— if oT STATE OF FLORIDA an ee le TY AGENCY FOR HEALTH CARE ADMINISTRATION cr JUY 2 8 PH l STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA CASE NO.: 2005003577 (Fine) AHCA CASE NO.: 2004011573 (Conditional License) vs. HEALTHCARE PROPERTIS OF ST. AUGUSTINE, INC. d/b/a PONCE DE LEON CARE CENTER, Respondent. ef ADMINISTRATIVE COMPLAINT COMES NOW Petitioner, the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter referred to as “AHCA” or the -“Agency”), by and through its: undersigned counsel, and files this. Administrative Complaint against Respondent, HEALTHCARE PROPERTIES OF ST. AUGUSTINE, INC. d/b/a PONCE DE LEON CARE CENTER, (hereinafter referred to as “Respondent”), pursuant vtesermnmnen oct song “130.869 “and 130.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action against Respondent to: (Count I) impose an administrative fine in the amount of $7,000.00 for three uncorrected Class III deficiencies; and (Count IT) impose conditional licensure status commencing April 18, en coveroenn ts. rr RASA eb Aes Sethe tiadb nD Parr Bit Dover Lise S cited in the counts below. Administrative Complaint Page 1 of 18 vateke BS PARTIES 2. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities, pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code (2004). 3. Respondent is a skilled nursing facility, located at 1999 Old Moultrie Road, St. Augustine, Florida 32086. Respondent is licensed by AHCA as a skilled nursing facility, having been issued license number 1450096. 4. Respondent is and was at all times material hereto a licensed skilled nursing facility, required to comply with rae ent Ratatat E Nn HEM Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code, respectively. JURISDICTION AND VENUE 5. AHCA has jurisdiction pursuant to Chapter 400, art, II, Florida Statutes (2004); Sections 120.569 and 120.57, Florida Statutes (2004); and Chapter 28-106, Florida Administrative Code (2004). 6. venue lies in St. Johns County, St. Augustine, Florida, pursuant to Section 120.57, Florida Statutes (2004); Chapter 59A-4, Florida Administrative Code (2004); and Rule 28-106.207, Florida Administrative Code (2004). Administrative Complaint Page 2 of 18 COUNT Tf RESPONDENT FAILED TO PLAN AND/OR FOLLOW MENUS FOR RESIDENTS RECEIVING FORTIFIED FOODS AND RESIDENTS ON LOW FAT/LOW CHOLESTEROL DIETS Uncorrected Class III Deficiency Tag Number - F363 42 CFR 483.35(c)(1) through (3) - Dietary Services Section 400.141(9), Florida Statutes (2004) - Section 400.23(8)(c), Florida Statutes (2004) - Rules, Evaluation and Deficiencies; Licensure Status 7. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 8. The regulatory provisions that are pertinent to this alleged violation, read as follows: Section 483.35 Dietary services. coe eng Ny ne ty SERN aa ine ge eaters tn ea athe BR AME AERie tee ee. es pee nepet feneng AR gee (¢) Menus and nutritional adequacy. Menus must-~- (1) Meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences; (2) Be prepared in advance; and (3) Be followed. 400.141 Administratior“aind management” of nursing home facilities. -- Every licensed facility shall comply with all applicable standards and rules of the agency and shall: -- eek (9) If the licensee furnishes food service, provide a wholesome and nourishing diet sufficient to meet generally accepted standards of proper nutrition for its residents and provide such therapeutic diets as may be prescribed by attending physicians. In making rules to implement this subsection, the agency shall be guided by the standards recommended by nationally recognized professional groups and associations with knowledge of dietetics. 9. On or about March 1-4, 2005, AHCA conducted a vein epesnechiie ona npigaeren erin nee eOTE an FV eee ORES POTMIE* OF PUCT I TE On” OF Administrative Complaint Page 3 of 18 — about March 1-4, 2005, AHCA cited the Respondent’s facility for failure to ensure that menus were planned in advance for 9 residents who were prescribed 2 gram sodium diets, 3 residents who were prescribed 1800 calorie diets, 10 residents who were prescribed fortified food diets, andl resident with a lactose intolerance diet. 10. Respondent's failure to ensure that menus were planned in advance is a violation of 42 CFR 483.35(c) (1)- (3), and Section 400.141(9), Florida Statutes (2004). 