE macs me EN RG RETR se | confers TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) r F 154 | Continued From page 1 F 154 documentation of the doctor discussing with the - . . resident why the resident is refusing the medication The Social Worker will and explaining to the resident the consequences of not review all new admissions j taking the medication. Further review revealed, the within 7 2 hours of an ) psychriatrist discontinued all psychological jaimission to determine iM medications on 6-11-03 without the documentation of ’ anguage Darrier exists that consulting with the resident to determine why resident from ” romibit the resident is refusing medication and explaining the effectively, and work with consequences of not taking the medication. the interdisciptinary team Further review of record revealed a progress note . dev elop and document a dated 7-13-03 from the Social Worker stating "resident pran For ongoing ; . communication has been refusing all PO meds therefore MD dc'd all management ) bls medications 6-10-03. Also "continues to have . episodes of yelling in Spanish". The Social Worker failed to provide documentation that the resident was interviewed to determine why resident was refusing the medication. 3. An interview with resident #11 and son on 8-28-03, at approximately 12:15 p.m. was conducted and this surveyor inquired why the resident is not taking medications. The resident stated, "I no take pills" in English and then began speaking in Spanish. This surveyor requested that the resident's son ask the resident why he/she is refusing medication in Spanish and then interpret his/her answer. The son asked the question and stated, "said the medication makes stomach sick". I asked the son to asked the resident if he/she has told the staff why he/she is refusing medications. The resident stated, "yes, but they don't understand me". The son stated, resident "goes back and forth from English to Spanish". The resident's son stated, "I talked with my sister last night and she was very upset with the facility because she was never informed that resident had refused medication and it was stopped”. © 4. An interview with the Social Worker on 8-27-03 212000 Event ID: OSNSi1 Facility ID: 20302 If continuation sheet 2 of 55 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-1 ENDELNONCoRRECHON |r) 2ROMDERSuRPLIEVCLA Op) MULTIPLE CONSTRUCTION OS COMLETED A BUILDING 3B. WING 105391 . 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1937 JENKS AVENUR © :/° +) SEA BREEZE HEALTH CARE wi Vas cae PANAMA QUHTR PERU Fo (x4) D SUMMARY STATEMENT OF DEFICIENCIES D PROVBDER’S PUA OS CORRECTION (5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED 10 THE APPROPRIATE DATE} DEFICIENCY) F 154 | Continued From page 2 F 154 at approximately 12:45 p.m. was conducted. This surveyor asked if the daughter of the resident #11 was informed that her mother was refusing her medication. The Social Worker stated, "no, I did not inform her because it is hard to get a hold of her because you can only reach her late in the evening”. a F221 | 5. An interview with the D.O.N. (Director of Resident #11 will have a Nursing) on 8-27-03 at approximately 12:30 a.m. this side rail screen completed surveyor requested any documentation that the resident to indicate need for/usage #11 had a consultation with any doctor to determine of side rails. If required, why the resident is refusing her miedication and the side rail order will be resident understands the consequences of not taking obtained with medical her medication. The facility failed to provide any needs indicated and side documentation. This surveyor asked the D.O.N. if rails will be put on the care anyone in the facility could speak Spanish and plan as an intervention. interpret Spanish. The D.O.N. stated, "no, but we have learned some Spanish words over the years and Residents will be reviewed she understands English if you speak slowly and with the care plan calendar clearly". with regards to side rails | we for accuracy of screen Class I based on medical need, 59A-4.1288 F.A.C. physicians’ orders and care Correction Date: 9-27-03 plan interventions in an effort to ensure accuracy related to use. cep 483.13(a) PHYSICAL RESTRAINTS F221 Nurses who complete RAI The resident has the right to be free from any physical wm pe reeeed kin the restraints imposed for purposes of discipline or th poranice of making sure . A ay at side rail screens, convenience, and not required to treat the resident's orders and care plans medical symptoms. match. This REQUIREMENT is not met as evidenced by: ° dit 3 core oles weokiy. rd | This requirement was not met as evidenced by: 4 weeks for accuracy of side rails screen, orders j Based on observation, record review and interview, and care plans. 4 bake the facility failed to ensure that 1 of 32 sampled 112000 Event ID: OSNS11 Facility ID: 20302 If continuation sheet 3 of 55 CMS-2567L EALTH AND HUMAN SERVICES D SERVICES LENT OF H EDICARE & MEDICA _ DEPART! CENTERS FOR} PRINTED: 09/04/2003 FORM APPROVED 2567-1. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105391 2) MULTIPLE CONSTRUCTION (3) DATE SURVEY &) ° COMPLETED A BUILDING B. WING 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, CITY, STATE, ZIP CODE 1937 JENKS AVENUE PANAMA CITY, FL 32401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Continued From page 3 residents who was restrained, lacked medical symptoms and a physicians order warranting the use of the restraint (#11). The findings are: 1. Resident #11 was observed on 8-25 -03 at approximately 10:00 a.m. and 3:15 p.m., lying in a low bed with side rails up on both sides of bed. Again, the resident was observed lying in the bed on 8-26-03 at approximately 9:30 a.m. and 10: 55 a.m. with side rails up on both sides. 2. Record review revealed the interdisciplinary careplan team reviewed careplans on 6-11-03. During this time no careplan was developed to address the usage of side rails. Further review of the resident's record revealed no current side rail assessment has been done and no physician orders for side rails has been attained for the use of side rails. 3. An interview with the D.O.N. (Director of Nursing) on August 26 at approximately 11:00 a.m., confirmed the lack of a current assessment for side rails, lack of physician orders, and a lack of a careplan for the use of side rails. The D.O.N. stated, "we failed to assess and careplan for the side rails". 4. On 8-27-03, the DON provided this surveyor with a side rail rationale assessment dated for 6-11-03 which states, "side rail(s) do not appear to be indicated at this time: utilizes low bed for safety”. Class DT 59A-4.1288 F.A.C, : Correction date 9-27-03 F221 —__} 112000 EventID: OSNS511 CMS-2567L Facility ID: 20302 If continuation sheet 4 of 55 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L TATE DEFICIENCIE P . ECON 3) Ds AXDDLANOF CORRECTION» | OD FROVIDERSUPSLTUCLA Og) MULTIPLE CONSTI COMPLETED A BUILDING ae ! 105391 [pres ——_________ 08/28/2003 NAME OF PROVIDER OR SUPPLIER : sreey abs a8 Pee ae SEA BREEZE HEALTH CARE 1937 TENKS ANENGE «3: . PANAMA { (X4)ID SUMMARY STATEMENT OF DEFICIENCIES | D ERE ORR: OF ‘CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH'CORREL CTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE : DEFICIENCY) F 223 | Continued From page 4 F 223 F 223 | F 223 | 483.13(b) ABUSE F223 SS=G | Investigation has been The resident has the right to be free from verbal, completed. No actual sexual, physical, and mental abuse, corporal abuse or perpetrator was _ punishment, and involuntary seclusion, identified. Resident #2 will 4 be evaluated by the This REQUIREMENT is not met as evidenced by: Psychiatrist on next visit. Based on resident and staff interviews the facility P failed to protect one of 32 sampled residents (#2) from Any resident who alleges abuse, Tesulting in the resident's stated psychological immediately to determine a harm, including fear of leaving his/her room. possible perpetrator. If the erpetrator is a staff The findings include: member, the staff member . wae will be suspended pending 1. During the initial tour on 8/25/03 at approximately investigation per policy. 10:10 A.M. resident (#2) stated on Thursday, 8/21/03 he/she had complained to the Director of Nursing Staff will be inserviced on (DON) about not receiving a shower. Two staff the policy for prevention members were sent to assist the resident with a shower. of/protection from abuse. The resident states the two staff members were Signs have been posted "rough" with him/ her and forced hin/ her to ambulate throughout the facility without his/her wheelchair. The resident began to cry regarding notification of and states he/she is "afraid" and "scared" to leave facility leadership related his/her room. The resident states the incident was to abuse. reported to the DON by the resident, on 8/21/03 after the completion of the shower. Executive Director will request attendance at next An interview with the Licensed Practical Nurse (LPN) resident council meeting to / Unit Manager at this time (who was present during provide information to the interview with the resident) confirmed the resident residents regarding facility had complained about not receiving her shower and policies and procedures the treatment by the Certified Nursing Assistants related to abuse. ED will (CNAs). The LPN/Unit Manager denied the resident interview 3 residents had any bnuises and states the resident is a "chronic weekly X 4 weeks to complainer." The LPN/Unit Manager states an determine if there is any “informal investigation" was completed and an unreported allegation of incident report was not completed. abuse and will report meat findings to QI/RM qe % | An interview was conducted with the resident on committee. CMS-2567L 112006 EventID: OSNS11 Facility ID: 20302 Ifcontinuation sheet 5 of 55 PRINTED: 09/04/2003 _DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA MULTIPLE CONSTRI _ (3) DATE SURVEY AND PLAN OF CORRECTION . > peeves ATION NUMBER: ome Mu pene Py & 8) COMPLETED A BUILDING B. WING 105391 : Gin 08/28/2003 = Pt tee 7 NAME OF PROVIDER OR SUPPLIER ‘ STREET ak tht Bt ZIP CODE 1937 JENKS AVENUE... |: A BREEZE HEALTH CARE aie an SEA : PANAMA CHEER SHOR vin 41D SUMMARY STATEMENT OF DEFICIENCIES 1D a’ €F CORRECTION j mor (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX ca Hee ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS: REFERENCED TO THE APPROPRIATE DATE * DEFICIENCY) 1 F 223 |.Continued From page 5 F 223 8/26/03 at approximately 9:30 A.M. The resident repeated the previous statements conceming the allegation of abuse by the CNA's. The resident stated was to receive a bath on Saturday 8/23/03 but did not receive a bath. The resident stated he/she did not receive a bath on Saturday 8/23/03 because of his/her a} complaints on Thursday 8/21/03. The resident stated was scared of the staff and scared to leave his/her room. An interview was conducted on 8/26/03 at approximately 11:30 A.M. with the DON. The DON confirmed the resident came to him/her on 8/21/03 and complained of not receiving a shower for one week. The DON denied the resident came to him/her after the shower to complain of abuse by the CNA's. The DON states the resident is a "complainer" and "spoiled." An interview was conducted on 8/26/03 at approximately 12:15 P.M. with the LPN/Unit Manager. He/she again stated the resident complained to the DON on 8/21/03 concerning not receiving a shower. The DON phoned the LPN/Unit Manager on 8/21/03 and notified him/ her of the complaint. The LPN/Unit Manager stated the DON came to the nurse station after the resident received his/ her shower and questioned the CNA's and the LPN/Unit Manager concerning complaints of the CNA's treatment of the resident. The LPN/Unit Manager stated s/he didn't feel the resident was abused because the resident bathes self in the shower room and there were other staff and residents in the shower at the time of the incident. The LPN/Unit Manager denied any injuries to the resident. The LPN/Unit Manager stated s/he saw the resident ambulate from the shower to the wheelchair in the hall and the CNA's took the resident to his/ her room after the shower. CMS-2567L 312000 Event ID: OSNS511 Facility ID: 20302 if continuation sheet 6 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES “CENTERS FOR MEDICARE &3 EDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105394 (X2) MULTIPLE CONSTRUCTION! * : A. BUILDING B. WING 04 JAN 28 PM (3) DATE SURVEY COMPLETED 08/28/2003 PREFIX TAG AID | NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, CITY, STATE, ZIP CODE 1937 JENKS AVENUB|\ | | PANAMA CITMBMBMGT RA: ye SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER BPEAN CTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F 223 CMS-2567L Continued From page 6 An interview was conducted on 8/26/03 at approximately 12:30 P.M. with the DON conceming conflicting information concerning the reporting of the resident's allegation of abuse. The DON denied he/she was made aware of an allegation of abuse on 8/21/03. An interview was conducted with the LPN/Unit Manager on 8/26/03 at approximately 1:00 P.M. conceming the reporting of the allegation of abuse by the resident and the conflicting information from the staff. The LPN/Unit Manager recanted the information given previously and stated s/he heard the allegation for the first time during the initial tour on 8/25/03 with the surveyor. The LPN/Unit Manager stated s/he believed the resident had reported the incident to the DON because the resident "reports everything to her." The LPN/Unit Manager stated the resident was moved closer to the DON's office so he/ she could "get to the DON easier." The resident's room was observed to be 3 doors from the DON's office. An interview was conducted with the family member of the resident on 8/27/03 at approximately 11:15 A.M. The family member confirmed the resident had complained of CNA’s being rough with hinvher during a shower on 8/21/03 and making the resident walk without the wheelchair. The family member states the resident goes to the DON's office frequently and feels "confident" the resident told the DON. The family member states the resident has voiced concems of being "scared of staff" since the incident on 8/21/03. | An interview was conducted with the DON on 8/28/03 at approximately 9:50 A.M. to follow up on any investigation into the allegations of abuse to the resident which were told to the LPN/Unit Manager on /25/03 and to the DON on 8/26/03. The DON denied