STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE Oy ADMINISTRATION, pr! Ngo! Petitioner, AHCA No.: 2004010407 “ v. 2004010328 Return Receipt Requested: PALM COURT JOINT VENTURE, d/b/a 7003 1680 0006 9825 8267 THE COURT AT PALM-AIRE, 7003 1680 0006 9825 8274 7003 1680 0006 9825 8281 Respondent. / (ONS-O12O ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Palm Court Joint Venture, d/b/a The Court at Palm-Aire (hereinafter The Court at Palm-Aire”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $8,000.00 pursuant to Section 400.23, Florida Statutes (2004), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure Status to The Court at Palm-Aire, pu:suant to Section 400.223(7) (b), Florida Statutes (2004). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 4. Venue lies in Broward County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules, governing skilled nursing facilities, pursuant to Chapter 400, Part II, Florida Statutes (2004), and Chapter 59A-4, Florida Administrative Code. 6. The Court at Palm-Aire operates a 60-bed skilled nursing facility located at 2701 N. Course Drive, Pompano Beach, Florida 33069. The Court at Palm-Aire is licensed as a skilled nursing facility license number 15550962, with an expiration date of March 31, 2005. The Court at Palm-Aire was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I THE COURT AT PALM-AIRE FAILED TO EMPLOY A FOOD SERVICE DIRECTOR (FSD) WHO MEETS THE MINIMUM CRITERIA FOR THE SUPERVISORY POSITION Rule 59A-4.110(3), Florida Administrative Code (DIETARY SERVICES SUPERVISOR QUALIFICATIONS) UNCORRECTED CLASS III VIOLATION 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. During the survey conducted on 8/27/2004 and based on interview and file review, the facility failed to employ a Food Service Director (FSD) who meets the minimum criteria for the supervisory position. 9. Review of the Food Service Director (FSD) personnel file disclosed that he did not meet the education requirements to meet the minimum standard for a _ food service manager. Correction date: September 27, 2004. 10. During the follow-up conducted on 10/06/2004 and based on the plan of correction for not employing a qualified FSD, the facility’s written compliance plan was the following: (a) "On 9/22/04, the facility employed a staff registered dietitian to assume the role of sanitation oversight of the kitchen." (b) The administrator was asked for the diecitian's (RD) personnel file. Review of the personnel file for the RD did not include a job description or any information indicating the responsibilities of the RD. This was brought to the attention of the administrator who came back with a job description entitled Directo: of Food Services with the name of the RD, department - Dietary, duty hours - days, date- 8/30/04 and supervisor's name. However, the job description was blank, and did not have the required signature of the FSD or administrator. (c) The administrator was asked for any time sheet, payroll or proof of time worked by the RD, however, none was available. (da) The person who was acting as the Food Service Director at the time of the 08/27/04 survey was still employed at the facility during the revisit on 10/06/04 and his/her duties and responsibilities remained the same. This person continued to be responsible for the food service supervision and management at the facility. 11. Based on the foregoing, The Court at Palm-Aire violated Rule 59A-4.110(3), Florida Administrative Code, an uncorrected Class III deficiency, which carries an assessed fine of $3,000.00. This violation also gives rise to a conditional licensure status pursuant toa Section 400.23(7) (b), Florida Statutes. COUNT ITI THE COURT AT PALM-AIRE FAILED TO PROVIDE CARE IN A MANNER THAT MAINTAINS AND ENHANCES EACH RESIDENT’S DIGNITY AND RESPECT IN FULL RECOGNITION OF HIS OR HER INDIVIDUALITY Title 42, Section 483.15(a), Code of Federal Regulations, as; incorporated by Rule 59A-4.1288, Florida Administrative Code {QUALITY OF CARE) UNCORRECTED CLASS III VIOLATION 12. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 13. During the survey conducted on 8/27/2004 and based on observation and group interview, the facility failed to provide care in a manner, that maintains and enhances each residents dignity and respect regarding speaking in a foreign language unknown to the residents, using cellular phones while providing care, and inappropriate assistance with meals. (a) During the group interview conducted on 8/24/2004 at approximately 3:00 PM, eleven of eleven residents present stated that staff on all shifts speak in a foreign language they do not understand when "they don't want us to know what they're saying". (b) During the group interview coriducted on 8/24/2004 at approximately 3:00 PM, nine of eleven residents present stated that staffs on all shifts speak on their cellular phones while providing care. (c) During an observation of the activities being provided on 8/25/2004 at 2:25 PM during a birthday party a certified nursing assistant (CNA) was observed feeding resident #3 while he/she was in his/her wheelchair. The CNA was observed standing over resident #3 feeding hinjher a piece of birthday cake, instead of assisting him/her on the same level in a dignified manner. Correction date: September 27, 2004 14. During the follow-up conducted on 10/06/2004 and based on observation and interview, the facility failed to maintain and enhance each resident's respect regarding 5 entering a resident room without receiving permission to enter for one (resident #4) of eight sampled residents. 15. On 10/06/2004 at 2:50 PM the surveyor knocked on the door of resident #4's room. The resident asked who was at the door and what was the nature of the visit. The reason was explained to the resident, along with an introduction and after asking a few more questions the resident granted entrance to his/her room. On exiting the room a staff member quickly knocked on resident #4's door, calling out "Speech" while already in the room and without receiving a response from the resident. 16. This was reported to the charge nurse and 2 other staff members at the nursing station. The charge nurse stated that the resident is very protective of his/her spouse (who also resides in the room) and does not like pecple coming in without knowing their intentions. The two otker staff members agreed with the charge nurse. 17. At approximately 4:00 PM, the resident. was asked how he/she felt about someone coming into his/her room the way that staff member did earlier. The resident raised his/her voice and stated, "Of course it bothers me, and I don't like it at all". 18. Based on the foregoing, The Court at Palm-Aire violated Title 42, Section 483.15(a), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, an uncorrected Class III deficiency, which carries an assessed fine of $1,000.90. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. COUNT Iit THE COURT AT PALM-AIRE FAILED TO PROVIDE THE PROPER AMOUNT OF ENTERAL FEEDING Title 42, Section 483.25(g) (2), Code of Federal Regulations as incorporated by Rule 59A-14.1288, Florida Administrative Code (QUALITY OF CARE) UNCORRECTED CLASS III VIOLATION 19. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 20. During the survey conducted on 8/27/2004 and based on observation on 8/26/2004 at 9:50 AM, resident #10 was observed in bed with the tube-feeding running. The enteral bag had 200 cc of formula left in the bag that originally contained 1000 cc. The label on the tube-feeding bag indicated that the formula was hung at 12:00 PM on 8/25/04 and the rate was 50 cc/hour. 21. Review of the most current tube-feeding order was Jevity 1.2 at 50 ec/hr x 22 hours via G-tube. 22. Based on calculating the rate of the formula (50 ec/hr), the time the formula was hung (12:00 pm) and observed (9:50 am) and the amount of formula left (200 cc), the resident should have been given 1000cc of formula. The resident received 200cc less than the ordered amount during this time period. Correction Date: September 27, 2004. 23. During the follow-up conducted on 10/06/2004 it was determined that this deficiency remains uncorrected. 7 24. The facility was cited on an annual certification and licensure survey conducted on 8/24/2004-8/27/2004, for not ensuring a resident that was fed via a gastrostomy tube received the volume of feeding ordered. Based on observation, interview, and record review conducted on 10/6/2004, it was determined that the facility still did not ensure that 1 of 2 sampled residents who received nutrition via a gastrostomy tube (#5) was provided with the volume of feeding ordered by the physician. 25. On 10/6/2004 at 1130 AM, Resident #5 was observed in bed while a tube-feeding was infusing via a gastrostomy tube into his stomach. The staff nurse present during this observation indicated that the resident was receiving Pulmocare at a rate of 50 cc per hour. She continued to report that the label on the bag documented that it was hung on 10/5/2004 at 4:30PM and that there was approximately 350 cc left. The bag is pre mixed and holds approximately 1000 cc indicating that the resident had received approximately 650 cc. 26. Review of this resident's clinical record with a staff nurse revealed that the most current physician's order sheet for October 2004 documents that the resident is to receive "Pulmocare at 50 cc per hour via PEG for 22 hours. On at 4PM off at 2 PM." The staff nurse calculated the amount that should have been infused fron 4:30PM to 11:30 AM to be 950 cc indicating that the resident had not received 300 cc (six hours) of feeding as ordered. 