41. On or about March 1-4, 2005, AHCA classified the nature and scope of this violation as a class III Feta nets nc nen aOR aR LET LNT D'S “RARE AOD Na RRR REF HII IIR Ma REE FETS A 12. AHCA provided Respondent a mandated correction date of April. 4,-2005 for this class III deficiency. 13. On or about April 18, 2005 AHCA conducted a follow-up to the recertification survey of March 1-4, 2005, at the Respondent's facility. On or about April 18, 2005, AHCA cited the Respondent’s facility for failure to plan and/or follow menus for residents receiving fortified foods and residents on low fat/low cholesterol diets. 14. Form CMS-2567 states the following as evidence that the Respondent failed to meet the requirements of 483.35(c) (1)-(3) and Section 400.141(9), Florida Statutes (2004): se ce ig ote Pe wlth te MW Gi SS ni BEET AE AP RN ENED EE A EEE EE MERE eS BES ESE Administrative Complaint Page 4 of 18 a. THIS CITATION WAS FOUND NOT CORRECTED AT THE TIME OF THE REVISIT SURVEY. b. Based on review of facility menu extensions, a review of the Diet/Nourishment Roster, observations and staff interview, the facility failed to plan and/or follow menus for residents receiving fortified foods and residents on low fat/low cholesterol diets. c. The findings include: On 4/18/05 at 10:15 ama review of the Diet/Nourishment Roster dated 4/18/05 indicates that the facility has 16 residents on fortified foods and 8 residents on a low fat or low cholesterol diet. da. Observation of the lunch tray line at 11:30 am on 4/18/05 revealed that there were no foods prepared for those residents who are to receive fortified foods or foods low in fat/cholesterol. e. Interview with the Cook serving the lunch tray line, revealed that there were no foods prepared for these diet orders. The Dietary manager asked the cook why the foods were not prepared and then stopped the tray line immediately. 15. Respondent’s failure to plan and/or follow menus for residents receiving fortified foods and residents on low fat/low cholesterol diets is a violation of 483.35(c) (1)-(3) and Section 400.141(9), Florida Statutes (2004). 16. On or about April 18, 2005, AHCA classified the nature and scope of this violation as an uncorrected class TII deficiency. 17. Pursuant to Section 400.23(8)(c), Florida Statutes (2004), a class III deficiency is a deficiency that the agenc determines will result in no more than minimal et RRC ik i + A eS eS aaa wehamy 0 Ne an le A ls RE REE RIS VHRR Rents oh te arr cre ee physical, mental, or psychosocial discomfort to the resident Administrative Complaint Page 5 of 18 an” ed 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, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for” éné ot more Clas8"I or class TI deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. 18. Pursuant to 400.23(8)(c), Florida Statutes (2004), this classification constitutes grounds for the imposition of an administrative fine of THREE THOUSAND DOLLARS ($3,000). 19. AHCA provided Respondent a mandated correction date of May 18, 2005 for this uncorrected class III deficiency. WHEREFORE, AHCA respectfully requests the following Administrative Complaint Page 6 of 18 20. Factual and legal findings as set forth in Count I of this Administrative Complaint, and; 21. Uphold the imposition of the administrative fine in the amount of THREE THOUSAND DOLLARS ($3,000), and; 22. Impose such other relief as this tribural may find appropriate. COUNT II RESPONDENT FAILED TO PROVIDE PUREED FOOD THAT WAS SMOOTH AND EVENLY TEXTURED FOR THOSE RESIDENTS PRESCRIBED PUREED DIETS Uncorrected Class III Deficiency Tag Number - F365 42 CFR 483.35(d) (3) - Dietary Services Section 400.141(9), Florida Statutes (2004) - Section 400.23(8)(c), Florida Statutes (2004) - Rules, Evaluation and Deficiencies; Licensure Status 23. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 24. The regulatory provisions that are pertinent to this alleged violation, read as follows: Section 483.35 Dietary services. RK (d) Food. Each resident receives and the facility provides - eka (3) Food prepared in a form designed to meet individual needs ... 