any investigation had begun into the allegation of 132000 EventID: OSN511 Facility ID: 20302 Ff continuation sheet 7 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105391 (X2) MULTIPLE CONSTRUGHON yom y) ~ Se Bp ge ag A BUILDING 3B. WING (X3) DATE SURVEY COMPLETED 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET mot CITY, STATE, ZIP CODE 1937 JENKS AVENDE | c CMS-2567L EA BREEZE HEALTH CARE fy ™ ; PANAMA CRISMINPSAPR AT OID "SUMMARY STATEMENT OF DEFICIENCIES D | PROVIPER f PDAM GF OORRECTION os) PREFIX: (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 223 | Continued From page 7 F223 F225 abuse by the resident or any measures put in place to eye protect the resident from further abuse while the cote nas been allegations are investigated. abuse or perpetrator was Prior to the end of the survey on 8/28/03 the DON identified Resident #2 will gave the surveyor a copy of the one day report which be evaluated by the was sent 8/28/03 to the Agency for Healthcare 2 «ge woe P . Administration . sychiatrist on next visit Any resident who alleges ons BAC. abuse will be interviewed ass in immediately to determine a Correction Date: September 27, 2003 possible perpetrator. If the perpetrator is a staff : member, the staff member | F 225 | 483.13(¢)(1)(ii) STAFF TREATMENT OF F 225 witl be suspended pending SS5=D | RESIDENTS investigation per policy. The facility must not employ individuals who have Staff will be inserviced on been found guilty of abusing, neglecting, or the policy for prevention mistreating residents by a court of law: or have hada of /protection from abuse. finding entered into the State nurse aide registry Signs have been posted concerning abuse, neglect, mistreatment of residents thr oughout the faci lity or misappropriation of their Property; and report any r egarding notification of knowledge it has of actions by a court of law against facility leadership related an employee, which would indicate unfitness for to abuse. service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. FE ive Di itt xecutive Director wi The facility must ensure that all alleged violations request attendance at next involving mistreatment, neglect, or abuse, including resident council meeting to injuries of unknown source and misappropriation of provide information to_ ; resident property are reported immediately to the residents regarding facility administrator of the facility and to other officials in policies and procedures accordance with State law through established related to abuse. ED will procedures (including to the State survey and weckty x 4 esigents rtificati . ekly eeks to cornincation agency) determine if there is any The facility must have evidence that all alleged naan fread of violations are thoroughly investigated, and must findin eto ‘O TR Ort. prevent further potential abuse while the investigation t q | 2) fs committee. 132000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 8 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES “CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2002 FORM APPROVEL 2567-L STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 2) MULTIPLE CONSTRUCTION? = pt Pr = “adoope A BUILDING : B. WING (&3) DATE SURVEY COMPLETED 08/28/2003 ——_ OL JAN ZB PM 4: 35 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, CITY, STATE, ZIP CODE 1937 JENKS AVBNWES | Uh (| PANAMA CD] iL) SoHRYA | 5 (4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER 'SIAL A CORRECTION x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE, CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F225 Continued From page 8 is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective ; action must be taken. This REQUIREMENT is not met as evidenced by: Based on resident and staff interviews the facility failed to immediately investigate an allegation bya resident, of abuse of a resident by two staff members, the facility failed to protect the resident from further potential abuse after the allegation, and the facility failed to immediately report the allegation of abuse to the Agency for Healthcare Administration for 1.of 32 sampled residents.(#2) The findings include: 1. During the initial tour on 8/25/03 at approximately 10:10 A.M. resident (#2) stated on Thursday, 8/21/03 he/she had complained to the Director of Nursing (DON) about not receiving a shower. Two staff members were sent to assist the resident with a shower. The resident states the two staff members were "rough" with him/her and forced him/ her to ambulate without his/her wheelchair. The resident began to cry and states he/she is "afraid" and "scared" to leave his/herroom. The resident states the incident was reported to the DON by the resident, on 8/21/03 after the completion of the shower. An interview with the Licensed Practical Nurse (LPN) / Unit Manager at this time )who was present during —_i CMS-2567L 122000 EventID: OSNS511 Facility ID: 20302 Tf continuation sheet 9 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES _CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2367-L STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 AULTIPLE CONSTRUCTION (3) DATE SURVEY 2) MULTIPLE CONS RUTHIN COMPLETED if 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE sffer SPI St CODE 1937 JENKS AVENUE = us r ‘ iS PLAN OF CORRECTION x4) D- | PREFIX TAG i SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ~ RRO H beak & CTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 5) COMPLETE DATE [ F 225 | receive a bath. The resident stated he/she did not Continued From page 9 the interview with the resident) confirmed the resident had complained about not receiving her shower and the treatment by the Certified Nursing Assistants (CNAs). The LPN/Unit Manager denied the resident had any bruises and states the resident is a "chronic complainer." The LPN/Unit Manager states an “informal investigation" was completed and an. incident report was not completed. An interview was conducted with the resident on 8/26/03 at approximately 9:30 A.M. The resident repeated the previous statements concerning the allegation of abuse by the CNA's. The resident stated was to receive a bath on Saturday 8/23/03 but did not Teceive a bath on Saturday 8/23/03 because of his/her complaints on Thursday 8/21/03. The resident stated was scared of the staff and scared to leave his/ her room. An interview was conducted on 8/26/03 at approximately 11:30 A.M. with the DON. The DON confirmed the resident came to him/her on 8/21/03 and complained of not receiving a shower for one week. The DON denied the resident came to him/her after the shower to complain of abuse by the CNA's. The DON states the resident is a “complainer" and J "spoiled." An interview was conducted with the family member of the resident on 8/27/03 at approximately 11:15 A.M. The family member confirmed the resident had complained of CNA's being rough with him/her during a shower on 8/21/03 and making the resident walk without the wheelchair. The family member states the Tesident goes to the DON's office frequently and feels "confident" the resident told the DON. The family member states the resident has voiced concerns of being "scared of staff” since the incident on 8/21/03. CMS-2567L 112000 EventID: OSNS511 Facility 1D: 20302 If continuation sheet 10 of 55 PRINTED: 09/04/2003 _ DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES ER /SUPPLIERCLL SULTPLE CON: (X38) DATE SURVEY AND PLAN OF CORRECTION ea) OE ERICA &) MULIETS OR ue COMPLETED ABULDING 7° 4 B. WING 105391 Py) 08/28/2003 NAME OF PROVIDER OR SUPPLIER T ADDRESS, CITY, STATE, ZIP CODE SEA BREEZE HEALTH CARE 1937 JENWS AVENUE : PANAMASCIT Y feb 32407 (&4) 1D SUMMARY STATEMENT OF DEFICIENCIES D 14 F BROVIDERS PLAN OF CORRECTION ms) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 225 | Continued From page 10 F 225 F 226 An interview was conducted with the DON on 8/28/03 Investigation has been at approximately 9:50 A.M. to follow up on any completed. No actual investigation into the allegations of abuse to the abuse or perpetrator was resident which were told to the LPN/Unit Manager on identified. Resident #2 will 8/25/03 and to the DON on 8/26/03. The DON denied a be evaluated by the . any investigation had begun into the allegation of Psychiatrist on next visit. abuse by the resident or any measures put in place to ; . protect the resident from further abuse while the Any resident who alleges. allegations are investigated. abuse will be interviewe: Prior to the end of the survey on 8/28/03 the DON immediately to determine a gave the surveyor a copy of the one day report which possible perpetrator. if the was sent 8/28/03 to the Agency for Healthcare pee ae isa at b Aduiinistration . member, the staff member will be suspended pending 59A-4.1288 F.A.C. investigation per policy. Class IIL Correction Date: September 27, 2003 att wit pe inserviced on e policy for prevention of/protection from abuse. ; . Signs have been posted F 226 483.13(C)(1)G) STAFF TREATMENT OF F 226 throughout the facility SS=D | RESIDENTS regarding notification of qs facility leadership related i The facility must develop and implement written to abuse. | policies and procedures that prohibit mistreatment, : i neglect, and abuse of residents and misappropriation Executive Director will of resident property. request attendance at next : resident council meeting to (Use F226 for deficiencies conceming the facility's provide information to development and implementation of policies and residents regarding facility procedures.) policies and procedures related to abuse. E. D will interview 3 residents This REQUIREMENT is not met as evidenced by: weekly X 4 weeks to Based on interview and policy review the facility determine if there is any failed to immediately implement the written policies unreported allegation of on the investigation and reporting of an allegation by a abuse and will report resident of abuse by two staff members and to protect findings to QI/RM 4 tbs the resident from continued abuse in 1 of 32 sampled committee. 112000 EventID: OSN511 Facility ID: 20302 If continuation sheet 1] of 55 CMS-2567L DEPARTM fENT OF HEALTH AND HUMAN SERVICES EDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L "CENTERS FOR MEDICARE &} STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1} PROVIDER’/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105391 x2) MULTIFLETCONS a A BUILDING B. WING oo 9 = (%3) DATE SURVEY COMPLETED 08/28/2003 = NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET Ne ay ce STATE, ZIP CODE ae nies ENUE YC. MS PaaS 32401 (x4) 1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Te ER OVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 5) COMPLETE DATE F 226 CMS-2567L protect the resident have not been implemented. Continued From page 11 tesidents. (#2) 1. During the initial tour on 8/25/03 at approximately 10:10 A.M. resident (#2) reported an allegation of abuse by two staff members, which had occurred on 8/21/03. The Licensed Practical Nurse ( LPNYUnit Manager was present during the reporting of the allegation. The resident states the incident of being treated "rough" by two Certified Nursing Assistants has left her "scared of staff" and "afraid to leave her room.” An interview was conducted with the Director of Nursing (DON) on 8/26/03 at 11:30 A.M. and again on 8/26/03 at 12:30 P.M. the allegation of abuse was discussed with the DON. A review of the facilities policy titled "Reporting Abuse to Facility Management” with a date of "1/00, states "Employees...must report any suspected abuse or incidents of abuse to the director of nursing services promptly” the incident will then be reported to the state licensing/certification agency, the Ombudsman, the resident's representative, Adult Protective Services, Law Enforcement Officials, Physician, and the facility Medical Director. The policy titled "Protection From Abuse, Neglect, and Exploitation" states the employee suspected of abuse would be suspended from work until an investigation is completed. Au interview was conducted with the DON on 8/28/03 at 9:50 A.M. to follow up on any investigation into the allegation of abuse by the resident, which the resident states was reported on 8/21/03 to the DON. The allegation was reported to the LPN/Unit Manager by the resident on 8/25/03 and to the DON on 8/26/03 by the surveyor. The DON denies any investigation into the allegation has been implemented and measures to Prior to completion of the survey the DON gave the surveyor a copy of the one day report of abuse to the F 226 322000 EventID: OSNS511 Facility ID: 20302 If continuation sheet 12 of 55 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L : ati fe , STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE Eonbreuctigy t. (83) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ~~ Yoke COMPLETED A BUILDING 3B. WING At 98 PHY 35 105391 08/28/2003 7 NAME OF PROVIDER OR SUPPLIER STREET ADD CTY, STATE, ZIP CODE | 1937 JENRS\a OR 7" SEA BREEZE HEALTH CARE ‘ i : PAN, AY GS401 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION xs) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE ; DEFICIENCY) — F 226 | Continued From page 12 F 226 Agency for Healthcare Administration which is dated | 8/28/03. ; 59A-4,.1288 F_A.C. Class Tf Correction Date: September 27, 2003 4 F241 A bowel and bladder screen F 241 | 483,15(a) QUALITY OF LIFE F241 will be completed for SS=G. resident #6. Care plan | The facility must promote care for residents in a interventions willbe manner and in an environment that maintains or written consistent with enhances each resident's dignity and respect in full resident needs. Resident recognition of his or hér individuality. #6 will be evaluated by Psychiatrist on next visit. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record Residents bowel/ bladder review, the facility failed to protect the dignity of a needs will be oedal vor resident by telling a continent resident to have a bowel the care plan sc “ u *. movement in an incontinence brief for 1 of 32 sampled at Oat os a ont ssidgnts. (# Be plan residents. (#6) bowel and bladder needs. The findings include: Adjustments will be made ° as indicated by the screen 1. During an observation of resident #6 wound care results. on 8/28/03 at approximately 8:50 A.M. the Licensed : A : e Practical Nurse(LPN)/ Treatment Nurse performed Nursing staff will b ‘dent’ . inserviced on the wound care to the resident's coccyx. After completion . rtance of maintaining of the wound care to the resident's coccyx the resident dienit vn toileting stated he needed to have a bowel movement. The LPN ignity : secured a diaper on the resident and stated to "go + zl : e will ahead" the "diaper is on." The nurse then proceeded ee ‘vest dents to perform wound care to the resident's right foot. weekly X 4 weeks to Upon completion of the wound care he/she left the determine if toileting needs room. are being met in ee . consideration of their 2. An interview with the resident was conducted at dignity. f 9:30 A.M. on 8/28/03 upon completion of the wound * & | afer care by the LPN. The resident stated he/she was told | CMS-2567L 112000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 13 of 55 DEPART? ENT OF HEALTH AND HUMAN SERVICES _ CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 2) MULTPLE consTRECTI A BUILDING * “seg 28-PH yi 39 08/28/2003 e2 Ni = | (3) DATE SURVEY - tee bee! COMPLETED NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, CITY, 5 TATE, pata CODE 1937 JENKS AVEX Aan PANAMA Ci ¢ bakes Asteccette) (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PRO ¢'S PLAN OF CORRECTION i xs (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 241 Continued From page 13 by the staff to have bowel movements in a diaper. The tesident is 56 years old. The resident stated " I am not old” and feels "bad" when told to have a bowel movement in a diaper. The resident states s/he has to use the call light to call for assistance and states,"a lot of times I sit for 2 hours in it." The resident denied being offered a bedpan, a fracture bedpan, or a bedside commode by the staff. The resident further stated s/he is "afraid" for the Certified Nursing Assistants (CNA) to transfer him/her because "they bang my leg." The resident is a left above the knee amputee with a decubitus ulcer to the heel of the right foot. The resident states often waits to have a bowel movement until the male CNA assists him with his/her shower and he/she is placed on the toilet. 3. Arreview of resident #6 medical record revealed on 6/2/03 the comprehensive assessment/ minimum data set (MDS) listed the resident as "usually continent" with bowel incontinence "less than weekly.” The resident's careplan for the resident dated 6/12/03 stated “assist of ] for transfer" "Initiate elimination pattern." The Physical Therapist on 7/24/03 listed the transfer ability of the resident as "max assist” "transfer from bed to wheelchair, stand-pivot technique" and ability to sit for "1-2 hours.” On 7/24/03 the Physical Therapist note "recommended a sliding board with slider" to ease transfers. An interview was conducted with the Physical Therapist on 8/26/03 at 2:17 P.M. who confirmed the slider board with rollers was recommended because the regular sliding board is painful to the resisdent's wound on the coccyx. The therapist states he/she was told by the supply manager the equipment was not ordered due to the cost of the equipment. An interview was conducted with the supply manager on'8/26/03 at 3:10 P.M. who confirmed the board was F 241 _ Lo CMS-2567L. 112000 EventID: OSNS511 Facility ID: 20302 Ff continuation sheet 14 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA ) MULTIPLE CONSTRUCTION (83) DATE SURVEY AND PLAN OF CORRECTION oe > FROVDE ‘ATION NUMBER: Me Te aiid COMPLETED A. BUILDING B. WING 105391 08/28/2003 NAME OF PROVIDER OR SUPPLIER Tsmezibo aM eBe ft By a : 1937 JENKS AVENUE, . SEA BREEZE HEALTH CARE PAN: & tS Sk ; (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES D mM R’§ FRAN OF CORRECTION x PREFIX (BACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFLX ACH CTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) a F 241 | Continued From page 14 F241 Hl ordered by the facility with equipment for other residents but "corporate office kicked it out because the total cost of the equipment was over $500." The equipment was not reordered by the facility. S9A-4,.1288 F.A.C. 3 Class II Correction Date: September 27, 2003 F 248 | 483.15(f)(1) QUALITY OF LIFE F 248 SS=D F 248 The facility must provide for an ongoing program of : activities designed to meet, in accordance with the Resident #11 will be comprehensive assessment, the interests and the reassessed for her activities physical, mental, and psychosocial well-being of each of choice which will be resident. care planned accordingly. This REQUIREMENT is not met as evidenced by: Residents wi Ube re- n Based on observation, record review and interview, assessed Oe tet actiois es the facility failed to design activities in accordance of interest and care plans with the interest of 1 of 32 sampled residents. 11) updated as needed j 1Be findings are: Activities staff will be i iced th 1. Record review revealed the facility care planned importan ve of involving to "encourage resident to be out of bed and out of residents in group activities room for socialization in small groups with other who enjoy group activities. people and continue to invite resident to manicure session in activity room". The care plan states, ED will randomly audit 3 "resident will not be socially isolated AEB daily care plans weekly X 4 interaction with staff, other resident, family visits, and weeks to see if residents by having interactions with others in small group who have group activities activities 2-3 times weekly”. on their care plans are’ . being included in group 2. On 8-25-03 and 8-26-03 from 7:00 a.m. until activities and report 10:00 a.m., the resident remained in day room until observations to QI/RM 1 this surveyor questioned why the resident was not committee. 9 [9 | a% participating in activities. 112000 EventID: OSNS1i Facility ID: 20302 Ifcontination sheet 15 of 55 CMS-2567L PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED " CENTERS FOR MEDICARE & MEDICAID SERVICES 25 orl STATEMENT OF DEFICIENCIES $1) PROVIDER/SUPPLIER/CLIA MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION Ee NUMBER: C2) MULT . COMPLETED A BUILDING B. WING 105391 rear.) 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATR,BIP CODE | SEA BREEZE HEALTH CARE 1937 JENKS AVENUE : PANAra JANY?6. PMot;: 35 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES i 1D (PROVIDER'S PLAN OF CORRECTION ast PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX KORREQTIVE ACTION SHOULD BE COMPLETE ; REGULATORY OR LSC IDENTIFYING INFORMATION) TAG A D 70 THE APPROPRIATE DATE Tae DPN ARS RD Ie rs F 248 | Continued From page 15 F 248 3. An interview with the Activity Director was conducted on 8-26-03 at approximately 10:30 a.m. The Activity Director stated the resident is provided a diverse activity program each week. Upon review of the clinical-record for the month of August, the s F250 resident was provided a stuffed animal placed in her . bed 4 times and a magazine offered to her 7 times. Social Worker will contact When asked for documentation the resident is being family of resident #11 to offered to go to a manicure session and being offered discuss advance directives to participate in other activities, the facility failed to as per care plan and provide the documentation. document conversation in the Social Services notes. 4. An interview the resident and her son on 8-26-03 at approximately 5:15 p.m., the resident stated, "I go Residents advance directive to church every week and the priest comes to give me needs will be reviewed by communion". She denies magazines and stuffed Social Worker per the care animals being offered to her. The son stated that his plan schedule and mother in the past would take other people to Bingo conversations documented and that she loved to go herself but no one takes her. with families/residents He stated if the staff would take her to other activities based on resident needs. - she would attend. He stated she loves to sit outside the room in the hallway so she can talk to the other people. Social Worker will be inserviced by Executive Class If Director related to the S9A-4.106(4)(a), F.A.C. importance of writing, Correction Date 9-27-03 following the care plan and documenting conversations with families related to F 250 | 483.15(g) SOCIAL SERVICES F250 advance directives. SS=D « - . The facility must provide medically-related social roe ecutive sarector wilt services to attain or maintain the highest practicable P per : ” . : week X 4 weeks for Social physical, mental, and psychosocial well-being of each Services interventions and resident. follow-through and | . : : : documentation This REQUIREMENT jis not met as evidenced by: will rep secret Same end Based on record review and interview, the facility QI/RM committee. Glaale’ : f : . : 2109 L failed to provide medically related social services as : 112000 EventID: OSNS1i Facil ity ID: 20302 If continuation sheet 16 of 55 CMS-2567L DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERVCLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 (X22) MULTIPLE CONSTRUCTION = A BUILDING B. WING (%3) DATE SURVEY COMPLETED 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE ZS. 1937 soe sel 78 ANAMA CTO BeHOT. a on (4) 1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) eae renPt bedd DEFICIENCY) CTION &s) caieea Siow SHOULD BE COMPLETE CED TO THE APPROPRIATE DATE F250 Continued From page 16 planned for in the care plan, for 1 of 32 sampled residents. (#11) The findings are: 1. Resident #11 has diagnoses of Parkinson's Disease, Senile Dementia with hallucination, Hypertension, Osteoporosis, Extrapyramidal Disease, Peptic Ulcer, Hiatal Hernia, PVD (peripheral vascular disease) and Arthropathy. The interdisciplinary care plan team updated the care plan for resident #11 . regarding nutrition/hydration risk on 6-9-03. The care plan signature form had a blank space for "date letter sent and "a care plan discussed with resident". There is no documentation of contact with the family to participate in the care plan meeting. The interdisciplinary care plan team added "consult with residents family regarding desire for Advanced Directives and wishes conceming possible gastric tube placement". 2, An interview was conducted with the Social Worker on 8-27-03 at approximately 10:20 a.m. concerning the care plan to consult with resident's family regarding her Advanced Directives and possible gastric tube placement. The Social Worker stated, "I assume I discussed this with the family". This surveyor requested the documentation of compliance with the care plan. The Social Worker stated she could not provide documentation of discussing these issues with the family and stated, "I don't document every conversation I have with the family”. 3. As of the survey date the facility can not provide documentation of discussing the Advance Directive and possible gastric tube placement with the resident or family members. Upon further review of the record, no diagnosis was provided for a gastric tube placement. The resident's diagnosis is Parkinson, CMS-2567L 112000 EventID: OSN511] Facility ID: 20302 If continuation sheet 17 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 Fi ORM APPROVED _ CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L TEMEN EFICIEN' > A ECONSTRIN 3) DATE ANDPLANGE CoRcTiON |"? ZROVIDERSURLIERcL1A CO) MULTIPLE CONSTRUCTION OO COMELETSS A BUILDING B. WING 105391 ee a 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CMY S#K'TESp CODE” 1937 JENKS AVEN . SEA BREEZE HEALTH CARE pants EE PM 4: 35 aD | SUMMARY STATEMENT OF DEFICIENCIES D (PROMIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX Re: case IVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ROPS REHERENCED TO. THE APPROPRIATE DATE HEAR BERGENCY) | F 250 | Continued From page 17 F 250 F 278 Senile Dementia with hallucination, Hypertension, : Osteoporosis, Extrapyramidal disease, Peptic Ulcer, Resident #4 no longer Hiatal Hernia, PVD (peripheral vascular disease) and resides in the facility. Arthropathy. Resident #12 will have Discomfort/Pain Data Class IT 2 Collection forms completed S59A-4.1288 to assess their pain and Correct by 9/27/03 their care plans will be updated accordingly. If data collection forms indi ignificant F 278 | 483.20(g) - (x) RESIDENT ASSESSMENT F273 | hanged correction MDS is SS=D tas required, it will be The assessment must accurately reflect the resident's completed. status. ; . All residents will have A registered nurse must conduct or coordinate each Discomfort/Pain Data assessment with the appropriate participation of health Collection forms completed professionals. with their quarterly . assessments per MDS A registered nurse must sign and certify that the schedule and MDS assessment is completed. . completed accordingly. Each individual who completes a portion of the MDS/RAI nurses will be assessment must sign and certify the accuracy of that inserviced on the portion of the assessment. importance of accurately assessing pain using Under Medicare and Medicaid, an individual who Discomfort & Pain Data willfully and knowingly-- Collection tool quarterly Certifies a material and false statement in a resident prior to completion of MDS. assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or DSN/Designee will check 3 Causes another individual to certify a material and charts weekly X 4 weeks false statement in a resident assessment is subject to a per MDS schedule for civil money penalty or not more than $5,000 for each completion of assessment. Discomfort/Pain Data : Collection forms and Clinical disagreement does not constitute a material correlated answers on MDS a] and false statement, and report findings monthly §fon ls This REQUIREMENT is not met as evidenced by: to the QI/RM committee. CMS-2567L, 4122000 Event ID: OSNS511 Facility ID: 20302 - If continuation sheet 18 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES _CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 ex) MULTIPLE CONSTRDGTORew A ‘BULDING BWING a (3) DATE SURVEY COMPLETED 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE TREED ED alt oe STATE, ZIP CODE 037 JEN Al ana eiet uP (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (BACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PRERIE TAG nea ee apn an SPDaENES OF CORRECTION TIVE ACTION SHOULD BE chose. REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE F278 : Findings include: Continued From page 18 Based on observation, record review and interview the facility failed to accurately assess 2 of 32 residents for signs and symptoms of pain (#4 and #12). 