STATE OF FLORIDA iD AGENCY FOR HEALTH CARE ADMINISTRATION, H0V -8 PM 4: 29 AGENCY FOR HEALTH CARE DIVISIUR ADMINISTRATION, ADMINIST RA. VE HEARINGS Petitioner, vs. AHCA No. 2004002062 CROSS CREEK HEALTH CARE ge . f Numb ASSOCIATES, LLC d/b/a Certified Article Number 7106 4575 12% 2050 2082 UNIVERSITY HILLS HEALTH AND REHABILITATION, SENDERS RECORD Respondent. an ad oa / Ct | ( | CAS ADMINISTRATIVE COMPLAINT COMES NOW, the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against CROSS CREEK HEALTH CARE ASSOCIATES, LLC d/b/a UNIVERSITY HILLS HEALTH AND REHABILITATION (‘Respondent’), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose administrative fines totaling TEN THOUSAND DOLLARS ($10,000), pursuant to Section 400.23(8), Florida Statues. JURISDICTION AND VENUE 2. AHCA and the Division of Administrative Hearings upon a request for formal hearing, have jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 1 of 12 3. Venue shall be determined pursuant to Rule 28-106.207, Fla. Admin. Code. PARTIES 4, AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part ll, Florida Statutes, and Chapter 59A-4, Fla. Admin. Code, respectively. 5. Respondent, CROSS CREEK HEALTH CARE ASSOCIATES, LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, UNIVERSITY HILLS HEALTH AND REHABILITATION (“Facility”), is a 420-bed nursing home located at 10040 Hill View Road, Pensacola, Florida 32514. Respondent is licensed as a skilled nursing facility, having been issued license number SNF114 1906, effective August 29, 2003. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. COUNT! UNCORRECTED CLASS Ill WIDESPREAD VIOLATION FOR FAILURE TO ENSURE RESIDENTS’ RIGHTS TO PERSONAL PRIVACY 42 CFR 483.10(e) Section 400.022(1)(m), Florida Statutes Section 400.23(8)( c), Florida Statutes Rule 59A-4.1288, Fla. Admin. Code 6. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 7. The regulatory provisions of the Code of Federal Regulations and Florida Statutes that are pertinent to this alleged violation, read as follows: Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 2 of 12 42 CFR 483.10 Resident Rights The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: (e) Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and Clinical records. 400.022 Residents’ rights.— (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: prey (m) The right to have privacy in treatment and in caring for personal needs; to close room doors and to have facility personne! knock before entering the room, except in the case of an emergency or unless medically contraindicated; and to security in storing and using personal possessions. Privacy of the resident’s body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene, except as needed for resident safety or assistance. Residents’ personal and medical records shall be confidential and exempt from the provisions of s.1 19.07(1). 8. AHCA surveyors conducted an annual survey of Respondent's facility on January 12 through 16, 2004, which revealed the following: The facility failed to ensure residents’ rights to personal privacy between beds. 42 of 52 semi- private rooms had privacy curtains that were not fully functional, thereby compromising residents’ rights to privacy. Specific findings are: Observations of 1/14/04 between 2:15 p.m. and 3:00 p.m. of rooms #101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 414, 115, 120, 121, 122, 124, 425, 127, 130, 131, 152, 153, 154, 155, 156, 201, 204, 205, 206, 207, 208, 209, 210, 211, 212, 214, 215, 251, 253, 254 and 256 found privacy curtains were not fully functional for one or both residents sharing a room. These semi-private rooms had either putty or screws in the tracks preventing curtains from closing around the foot of the beds and/or had only one curtain to use between the two beds preventing closure around the foot of the beds, and/or curtain fixtures jammed in the tracks and would not close about one or bother, compromising residents’ rights to privacy. This was confirmed via interview with the maintenance director on 1/14/04 at 2:45 p.m. 9. AHCA cited Respondent with a violation of the referenced regulatory provisions and provided Respondent with a mandated correction date of February 15, 2004. 