400.142 Administration and management of nursing home facilities. -- Every licensed facility shall comply with all applicable standards and rules of the agency and shall: -- REE (9) If the licensee furnishes food service, provide a wholesome and nourishing diet sufficient to meet generally attending physicians. In making rules to implement this Administrative Complaint Page 7 of 18 subsection, the agency shall be guided by the standards recommended by nationally recognized professional groups and associations with knowledge of dietetics. 25. On or about March 1-4, 2005, AHCA conducted a recertification survey at the Respondent’s facility. On or about March 1-4, 2005, AHCA cited the Respondent’s facility for failure to provide pureed food that was smooth and evenly textured for 9 residents prescribed pureed diets. 26. Respondent’s failure to provide pureed food that was smooth and evenly textured for 9 residents prescribed ‘ oi : x a e. Me ve pureed diets is a violation of 42 CFR 483.35(d) (3), and “ oe Se Pe Sener et Section 400.141(9), Florida Statutes (2004). 27. On or about March 1-4, 2005, AHCA classified the nature and scope of this violation as a class III deficiency. 28. AHCA provided Respondent a mandated correction date of April 4, 2005 for this class III deficiency. 29. On or about April 18, 2005 AHCA conducted a follow-up to the recertification survey of March 1-4, 2005, at the Respondent’s facility. On or about April 18, 2005, AHCA cited the Respondent’s facility for failure to provide pureed food that was smooth and evenly textured for those residents prescribed pureed diets. 30. Form CMS-2567 states the following as evidence that the Respondent failed to meet the requirements Of ue: aren One nk OMA Rte plinth Re i oe rise REE Administrative Complaint Page 8 of 18 483.35 (d) (3) (2004): and Section 400.141(9), Florida Statutes _ THIS CITATION WAS FOUND NOT CORRECTED AT THE TIME OF THE REVISIT SURVEY. . Based on record review of the census report, observation of the lunch tray line at 11:30 am and 12:15 PM on 4/18/05 and staff interview on 4/18/05 at 12:45 the facility did not provide pureed food that was smooth and evenly textured for those residents prescribed pureed diets. . The findings include: 1. Record review on 4/18/05 of the facilities census report as of 3/31/05 indicates that the facility has 12 woed dont residents who are to receive a puree diet. . Observation of the lunch tray line that began at 11:30 am revealed the following foods were prepared for those residents on a puree diet: puree Swiss steak and gravy mashed potatoes with gravy tomato juice bread aanow _All the foods were placed on the same plate and began running together. It was difficult to see what was gravy or beef and the tomato juice was also placed on the plate in the same runny consistency. The foods were not holcing form to a smooth and evenly textured consistency per observation at 12:15 PM. . Interview with the Dietary Manager and the Consultant Registered Dietitian on 4/18/05 at 1:00 PM revealed that an in-service had been provided to the facility dietary staff on how to prepare and serve puree foods. The Dietary Manager stated that he/she did not know why the cook did not prepare puree foods that were the appropriate texture and he/she did not know why the foods were runny and not holding shape on this date. 31. Respondent's failure to provide pureed food that was smooth and evenly textured for those residents Administrative Complaint Page 9 of 18 ae” prescribed pureed diets is a violation of 483.35(d) (3) and Section 400.141(9), Florida Statutes (2004). 32. On or about April 18, 2005, AHCA classified the nature and scope of this violation as an uncorrected class IIL deficiency. 33. Pursuant to Section 400.23(8)(c), Florida Statutes (2004), a class III deficiency is a deficiency 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, as defined by an sa mamta accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 fora patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time fey pepe ge eng agement te ap acon meme Tog SS ROG specified, no civil penalty shall be imposed. Administrative Complaint Page 10 of 18 34. Pursuant to 400.23(8)(c), Florida Statutes (2004), this classification constitutes grounds for the imposition of an administrative fine of ONE THOUSAND DOLLARS ($1,000). 