1. Resident #4 was observed being repositioned on 8/25/03 at 12:30 PM. The resident was following the staff with his/her eyes, facial grimacing was noted upon movement. On 8/27/03 at 10:30 AM the resident was observed being taken from the shower room and was noted to be crying. The Certified Nursing Assistant (CNA) stated he/she "usually cries when we shower" him/her "with all the movement." Clinical record review was conducted for resident #4. The record revealed the resident was admitted to the facility.on 1/13/03 with multiple diagnoses including Anoxic Brain Damage, Coutractures, Decubitus Ulcer, Tracheostomy and Gastrostomy. The initial Resident Assessment Instrument (RAT), Minimum Data Set (MDS) dated 1/24/03 revealed the resident exhibited no signs or symptoms of pain. The physician orders on admission contained an order for Darvocet-N 100 as needed for pain. The resident began receiving the Darvocet-N on 2/8/03 and 2/18/03 for "winces when moved" and "restless." The resident also received Darvocet-N on 4/15 and 4/17/03. The resident was noted on 4/19/03 to have an elevated temperature and "facial expression suggest she is in pain. Moaning and crying. Bowing her back. Robaxin uneffective." The resident received Darvocet-N on 4/20/03 on both the day and evening shifts. On 4/21/03 the resident was again medicated on the evening shift with Darvocet-N for "Moaning." On 4/23/03 the physician orders changed the Darvocet-N to every 6 hours "routine." A quarterly MDS dated 4/25/03 with.a look back period of 7 days stated the resident exhibited no signs or symptoms of pain. An interview with the MDS/Care _ F278 CMS-2567L. 212000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 19 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIERICLIA (&3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED 105391 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE ee A MERAMAT GURY, FL 32403 | STREET ADDRESS, CITY, STATE, ZIP CODE {9SYENKSA VENUE | (X4) 1D PREFIX TaG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) HE 7ST RROUIDER'S PLAN OF CORRECTION os) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE | CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 278 Continued From page 19 Plan nurse on 8/26/03 at 2:00 PM was conducted. The MDS nurse stated - "She's controlled with her medication so she's not having any pain." The MDS | burse also stated he/she has no recall of being made aware of the resident exhibiting any signs or symptoms of pain at the time of the quarterly assessments on 4/25 and 7/24/03. The MDS/Care Plan Nurse had no explanation for the lack of knowledge of documented changes in the status of resident #4 in regard to pain. 2. Resident #12 is a mildly cognitively impared resident who, based on review of clinical record and interviews, is able to make his/her needs known. On 08/27/03 at 8:15 AM resident #12 was observed/interviewed as he/she lay awake in bed (head of bed elevated approx 30 degrees). The resident was slouched in the bed in what appeared to be an uncomfortable position. A 7-3 shift Licensed Practical Nurse (LPN) was present at the resident's bedside, at the time of the observation/resident interview. During this 8:15 AM interview, the resident complained of difficulty sleeping the night before due to foot and leg pain. The LPN replied that's the first she'd heard of it. The LPN left the room without asking the resident if he/she needed assistance with repositioning in the bed. When the surveyor asked resident if he needed help scooting up in the bed, the resident explained he/she is able to do it independently and proceeded to do so. The resident used the raised bedside rails to pull and pushed with his heels against the foot of his bed and in doing so, grimaced and groaned slightly. Resident #12 was observed/interviewed again on 08/27/03 at 9:10 AM, awake in his/her bed. When asked if he/she still had pain in legs/feet, the resident responded "Ail the time". When asked if his/her nurse gave him anything for pain this moming, the resident replied, "No". CMS-2567L 122000 EventID: OSNS1I Facility ID: 20302 If continuation sheet 20 of 55 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES (Xl) PROVIDER'SUPPLIERICLI xy EcoNsTRECHON FE (X3) DATE SURVEY SND PLAN OF CORRECTION en) DENTE eA 2) MULTIPLE CONSTRECTIO / r) COMPLETED A BUILDING ind B. WING 105391 DIAL 78 PM bs: 36 08/28/2003 ——- NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, | CITY, STATE, ZIP CODE 1937 JENKS AVEMIE | ONC: PANAMA DHS SR0} | | SUMMARY STATEMENT OF DEFICIENCIES (GACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 1D PREFIX | TAG “ad ibARS UR GF CORRECTION on) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 20 On 08/28/03, a review of resident #12 clinica] record revealed the resident has an "as needed" (PRN) order for the pain medication Darvocet (start date for this order is 01/26/03). Further review revealed the resident also was receiving Celebrex for management of osteoarthritis and Clonazepam for "Restless Leg Syndrome" (a syndrome described in Taber's Cyclopedic Medical Dictionary as '...intolerable creeping and internal itching sensation occurring in the lower extremities and causing an almost irresistible urge to move the legs...may produce insomnia’). Review of this resident's Medication Administration Record (MAR) revealed the resident received no PRN pain medication for the months of June, July, Aug 2003. Review of the resident's “Pain Intervention Flowsheets" for the months of June, July, Aug 2003 revealed nothing recorded except the resident's name, Toom number and month on these flowsheet/assessment tools. Further review of the clinica] record revealed pain and comfort was not included in this residents current plan of care, nor was there an assessment in the Resident Assessment Protocols (RAPs) during the resident's annual assessment, which was completed on 03/12/03. F 278 Resident #12 was again observed/interviewed on 08/28/03 at 08:28 AM. When asked if he/she slept better last night, the resident again complained of leg/foot pain. When asked if he/she was hurting last night, he/she replied "I hurt all the time". Resident #12 shares a room with his/her spouse and during the 08/28/03 interview at 08:28 am, the spouse shared his/her concern that the resident doesn't walk much anymore because of the pain in his/her feet and legs. An 8:40 AM interview on 08/28/03 with the LPN unit manager revealed the resident ambulates to the —____! 112000 EventID: OSNS51] CMS-2567L, Facility ID: 20302 If continuation sheet 21 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED "_CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES oc) PROVIDER/SUPPLIERICLIA =) MULTPLE CONSTR (&3) DATS SURVEY AND PLAN OF CORRECTION eR ER SE NUMBER: OD MULTIPLE CONS ea t COMPLETED A. BUILDING « 2 teas 3B. WING 105391 28 PH fa 36 08/28/2003 te ; NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE ADDRESS, CITY, STATE, ZIP CODE 1937 JENESAVENUE, _ PASM RTIRR 321 (X4)ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRBCEEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) iF BROW PLAN OF CORRECTION os) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 278 | Continued From page 21 bathroom with staff assistance and a rolling walker. The LPN was unsure if the resident is ambulated regularly by restorative nursing. The LPN was unable to provide explanation or further information when asked why this resident's current assessments and care plan did not include pain management. Class HI 59A-4.1288, F.A.C. Correction date, September 27, 2003 F 280 | 483.20(k)(2) RESIDENT ASSESSMENT F 280 F 280 SS=D A comprehensive care plan must be: Resident #4 no longer resides in the facility. Developed within 7 days after the completion of the Resident #12 will have comprehensive assessment; Discomfort/Pain Data Collection forms completed Prepared by an interdisciplinary team, that includes to assess their pain and the attending physician, a registered nurse with their care plans will be responsibility for the resident, and other appropriate updated accordingly. if staff in disciplines as determined by the resident's data collection forms needs, and, to the extent practicable, the participation indicate a significant of the resident, the resident's family or the resident's change/correction MDS is legal representative; and required, it will be completed. Periodically reviewed and revised by a team of qualified persons after each assessment. Residents will have Discomfort/Pain Data This REQUIREMENT is not met as evidenced by: Collection forms completed Based on interview and record review the facility with their quarterly failed to periodically revise and individualize the plan assessments per MDS of care for 1 of 32 sampled residents(#4). schedule and care plan will - up dated accordingly. 4 {an oF, Findings include: . 1. Clinical record review was conducted for resident #4, The record revealed the resident was admitted to If continuation sheet 22 of 55 CMS-2567L 332000 EventID: OSN511 Facility ID: 20302 PRINTED: 09/04/200: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVEL ~_CENTERS FOR MEDICARE & MEDICA SERVICES 2567-1 4 . — (%3) DATE SURVEY ANDHLANOF ConREGHON [OCD PROVDENSuPrLemuctiA | oe ut TRLE CONSTRUCTION ee A BUILDING 105391 3 WING ; 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADDRES JCOTYEST Avg, ZP CODE 1937 JENKS AVENUE SEA BREEZE HEALTH CARE PANG MAGE DOP HAG! 36 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION ms) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (GAGHCORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG . fet ie sed QLTEE APPROPRIATE DATE ADMIN'S IDENCY) HESFTHES F 280 | Continued From page 22 F 280 the facility on 1/13/03 with multiple diagnoses MDS/RAI nurses will be including Anoxic Brain Damage, Contractures, inserviced on the Decubitus Ulcer, Tracheostomy and Gastrostomy. importance of accurately The initial Resident Assessment Instrument (RAD, assessing pain using Minimum Data Set (MDS) dated 1/24/03 revealed the Discomfort & Pain Data resident exhibited no signs or symptoms of pain. The , Collection tool quarterly initial care plan dated 1/14/03 stated “Evaluate pain prior to completion of intensity." An update to the care plan dated 1/29/03 MDS/care plan. stated, "Cont. at risk for alterations in comfort r/t (related to) multiple contractures. Unable to verbalize DSN/Designee will check 3 pain; facial grimacing, pulling away as signs of charts weekly X 4 weeks pain/discomfort. Indwelling F/C (foley catheter) for per MDS schedule for comfort d/t (due to) pain when moving resident." The completion of interventions listed included, "DCN 100 as ordered Discomfort/Pain Data pm for pain." The care plan was updated on 4/30/03 Collection forms, after a quarterly MDS of 4/25/03 with a look back correlated answers on MDS period of 7 days. The MDS stated the resident and interventions on the exhibited no signs or symptoms of pain. The care plan care plans and report stated, "continue problem" and "continue goals (goal findings monthly to the | date 7/29/03)" and "cont. approaches." The resident, QI/RM committee. 4 Ey o3 however, had been receiving the Darvocet-N since : 2/8/03 for "winces when moved" and "restless" with increasing frequency. On 4/23/03 the physician orders changed the Darvocet-N to every 6 hours "routine" for the increasing episodes of “winces when moved, restless, moaning and crying" and “arches back" indicating pain.. The current quarterly MDS dated 7/24/03 also stated no signs or symptoms of pain. The care plan for "Pain Management" was revised on 7/30/03 with the state "Continue." The indwelling foley catheter listed in the care plan for comfort was discontinued on 7/24/03. This fact was not addressed in the care plan revision. The current physician order sheet contains an order for Lortab 5/500 every 8 hours routine and every 4 hours as needed. The care plan continues to list "DCN 100 as . ordered prn for pain" even though the resident is now receiving Lortab. An interview on 8/28/03 at 2:00 PM with the Licensed Practical Nurse (LPN)Unit Manager Lo __| If continuation sheet 23 of 55 CMS-2567L 12000 EventID: OSNS511 Facility ID: 20302 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA MULTIPLE CONSTRUCTION GS) DATE SURVEY AND PLAN OF CORRECTION ea) IDENTIFICATION NUMBER: 2) MULTIPLE CO? eae oe COMPLETED A BUILDING v4 : 105391 2 NING 08/28/2003 >. ETF 4 f—________ NAME OF PROVIDER OR SUPPLIER Sc Sth ZIP CODE SEA BREEZE HEALTH CARE 1937 JEN } : PANAL 4) SUMMARY STATEMENT OF DEFICIENCIES D LAN OF CORRECTION 5) PREFIX (BACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX ‘TIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS. "REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 1 F 280} Continued From page 23 F280 and the MDS/Care Plan nurse was conducted. Both agreed the resident information is discussed at moming nurse meetings. The MDS/Care Plan nurse stated he/she has no "recall" of being made aware of the changes in the resident in regard to pain management though the information was clearly s documented in the clinical record. The MDS/Care F282 Plan nurse had no other explanation for the lack of appropriate revision to the care plan. Resident #10 had catheter changed on 8/26. The | ae 0)3), FAC facitity policy wilt be ie eas revised to indicate that Correction date, September 27, 2003 catheters are changed per physician order and that bags are changed when F 282 | 483.20(k)(3)(ii) RESIDENT ASSESSMENT F 282 catheters are changed. SS=D | The services provided or arranged by the facility must Residents’ care plans will be provided by qualified persons in accordance with be reviewed per care plan each resident's written plan of care. schedule for interventions that use the phrase “per This REQUIREMENT is not met as evidenced by: facility policy” and where Based on record review and surveyor observation, the even wil hy poysicien s facility failed to implement the care plan for one orcers WIN De revise o sampled resident (#10). indicate interventions will occur per physician’s order. Findings include: MDS/RAI nurses will be Resident #10 care plan noted resident was at risk for reflect physiclans eevee in complications related to indwelling Foley catheter. the care plan This care plan problem was last updated on June 19, . 