10. | AHCA surveyors conducted a follow-up survey of Respondents’ facility on February 16 and 17, 2004, which revealed the following: Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 3 of 12 The facility failed to ensure residents’ rights to personal privacy between beds. 26 of 45 semi- private rooms had privacy curtains that were not fully functional, thereby compromising resident's rights to privacy. Specific findings were: a). Observations on 2/16-2/17/04 between the hours of 10:15 a.m. and 2:30 p.m. on both days, of rooms 105,109, 112, 114, 115, 120, 127, 128, 129, 155, 201, 204, 205, 206, 207, 208, 209, 210, 211, 212, 215, 250, 251, 253, 254 and 256 found privacy curtains were not fully functional for one or both residents sharing the room. Review of the approved facility plan of correction revealed 12 of the above room curtains were listed as being repaired or functional (rooms 105, 112, 120, 128, 209, 210, 211, 215, 250, 251, 253 and 256). The plan of correction revealed a completion date of 2/15/04. b). Interview with a staff RN at 9:30 a.m. on 2/16/04 indicated no repair or replacement work had been conducted on any of the curtains and the surveyors would be wasting their time to look at them. Review of two quotations for the replacement/repair of cubicle curtains revealed dates of 4/27/04 for $15,202.20 approved by the regional vice president on 2/17/04 and 2/1 0/04 for $3,203.40 approved by the regional vice president on 2/10/04. Interview with the regional vice president at 10:15 a.m. on 2/1 7/04 revealed the work had not been started as of this date. 11. | Respondent's failure to ensure residents’ rights to personal privacy is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.10(e). 42. Respondent's failure to ensure residents’ rights to personal privacy is a violation of Section 400.022(1)(m), Florida Statutes. 13. | AHCA classified the nature and scope of this violation as an uncorrected class III “widespread” violation. Pursuant to Section 400.23(8)(c), this classification constitutes grounds for the imposition of an administrative fine of SIX THOUSAND DOLLARS ($6,000). The normal fine amount for a class III widespread deficiency is doubled as required by Section 400.23(8)(c) because 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 class Il violation is defined as one that “the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being.” Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 4 of 12 COUNT II UNCORRECTED CLASS Ill ISOLATED VIOLATION FOR FAILURE TO PROVIDE FOOD PREPARED IN A FORM DESIGNED TO MEET RESIDENTS’ NEEDS 42 CFR 483.35(d)(3) Section 400.23(8)( ¢), Florida Statutes Rule 59A-4.106(4)(h), Fla. Admin. Code Rule 59A-4.1288, Fla. Admin. Code 22. AHCAre-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 23. The regulatory provisions of the Code of Federal Regulations and the Florida Administrative Code that are pertinent to this violation, read as follows: 42 CFR 483.35 Dietary services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. ek (d) Food. Each resident receives and the facility provides— (3) Food prepared ina form designed to meet individual needs. Rule 59A-4.106 Facility Policies. whe (4) Each facility shall maintain policies and procedures in the following areas: (h) Dietary services. 24. AHCA surveyors conducted an annual survey of Respondent's facility on January 12 through 16, 2004, which revealed the following: The facility failed to provide food prepared in a form designed to meet the resident's needs. Specific findings were: a). During the re-certification survey conducted on 1/12-16/04 observations of Resident #9 in the Heritage dining room on 1/12/04 at 6:00 p.m. revealed a menu card documenting a Pureed diet with large meat portions (confirmed by review of physician order) on the diet tray. The diet tray contained pureed food and a salad with lettuce and tomatoes and a slice of peach pie, which were of regular consistency. Interview with a staff member present in the dining room at 6:05 p.m. indicated resident did not usually have regular consistency on his/her tray, but it was on the tray this night. No action was taken to remove the food from the tray or seek counsel as to whether the food should be present on the tray or not. Observations of Resident #9 on 1/16/04 at 12:45 p.m., again in the Heritage dining room, revealed Resident #9 had a slice of regular white bread along with pureed foods on the tray with a menu card reading Pureed diet with large meat portions. Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 5 of 12 b). Record review for Resident #4 indicated diagnoses of Gastrostomy tube, Depression, CVA, Nutrition Deficient, Aspiration Precautions and HTN. Record review indicated the resident was assessed and had physician order to need honey thick liquids. On 1/12/04 water with ice not thickened was observed on the over bed table next to the resident. Again on'4/13, 14 and 15 water with ice not thickened was observed on the over bed table next to the resident. Resident stated “I drink the water with the ice daily when the aides fill it.” 25. AHCAcited Respondent with a violation of the referenced regulatory provisions and provided Respondent with a mandated correction date of February 15, 2004. 26. AHCA surveyors conducted a follow-up survey on February 16 and 17, 2004, which revealed the following: The facility failed to provide food prepared ina form designed to meet resident needs for 1 of 14 sampled residents (Resident #7). Specific findings were: Review of the medical record of Resident #7 revealed a diet order of mechanical soft with chopped meat. Observation of the resident in his/her room on 2/16/04 at 1:15 p.m. revealed a diet tray with bite-sized ham mostly uneaten, but with several pieces, which had been chewed on and spit out. Interview with a staff member feeding the resident revealed the resident could not eat the meat unless it was chopped finely and not in bite-sized pieces. 27. Respondent's failure to provide food prepared ina form designed to meet residents’ needs is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.35(d)(3). 28. Respondent's failure to provide food prepared in a form designed to meet residents’ needs is a violation of Rule 59A-4.106(4)(h), Fla. Admin. Code. 29. AHCA classified the nature and scope of this violation as an uncorrected class III “isolated” violation. Pursuant to Section 400.23(8)(c), this classification constitutes grounds for the imposition of an administrative fine of TWO THOUSAND DOLLARS ($2,000). The normal fine amount for a class II! isolated deficiency is doubled as required by Section 400.23(8)(c) because the facility was previously cited for one or more class | or class | deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A class Ill Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 6 of 12 . violation is defined as one that “the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being.” COUNT II UNCORRECTED CLASS Ill ISOLATED VIOLATION FOR FAILURE TO ENSURE ALL PHYSICIAN ORDERS WERE FOLLOWED AS PRESCRIBED Section 400.23(8)(c), Florida Statutes Rule 59A-4.107(5), Fla. Admin. Code 30. | AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 31. | The regulatory provision of the Florida Administrative Code that is pertinent to this alleged violation, reads as follows: 59A-4.107 Physician Services. wee (5) All physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident's medical record during that shift. 32. | AHCA surveyors conducted an annual survey of Respondent's facility on January 12 through 16, 2004, which revealed the following: The facility failed to follow physician orders for 1 of 26 sampled residents (#23). Specific findings were: a). During the annual licensure survey conducted on 1/12-16/04, review of the medical record of Resident #23 revealed an order written by a health care provider on 12/22/03 to “increase Duragesic patch to 50 meg and change every 72 hours, monitor for increased lethargy.” A note in the health care provider progress notes dated 12/29/03 late entry reads, “Notified by registered nurse with Hospice she had found two (2) 50 mcg patches on the resident. This advanced registered nurse practitioner (ARNP) observed resident to be relaxed, comfortable without acute distress noted. Resident alert and at base line neurologically. Nursing will monitor for any changes.” Nursing note dated 12/29/03 late entry, 1:00 p.m. indicates, “Hospice nurse removed the extra Duragesic patch.” b). On 11/18/03 Resident #23 was hit in the head by a falling closet door and was taken to a local hospital emergency room for care. The follow up included a recommendation for a lateral view of the cervical spine or a CT scan of the area be performed. Notation made on the diagnostic findings of a cervical spine x-ray done while in the emergency room on 11/18/03 is dated 11/21/03 and signed by the attending physician to schedule a CT of the cervical spine. Review of the medical record and physician order sheets following 11/21/03 reveal no orders or results of the test showing it was completed. Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 7 of 12 c). Interview with the facility risk manager on 4/13/04 at 1:15 p.m. confirmed these findings. 33. AHCA cited Respondent with a violation of the referenced regulatory provision and provided Respondent with a mandated correction date of February 15, 2004. 34. AHCA surveyors conducted a follow up survey on February 16 and 17, 2004, which revealed the following: The facility failed to ensure all physician orders were followed as prescribed for 1 of 14 sampled residents (#6). Specific findings were: Review of the clinical record of Resident #6 revealed a physician order dated 2/12/04 for Oxygen therapy to be delivered at 2 liters via nasal canula. Observation of the resident on 2/16/04 at 1:15 p.m., 3:45 p.m. and 4:30 p.m. and again on 2/17/04 at 9:00 a.m. revealed no evidence of oxygen therapy being given. During interview on 2/1 7/04 at approximately 11:45 a.m., a facility LPN stated the resident did not need oxygen therapy at this time, as determined by oxygen saturations tested at 6:00 a.m. on the same morning. When questioned further about the process for testing the resident's oxygen saturation level, staff confirmed there was no physician order for routine testing and that prior to the 2/17/04 measurement, the last recording of the oxygen saturation level for this resident was dated 2/14/04 at 5:30 p.m. The current physician order for oxygen therapy was not written as an “as needed” order and there was no evidence of a current physician order to check for oxygen saturation levels to determine the need for oxygen therapy. 35. Respondent's failure to ensure all physician orders were followed as prescribed is a violation of Rule 59A-4.107(5), Fla. Admin. Code. 36. AHCA classified the nature and scope of this violation as an uncorrected class III “isolated” violation. Pursuant to Section 400.23(8)(c), this classification constitutes grounds for the imposition of an administrative fine of TWO THOUSAND DOLLARS ($2,000). The normal fine amount for a class III isolated deficiency is doubled as required by Section 400.23(8)(c) because 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. Aclass Ill violation is defined as one that “the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 8 of 12 a to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being.” CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of the Agency on Counts | through Ill. 2. Imposition of administrative fines as follows: Count 1, SIX THOUSAND DOLLARS ($6,000), Count II, TWO THOUSAND DOLLARD ($2,000), Count Ill, TwO THOUSAND DOLLARS, for a total of TEN THOUSAND DOLLARS ($10,000). 3. Such other relief as this Court Deems is just and proper. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569 and 120.57, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Agency Clerk Agency for Health Care Administration Building #3, MSC #3, 2727 Mahan Drive Tallahassee, Florida, 32308 RESPONDENT IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSITUTE AN ADMISSION OF THE Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 9 of 12 FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted on Wednesday, October 06, 2004 iowa Bol Joanna Daniels, Asst. General Counsel Fla. Bar No. 0118321 Counsel for Petitioner Agency for Health Care Administration 2727 Mahan Drive, Building #3, MS #3 Tallahassee, FL 32308 (850) 922-5873 (office) (850) 413-9313 (fax) CERTIFICATE OF SERVICE | hereby certify that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Explanation of Rights Under Section 120.569, F.S.A. form, have been forwarded by certified mail, return receipt requested, to: Mr. Jerry Banks CT Corporation System Administrator Registered Agent for University Hills Health and Rehabilitation Cross Creek Health Care Associates, LLC 10040 Hillview Road 1200 South Pine Island Road Pensacola, FL 32514 Plantation FL 33324 (Certified # 7106 4575 1294 2050 2082) = (Certified #8& 7003 1010 0002 6160 5075) On this on Wednesday, October 06, 2004 BE site Administrative Complaint 2004002062 Certified Numbers 7106 4575 1294 2050 2082 & 7003 1010 0002 6160 5075 Page 10 of 12 oe

Docket for Case No: 04-004055