35. AHCA provided Respondent a mandated correction date of May 18, 2005 for this uncorrected class III deficiency. WHEREFORE, AHCA respectfully requests the following relief: 36. Factual and legal findings as set forth in Count Il of this Administrative Complaint, and; 37. Uphold the imposition of the administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000), and; Impose such other relief as this tribunal may find appropriate. COUNT III RESPONDENT FAILED TO STORE, PREPARE, SERVE AND DISTRIBUTE FOOD UNDER SANITARY CONDITIONS Uncorrected Class III Deficiency Tag Number - F371 42 CFR 483.35(h) (2)- Dietary Services Section 400.141(8), Florida Statutes (2004) - Section 400.23(8)(c), Florida Statutes (2004) - Rules, Evaluation and Deficiencies; Licensure Status 38. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 39, The regulatory provisions that are pertinent to this alleged violation, read as follows: Administrative Complaint Page 11 of 18 Section 483.35 Dietary services. aK (h) Sanitary conditions. The facility must - kkk (2) Store, prepare, distribute, and serve food under sanitary conditions; -- 400.141 Administration and management of nursing home facilities. -- Every licensed facility shall comply with all applicable standards and rules of the agency and shall: -- wkaeK (8) Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 40. On or about March 1-4, 2005, AHCA conducted a recertification survey at the Respondent's facility. On or about March 1-4, 2005, AHCA cited the Respondent’s facility for failure to store, prepare, serve, and distribute food under sanitary conditions. . 41....Respondent’s, failure to store, prepare, serve, and distribute food under sanitary conditions is a violation of 42 CFR 483.35(h) (2), and Section 400.141(8), Florida Statutes (2004). 42. On or about March 1-4, 2005, AHCA classified the nature and scope of this violation as a class III deficiency. 43. AHCA provided Respondent a mandated correction date of April 4, 2005 for this class III deficiency. 44. On or about April 18, 2005, AHCA conducted a follow-up to the recertification survey of March 1-4, 2005, at the Respondent's facility. On or about April 18, 2005, AHCA cited the Respondent’s facility for failure to: label Administrative Complaint Page 12 of 18 — and/or date foods stored in the walk-in refrigerator; discard foods after 72 hours; ensure proper holding temperatures for potentially hazardous foods; and ensure that cross contamination of potentially hazardous foods did not occur. 45. Form CMS-2567 states the following as evidence that the Respondent failed to meet the requirements of 483.35(h) (2) and Section 400.141(8), Florida Statutes (2004): a. THIS CITATION, WAS..ROUND MOF ORRECTED..AT..THE. . TIME OF THE REVISIT SURVEY. b. Based on observations, record review and staff interviews on 4/18/05 beginning at 9:30 am until 12:30 PM, the facility failed to label and/or date foods stored in the walk-in refrigerator and they failed to discard foods after 72 hours. The facility also failed to ensure proper holding temperatures for potentially hazardous foods, and to ensure that cross contamination of potentially hazardous foods did not occur. c. The findings include: 4. Observation of the walk-in refrigerator on 4/18/05 at 9:30 am revealed cooked chicken that was in a wrapper which was dated 4/13, ham slices that were dated 4/8 and one dated 4/11, and spaghetti sauce which was dated 4/9. The time was not included on any of the foods noted. ii. Observation of the reach-in refrigerator revealed cottage cheese and peanut butter in Styrofoam containers that did not have dates, labels or times. After interviewing the Dietary Manager he/she stated, "these foods SO Eh Oki Sak Dell mat a FBEESES.. a to discar em. Administrative Complaint Page 13 of 18 iii. Record review at 9:30 am indicated that the temperatures of the cold foods had not been recorded for breakfast. Dietary Manager stated, he/she did not know why the temperatures were not taken. During the lunch line at 11:30 am the temperatures were taken for the cold foods and the fantasy fruit being served for the regular diets was 60 degrees F. The food was not held at 41 degrees or below. iv. Food temperatures taken on the lunch tray line being served at 12:15 PM on 4/18/05 revealed that the holding