STATE OF FLORIDA "EE BE py AGENCY FOR HEALTH CARE ADMINISTRATION 9 fy is STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2006003576 2006003578 PERRY HEALTH CARE ASSOCIATES, LLC, d/b/a MARSHALL HEALTH AND REHABILITATION CENTER, . , Ol d9 3 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Perry Health Care Associates, LLC, d/b/a Marshall Health and Rehabilitation Center (hereinafter “Respondent”, pursuant to §§ 120.569 and 120.57 Fla. Stat. (2005), and alleges: NATURE OF THE ACTION This is an action to impose administrative fines in the amount of Two Thousand Dollars ($2,000.00) based upon Respondent being cited for two uncorrected State Class III deficiencies. JURISDICTION AND VENUE 1 The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2005). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of 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 I, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4, Respondent operates a 120-bed nursing home located at 207 Marshall Drive, Perry, Florida 32347, and is licensed as a skilled nursing facility, license number SNF1436096. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes, COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. . 7. Pursuant to Fla. Admin. Code R. 59A-4.106(2) and (3), each nursing home facility shall adopt, implement, and maintain written policies and procedures governing all services provided in the facility. All policies and procedures shall be reviewed at least annually and revised as needed with input from, at minimum, the facility Administrator, Medical Director and Director of Nursing. 8. On or about 12/29/05, the Agency conducted a complaint investigation (CCR #2005010705) of Respondent. 9. Based on observation, record review and interviews it was determined the Respondent failed to ensure that its written policies and procedures for reporting complaints/grievances were implemented for a complaint of an improperly functioning window in a resident's room in the facility for two of five sampled residents. 10. On 12/29/06, the Agency conducted an interview with a family member of Resident # 1. 11. The family member reported that he/she called the facility about a month ago and reported the window in Room 504 would not close and that cold air has been coming into the room. 12. The family member stated it was reported to a staff person in the administrative department. 13. The family member reported a visit was made to the facility on 12/28/05 and the window remained the same, unable to close. 14. The Agency conducted interviews Resident # 1 and Resident #2, roommates of Room 504. 15. Resident #1 stated, "My room is cold. It's always cold in here." He/she reported a family member notified the facility about a month ago of the window not being able to close properly. 16. Resident # 2 reported he/she told a certified aide, name unknown, about the window not closing about a month ago and the room was always cold. 17. The Agency interviewed the Respondent's Maintenance Director on 12/29/05. He did not recall any communication in the past month regarding a faulty window in Room 504. 18. The Agency conducted an interview with the Respondent's Adminisirative Assistant on 12/29/04. She stated, "I recall someone calling regarding a window problem. I put the call back to the maintenance department. I didn't write it up as a grievance. Once I transfer a call...I receive so many...I put it out of my head. I transfer to the head of the departments to handle the situation." 19. Record review of Resident # 1's Minimum Data Set (MDS), dated 10/04/05, revealed Resident # 1 was without any short term or long term memory problems and was cognitively independent for decision-making. 20. Review of Resident # 2's MDS, dated 09/28/05, revealed the same. 21. Record review of the Respondent's policies and procedures for reporting a compliant/grievance disclosed that, "Upon receipt of the grievance/complaint the receiver completes and signs ‘Section I: Receipt of Grievance/Complaint’ of the Grievance/Complaint Report." 22. Review of the Respondent's Grievance/Complaint Log disclosed the last entry to be in October 2005. 23. Interview with the Respondent's Social Service Director revealed no filings of complaints for November 2005 or December 2005. She stated all staff were responsible to report any complaints or grievances. 24. A request was made to review any policies and procedures for routine maintenance checks, including checking windows and doors. 25. The Maintenance Director provided a log that documented checking all exterior doors routinely, but he stated it did not document windows were to be checked routinely. 26. Review of the West Unit’s Maintenance Log did not document the faulty window in Room 504. 