8 27. Further review of the resident's clinical record revealed that the resident's ideal body weight range is 122-150 pounds and the latest weight recorded for the resident is 116 pounds on 9/27/2004. The most current care plan that addresses the resident's nutritional status documents that the "Resident is dependent on tube feeding for adequate nutrition and support." 28. During interview on 10/06/2004 at 2:15 PM with the staff nurse assigned to the resident, she reported that she had hung a new bag a 12:15PM and checked on the pump about an hour later. She continued to report that 50 cc of feeding had infused indicating that there was nothing wrong with the pump. The facility was unable to provided evidence prior to the end of the survey that would substantiate that the resident had received the required amount of feeding. 29. Based on the foregoing, The Court at Palm-Aire viclated Title 42, Section 483.25(g) (2), Code of Federal Reculations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, an uncorrected Class III deficiency, which carries an assessed fine of $1,000.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23{7) (b), Florida Statutes. COUNT IV THE COURT AT PALM-AIRE FAILED TO STORE, PREPARE AND SERVE FOODS UNDER SANITARY CONDITIONS FAILING TO ENSURE THAT FOOD CONTACT SURFACES OF EQUIPMENT WERE CLEAN, APPROFRIATE FOOD ‘TEMPERATURES ARE MAINTAINED AND SINGLE SERVICE USE ITEMS WERE STORED IN A MANNER TO PROTECT THEM FROM CONTAMINATION. 9 Title 42, Section 483.35(h) (2), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code (DIETARY SERVICES) UNCORRECTED CLASS IIIf VIOLATION 30. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 31. During the survey conducted on 8/27/2004 and based on observation and staff interviews, the facility did not store, prepare and = serve foods under sanitary corditions failing to ensure that food contact surfaces of equipment were clean, appropriate food temperatures are maintained and single service use items are stored in a manner to protect them from contamination. 32. The following was observed on the initial tour of the kitchen on 8/24/2004 starting at 9:15 AM with the administrator: (a) A bottle of borscht was observed in the dry storage room on a shelf. The borsht (beet soup) had been opened and approximately half of the liquid was missing. Based on the labeling on the bottle, the borsht would need tc be refrigerated after opened, to prevent the growth of bacteria. (bo) The dishwasher was observed from 9:20 AM to 9:30 AM. At this time the staff member working the machine was asked if the machine is a low or high temperature machine, and at what temperature should the machine be running at and he answered 180 degrees Fahrenheit. At this 10 time the food service director joined the administrator at the dishwasher, the highest reading on the thermometer was 150 degrees Fahrenheit. The porters continued to run the resident dishes through the machine even though it was determined by the FSD that the machine was not functioning properly. The FSD stated that he would hook up the sanitizer to the rinse cycle until the machine could be repaired, however, he did not have the test strips to check the dilution of the sanitizer. (c) Numerous scoops, ladles and other utensils were observed in a stainless steel drawer. The drawer had an accumulation of caked on yellow/white debris that the utensils were lying on top of. The utensils come in direct contact with food intended for nursing home residents. (ad) On 8/25/2004 in the afternoon, the “nutrition room” was observed to have several drawers, two of which were filled with disposable forks and spoons. Both forks and spoons were not in their original packaging or cleaned container to protect them from contamination. Correction date: September 27, 2004. 33. During the follow-up conducted on 10/06/2004 and based on observation and staff interviews, the facility did not store, prepare or serve foods under sanitary conditions failing to ensure that food service equipment were clean and in good repair, dried appropriately, ensure that potentially hazardous foods were cooled down properly, expired foods are disposed of promptly and that foods are maintained at appropriate temperatures. 34. The following was observed on 10/6/04: (a) At 10:45 AM a container of limejuice was observed in the activities room. The limejuice was in a cupboard, without refrigeration. The expiration date on the bottle was 5/28/2004 and states that it must be refrigerated after opened; there was approximately 1/2 of the juice left in the bottle. (b) There was a clear container full of serving utensils, a white slotted spoon was observed to be broken, cracked, and severely discolored. 