temperature of the ground Swiss steak was 120 degrees F. The potentially hazardous food was not held at 140 degrees F or above to minimize the bacterial growlh and/or toxin cna gs 0a ana ees he le 2 Sean mort ARE QPUGE TON. LQG «6 eon ws area RNRIRNNISIRNARE v. Observation of the clean pots on 4/18/05 at 9:45 am revealed that the pans were not being air dried before stacking. After lifting 3 pans deep, the surveyor still felt and saw wet pans. vi. Observation of the dish machine at 10:15 am indicated that the sanitizer was not registering at 50/100 parts per million per manufactures recommendations. vii. Observation of the evening cook preparing chicken for the dinner meal revealed that the cook was washing raw chicken parts in the facilities sanitizing sink. When the Dietary Manager informed the cook that the chicken should be cleaned in the appropriate sink, the cook moved the chicken by hand with gloves on. After cleaning the chicken and placing the raw parts on a sheet pan, the cook grabbed the spices with the same gloved hand. Interview with the cook revealed that he would clean the spice containers later. The Dietary Manger stated, "they will need to be sanitized, and it is easier to not grab the spices with a contaminated w sant stg sitet een OT NATL AEGAN OO IONAO Smt Administrative Complaint Page 14 of 18 46. Respondent’s failure to: label and/or date foods stored in the walk-in refrigerator; discard foods after 72 hours; ensure proper holding temperatures for potentially hazardous foods; and ensure that cross contamination of potentially hazardous foods did not occur, is a violation of 483.35(h) (2), and Section 400.141(8), Florida Statutes (2004). 47. On or about April 18, 2005, AHCA classified the nature and scope of this violation as an uncorrected class cast aNtgnia RR oe eA ORE TTEN tls ARON ene Mihinala1e PSA TIL deficiency. . 48. Pursuant to Section 400.23(8)(c), Florida Statutes (2004), a class III deficiency is a deficiency 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, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously snaraennanninatann cia eiaianaia ives eineidniiieananitianaichiainagadiehlitdacabihclthedaliliemam wnat ovnemeree during the last annual inspection or any inspection or Administrative Complaint Page 15 of 18 complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. 49. Pursuant to 400.23(8)(c), Florida Statutes (2004), this classification constitutes grounds for the imposition of an administrative fine of THREE THOUSAND DOLLARS ($3,000). 50. AHCA provided Respondent a mandated correction date of May 18, 2005 for this uncorrected class iII ‘deficiency, © 7 WHEREFORE, AHCA respectfully requests the following relief: 51. Factual and legal findings as set forth in Count TIL of this Administrative Complaint, and; ow Me ie es a he ee elle eS a mal eR ac ME AR 52. Uphold the imposition of the administrative fine in the amount of THREE THOUSAND DOLLARS ($3,000), and; 53. Impose such other relief as this tribunal may find appropriate. NOTICE OF RIGHTS 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 Election of Rights (one page) and ages”. A tA Administrative Complaint Page 16 of 18 vem Further, all requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Attention: Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Building #3, Mail Stop #3 Tallahassee, Florida 32308 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 this OT day of June 2005, Leon County, Tallahassee, Florida, on behalf of the Agency for Health Care Administration by, alee Tracie Wilks Assistant General Counsel Fla. Bar. No. 0559921 Agency for Health Care Administration tn nc te et ARE ‘“: 2927 Mahan Drive Brady? 37" Mst™ #3 Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921-0158 (fax) ne: Senta tei Administrative Complaint Page 17 of 18 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights form have been sent by U.S. Certified Mail, Return Receipt Requested, to: Gene R. Larrabee, Administrator, Ponce De Leon Care Center, 1999 Old Moultrie Road, St. Augustine, Florida 32086, on the O™ day of June 2005. caw Nb Assistant General Counsel we. a ee er acces tet: gine ut tal Ny A LLNS ALANA PTE A OE: NP AR en RB RR Administrative Complaint Page 18 of 18

Docket for Case No: 05-002330