ne “EE E my STATE OF FLORIDA Sa fos fF AGENCY FOR HEALTH CARE ADMINISTRATION? MAR 1 ¢ py 4 96 STATE OF FLORIDA, AGENCY FOR A pe VISION oc HEALTH CARE ADMINISTRATION, HINIS TRATIY IEARINGS YE ’ Petitioner, vs. AHCA No. 2007001548 HEARTHSTONE SENIOR COMMUNITIES, INC., . d/b/a BAY CENTER, : dS Respondent. O “| | Ole ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against HEARTHSTONE SENIOR COMMUNITIES, INC., d/b/a BAY CENTER, (hereinafter “Respondent” or “facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate a skilled nursing facility pursuant to Chapter 400. 00.121 (3) (4), Florida Statutes (2006) and to impose an administrative fine in the sum of thirty-five thousand dollars ($35,000) based upon two widespread Class I deficiencies and one isolated Class II deficiency, pursuant to Chapters 400,23(8) (a) and (b), Florida Statutes (2006). Additionally, this is an action assessing a $6,000.00 survey fee pursuant to Section 400.19(3) Florida Statutes (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, 400.121, Florida Statutes (2006). . 2. Venue lies in Bay County, Florida, pursuant to Rule 28-106.207, Florida Administrative Code (2006). PARTIES 3. The Agency is the regulatory authority responsible for licensure of skilled nursing homes and enforcement of all applicable federal regulations, state statutes, and rules governing skilled nursing homes pursuant to the Chapter 400, Part Tl, Florida Statutes, and Chapter 58A-4, Florida Administrative Code, respectively. 4. Respondent operates a one hundred sixty (160) bed skilled nursing home located at 1336 St. Andrews Boulevard, Panama City, Florida 32405, and is licensed as a skilled nursing home, license number 10340961. | 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I - Respondent failed to implement an effective. Infection Control Program to ~ ensure laboratory tests for culture and sensitivity were completed as ordered by the physician. Respondent failed to ensure employee health was implemented into the Infection Control Program. Respondent failed to implement a system to identify, investigate, control, and prevent Gastrointestinal Symptoms of residents. Respondent failed to ensure the environment was free of Infection Control i) hazards. Respondent failed to ensure the implementation of policies to prevent food borne illness for 57 out of 84 sampled residents, in contravention of Chapter 400.102(1)(a), Florida Statutes (2006) 6. ° The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. That on January 26, 2006, an annual licensure survey of the Respondent facility was conducted. 8. Based on record review, observations, resident and staff interview, and policy review, the facility failed to implement an effective Infection Control Program to ensure laboratory tests for culture and sensitivity were completed as ordered by the physician; failed to ensure employee health was implemented into the Infection Control Program; failed to implement a system to identify, investigate, control, and prevent Gastrointestinal Symptoms of residents; failed to ensure the environment was free of Infection Control hazards; failed to ensure the implementation of policies to prevent food borne iliness For 57 out of 84 sampled residents ( #2, #3, #7, #9, #11, #13, #14, #15, #16, #18, #20, #22, #23, #26, #27, #29, #30, #31, #32, #36, #42, H43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70; #71, #72, #73, #74, #75, #76, #77, #78) Immediate -- -—- Jeopardy was identified 1/26/07 and removed on 2/10/07. Scope and severity was reduced to an F, The findings include: a. The Resident Group Interview was conducted on 1/23/07 at 10:30 AM. During this interview the residents reported that there is some type of illness going around and that multiple residents are getting sick. An interview was conducted with Resident #13 on 1/22/07 at approximately 11:20 AM. Resident #13 stated that "lots of people are sick in here". He/she stated vs) that for a few days multiple people including him/herself have been sick on their stomachs and having diarrhea. b. A review of the medical records and interviews with staff and residents on 1/25/07 and 1/26/07 the following residents were noted to have experienced Gastrointestinal symptoms of Diarrhea and/or nausea and vomiting in January 2007: (the specific interviews with date and time are contained within this deficiency) 1) #67- (room 307A)- 1/2/07 2) #36- (room 415A) - 1/13/07 3) #42-(room 402B)- 1/13/07.. The resident died 1/14/07. 4) #45- (room 312A)- 1/14/07 5) #56-(room 401 A)- 1/15/07 and 1/17/07. 6) #7- (room 412A)- 1/15/07 7) #57- (room 413B)- 1/15/07 8) #51- (room 201B- 1/16/07 9) #58- (room 129A) - 1/16/07 Emergency Room 1/24/07 with a decline in condition. 