Oo ih, fe STATE OF FLORIDA S& 29 aD AGENCY FOR HEALTH CARE ADMINISTRATION 4 ar Ps STAT A STATE OF FLORIDA, AGENCY FOR Hee Sige Or HEALTH CARE ADMINISTRATION, Sap, Vip Petitioner, AHCA No.: 2005006216 AHCA No.: 2005006215 v. Return Receipt Requested: 7004 1350 0000 5650 2262 JACKSON HEIGHTS NH, LLC d/b/a 7004 1350 0000 5650 2279 UNITY HEALTH AND 7004 1350 0000 5650 2286 REHABILITATION CENTER, Respondent. ) OS _ as oO ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, 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 120.60, Florida Statutes, (2004) and 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 400.23(8) (b), Florida Statutes (2004) [AHCA No.: 2005006215]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2004) [AHCA No. 2005006216]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes (2004) and Chapter 28-106, Florida Administrative Code (2004). 4. Venue lies in Dade County, pursuant to Section 400.121, Florida Statutes (2004) and Chapter 28-106.207, Florida Administrative Code (2004). PARTIES 5. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (2004) and Rule 59A-4, Florida Administrative Code (2004). 6. Unity Health and Rehabilitation Center is a skilled nursing facility located at 1404 N. WwW. 22m4 Street, Miami, Florida 33142 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. "w COUNT TI UNITY HEALTH AND REHABILITATION CENTER FAILED TO PROVIDE CARE AND SERVICES TO A RESIDENT AT RISK FOR CONSTIPATION RESULTING IN HOSPITALIZATION OF THAT RESIDENT. TITLE 42 SECTION 483.25, CODE OF FEDERAL REGULATIONS RULE 59A-4.1064(4) (aa), FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS IIL 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, A licensure and re-certification survey was conducted from April 25, 2005 through April 29, 2005. Based on interview and record review, it was determined that the facility failed to provide care and services to one out of 27 residents at risk for constipation. This failure resulted in the hospitalization of that resident. The findings include the following: 10. A vreview of the clinical record for Resident #17 revealed that the resident was admitted to the facility on 1/31/05 with the following diagnoses: neurogenic bladder, cervical stenosis and tetraplegia. A review of the Minimum Data Set (MDS) dated 2/15/05 for Resident #17 indicated that the resident was independent with decision-making and had no short or long-term memory problems. The MDS further indicated that the resident was dependent on staff for Activities of Daily Living (ADLs). A review of the care plans in the clinical record revealed that the resident was at risk for constipation due to impaired mobility secondary to cervical stenosis, obesity and tetraplegia. The approaches listed included: assessing the resident for signs and symptoms of constipation, (i.e. elevated temperature, episodes of shortness of breath, abdominal distention and rigidity, and decreased appetite) and then to give diet as prescribed and to encourage non-medication regimen, such as encouraging adequate fluids and monitoring bowel patterns. 11. A review of the Medication Administration Record (MAR) for the month of March 2005 indicated that the resident received Flexeril, Neurontin, Ferrous Sulfate and Methadone on a daily basis and Roxanol prn (as needed) . A Review of the PRN (as needed) Administration Record for the month of March 2005 indicated that the resident received Roxanol at least twice a day. One of the side effects of the above medications is constipation. A further review of the MAR indicated that Resident #17 received Dulcolax. suppositories (2), a Metamucil packet ‘and Sorbitol daily for the treatment of constipation. 12. A review of the nurses' notes in the clinical record dated 3/15/05 at 11:30AM, revealed that the resident complained of constipation, but refused the sorbitol at the time because he/she wanted to go outside to have a cigarette. The resident was quoted as saying, "I'll take it later. I don't want to explode outside." A review of the MAR indicated that the Sorbitol was not given on 3/10/05 or 3/15/05. The explanation on the back of the MAR stated that the resident would take it later. However, there was no indication in the nurses' notes or in the MAR that the resident was offered the medication at a later time. 13. A review of the CNA (Certified Nursing Assistant) Monthly Hydration/Nutrition Offering Form for the month of March 2005 under the subheading "BM record" indicated that the resident had no bowel movement on 3/13/05, 3/14/05, 3/15/05, 3/16/05 or 3/17/05. There was a weekly nurse review on the bottom of the form for a nurse’s signature. There was a nurse's signature for days 1 through 7, days 8 through 15 and days 16 through 21 indicating that they reviewed the information for that time frame. A review of the nurses’ notes dated 3/17/05 indicated that the resident was then transferred to a local hospital. 14. A review of the progress notes from the resident's hospital record dated 3/21/05 stated that the resident was sent ui from the nursing home for "obstipation" (constipation). ‘The resident stated that he/she had not had a bowel movement in seven days. A further review of the hospital's progress notes under the heading "plan" revealed the following: severe constipation: several large bowel movements, feeling much better but stated he/she still has constipation-requesting one more fleets enema. 