27. During the imitial tour on 12/29/05 at approximately 11:50 a.m. Room 504 was observed to have a vertical opening window, approximately 5 feet x 2 % feet in size, open approximately one (1) inch from top to bottom of the window with a cool draft coming into the room. 28. The window was unable to be opened or closed by the certified nurse's aide (CNA). 29. ‘The Agency interviewed the CNA on 12/29/05. She reported she was instructed to check windows for proper functioning on 12/29/05 and she found Room 504 opened and was unable to close it. 30. She further explained that she reported it to the Director of Nursing (DON), but did not write it up on the grievance/complaint form, nor on the maintenance log. 31. The facility failed to ensure implementation of their policies and procedures for reporting a grievance/complaint. 32. The Agency determined that the deficient practice would result in no more than minimal physical, mental, or psychosocial discomfort or had the potential to compromise the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited the Respondent with a State Class III deficiency. 33. The Agency provided Respondent with the mandatory correction date for this deficient practice of 01/29/06. 34. On or about 02/20/06, the Agency conducted a re-visit survey to the complaint investigation conducted of Respondent on 12/29/05. 35. Based on observation, record review and interviews it was determined the facility failed to ensure that written policies and procedures for hand washing and for enteral feeding were implemented for three of six sampled residents. 36. The Agency conducted an uninterrupted dining observation in the main dining room on 02/20/06, from 11:55 a.m. through 1:08 p.m. 37. Resident #2 had been placed in a wheelchair at a long table next to Resident # 6. 38. The Respondent's Interim Activities Director (LAD), was observed to be sitting between Residents # 2 and Resident # 6. 39. From 12:20 through 1:02 p.m. the IAD was observed to feed, and sometimes assist with feeding the residents, interchanging her right and left hands with utensils with food, picking up glasses and cartons and handing them to the residents' hands. 40. During the course of the meal, the IAD used her right hand, offering mashed potatoes from a spoon, followed by a glass of orange juice, into Resident # 2's hands. Using her left hand, she placed salt on Resident # 2's food. 41. During the meal, the IAD received a paper bag containing a piece of cornbread from another staff person. The bag was held in the [AD's left hand and the contents removed from the bag by her right bare hand, then handed to Resident # 6's right hand. 42. The IAD patted Resident #2 on the back with her right hand. 43. The IAD then picked up Resident # 6's spoon containing food with her left hand and fed the resident, subsequently using the same hand to pick up Resident # 2's cup of orange juice and handing it to the resident. 44. During the course of the meal, the IAD would wipe Resident # 2's mouth with a napkin using her left hand. 45. Throughout the observing period the IAD frequently rested her left hand on the back of Resident # 6's wheelchair. 46. The IAD frequently patted Resident # 2 and Resident # 6 on the back during the observation period. 47. Neither hand washing nor hand sanitizer was used by the IAD prior to sitting next to Resident # 2 and Resident # 6, or during the lunch observation period. 48. Review of the facility's policies and procedures for "Hand washing," revised 10/04 states, "Hand washing is mandated between resident/patient contact in an effort to prevent the spread of infection. Hands must be washed after the following, including, but not limited to...contact with resident/patient." 49. During an interview with the DON on 02/20/06, it was revealed that hand washing was to be done between resident contact. 50. A companion review of the facility's “Infection Control Manual” indicated a policy and procedure for “Infection Prevention”, subtitled “Hand washing”. The document had an original date of 09/03 and a revised date of 10/04. It stated, "Hands must also be washed before initiating a clean procedure ...” 51. A review of the facility's “Nursing Procedure Manual” indicated a policy and procedure for “Enteral Feeding”. The document listed "gloves" as equipment to be used during an enteral feeding, stating, “Wash hands and apply gloves," as part of the procedure. 52. On 02/20/06, prior to initiating the bolus feed to Resident # 3, the nurse failed to wash his/her hands before the bolus feed to the resident and failed to apply gloves. 53. The Agency determined that the deficient practice would result in no more than minimal physical, mental, or psychosocial discomfort or had the potential to compromise the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as an uncorrected State Class II deficiency. 54. The Agency provided Respondent with the mandatory correction date for this deficient practice of 03/20/06. 