2003. Interventions included catheter care per facility DNS/ Designee will policy. Facility policy indicated that "Indwelling randomly audit 3 care plans Catheters are changed on the 15th of every month on per week X 4 weeks for the 11-7 shift and prn. The bags should be dated when f coogdination of care plan hanged. " caked Wht b weed A p ¢ Ve ‘oes, . ims Fi Urancey Wit[f physicians orders and : « . Londen TE ‘report findings to QI/RM Observation of 8/26/03 revealed tesident #10 Foley committee. g | 2 op catheter bag was dated 7/17/03. This observation was 112000 EventID: OSNS11 CMS-2567L If continuation sheet 24 of SS Facility ID: 20302 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES ~ FORM APPROVED -_ CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (2) MULTELE CONSTRUCTION _. {@3)DATE SURVEY AND PLAN OF CORRECTION DENTIFICATION NUMBER: . mn Loree p COMPLETED A BUILDING cad t) B. WING aes 05391 ee 08/28/2003 105 NAME OF PROVIDER OR SUPPLIER . - STREET ankles, McA, Ee SEA BREEZE HEALTH CARE 4D SUMMARY STATEMENT OF DEFICIENCIES 5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE : DEFICIENCY) | ; , F 282 | Continued From page 24 F 282 verified and documented and initialed by nurse Unit Supervisor. Interdisciplinary care plan for resident #10 was not implemented, the catheter was not changed. Class Ti 59A-4.1288 F.A.C. | Correction date: 9-27-03 F 309 | 483.25 QUALITY OF CARE F309 F309 $S=G ; : : - dent #4 no longer Each resident must receive and the facility must ies in the facility. provide the necessary care and services to attain or Resident #12 will have maintain the highest practicable physical, mental, and Discomfort/Pain Data psychosocial well-being, in accordance with the Collection forms completed comprehensive assessment and plan of care. to assess their pain and their care plans will be ‘ oe updated accordingly. If Use F309 for quality of care deficiencies not covered data collection forms ~ by s483.25(a)-(m). indicate resident may . . benefit from pain This REQUIREMENT is not met as evidenced by: medication, therapy or restorative programming, the physician will be contacted and referrals will be made as indicated. Based on observation, record review and interview the facility failed to accurately assess 2 of 32 residents for signs and symptoms of pain (#4 and #12). Findings include: Residents will have Discomfort/Pain Data Collection forms completed with their quarterly assessments per MDS schedule and their physicians’ contacted for further orders if information indicates pain needs ‘are not met. qfarle3 If continuation sheet 25 of S5 1. Resident #4 was observed being repositioned on 8/25/03 at 12:30 PM. The resident was following the staff with his/her eyes, facial grimacing was noted upon movement. On 8/27/03 at 10:30 AM the resident was observed being taken from the shower room and was noted to be crying. The Certified Nursing Assistant (CNA) stated he/she "usually cries when we L shower" him/her "with all the movement." Clinical CMS-2567L 132000 EventID: OSNS511 Facility ID: 20302 PRINTED: 09/04/2002 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVEL _ CENTERS FOR MEDICARE & MEDICA SERVICES 2567-1 TEMENT OF DEFICIENCIES F 318 | Continued From page 34 F318 further states "I don't want to lose my leg like I lost the other leg." An interview was conducted on 8/28/03 at 9:45 A.M. with the supply manager. He/she states has called the equipment supplier this morning after the Physical Therapist requested the brace. The supply manager ’ states the equipment should be in today. As of 3:00 P.M. on 8/28/03 the resident had not received the knee brace or sliding board with rollers. S9A-4.1288 F.A.C. Class II - F 322 Correction Date: “September 27, 2003 Resident #18 was repositioned with head of F 322 | 483.25(2)(2) QUALITY OF CARE F322 bed at approximately 30 Ss=D srees. Based on the comprehensive assessment of a resident, Residents who are tube fed the facility must ensure that a resident who is fed by a will have the heads of their naso-gastric or gastrostomy tube receives the beds at approximately 30 | appropriate treatment and services to prevent degrees. aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and . Nursing staff will be ‘ nasal-pharyngeal ulcers and to restore, if possible, inserviced on the normal eating skills. importance of elevating the head of the bed for all tube This REQUIREMENT is not met as evidenced by: feeders to prevent Based on observation, record review and staff complications of tube interview, the facility was found not to be in feedings. compliance with special needs for positioning of tube | fed residents for 1 of 32 residents in sample selection. Unit Manager will make rounds twice daily X one Observation during facility rounds at 8:20 am on 200 week and at various times hall, resident #18 was found to be lying flat in bed once daily X 3 weeks to with bolus tube feeding infusing into abdominal ~ check for comptiance with Gastric Tube. -The staff was notified and resident was Positioning of all tube fed repositioned and cleaned. residents and report Interview was conducted at 8:20 with two LPN's who Findings to QI/RM af_J L were in 200 hall and upon them entering room, the committee. 4 | 29/03 122000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 35 of 55 CMS-2567L DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPELIER/CLIA ULTIETE bons Tie Fj: (3) DATE SURVEY AND PLAN OF CORRECTION a ORE ee RCIA C2 MULTE bporfivc a COMPLETED A BULDING B.WING : 105391 ar P31 037282003 | eos OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE aN pace eae BOOM One 33407 vv. SBROVIDER'S PLAN OF CORRECTION (X4) ID “SUMMARY STATEMENT OF DEFICIENCIES D 3 (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) | F 322 | Continued From page 35 F 322 resident was observed to be immediately Tepositioned and HOB was elevated. At 11:20 am resident #18 was found lying on her right side, against side rail with brown emesis on shirt. The staff was notified and resident was cleaned. Record review of physician orders dated 7/28/03, 4 residents care plan dated 5/14/2003 and facility Gastric Tube Feeding Via Gravity Bag policy and procedure, residents with gastric tube feedings the facility is to keep the residents’ head of bed elevated 30 degrees. S9A-4.1288 F.A.C. F 323 Class TI The beauty shop was locked as soon as the unit manager F 323 | 483.25(h)(1) QUALITY OF CARE F323 was notified. No specific Ss-K residents identified. The facility must ensure that the resident environment . remains as free of accident hazards as is possible. The chemicals were : names : removed from the beauty shop door to off site This REQUIREMENT is not met as evidenced by: storage until locks could be i . ; changed/installed. The ' Based on observations, record review, and staff door lock to the beauty interview, the facility failed to ensure that harmful shop was replaced with an chemicals were not.easily accessible to independently automatic lock on the ambulatory residents, residents with psychiatric afternoon of 8/25/03. diagnoses, residents with cognitive impairment, and Locks were installed on the residents with dementia. cabinets in the beauty shop. MSDS for chemicals Findings inchide: used in the beauty shop were obtained form the During the initial tour of the facility with a facility beautician on the morning LPN, on Monday 8/25/03 at 10:15 AM, the door to the of 8/26 and copies were beauty salon was found to be unlocked. A tour of the placed in the MSDS book on beauty salon room revealed 8 chemicals in unlocked the afternoon of 8/26. A cabinets, in the bathroom, and on the counter. The policy was obtained for the following items were found in the unlocked cabinets: beauty shop on the Quantum Acid Perm, Créme Developer Stabilized afternoon of 8/25. 112000 Event ID: OSNS11 Facility ID: 20302 If continuation sheet 36 of 55 2MS-2567L PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED "CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L TATEMENT OF DEFICIENCIES ECONSTREX i 3) DATE SURVEY Sorascrcomama «|W aarmararmaa — [Pmemecasmay = py foamy A BUILDING te Sous bed 105391 ame +it-28 PH &: 37 08/28/2003 NAME OF PROVIDER OR SUPPLIER ommezr DB! CITY, STATE, ZIP CODE . 1937 JENKS AVENUR ON SEA BREEZE HEALTH CARE PANAMA HAE SRY pil: © (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PRpNED \PLEINOF CORRECTION as PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F323 Continued From page 36 F 323 : formula, Moisturizing Treatment, Color Styling Staff members were Mousse Hair Color, Barbicide (disinfectant, fungicide, inserviced on the need to | Viricide), clipper blade disinfectant, and One Step keep the beauty shop germicidal cleaner. The following item was found in locked at all times when the unlocked bathroom: Comet cleanser. The not attended beginning on following items were found in the unlocked cabinet , the afternoon of 8/25. under the sink: 2 unmarked bottles of liquids. The Staff will be inserviced on following item was found on the counter behind the the location of MSDS for sink: A glass jar with Barbicide (disinfectant, beauty shop. fungicide, virucide) fluid with combs soaking in it. The bottle of Barbicide (disinfectant, fungicide, The policy for the beauty virucide) had a warning on the Jabel that read shop will be approved by "Harmful if swallowed". According to the Material the QI/RM committee : Safety Data Sheet Quantum Acid Perm is moderately during their next scheduled aon o> toxic with instructions to call physician or poison meeting. control; Barbicide is hazardous to eyes, skin, mucous membranes with instructions to call physician. The LPN that was touring with the surveyor stated that the door to the beauty salon was supposed to be locked when the beautician wasn't in the room and the at beautician was only in on Tuesdays. The LPN witnessed the surveyor open the door and stated that the room was supposed to be locked. The same surveyor checked the door to the beauty salon at 12:45 PM on Monday 8/25/03 and found the door to still be unlocked. An interview with the Charge Nurse revealed that the LPN who toured with the surveyor failed to let anyone know that the door was unlocked and failed to lock the door. The Charge Nurse locked the door at that time. The Charge Nurse stated that the door to the beauty salon was supposed to be locked. On Monday 8/25/03 at approximately 1:00 PM, an interview with facility LPN revealed that the Material Safety Data Sheet (MSDS) should include the chemicals from the beauty salon. Three surveyors 12000 EventID: OSNS5I1 Facility ID: 20302 Tf continuation sheet 37 of 55 2MS-2567L PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 25 OTL STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (£2) MULTIPLE CONSTRUCTION (43) DATE SURVEY ~ Preis COMPLETED AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 A. BUILDING B. WING read 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE ‘STREET ADDREMG ong 4) D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BYFULL REGULATORY OR LSC IDENTIFYING INF ORMATION) TV# AChON SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F 323 Continued From page 37 observed there were no Minimum Safety Data Sheets posted in the beauty salon. The Material Safety Data Sheets posted in the facility failed to include any of the chemicals found in the beauty salon. The Director of Nursing and the agency nurse consultant were made aware of the findings at approximately 4:45 PM. On 8/27/03 at approximately 3:00 PM the Administrator was asked to provide surveyor with the Minimum Safety Data Sheets for the chemicals in the beauty salon. At approximately 5:00 PM the Administrator provided the MSDS for the beauty salon chemicals. : - An interview with the facility Administrator on 8/26/03 at approximately 8:30 AM revealed that there were no policies and procedures regarding locking the door to the beauty salon, but it was known by all that the door is to remain locked. At approximately 9:00 AM on 8/26/03, the Administrator provided a procedure noting that the beauty parlor be locked when not in use. The Administrator also stated that the lock has been changed so it automatically locks when it is shut and locks have been placed on the cabinets and all of the chemicals have been removed from the room. The surveyor verified the above by observation on 8/26/03 at approximately 9:15 AM. Review of the Resident Census and Conditions Teport completed by the facility revealed that there were 17 independently ambulatory residents, 65 residents with diagnoses of dementia, and 47 residents with psychiatric diagnoses. An interview with the Director of Nursing on 8/28/03 at 3:00 PM revealed that they have a monitoring program where one Certified Nursing Assistant is assigned to monitor specifically identified, wandering residents and does not take on any other responsibilities. Documentation provided by the _| MS-2567L 122000 EventID: OSNS11 Facility ID: 20302 Jf continuation sheet 38 of 55 ENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED DEPARTS _ CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA )M LE CONSTRUCTION (5) DATE SURVEY AND PLAN OF CORRECTION om IDENTIFICATION NUMBER: 2) MULTP rite COMPLETED A BUILDING pe BOWING ose 105391 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET Dende, et best SEA BREEZE HEALTH Cz 1937 JENKS AVENUE (x4) 1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) pres PREFIX TAG PANAMA ow Si: 401 ‘ OF CORRECTION: (EA! Comsat cron SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE, DATE DEFICIENCY) F 323 CMS-2567L Continued From page 38 Director of Nursing revealed that there were currently six (6) residents being monitored. The Director of Nursing stated that they have no one responsible to check that doors that are supposed to be locked are locked. The Director of Nursing stated that the therapists store supplies in the beauty salon and one of the therapists said that he/she went in the beauty salon the moming of 8/25/03 and doesn't remember locking } the door. A review of resident # 1's record revalued 2 incidents of abuse on another resident on 7/2/03 and 8/25/03, in the other resident's room. The record also revealed that resident # 1 had a diagnosis of senile dementia, depression, and paranoia. Review of resident # 1's MDS showed that he/she was coded for socially inappropriate behaviors, a history of delusions, and agitation. Observations of resident # 1 on 8/26/03 at approximately 1:30 PM revealed him/her sitting in a chair outside of the beauty salon with no staff supervision. Observation of resident # 1 at approximately 4:30 PM on 8/26/03 showed him/her sitting in the lobby with no supervision. Resident # 1 was seen in his/her wheelchair outside of the therapy room at approximately 5:30 PM on 8/26/03. Observation of resident # 1 on 8/27/03 at approximately 9:00 AM revealed him/her to be walking up and down the hallways of the 200 wing near the beauty salon with no supervision. A