10) #44- (room 311A)- 1/16/07, 1/17/07, 1/23/07, 1/24/07, 1/25/07. (A Protime with a critical value on 1/25/07.) 11) #59-(room 129B)- 1/17/07, 1/19/07, 1/22/07, 1/24/07. 12) #69 (room 111) 1/17/07, 1/18/07 13) )#13- (room 120B) - 1/8/07, 1/19/07, 1/20/07, 1/21/07, 1/26/07. 14) #46 - (room 208A)- 1/18/07, 1/21/07. 15) #20- (room 122)- 1/18/07 os 16) #60- (room 131A)- 1/18/07 17) #61- (room 132A)- 1/18/07. 18) #64- (room 130A)- 1/18/07, 1/20/07 (Spouse/Visitor with symptoms ) 19) #49- (room 215B)- 1/18/07, 1/21/07 20) #63 (room 136)1/18/07, 1/19/07, 21) #43- (room 301A)- 1/19/07, 1/20/07 22) #71 (room 109A) 1/19/07 23) #62 (room 132C) 1/20/07 24) #23- (room 206A)-~ 1/21/07 25) #I1- (FOGH ZTGA)- 1/21/07 — 26) #50 ~ (room 215A)- 1/21/07 , : 27) #26- (room 201A) - 1/21/07 " 28) #2- (room 206B) - 1/21/07- 29) #29 - (room 114) - 1/21/07 —- Hospitalized on 1/22/07. 30) #47 - (room 219B)- 1/22/07- Hospitalized 1/23/07 with critical Protime value. 31) #48- (room 216B)- 1/22/07 . 32) #53- (room 220A)- 1/22/07, 1/24/07 33) #55- (room 209B)- 1/22/07, 1/23/07, 1/24/07 34) #54- (room 209A)- 1/23/07, 1/24/07. 35) #52- (room 218) - 1/23/07. 36) #72- (room 101)- 1/25/07, 1/26/07. 37) #78- (room 213B)- 1/25/07, 1/26/07. 38) #73- (room 307) - 1/25/07, 1/26/07. 39) #74- (room 309) - 1/26/07. 40) #22- (room 204) - 1/25/07, 1/26/07 41) #75- (room 205) - 1/25/07, 1/26/07. 42) #76- (room 312)- 1/25/07, 1/26/07. 43) #77- (room 210B)- 1/26/07. The following resident information was obtained via staff and resident interview which confirmed symptoms of Nausea/Vomiting and/or Diarrhea. The medical record was incomplete and did not specify the dates and specific Gastrointestinal symptoms. The specific interviews are contained within this deficiency with dates and times. 44) #32 (room 120A) 45) #16 (room 127) 46) #15 (room 125B) 47) #27 (room 118) 48) #65 (room 123) 49) #3 (room 126) 50) #18 (room 128) 51) #66 (room 302A) 52) #68 (room 106B) © 53) #70 (room 113A) 54) #31 (room 217A) The 100 Hall - 22 residents exhibiting Gastrointestinal Symptoms. The 200 Hall - 19 residents exhibiting Gastrointestinal Symptoms. The 300 Hall - 8 residents exhibiting Gastrointestinal Symptoms. The 400 Hall - 5 residents exhibiting Gastrointestinal Symptoms. 54 residents of a current census of 129 exhibited Gastrointestinal Symptoms of ‘Nausea/Vomiting and/or Diarrhea during the month of January 2007. (42%) Cc. An interview with the Director of Nurses (DON) on 1/25/07 at 8:40 A.M. stated the facility Lab and Infection Control process includes: - Nurse observes signs and symptoms of an infection and contacts the physician. - The nurse writes the physician order and completes an infection control sheet - The infection control sheet goes to the DON who logs the information - The DON diagrams the rooms in a color code for the type of infection - If a pattern is noted the DON in services staff and reports to the monthly QA meeting. The DON stated the she began reviewing all physician orders about 2 months ago. The DON reviews the infection control sheets, which are completed by the nurse. If the nurse did not complete an infection control sheet the DON would go to the nurse to complete the sheet. The DON, as the Risk Manager, would track and trend the infections. The DON was the Risk Manager until 12/25/06, when a new employee was hired. The DON stated the last Infection Control in service to all staff was in December 2006 on hand-washing. The DON stated the last trend identified was related to Urinary Tract Infections in residents with a catheter. The DON stated the infection rates have gone up since the in service. But the DON stated the increase was related to increased reporting of infections by the staff. d. Review of Resident #14's clinical record revealed the results of a urinalysis with culture and sensitivity dated 12/20/06. The results stated: catheterized urine, greater than 100,000 organisms/ml PROVIDENCIA RETTGERI, Multiple organisms isolated from this urine specimen’ suggesting possible contamination. Predominant organism listed above. Final 12/23/06. A hand written note on the bottom of the report states 12/23/06 repeat UA, C&S. A review of the nurse note dated 12/23/07 stated a verbal order was received to repeat the UA/C&S. Further review of resident #14's clinical record contained no evidence of a second completed UA, C&S or treatment of the UTI. The facility did not communicate to the physician the failure to complete the ordered lab. An interview conducted with RN assisting in care for resident #14 on 01/24/07 at approximately 12:50 p.m. confirmed that a repeat UA, C&S is not included in this