35. The following was observed during the tour of the kitchen starting at 11:30 am with the staff member idertified as the food service manager (FSM) in charge. (a) A scale in the food preparation was noted to be rusted. (b) A pan of hard-boiled eggs were lying in a sink, above them was another pan of produce the staff member was working on. The FSM stated that they were cooling off the eggs prior to refrigerating them. The FSM was asked if that was the correct way to cool down potentially hazardous food and he stated that refrigeration should be better. (c) Two juice towers were severely cracked, broken and discolored. 12 (a) A clear plastic container on the food storage shelf was observed be cracked, broken and stained yellow. (e) A can opener that had just been cleaned at the clean side of the dishwasher was examined. There was a build up of food debris on the worn blade and the housing unit was severely rusted. The blade may come in direct contact with food when being used, potentially contaminating the food. (f) Three large green cutting boards were observed (2 were in use) that had deep scoring with multiple areas that were browns and black, indicating bio- growth. Several more cutting boards were observed in the storage rack, also deeply scored and had more discoloration indicating bio-growth. Once the integrity of the board is lost, it must be sanded (if possible) to a clear. depth, or discarded as it cannot be cleaned or sanitized. Food comes into direct contact with the cutting boards, potentially contaminating the food. (g) Numerous steam table pans (over 25) were observed stacked together on a storage rack, when pulled apart it was revealed that there were droplets of water in between them. Food service equipment must be air dried to prevent the growth of bacteria. 36. The following temperatures of food were taken on the steam table lunch line starting at 12:40 pm. A 13 calibrated thermometer was used by the dietetic technician (DTR) in taking the temperatures: Grilled cheese - 121 degrees Fahrenheit Omelet - 110 degrees Fahrenheit Pureed soup - 121 degrees Fahrenheit 37. Hot food must be maintained at 140 degrees Fahrenheit or above. 38. At approximately 3:45 pm liquids in glass carafe containers were observed on the door of the refrigerator in the nourishment room on the nursing home unit. The liquids were identified by staff as orange juice; apple juice, cranberry juice and water, all were dated 10/02/04. This is an uncorrected deficiency from the 8/27/2004 survey. 39. Based on the foregoing, The Court at Palm-Aire violated Title 42, Section 483.35(h)(2), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, an uncorrected Class III deficiency, which carries an assessed fine of $3,000.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through Iv. 14 B. Assess an administrative fine of $8,000.00 against The Court at Palm-Aire on Counts I through IV for three uncorrected Class III violations. c. Grant such other relief as this Court deems is ‘ust 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 (2004). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. l, Vive, (/ Larner} fourdes A. Naranjo, Esq. ‘ la. Bar 997315 Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N. W. 52° Terrace Miami, Florida 33166 15 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1719 East Tiffany Drive, Suite 100 West. Palm Beach, Florida 33407 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office Mail) Lony Term Care Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Beverly Eliahu, Administrator, The Court at Palm-Aire, 2701 N. Course Drive, Pompano Beach, Florida 33069, Palm Court Joint Venture, P. O. Box 12926, Salem, Oregon 97309, and to William E. Colson, P.O. Box )) cv 14111, Salem, Oregon 97309 on LEO . 23 , 2004, Fiche A [Are P urdes A. Naranjo y te si “eS A a! Bi AUATAS HAH > SNF15550962 LICENSE # CERTIFICATE #: 11940 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE ied with the rules and regulations adopted by the State of Florida, z Zz 2 = Pa fe) s) me! oe] —_ Ss —_ em e) Z, —_ DN a =) Z, (an) ea) — = am nd N This is to confirm that PALM COURT JOINT VENTURE has compl , Part II, Florida Statutes, and as the licensee is authorized to operate the following Agency For Health Care Administration, authorized in Chapter 400. 2701 N. COURSE DRIVE COURT AT PALM-AIRE, THE POMPANO BEACH, FL 33069 ;_ 60 BEDS TOTAL: STATUS CHANGE ACTION EFFECTIVE DATE: 10/06/2004 Deputy Secréyary, Division of Health Quality Assurance LICENSE EXPIRATION DATE: 03/31/2005

Docket for Case No: 05-000120