review of the list of wandering residents that are in the monitoring program revealed that resident # 1 was not on the list. 59A-4.1288, FAC. 132000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 39 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED “ CENTERS FOR MEDICARE & MEDICA SERVICES 2367-L 7 IT OF DEFICENCIE —— . . ms DATE SUR’ ANDMANGE ComscTION | ZROWDERSIRLEEcLiA Cori mmmoossrauenioy FI TY | cineca A BUILDING We B. WING 105391 ag 8PM te: 37 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADURHss, ot STATE, ZIP CODE 1937 JENKS AV) SYA SEA BREEZE HEALTH CARE PAN ; OM et fGIVE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES Fie) FROVISERS LAN GtoRRECTION as | PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 4 F 323 | Continued From page 39 F 323 Class I Correction Date: 9/27/03 F 332 | 483.25(m)(1) QUALITY OF CARE F332 SS=E 4 F 332 ‘The facility must ensure that it is free of medication . , error rates of five percent or greater, Resident #27’s orders were clarified and clarifications This REQUIREMENT is not met as evidenced by: marked on the MAR. i 5 Resident #23 had orders Based on Observation, Staff Interview and Record clarified and medication Review the facility was found to not in compliance reordered from the with a medication errors rate of 14%, pharmacy. Medication errors were found on residents # 27, and Staff /pharmacy will review #23. Three nurses were observed on two different orders against MARS/TARS shifts with 7 errors in 50 opportunities, resulting in a and available medications 14% medication error rate. in cart for resident . population at time of 1) Resident # 27 was given two 25mg Atenolol tablets. review. Physician order reconciliation indicates one 23mg tablet to be given daily. Licensed staff will be 2) Resident #27 had an order for Folic Acid 1 tablet inserviced on principles of daily. This medication was omitted on morning medication administration. medication pass. ’ Medication Error reporting procedure was followed by Med Pass observations will staff with physician notification of errors. be done with licensed 3) Resident # 23 was given K-Phos 500 mg 2 tabs with nurses beginning with those 60cc water approximately 20 minutes before lunch was involved in errors and due to arrive. Physician order indicated medication to randomly audit remainder be given with meals K-Phos 1000mg po tid with of licensed nursing staff meals, for error rate less than 5%. Results will be forwarded 4 | | On 8/26/03 at 4:45 PM a medication pass observation to QI/RM committee. iPr was done on the North Hall with a Licensed Practical Nurse (LPN). The LPN was observed to wash his/her hands and administer Alphagan 0.15% ophthalmic drops one drop to each eye using his/her bare hands to pull down the lower lid. The label on the Alphagan 12000 EventID: OSNS511 Facility ID: 20302 If continuation sheet 40 of 55 “MS-2567L PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED _ CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L x ICENCE ; ee + 5) DATE SURVE ANDELANOF CORRECTION» | 00) SRCVDEVSUEPLTERCH1A COMATRECOSTEUCION ee DY |“ coupe A BUILDING bas teal 105391 ae 08/28/2003 S. 4 4 P AME OF PROVIDER OR SUPPLIER STREET ADDRAMS, ates nan 1937 JENKS AVE; WWE 2 ih SEA BREEZE HEALTH CARE PANAMA CIT WW a aap | SUMMARY STATEMENT OF DEFICIENCIES 1D PROV FS PLAN'OE- CORRECTION x) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (ZACH CORRECTIVE ACTION SHOULD BE ~ COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 332 | Continued From page 40 F 332 | drops stated “opened 7/8/03." The label also stated “discard 42 days after opening” and 8/19/03 is 42 days from that date. The drops were signed on the Medication Administration Record (MAR) for twice a day for a total of 14 doses past the pharmacy designated end date. A review of the facility policy 4 for the "Administration of Eye Medications" was conducted. The policy stated, "2. Wash your hands and apply clean disposable gloves." The section of the policy labeled "Issues and Problems With Eye | Medications" stated, "1. Record the date opened so you can discard expired medications according to your facility's policies." F 333 Residents’ # 24, 25,26, & | 59A-4.1288F.A.C. 27 will have notes made on | Correction Date: 27 September 2003 MARS to more clearly | denote appropriate i dosages. a3 F 333 | 483.25(m)(2) QUALITY OF CARE F 333 Staff/pharmacy will review SS-E . : orders against MARS/TARS The facility must ensure that residents are free of any and available medications . significant medication errors. in cart for resident population at time of This REQUIREMENT is not met as evidenced by: review: This requirement was not met as evidenced by: Licensed staff will be Based on observation, interview, and record review it inserviced on principles of was determined the facility failed to ensure 4 of 32 medication administration. sampled residents received medication without significant error.(#24, #25, Med Pass observations wilt #26) be done with licensed nurses beginning with those The findings are: involved in errors and randomly audit remainder 1. During the narcotic reconciliation part of the of licensed nursing staff medication pass observation conducted on 8-26-03 at Tor error rate less than 5%. approximately 4:00 p.m. with the nurse, it was Results will be forwarded aly | 33 determined 3 significant errors were made which to QI/RM committee. 112000 EventID: OSNS1i FacilityID: 20302 If continuation sheet 41 of 55 OMS-2567L DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105391 > ett 2) MULTRLE constaucrion $ A BUILDING 3 WINS ___§pe—t-26- PH bi: 37 (5) DATE SURVEY COMPLETED 08/28/2003 | NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, CfT 1937 JENKS AVENUE PANAMA CI¥¥! # pare t abt Si 8 aD | PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (5) COMPLETE DATE F 333 | Continued From page 41 include: a. Resident #24 MAR (medication administration record) stated there should be 6 remaining Valium 5 mg (milligram) but the medication card had 7 remaining pills. The nurse.acknowledged verbally and provided a progress note that she gave resident # 24 only 1 pill of Valium 5 mg instead of the physician order of 10 mg Valium. b. Resident #25 MAR stated there should be 7 pill of Phenobarbital 32.4 mg but the actual count was 6 pis on the medication card. The nurse acknowledged verbally and provided a progress note that she gave resident two (2) pills of 32.4 mg (64.8 mg) instead of the physician order for one (1) pill of 32.4 mg. c. Resident #26 Mar stated there should be 15 pills of Phenobarbital 15 mg. but the actual count was 17 pills on the medication card. The nurse acknowledge verbally and provided a progress note that she gave only 15 mg of Phenobarbital instead of the physician order for two (2) pills of 15 mg (30 mg). d. Resident # 27 was given Atenolol 50 mg. on August 27, 2003 during am medication pass. Upon reconciliation with physician orders, medication order was Atenolol 25mg. One tablet by mouth daily. Nurses followed facility medication error protocol and physician was notified of medication error. Class S9A-4.1288 F.A.C. Correction date: 9-27-03 CMS-2567L 212000 EventID: OSNS1H Facility ID: 20302 If continuation sheet 42 of 55 PRINTED: 09/04/2003 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES (Kl) PROVIDER/SUPPLIER/CLIA 0k) MULTIPLE CONSTRUCTION t 7 on (5) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: = feat > a5) COMPLETED A BUILDING bf ae Bad B. WING 105391 JAN 28 : 08/28/2003 _ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE oP 1937 JENKS AVENDRY [5 .i)}5 ¢ SEA BREEZE HEALTH CARE A a : PANAMA CITX SFM HBT RAL YC (x4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVID LAN OF CTION x) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BS COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) L F 353 | Continued From page 42 F 353 F 353 | 483.30(a)(1)&(2) NURSING SERVICES F353 SS=F F 353 The facility must have sufficient nursing staff to No specific residents provide nursing and related services to attain or identified maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as ; Unit managers/designee determined by resident assessments and individual will make rounds at least plans of care. twice during their shift for g ay . : two weeks, and then at The facility must provide services by sufficient least once per shift for two numbers of each of the following types of personnel weeks to determine the ona 24-hour basis to provide nursing care to all delivery of care and residents in accordance with resident care plans: services within an . . appropriate time frame. Except when waived under paragraph (c) of this Identified issues will be section, licensed nurses; and other nutsing personnel, addressed and resolved when identified. Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to Nursing staff will be re- serve as a charge nurse on each tour of duty. educated in the importance oT ~ of providing care arid This REQUIREMENT is not met as evidenced by: services within an Based on observation, interview and record review the appropriate time frame. facility failed to provide nursing staff sufficient to ; meet the assessed needs of the residents allowing them Resident perception of the to achieve or maintain the highest practicable timeliness of care and well-being. services will be monitored through the Guardian Angel Findings include: program. The ED or designee will request to i 1. On 8/26/03 at 10:00 AM at the North Nurse's attend the resident council i Station a call light was observed on for 10 minutes. monthly to review with the The Unit Manager was asked why no one answered the members the timeliness of light and replied the light was broken. The Unit care and services. Results Manager then went to the resident room to check and will be reviewed an hich found the light was functional and the resident had a analyzed for ‘ren Ms ec need. The need was then met. On 8/28/03 from 10:00 will be reporte to the . AM to 10:30 AM the surveyor sat at the South Nurse's QI/RM meeting. | a Station. During the time frame 4 different call lights "MS-2567L 2000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 43 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES __ CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 (X2) MULTIPLE CONSTRUCTION ,, . : “Ek EP) A. BUILDING B. WING (%3) DATE SURVEY COMPLETED 08/28/2003 : —— NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE saxzer appares Uy, SANE ZB PH rst NK: Vv ae 1937 JENKS AVENU PANAMA CITY, (x4) 1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES . (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORREC' ccnconeenvehonoessounose | cote CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) L F 353 | Continued From page 43 were observed to come on. One light was answered in approximately 3 minutes. The other three call lights had a wait of approximately 5 minutes. 2. On 8/26/03 at 2:15 PM a group interview was conducted with residents who the facility identified as cognitively intact. When asked if the facility had adequate staff to answer the call lights in a timely manner 7 of 12 residents stated, "no." The residents stated, “nobody answers it" and "believe something's wrong - ‘cause they don't come." 3. A confidential interview was conducted 8/28/03 at 10:30 AM with a South Hall resident who is cognitively intact according to facility assessment. The resident stated the staff "are good to me" but "they don't have enough help and I have to remind them to do things or sometimes do them myself." A second confidential interview was conducted at 1:00 PM with a North hall resident who is cognitively intact according to facility assessment. The resident stated “they treat me nice" and "it takes a Jong time to get help sometimes - J don't think they have enough help.” 4. A review of the facility "Resident Census and Conditions of Residents" was conducted. The facility has a high percentage of residents requiring assistance with the activities of daily living (ADL's). The facility listed a current in house census of 106 residents. Of those residents 29 (or 27%) are "bedfast all or most of the time." Of the 106 residents, 81 (or 76%) are listed as "in chair all or most of time." The facility listed 65 residents (or 61%) with contractures and listed only 1 of those 65 as having the contractures on admission. The percentage of residents with bladder incontinence is 49% (52 residents). The percentage of residents with bowel incontinence is 53% ( or 57 residents). The census contains 65 residents (61%) with Dementia and 47 residents (44%) with "documented psychiatric ! CMS-2567L 112000 EventID: OSNS11 Facility ID: 20302 Ff continuation sheet 44 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED “CENTERS FOR MEDICARE & MEDIC: SERVICES 2567-L SNDPLANOS CORRECTION» |) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION Oe COMELEISD A BUILDING B. WING 105391 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 7B CODE SEA BREEZE HEALTH CARE 1937 JENKS AVENG . PANAMA CITY, FL 30901° | = > SRB | eacubencuncr must serescenoe sy run PRERIK ORR EERE Boe | coe TAG} REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE Di VESCENEY , if F 353 | Continued From page 44 F353 ‘ ; ‘ 4 aS é ns diagnosis (exclude dementias and depression).” ww 5. The facility failed to ensure the established policies and procedures in regard to staff treatment of residents related to reporting and investigating allegations of abuse were followed (refer to F225 and F226). The y, 7 facility failed to ensure all residents were accurately F 365 I assessed and care planned for pain (refer to F278 and | F280). The facility failed to ensure all residents were Food preferences will be treated with dignity (refer to F241). The facility failed reviewed for Resident #2 to ensure all residents the assessed and planned for and updated as necessary. assistance with ADL's and nutrition/hydration (refer to Food preferences for this F312 and F322). The facility failed to ensure the resident will be placed on | monthly pharmacists recommendations were acted her care plan and tray card | upon in a timely manner (refer to F430). The facility by Dietary Manager. A failed to ensure all potentially hazardous chemicals screen will be sent to were locked and stored appropriately away from Speech Therapy to screen, resident access. The cumulative effect of these the resident for possible systemic issues resulted in the inability of the facility change in diet due to do to provide quality health care in a