55. A State Class III uncorrected deficiency subjects Respondent to an administrative fine in the amount of $1,000.00. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2005), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2005). COUNT I 56. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 57. Pursuant to Fla. Admin. Code R. 59A-4.107(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. 58. On or about 01/10/06, the Agency conducted a complaint investigation (CCR #2006000057) of Respondent. 59. Based on observation, interview and record review the facility failed to ensure physician orders for medication and oxygen administration, and wearing of Geri-sleeves were followed, as prescribed for one of six sampled residents. 60. Resident # 1 was admitted to the facility on 08/23/05, and readmitted from a hospital on 09/09/05, with diagnoses that included Alzheimer’s, mood disorder, peripheral vascular disease, congestive heart failure and dementia. 61. During a record review on 01/09/06, physician orders were found to be incorrectly administered, or not provided by facility staff. 62. An order, dated 12/09/05, prescribed, "Decrease Risperdal (from 0.5 mg) to 0.25 mg and give every moming for fourteen days then stop." This order was initially given on 12/13/05 and documented on the Medication Administration Record (MAR) as given and Risperdal 50 mg was given through 12/12/05. 63. Anorder, dated 12/15/05, prescribed, “Magic Mouthwash, Benadryl, Nystatin and Carafate." This order was clarified on 12/20/05 stating, "Magic Mouthwash (1-1-1), Benadryl- Nystatin-Carafate, 5 cc's, orally after meals, three times a day." This order was documented on the MAR as given initially on 12/21/05. 64. An order, dated 12/31/05, prescribed, "Coumadin 6mg, orally, every day at bedtime." Review of the MAR revealed that it was not given every evening from 01/06/06 through 01/09/06. Review of the physician's orders did not document an order to hold the Coumadin. 65. An interview with a staff nurse on 01/09/06, revealed that no order was written to hold the medication. 66. An interview with the DON disclosed that this should have been followed-up with an incident report and notification to the physician. 67. Anorder, dated 12/31/05, prescribed, "Oxygen at 2 Liters via oxygen concentrator by nasal cannula continuously." Review of the care plan, dated 12/07/05, stated, "Keep oxygen in place as ordered." 68. Observation of Resident # 1 on 01/09/06, at 11:15 a.m., revealed the resident in bed with oxygen on at | Liter per minute, via nasal cannula. At 2:10 p.m. the resident was in bed and the oxygen was off, and at 4:10 p.m. the resident was in the day room without any oxygen from the concentrator or portable tanks. 69. An interview with the unit manager verified that the oxygen was to be on continuously. 70. The oxygen order had been clarified with the physician on 01/09/06 and an order written, "To discontinue continuous oxygen at 2 Liters; Apply oxygen at 2 Liters as needed for oxygen saturations below 90%." 71. Record review conducted on 01/10/06, revealed that the oxygen saturation was 95% on 01/10/06 for 7-3 shift. 72. Observation done on 01/10/06 at approximately 11:00 a.m. revealed Resident # 1 in bed with oxygen on at 2 Liters per minute via nasal cannula. 73. An interview with the unit manager verified the oxygen saturation reading was to be 95% and disclosed that the oxygen should have been turned off and the nasal cannula removed from the resident's nares. 74. An order for Resident # 1, dated 11/17/05, required, "Geri-gloves to bilateral arms. Wear at all times." 75. An interview with the DON verified that this order referred to bilateral Geri-sleeves. 76. Review of the care plan, dated 12/01/05, did not include any documentation of Geri- gloves to bilateral arms to be worn by Resident # 1 at all times. 77. Acare plan, dated 12/07/05, was obtained from the MDS coordinator documenting, "Geri-gloves on at all times." 10 78. Observation of Resident # 1 on 01/09/06, at 11:15 a.m. revealed the resident in bed with hands and arms bare. At 2:10 p.m. the resident was in bed with bare hands and arms. At 4:10 p.m. the resident was in the day room without the bilateral Geri-gioves on bilateral arms. 79. The Agency determined that the deficient practice would result in no more than minimal physical, mental, or psychosocial discomfort or had the potential to compromise the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as a State Class III deficiency. 80. The Agency provided Respondent with the mandatory correction date for this deficient practice of 02/10/06. 81. On, or about, 02/20/06, the Agency conducted a re-visit to the complaint investigation of Respondent conducted on 01/10/06. 82. Based on observation, interview and record review the facility failed to ensure physician orders for hand rolls and use of an elbow soft splint was applied as prescribed for one of six sampled residents. 