15. The Director of Nurses (DON) was interviewed on 4/28/05 at 11:00AM regarding the CNA Monthly Hydration/Nutrition Offering Form for March 2005 for Resident #17. She stated that the nurses review the form every seven days and sign their names signifying that they reviewed the form for that time period. She stated that under the heading “BM record” the nurse signed but didn't identify that the resident had not had a bowel movement for 5 days. The DON stated that if a resident has not had a bowel movement for three days, the CNA is to notify the nurse. Then the nurse is to administer medications for the constipation. If the resident has no medications, then the nurse is to call the physician. 16. While reviewing the CNA flow sheet with the DON for the month of March 2005 (especially 3/13, 3/14, 3/15, 3/16 and 3/17/05) she stated that she doubted that the resident went five days without a bowel movement. The DON stated that if a resident refuses a medication or states that they will take it later, the nurse should go back to the resident and offer the medication again. She confirmed that there was no indication that Resident #17 was offered the Sorbitol at a later time. When asked about the resident's hospitalization from 3/17/05 to 3/25/05, the DON stated that the resident went to the hospital because he/she wanted to go. On 3/17/05, the resident was unable to stand, had shortness of breath and wheezing. When informed of the hospital progress note, the DON stated that the resident was on a lot of medications that would make him/her constipated. 16. Based on the foregoing facts, Unity Health and Rehabilitation Center violated 483.25, Code of Federal Regulation (2004) and Rule 59A-4.106 (4) (aa), Florida Administrative Code (2004), herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes (2004). DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes (2004) 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: 04/29/2005 Expiration date: 09/19/2005 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 violation cited above. 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 (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 Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, 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. lien/ fsq. Margaret i} Asst mt General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6800 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration Manchester Building 8350 NW 52 "? Terrace - Suite 103 Miami, Florida 33166 (Interoffice Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) 11 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. 2274 Street, Miami, Florida 33142; Jackson Heights NH, L.L.C., C/O Greystone & Company, 152 W. 57 Street - 60 Floor, New York, New York 11019; Corporation Services Company, 1201 Hays Street, Tallahassee, Florida 32301- 2525 on this (Stt\aay of Pr ogad , 2005. iv, Esq. Margar ulien SENDER: COMPLETE THIS SECTION : ; @ Complete items 1,2, and 3. Also complete U.S. Postal Servicer Wares me CERTIFIED MAiLm RECEIPT hecerdtoyou (Domestic Mail Only; No insurance Coverage Provided) back of the mailpiece, Permits. For delivery information visit our website at www.usps.com OFFICIAL USE D, Is delivery address different from item 17_LJ Yes 'f YES, enter delivery address below: ©] No Return Aeclapt Fae indorsemant Required) Mestrictad Delivery Fae \dorsamant Raqulred) 3. Service Type O Certified Mail © Express Mail O Registered D Returm Recelpt for Merchandise O insured Mall | c,0.D. 4, Restricted Dellvery? (Extra Fea) be mu ~ nm n fos] un a] un o oa o n o uy m Fi or o ao rm PS Form 3800, June 2002 See Reverse far instruc! US ED MAIL. REC SENDER: COMPLETE THIS SECTION ’ 3. Service Type Total Postage & Fees 1 Certified Mall) (1 Express Mall (1 Return Receipt for Merchandise 1 Registered Pr 4 6 A, Signature ru ic Mall [ 2, and 3, Also completa . jail Only; No fi = Complete items 1,2, | Br} ee Item 4 if Restricted Delivery ts desired, ANN For delivery information visit our website 4 m Print your. name and addrass on the reverse eel rr so that we can return the card to you. : acéived by ( Printa re @ Attach this card to the back of the mallplece, d " oron jhe fen aes permit D. {s delivery address differant from tam 1? a = : If YES, enter delivery address below: a 3 Retum Raclapt Fea © (Endorsement Required) 3 Restricted Dallvery Fao 1.) (Endorsement Required) m i) =r a o i lesan UR 52 ult Adnot — On y Nour Yer m Complete items 1, 2, and 3, Also complete . Item 4 if Restricted Delivery is desired. O Agent @ Print your name and address on the reverse (Addressee so that we can return the card to you. é Date of Dalivary PCC © Attach this card to the back of the malipiece, , ¥ (@) F E j Cc i A L L or on the front if space permits. é 7 O. Is delivery address diffdrent from itam 1 Postage ls sd 1. Article Addressed to: If YES, enter delivery address below: + CI No | Cartiiad Fae | latum Reciept Fae (Encpreemant Required) flastrictad Delivery Fea (Endorsament Required) 3, Service Type CO Certified Mall {1 Express Mail 1 Registered O Return Receipt for Merchandise Cl Insured Mail =O G.0.D. 4 Qerticted Delivery? (Extra Fea) D Yes 7OO4 1350 OO00 sesu seou- AiG REE A NODA PS Form 3800, June 2002 Page | of 1 Lopez, Olivia From: = Mills, Janice K. Sent: Wednesday, September 14, 2005 2:46 PM To: Torres, Lorraine; Lopez, Olivia j po Subject: option 3 Petition on case #2005006215 &2005006216 Jackson aig aldhd Gig7yeattn & Rehab Hoc Uh JENNER : SENERAL CouNSe This case was formerly assigned to Margaret Julien. We received an option petition on the above cases. Please send a copy of the signed AC's and green cards. SEP 21 2005 thanks! jan Agency for Hea i Cave Admi ith nistration Er ie ra 99. SS ee le REA e a) Boe B 3 ode) aor ae Bro, F. wa ns) a oO 09/14/2005

Docket for Case No: 05-003572