safe environment. chewing difficulties. Class I Residents will have their 59A-4.108(4) food preferences reviewed Correction date, September 27, 2003 during the next quarter per the care plan schedule and tray cards and care plans updated accordingly. F 365 | 483.35(d)(3) DIETARY SERVICES F 365 i SS=D Dietary staff will be Each resident receives and the facility provides food inserviced on the prepared in a form designed to meet individual needs. importance of following . food preferences when This REQUIREMENT is not met as evidenced by: preparing meal trays. Based on observation, record reviews, and interviews . the facility failed to honor the food preferences to Dietary Manager will audit maintain the residents nutritional status for 1 of 32 5 trays 5 days per week x 4 residents. (#2) - weeks for compliance with i preferences and report - ines i . findings to QI/RM i The findings include: Findings to | lea I 2 112006 EventID: OSNS511 Facility ID: 20302 If continuation sheet 45 of 55 CMS-2567L DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 (2) MULTIPLE CONSTRUCTION A BUILDING B. WING: NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE STREET ADDRESS, CITY, STATE, ZIP CODE 1937 JENKS AVENUE PANAMA CITY, FL ABHMINISTRAL VT. QV Siun co: 3) DATE SURVEY COMPLETED 5/28/2003 (4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN GF CORRECTION 5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F365 | lunch. Continued From page 45 F 365 1. A dining observation was conducted on 8/25/03 at approximately 12:50 P.M. in the resident's room. 2) The resident was served a hamburger on a bun with tomato and lettuce, mashed potatoes, tea, and water. The resident complained to the Certified Nursing Assistant (CNA) that he/ she could not eat the hamburger. The resident states "I have a hernia and can't eat some meats.” The resident demonstrated how hard the hamburger meat was by picking up the hamburger and tapping it on the side of the tray. The CNA offered a substitute of soup, the resident refused. The-CNA left the room and retumed with soup. The tesident refused. The CNA offered the substitute of chicken nuggets and hash browns. The CNA brought fried chicken nuggets and two fried hashbrowns. The resident states "It is hard, I can't eat it.” The resident demonstrated how hard the hashbrowns and chicken nuggets were by attempting to cut with a fork. -The resident was unable to cut the chicken nuggets and the hashbrown crumbled into hard pieces. He/she states the chicken nuggets and hashbrowns have a hard crust, which he/she is unable to eat. The resident refused The resident gave the surveyor the lunch slip from his/ her lunch tray. The slip states “Special Requests”, " NO HARD MEAT!" The slip lists "Dislike" as "Breaded Meat...Fried Foods... Vegetable Soup." A "Diet Preference List" dated 8/22/03 completed by the dietary manager lists: no fried foods, dislikes vegetable soup, and dislikes breaded meat. An interview was conducted with the resident on 8/26/03 at approximately 9:30 A.M. The resident complained of the food. The resident states has complained to the Director of Nursing, his/her physician, and the dietary manager. The resident opened his/her mouth and showed the surveyor his/her 4 teeth, the resident does not wear dentures. The resident states can not chew hard foods and is unable to digest hard food because of a hernia. The __| °MS-2567L 112000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 46 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2002 FORM APPROVED _ CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-1 oT OF DEFICIENCEE: . 2/6 , — (X3) DATE SURVEY sonacccomeno — (Oziomeemnene | onaaraneconenanercf () ES ABURDNG aU B. WING ow: 38 105391 ze 08/28/2003 NAME OF PROVIDER OR SUPPLIER. DRESS, CITY, STATE, ZIP CODE . a e37 erent we SEA BREEZE HEALTH CARE PANAN eed fL (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 2 ay PLAN OF CORRECTION xs) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREF (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) r F 365 | Continued From page 46 F 365 resident states the food "gets stuck.” The resident states has lost weight and is concerned will continue to lose weight if foods are not served which he/she can , eat. A dining observation was performed on 8/26/03 at approximately 5:30 P.M. The resident was served 2 vegetable soup which is on lists of dislikes. A review of the medical record revealed a notation by the physician on 8/21/03 which states the resident complained about the food. The resident's weight is listed as follows: 2/1/03 , 117.4 pounds, 6/29/03, 108.2 pounds, and 8/1/03, 110.4 pounds. The dietary records list on 6/4/03 a weight loss of 6.3% for one month. The resident has a diagnosis of Diaphragmatic Hernia. F 367 An interview was conducted with the family member of the resident on 8/27/03 at approximately 11:15 Resident #11 will have tray A.M. He/she confirmed the resident has difficulty card updated with current chewing due to her teeth and difficulty swallowing due physician’s order. to her hernia. He/she confinms the resident complains |.of the food. He/she is aware of.the. food preferences. Physician’s orders will be and dislikes of the resident. He/she denies being audited against tray cards consulted by the facility on the food choices of the and tray cards updated as resident. necessary to reflect most current physician orders. F 367 | 483.35(e) DIETARY SERVICES F367 Dietary Staff will be SS=D inserviced on the Therapeutic diets must be prescribed by the attending importance of following physician. physicians’ orders for diet. This REQUIREMENT is not met as evidenced by: Dietary Manager will review : 5 : 5 trays 5 X per week X 4 This requirement was not met as evidenced by: weeks for compliance with Based on observation, record review and interview, eee lea : ee pe ‘or 4 the facility failed to provide the therapeutic diet as report findings to QI/RM | ordered by the physician for 1 of 32 sampled residents. committee. i @t) » | alan fo 112000 Event ID: OSNS11 Facility ID: 20302 If contimuation sheet 47 of 55 IMS-2567L DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L = F 2 = A ; 3) DATE SURVEY ANDELANGEconREcTION | ZROVERRSOTEESCA [QML TILE CONSTRUCTION OP COMPLETED A BUILDING wl B. WING L 105391 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADIgRSS, OMY, 1937 JENKS AVENU. SEA BREEZE HEALTH CARE PANAMA C 13 - 4a) D SUMMARY STATEMENT OF DEFICIENCIES ID DER'S PLBVIQRCORRECTION os) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX GACH C "ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 1 TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ij “J | F 367 | Continued From page 47 F 367 | The findings are: i} [ . | 1. Review of resident's (#1)) clinical record revealed the resident has the diagnosis of hypertension. The resident current physician order is for a mechanical | soft diet with NAS (no added salt) which is recorded 4 on the current physician orders dated 7-9-03. 2. Observation of resident's breakfast on 8-25-03, and breakfast and lunch on 8-27-03 revealed opened packets of regular, iodized salt on the resident's tray. The meal card on the resident's meal tray stated "mech F371 soft". The dietary department did not print the NAS on the meal card. No specific residents were identified. 3. During an interview conducted on 8-27-03 with . . the dietary manager at approximately 2:00 p.m., the Meats will be thawed in the manager stated she was not aware of a NAS diet refrigerator on lower ordered by the physician. This surveyor showed the shelves, separate from physician order dated 7-9-03 and the resident food other meats to prevent preference sheet filled out by the dietary manager _ EFOSS contamination. Clean which states, "diet: mech soft NAS". The dietary dishes will be handled manager stated this would be corrected immediately. separately from dirty dishes. Dietary staff will be F 371 | 483.35(h)(2) DIETARY SERVICES F 371 inserviced on preventing SSE cross contamination related The facility must store, prepare, distribute, and serve to thawing meats, dating food under sanitary conditions. opened containers of food : and dish handling. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed Dietary manager will to store food and in a manner that decreases risk of conduct rounds in foodborne illness. refrigerator and dish room 3 X weekly for 4 weeks to Findings include: check for issues of cross - contamination and report During the initial kitchen tour at 9:35 AM on 08/25/03 findings to QI/RM 6 | L the following was observed: Committee. Yayo —I CMS-2567L 172000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 48 of 55 PRINTED: 09/04/2003 4 2MS-2567L DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED _ CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA pers S (X3) DATE SURVEY AND PLAN OF CORRECTION ss IDENTIFICATION NUMBER: oa) MUL BoE mY COMPLETED : A “BULDING'* 5 B. We ee 39 105391 Tae Ps 33 08/28/2003 NAME OF PROVIDER OR SUPPLIER ites CITY, STATE, ZIP CODE : 7 SEA BREEZE HEALTH CARE 193 Sperm. 5 5501 4D | SUMMARY STATEMENT OF DEFICIENCIES | i E Bas 'S PLAN OF CORRECTION on PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PRE ! " YSACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F371 | Continued From page 48 F 371 1. A a one-gallon plastic bag of chicken nuggets was observed on top of a baking sheet layered with raw bacon slices, loosely covered with butcher paper, on the center shelf of the walk-in cooler. Uncooked meats should be thawed separately on a bottom shelf s to prevent cross-contamination. 2. One opened, undated, unlabeled five-pound bag of F 430 shredded cheddar cheese was noted in the walk-in The drug regimen cooler. 8 . recommendations made on During a 12:45 PM observation of dish washing rest months ‘te pee have operations in the dish machine room, a dietary aide residh nts B 8 39 r 30, 31 was observed wearing latex gloves (with holes) and & 30 e pee As loading dirty dishes into the dish machine racks. After . loading dirty dishes, the dietary aide left the dish room and washed his/her hands without removing the Pharmacy was contacted gloves, then returned to the dish room. During an interview wi thonarsin interview with the dietary aide at the time of this leaders each month he .| observation, he/she stated they usually have two staff ||... verbally communicate in the dish room, one loads dirty dishes and one issues requiring prompt unloads clean dishes. follow up prior to exiting the facilit -h month. Class III acility eac nth 59A-4.1288 BAC. Nursing teaders will be Correction date: 27 September 2003 inserviced on the importance of promptly following up on pharmacy F 430 | 483.60(d)(2) PHARMACY SERVICES F 430 recommendations. SS=E The pharmacist must report any irregularities and DNS/Designee will audit 6 these reports must be acted upon. pharmacy recommendations monthly This REQUIREMENT is not met as evidenced by: X3 months for prompt Based on record review and interview the facility completion or follow a to failed to act in a timely manner on pharmacist reported repo in lin nto al TRA ; drag irregularities for 6 of 32 residents (#8, #28, er eins 4 bn loo | #29,#30, #31 and #32). : 122000 EventID: OSNS11 Facility ID: 20302 If continuation sheet 49 of 55 DEPARTD NT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUFPLIER/CLIA IDENTIFICATION NUMBER: 105391 (X2) MULTIPLE CONSERUCTICDL 7 me i A BUILDING B. WING oe a (X53) DATE SURVEY COMPLETED 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE (4) 1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INF! ORMATION) sTRE} kooaall ah, STATE, a CODE 1937 JENKS AVES PANAMACHT Ye: 5) COMPLETE DATE OVIDER | “AN OF CORRECTION eee CTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) F 430 Continued From page 49 Findings include: 1. Clinical record review for resident #8 revealed a handwritten Drug Regimen Review (DRR) dated 8/12/03 which stated "look for H & H." The clinical record contained a copy of laboratory values from a recent hospitalization from 6/30 to 7/11/03 which included abnormally low Hemoglobin (Hgb) and Hematocrit (Hct) values. The Hgb was <10 grams per deciliter (gm/dl) and the Hct was < 30 % indicative of a possible anemia or bleeding disorder. The record contained no further indication of follow up to these abnormal values. An interview was conducted with the Unit Manager Licensed Practical Nurse (LPN) on | 8/26/03 at 1:30 PM. The LPN stated he/she "hasn't received for this month yet." The LPN was unaware of the handwritten DRR in the record. An interview was then conducted at 2:30 PM with the Director of Nurses (DON). The DON stated he/she had not .