STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE { My i224 1 ADMINISTRATION, Petitioner, AHCA No.: 2004004029 AHCA No.: 2004003081 Vv. Return Receipt Requested: 7002 2410 0001 4237 7309 JACKSON HEIGHTS NH, LLC d/b/a 7002 2410 0001 4237 7316 UNITY HEALTH AND 7002 2410 0001 4237 7323 REHABILITATION CENTER, Respondent. ADMINISTRATIVE COMPLAINT ' ’ COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against Jackson Heights NH, LLC d/b/a Unity Health and Rehabilitation Center (hereinafter “Unity Health and Rehabilitation Center”) pursuant to Chapter 400, Part II and Section 128-60, Florida Statutes, (2003) hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $2,500.00 pursuant to Sections 490.23(8) (b), Florida Statutes [AHCA No.: 2004003081]. 2. This is an action to impose a conditional licensure i t rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA ‘ No. 2004004029] . JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida administrative Code. , 4. Venue lies in Miami-Dade County, pursuant to Section 400.121 Florida Statutes and. Chapter 28-106.207, Florida Administrative Code. . PARTIES 5. AHCA is the enforcing authority with regard to nursing home licensure pursuant to ‘Chapter 400, Part II, . Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Unity Health and Rehabilitation Center is a skilled nursing facility located at 1404 N. W. 22 Street, Miami, Florida 33142 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I UNITY HEALTH AND REHABILITATION CENTER FAILED TO PROVIDE SERVICES TO PREVENT NEW SORES FROM DEVELOPING FOR ONE (R#35) bo ‘ RANDOMLY OBSERVED RESIDENT AT HIGH RISK OF DEVELOPING PRESSURE SORES. TITLE 42 SECTION 483.25(c), CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS IT 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth ‘herein. | 8. Because, Unity Health and Rehabilitation Center participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. During a complaint investigation conducted on March \ . 18, 2004 and based upon observation, record review and interview the facility failed to provide services ‘to prevent new sores from developing for ‘one (R#35) randomly observed resident at high risk of developing pressure sores. the findings include the following. 10. Review of the clinical record for resident #R35 revealed the resident was admitted to the facility with diagnoses of decubitus ulcer, methicillir resistant Staphylococcus aureus, and arterial disease. The "Braden Scale - - For Predicting Pressure Sore Risk" completed for the resident showed a total score of 11 on 12/2/03. The legend on the form stated "Total score of 12 or less represents HIGH RISK." Review of the admission Resident Assessment Instrument (RAI) with reference date of 9/22/03 revealed the resident had one stage III pressure ulcer ("Pull thickness of skin is lost, exposing the subcutaneous tissues") and one stage IV pressure ulcer ("Full thickness of skin and subcutaneous tissue is lost exposing muscle or bone"). The RAI also confirmed a history of previous pressure ulcers, which had resolved prior to that date. 11. Review of the resident's care plan on the clinical record when it was photocopied on 3/17/04 at approximately 3:00pm revealed no specific care plan for "alteration of skin integrity" but did address repositioning and skin assessment under the care plan for "impaired physical mobility." puring an interview with the Director of Nursing on 3/18/04 at approximately 11:00am the care plan nurse for resident R#35 produced a care plan for Alteration in skin integrity", which listed the following as an approach: "Skin inspection daily during care report any new changes to MD." Review of the "Physician's Order Sheet" for 3/04 revealed an order for "Off load bilateral heels with pillows." Review of the "Treatment Administration Record" for the month of March 2004 revealed an entry that stated "Off load bilateral heels with pillows." This entry was initialed as having been done for all shifts during the month including the 7am to 3pm shift on 3/17/04. t 12. Wound Care Progress Notes d@ated 2/3/04 through 3/16/04 revealed a right foot pressure ulcer resolved by 2/24/04. The same records revealed the resident received wound care to the left foot on 3/16/04. Review of the "Weekly Skin Review" for dates 2/18/04, 2/25/04, 3/3/04, 3/10/04 and 3/17/04 revealed no markings on the left hand side of the form, which would indicate the location of a skin condition. On the right hand side of the form the box "No new areas of skin impairment" is checked for each week, including 3/17/04. 13. On 3/17/04 at approximately 1:45am two Certified Nursing Assistants (CNAs) were observed performing coerineal care on resident #R35. When the bed linens were initally removed to allow care, there was no off loading of the resident! s heels and the only pillow on the bed was under the ‘resident's head. There was also no protective foot wear on the resident at that time. As the CNAs were performing care a nickel size black blister was clearly visible on the lateral aspect of the resident's right foot. About a quarter inch behind the blister there was also a small black streak. At that time the CNAs were asked about the blister. CNA #1 stated the nurses knew about it and it was "getting better." 14. However, discussion with the charge nurse assigned to the resident on 3/17/04 at approximately 2:25pm revealed she was unaware of any wound on the resident's right foot but she would nr contact the wound care nurse. Interview with the wound care nurse at 2:35pm on 3/17/04 in the nursing station revealed she was unaware of any wound on the right foot currently. After viewing the area with this surveyor the wound care nurse stated she would call the doctor and obtain treatment orders. When asked if the resident was suppose to have foot protectors on she stated, "yes." She further stated that they may have been soiled and sent to the laundry but that if that was the case something else should have been provided in the interim. 15. Review of the facility's policy for "Prevention of Pressure Ulcers" states, "Routinely assess and document the ' condition of the resident's ‘skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor." 16. The development of a new pressure ulcer. was not | assessed timely. The physician's orders and care plan were not carried out and treatment was delayed. 17. Based on the foregoing, Unity Health and Rehabilitation Center violated 483.25(c), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries, in this case, an assessed fine of $2,500.00. This also gives ' 4 rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Unity Health and Rehabilitation Center shall post the license in a prominent place:that is clear and unobstructed public view at or near the place " where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A” EXHIBIT “A” Conditional License License # SNF 1254096; ‘Certificate No.: Effective date: 3-18-2004 Expiration date: 09-19-2004 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Unity Health and Rehabilitation Center an administrative fine of $2,500.00 for the one (1) Class II deficiency. 3. Assess against Unity Health and Rehabilitation Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess ' costs related to the investigation and prosecution of this matter, if applicable. ‘ 5. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and. delivered to the Agency Clerk, Agency for Health Care Administration, (2727 Mahan Drive, MS #3, 4 1 1 Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, ' PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. ' courdes A. Naranjo, Assistant General Counsel Agency for Health Care Admiristration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Castillo Field office Manager Agency for Health Care Administration Manchester Building 8350 NW 52 “? Terrace Miami, Florida 33166 Long Term Care Program office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Ira Siev, Administrator, Unity Health and Rehabilitation Center, 1404 N. W. 22 Street, Miami, Florida 33142; Jackson Heights NH LLC, c/o Greystone & Company, 152 W. . 57 Street - 60m Floor, New York, New York 10019; CT Corporation 4 System, 1200 South Pine Island Road, Plantation, Florida 33324 on this 21 x, of 46 , 2004. drdes A. Naranjo, Esq.

Docket for Case No: 04-002297