83. Resident # 1 was admitted to the facility on 10/07/04, with diagnoses that included late effect hemiplegia, cerebral vascular accident and contractures. 84. On 02/20/06, the Agency observed Resident # 1 sitting in a wheelchair in the hall outside Room 213 with geri sleeves on both arms. Bilateral upper extremities, including the resident's hands, were observed with severe contractures. The residents right hand had a hand-roll placed in the palm of the hand; the left hand was without a hand-roll. Neither arm had any splints applied. 85. Continuous observation was conducted by the Agency from 11:55 a.m. through 1:08 p.m. when the resident was transported in the wheelchair to the day-room and then to the dining room. 86. ‘The left hand remained without a hand-roll and a splint was never applied to Resident # 1's right elbow during this observation period. 87. Additional observations from 6:15 p.m. through 6:25 p.m. revealed Resident #1 in bed without hand-rolls in either hand. 88. Record review on 02/20/06, revealed a physician's order, dated 01/31/06, and originally written 11/03/04, prescribing, "Hand rolls on at all times, except when bathing. Right elbow soft splint on when up in wheelchair. Check for pressure sore after wearing it.” 89. The "Abnormal Involuntary Movement Scale" completed by facility staff on 09/15/05, revealed no movement ability for Resident # 1's upper and lower extremity movement and stated, "Resident unable to flex or extend bilateral extremities due to contractures and unable to ambulate." 90. Further review of the care plan, dated 01/18/06, advised, "Certified Nurse Aide (CNA) will provide...hand roll on both hands at all times, except bathing. CNA will apply splint to the left elbow when up in wheelchair." 91. Aninterview was conducted with the medication nurse on 02/20/06, She reported she was unaware that Resident # 1 had an order for a splint to be applied to the right elbow and was unaware of the location of the splint. 92. The Agency determined that the deficient practice would result in no more than minimal physical, mental, or psychosocial discomfort or had the potential to compromise the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as an uncorrected State Class III deficiency. 93. The Agency provided Respondent with the mandatory correction date for this deficient practice of 03/20/06. 94. _ A State Class III uncorrected deficiency subjects Respondent to an administrative fine in the amount of $1,000.00. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2005), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2005). Respectfully submitted this Zip day of July 2006. Gerald L. Pickett Fla. Bar. No. 559334 Agency for Health Care Administration §25 Mirror Lake Drive, 330K St. Petersburg, Florida 33701 727.552.1526 (office) 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. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No: 7005 1160 0002 2254 8658 on July 9. \_, 2006 to: Corporation Service Company, Registered Agent, Perry Health Care Associates, LLC, d/b/a Marshal! Health and Rehabilitation Center, 1201 Hays Street, Tallahassee, Florida 32301-2525 and U.S. Mail to: Lisa Mitchem, Administrator, Marshall Health and Rehabilitation Center, 207 Marshall Drive, Perry, Florida 32347. Deohd) Ain) Gerald L. Pickett, Esquire Copies furnished to: Corporation Service Company Lisa Mitchem Gerald L. Pickett, Esquire Registered Agent Administrator Senior Attorney Perry Health Care Associates, Marshall Health and Agency for Health Care LLC, d/b/a Rehabilitation Center Administration Marshall Health and Rehabilitation | 207 Marshall Drive ' 525 Mirror Lake Drive, 330K. Center Perry, Florida 32347 St. Petersburg, Florida 33701 1201 Hays Street (U.S. Mail) (Interoffice) Tallahassee, Florida 32301-2525 (U.S. Certified Mail) Donna Stinson, Esq. Broad and Cassel 215 South Monroe Street, #400 P.O, Drawer 11300 Tallahassee, Florida 32302 SENDER: COMPLETE MIS SECTION @ Complete items 1, 2-03. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can retum the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. 1, Article Addressed to: orporation. Sewviee a Ongwwt » taal ‘lou, 5 Sheet Jadlahags ce, Men ola. Ato jepepsteted bewveny nm Fo 7005 L160 0002 2254 4b5a 2. Articla Number (Transfer from si COMPLETE THIS SECTIONAON DELIVERY. gpature WY) B. aa ved by (Printed Name] OI Agent Ol Addressee C, Date of Delipy D, Is delivery address different from item 1? 01 Yes — (f YES, enter delivery addrass below: [© No Marsha prec Doty, Cenlth Cone, Assaridtes Rehalo. Cr Lic Ndfbja. morshout Me ¥ ) Serica Type. © Gl Oertifed Mall * Cl Express Mall | —+~——___ C Registered “C1 Retum Receipt for Merchandise CI Insured Mall §~=1 C.D, ~ C Yes pp LENGE ¢ nnn or) FEB PS Form 8811, February 2004 Domestic Return Recelpt 102595-02-M-1540 }

Docket for Case No: 06-002921