| received the recommendations for this month yet. The. DON also stated he/she does act on the handwritten recommendations in the record but waits 1 to-2 weeks for the typed copy before following up 2. A follow up interview with the DON was conducted 8/27/03 at 9:00 AM. The DON stated he/she found the DRR's for this month in a folder on the floor of his/her office. The DON stated he/she doesn't know when the DRR's were received. A review of the DRR revealed pending recommendations from June and July as follows: | Resident #28 had a recommendation dated 6/16/03 requesting, "Please add this resident's FBS (fasting blood sugar) level to the chart per MD orders." The DON had no explanation for the recommendation not being acted upon. A new order for a Hemoglobin AIC (an indicator of the effectiveness of diabetic therapy) — 2MS-2567L. 112000 EventID: OSNSI1 FacilityID: 20302 If continuation sheet 50 of 55 DEPARTMENT OF HEALTH AND HUMAN SERVICES _ CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2003 FORM APPROVED 2567-1. STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 (X2) MULTIPLE CONSTRUCTION A BUILDING © B. WING A by (83) DATE SURVEY COMPLETED 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE BEALTH CARE stREEQ Lop: eevee 33 S, CITY, STATE, ZIP CODE 1937 JENKS AVENTIS 8c PANAI FL BRO * (4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D PREFIX TAG eamtion, OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE, DEFICIENCY) XS) COMPLETE DATE F 430 Continued From page 50 was completed on 8/27/03 while the surveyors were on site. Resident #29 had a recommendation dated 7/11/03 stating, "This resident has diabetes mellitus (DM) and is receiving Amaryl 2 mg (milligrams) daily (and is receiving prednisone). The resident's blood glucose is being monitored routinely. Testing for hemoglobin AIC (HPAIc) also is routinely recommended in all residents with DM. HbAIC reflects metabolic control during the preceding 3 months. HbAlc testing is a more definitive measure of long-term glycemic control than blood testing. Based on the American Diabetes Association's guidelines, HbAIc testing should be performed with the following frequency: At least yearly in stable residents Quarterly in residents whose therapy has changed or whose glycemic control is inadequate. Please consider obtaining a baseline HbA Ic at this time and quarterly thereafter." The DON had no explanation for the lack of follow up on the recommendation. An order was obtained 8/27/03 to change the Fasting Blood Sugar test to the HbAIc beginning 8/26/03 while the surveyors were on site, Resident #30 had a recommendation dated 7/11/03 | stating, "On 5/16/03 orders were written by Dr. .. to decrease Xanax to 0.125 mg (uilligrams) daily. The current Physician's Orders still have the old order. Please clarify." The Medication Administration Record (MAR) for May 2003 stated, "Kanax 0.125 mg PO daily" with a start date of 5/16/03. The MAR for June 2003 stated "Kanax 0.25 mg PO QDAY" with a Start date of "5/16/03" and the resident received the incorrect dose for the month of June. The MAR remained the same until’7/21/03 when the correct dose was again placed on the MAR. The DON and UM had no explanation other than "order missed." F 430 °MS-2567L 112000 EventID: OSNS511 Facility ID: 20302 Hf continuation sheet 51 of 55 PRINTED: 09/04/2003 _ DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICA’ SERVICES 2567-L STATEMENT OF DEFICIENCIES PROVIDER/SU : y E CONSTRUCTION (X35) DATE SURVEY AND PLAN OF CORRECTION a) DENUNCL TON ee CE) MULTIPLE CONSTRU STON ae “COMPLETED : A BUILDING i oa B. WING i 105391 Te 08/28/2003 STREET ADIGESS, ot, Zetss? CODE NAME OF PROVIDER OR SUPPLIER 1937 mee AVENUE °MS-2567L. SEA BREEZE HEALTH CARE PANAMA CIT Ye sub) | - ; x4) D SUMMARY STATEMENT OF DEFICIENCIES dD | Soe ORRECTION i sy | PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (BACH C TION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE | DEFICIENCY) F 430 | Continued From page 51 F 430 Resident #3 lhad a recommendation dated 6/13/03 F 514 stating, "The resident is receiving Actos without current Jab work on the chart. Please order a FBS on Orders for residents #14 & next lab day and repeat every 2 months to monitor 10 were clarified and therapy." An order was not obtained for a FBS until s MARS/TARS updated to one month later on 7/1/3/03. The DON had no indicate date orders are to explanation for the time delay in response to the be completed. Resident #4 recommendation. no longer resides in the facility. The DNS will Resident #32 bad a recommendation dated 6/13/03 determine aides involved in ‘stating, "Please add this resident's Potassium level to failing to document care. the chart per MD orders." A copy of the Potassium Individual inservices were level dated 6/5/03 was obtained from the laboratory on provided to involved aides 8/27/03 while the surveyors were on site and the related to importance of results (which were 3.5 mmol/L - normal is 3.5 - 5.5) documenting care were called to the Advanced Registered Nurse detivered. Practicioner (ARNP). The DON had no explanation . . for the lack of follow up on the recommendation. Staff/pharmacy will review orders against MARS/TARS Class I . _and available medications 50A-4.1288 F.A.C. in cart for resident Correction date, September 27, 2003 population at time of review and MARS/TARS will be marked as indicated by 7 ° - physician orders. F514.) 483.75()(1) ADMINISTRATION F514 wae toe, Nursing staff will be The facility must maintain clinical records on each jnserviced on the resident in accordance with accepted professional importance of standards and practices that are complete; accurately documentation to include documented; readily accessible; and systematically methods for clarifying ~ organized. dates/times when treatments are to be done. This REQUIREMENT is not met as evidenced by: Based on observation, record review and staff DNS/Designee will audit 6 interview, the facility failed to provide accurate documents each week X 4 documentation on clinical records of 3 of 32 sampled weeks for completion and . residents. (#4, #14, and #10) report findings to QI/RM an [o3 Committee. 112000 Event ID: OSNS11 Facility ID: 20302 If continuation sheet 52 of 55 PRINTED: 09/04/200: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVET —CEN TERS FOR MEDICARE & MEDICAID SERVICES 2567-1 STATEMENT OF DEFICIENCIES PROVIDER/SUPPLIER/CLIA 3 , JLTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION ee OUT ERSUFE NUMBER: C2) Mu COMPLETED , A BULDING: B. WING . 3 : 105391 . 08/28/2003 NAME OF PROVIDER OR SUPPLIER ‘ STREET ADDRESS AT Pid ban89 1937 JENKE A EEZE HEALTH CARE SEA BRE t ce PANAMA CI’ a B24Q1. _ (x4) ID SUMMARY STATEMENT OF DEFICIENCIES D 2 FR SP F CORRECTION XD PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX GA : GTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- NCED TO'THE APPROPRIATE DATE DEFICIENCY) F514 | Continued From page 52 FS5i4 I. Clinical record review for resident #4 revealed the resident to have multiple diagnoses including Anoxic Brain Damage, and Contractures. Further record review also revealed the resident is incontinent of bowel and bladder and dependent on staff for all care including nutrition and hydration per tube feeding. A a review of the "ADL & Nutrition/Hydration Care Record" was conducted. The current month of August 2003 contained many areas not completed. They include the following: Bed Mobility and Transfers - no documentation for 7-3 shift-on 8/1-3, 8, 12, 14 and 23-27/03. The 3-1] shift contained no documentation for 8/9, 15, 16, and 26/03. Toileting - no documentation for 7-3 shift on 8/1-3, 8, 12, 14, 17-21 and 23-27/03. The 3-11 shift contained no documentation for 8/9, 15, 16 and 22/03. Bowel Movement - no documentation for 11-7 shift on 8/8 and 11-16/03. The 7-3 shift contained no documentation for 8/1-3, 8, 12, 14, 16 and 23-27/03. The 3-11 shift contained no documentation for 8/9, 15. and 16/03. A review of the Restorative Nursing flow sheet revealed the following blank areas: Incontinence Management - no documentation for 7-3 shift for 8/2, 3, 8, 12, 14, 16-20 and 23-27/03. The 3-1] shift contained no documentation on 8/9, 15 and 16/03. The 11-7 shift contained no documentation on 8/10 and 14/03. ROM(range of motion): PROM (passive range of motion) to all extremities daily during ADL (activities of daily living) care bid(twice a day) - no documentation for 7-3 shift on 8/2, 3, 8, 12, 14, 16-20 and 23-27/03. The 3-11 shift contained no documentation on 8/9, 15 and 16/03. 2. Clinical record review for resident #14 revealed the resident had multiple diagnoses including Quadriplegia, Neurogenic Bladder and Decubitus =MS-2567L 112000 EventID: OSN511 Facility ID: 20302 If continuation sheet 53 of 55 _ DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/04/2003 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 256T-L STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIERCLIA MULTIPLE CONSTRUCTION (3) DATE SURVEY AND PLAN OF CORRECTION oop wove “ATION NUMBER. 2) MUL TPL COMPLETED . A BUILDING B. WING 105391 08/28/2003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE ZIP mT) 37 JENKS AVEN foe be SEA BREEZE HEALTH CARE 1937 JENKS AVENUE PANAMA CITY, FL 32401 PREFIX TAG CAD | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F514 Continued From page 53 Ulcer. Further review revealed the resident hasa supra-pubic catheter and a PICC (peripherally inserted central catheter). The resident has a history of UTI (urinary tract infections) and infection in the Decubitus Ulcer. The current Treatment Administration Record (TAR) states, "7/30/03 P.LC.C. line dsg. chg. (dressing change) 3 X wkly (weekly). M-W-F (Monday, Wednesday, Friday) using sterile technique.” It is unclear which days the PICC line dressing was changed as the method for marking off the days changed during the month . The days of 8/4, 8/6, 8/8, 8/11, 8/13 and 8/15 - were marked off with a square. The square for 8/4 was blank. The area for 8/16, 8/17, 8/19, 8/21, 8/23, 8/24 and 8/26 had X's in the squares. The dates of 8/20 and 8/22 were also blank. The current physician's order sheet contained an order to change the supra-pubic catheter every 3 weeks and administer Ampicillin 1000 milligrams by mouth before changing. The TAR contained initials in each day of the month for changing the supra-pubic catheter, so it is unclear which day it was changed. The Medication Administration Record (MAR) was completely blank next to the Ampicillin indicating the Atpicillin was not given this month. A review of the "Supplies" sign out sheet revealed the catheter was changed 8/17/03. An interview with the Unit Manager on 8/28/03 at 10:30 AM revealed he/she could not determine if the Ampicillin had been given and had no explanation for the lack of clear clinical documentation in the record. 3. On August 26, 2003 resident # 10 was observed to have a foley cath dated July 17, 2003, date verified by Unit Manager of 200 hall. At approximately 12:00 the catheter was changed by LPN on duty upon resident returning from Physician Office with order to "Change foley cath today." Medication Administration Record dated August 15, 2003 indicated that catheter was ‘MS-2567L 112000 Event ID: OSNS511 Facility ID: 20302 One & Bictinss TT Z| If continuation sheet 54 of 55 _ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/04/2002 FORM APPROVED 2567-L STATEMENT OF DEFICIENCIES (£1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105391 2) MULTPLE CONSTRUCTION A BUILDING B. WING (85) DATE SURVEY COMPLETED 08/28/2003 NAME OF PROVIDER OR SUPPLIER SEA BREEZE HEALTH CARE r (x4) 1D PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ov rit BB DN Ae BARCODE PANAMA CITY, EL,.32401 ‘3 PLAWN OF CORRECTION 5) DEFICIENCY) ACTION SHOULD BE COMPLETE. TO THE APPROPRIATE DATE F514 Continued From page 54 changed by LPN on 11-7 shift. Documentation was shown to Unit Manager on duty who had no explanation why residents record was signed that the | catheter was changed on August 15 when it had not been. Interview with DON who called the LPN on duty on August 15, 2003 and had signed the residents record. Stated that the LPN had not indeed changed the catheter but could give no explanation as to why the record had been signed that the care had been done. Laboratory Results dated August 18, 2003 indicate resident #10 to have urinalysis results with bacteria too numerous to count. Resident was subsequently sent to the hospital on August 27, 2003 for insertion of a Peripherally Inserted Central Line Catheter and started on Intravenous Antibiotics for this infection. Class TI 59A-4.106(4)(p), F_A.C. Correction Date: 27 September 2003 2MS-2567L 122000 EventID: OSNS51] Facility ID: 20302 | if continuation sheet 55 of 55

Docket for Case No: 04-000334

Issue Date	Proceedings
Feb. 04, 2005	Final Order filed.
Jul. 21, 2004	Recommended Order cover letter identifying the hearing record referred to the Agency.
Jul. 21, 2004	Recommended Order (hearing held May 17, 2004). CASE CLOSED.
Jun. 28, 2004	Respondent`s Proposed Recommended Order filed.
Jun. 25, 2004	Agency`s Proposed Recommended Order (filed via facsimile).
Jun. 17, 2004	Deposition (of R. Watford) filed.
Jun. 16, 2004	Deposition (of G. Jerusalem, M.D.) filed.
Jun. 16, 2004	Notice of Filing of Deposition Transcripts filed by R. Thomas.
Jun. 16, 2004	Transcript filed.
May 26, 2004	Notice for Deposition (R. Watford and G. Jerusalem) filed via facsimile.
May 17, 2004	CASE STATUS: Hearing Held.
May 07, 2004	Joint Pre-hearing Stipulation (filed by Respondent via facsimile).
May 07, 2004	Notice of Taking Deposition (R. Watford, P. Blanchard, R. Slade, J. Gainer, J. Bryan, T. Manguta, B. Gilliland, P. Holly, A. Perkins, K. Dean, and V. Hand) filed via facsimile.
Apr. 26, 2004	Notice of Deposition Duces Tecum of Susan Harris (filed via facsimile).
Apr. 26, 2004	Notice of Deposition Duces Tecum of Debra Barber (filed via facsimile).
Apr. 23, 2004	Response to Amended Administrative Complaint (filed by Respondent via facsimile).
Apr. 20, 2004	Order (the case shall proceed upon the First Amended Administrative Complaint filed simultaneously with the Motion to Amend and Serve Administrative Complaint).
Apr. 19, 2004	Order Granting Continuance and Re-scheduling Hearing (hearing set for May 17, 2004; 9:30 a.m.; Panama City, FL).
Apr. 14, 2004	Joint Motion for Continuance (filed by R. Thomas via facsimile).
Apr. 02, 2004	First Amended Administrative Complaint (filed via facsimile).
Apr. 02, 2004	Motion to Amend and Serve Administrative Complaint (filed by Petitioner via facsimile).
Mar. 19, 2004	Order of Qualified Representative (R. Davis Thomas, Jr. is accepted as Respondent`s Qualified Representative).
Mar. 19, 2004	Order of Pre-hearing Instructions.
Mar. 19, 2004	Notice of Hearing (hearing set for April 26 and 27, 2004; 9:30 a.m.; Panama City, FL).
Mar. 19, 2004	Order of Consolidation. (consolidated cases are: 04-000334, 04-000338)
Mar. 11, 2004	Letter to Judge Davis from D. Thomas regarding consolidation of Case No. 04-0334 and 04-0338) filed via facsimile.
Feb. 11, 2004	Notice of Substitution of Counsel and Request for Service (filed by G. Pickett via facsimile).
Feb. 05, 2004	Affidavit of R. Davis Thomas, Jr. (filed via facsimile).
Feb. 05, 2004	Motion to Allow R. David Thomas, Jr. to Appear as Respondent`s Qualified Representative (filed via facsimile).
Feb. 05, 2004	Response to Petitioner First Request to Produce (filed by Respondent via facsimile).
Feb. 05, 2004	Respondent`s Notice of Service of Answers to Petitioner`s First Set of Interrogatories (filed via facsimile).
Feb. 05, 2004	Response to Petitioner`s First Request for Admissions (filed via facsimile).
Feb. 04, 2004	Unilateral Response to Initial Order (filed by Petitioner via facsimile).
Jan. 29, 2004	Initial Order.
Jan. 28, 2004	Administrative Complaint filed.
Jan. 28, 2004	Request for Formal Administrative Hearing filed.
Jan. 28, 2004	Notice (of Agency referral) filed.
Jan. 06, 2004	Notice of Service of Petitioner`s First Interrogatories to Respondent ; Petitioner`s First Request for Admissions ; and Petitioner`s First Request to Produce (filed via facsimile).

Orders for Case No: 04-000334

Issue Date	Document	Summary
Jan. 21, 2005	Agency Final Order
Jul. 21, 2004	Recommended Order	Respondent committed three class two deficiencies and thus imposition of $7,500 in civil penalties and conditional licensure status is appropriate.