resident's chart. She stated that she would call the lab to see if they have the results for this resident. She was asked if there was anywhere else in the chart that the test might be documented. She states that the nurse who received the original urinalysis results should have contacted the resident's doctor. The nurse should have written an order in resident #14's chart. She should have written it in the lab book, and in her nurses notes. Record review revealed no evidence of a written physician order for the repeat U/A C&S. The Lab Request Book contained a request from the RN for a Urine C&S dated 12/23/06. The RN contacted the lab to attempt to retrieve a report for the U/A C&S for 12/23/06. The lab told the nurse they did not receive a specimen for resident #14 for 12/23/06. The RN contacted the physician to obtain a new order for a urinalysis. The order was received on 01/24/07 for a STAT urinalysis with C&S. The _specimen-report.was-dated-01/25/07 as.the.date the specimen was received. Results of the original urinalysis done on 12/20/06 sliow a white blood cell count 10 to 20-with a normal range of 0-10, and the preliminary results of the urinalysis done 01/25/07 revealed a white blood cell count increased to 30 to 50. These results confirm that the white blood cells, the cells responsible for reacting to infection, have increased in the Jast month, while the resident has gone without treatment. An interview was conducted with RN on 01/25/07 at 9:23 a.m. She stated that the process of reporting lab results includes writing the fax number of the unit that the resident is on for the lab to fax their report to, but she is not sure what other murses do. She was asked if a number is not written on the lab request, where the report would be faxed. She stated she thinks the lab would probably fax the report to the Administrative office. Continued review of resident #14's clinical record revealed the vital signs record with the last vital signs entry on 12/22/06. The entry documents the resident's temperature as 98.0, pulse of 74, respirations 20, and blood pressure 124/76. An interview with the RN on 01/24/7 at 12:55 p.m., she states that the nurses taking care of resident #14 should be documenting her vital signs weekly. Vitals signs done on 01/24/07 as documented in the nurses notes include: temperature 99,3, pulse 96, respirations 17, and blood pressure 125/68. Elevated temperature and pulse may indicate the presence of infection. An interview of the DON on 1/25/07 at 8:40 A.M. stated the nurse is responsible for the error in obtaining the Urine C&S for resident #14 due to failing to write the order and putting a lab-slip in the lab book. The Quality Assurance system ~ to ensure physician lab orders are completed includes the medical records staff member to audit the medical records monthly for completion of labs, orders, complete charts. The medical records staff member gives a list of labs missed to the DON and Risk Manager. The Unit Managers do separate lab audit. The 11-7 shift completes the lab paperwork, places a copy of the lab request in a lab manual, the Jab person comes in each morning, the results of the lab are faxed to the 300 Hall which distributes the results tothe nurses. The Unit Managers audit | the lab book each day and remove the lab request as the results are received. The Unit Managers, DON, :and Risk Manager review the 24 hour report each morning. The nurses document any stat or extra labs which were ordered. The nurses fax ’ the lab results to the physician. If no response in 24 hours then the nurse contacts the physician again. If still no response the nurse is to contact the Medical Director. A review of the December 2006 Monthly Infection Control Log does not list the resident #14. An interview with the Medical Records staff member on 1/24/07 at 12:55 P.M. stated she audits the medical record for routine labs.’ She does not audit for stat or other unscheduled. labs. e. A review w oF the lab request form book for the Unit 100 Hall contains lab requests from 10/06 until 1/25/07. The book contains a lab request for resident #14 Urine with C&S dated 12/23/06. The facility was unable to provide the completion and results of this test. The Unit has a lab tracking book and lab request book which do not match. A request for a C&S for C-Diff dated 1/16/07 for resident #58 is noted in the lab request book. A review of the resident #58's medical record the resident was experiencing diarrhea and the physician ordered a C&S to rule out C-Diff on 1/16/07. The nurse notes document the obtaining of the specimen. An interview with a Staff Developer/Registered Nurse (RN) on 1/25/07 at 9:30 A.M. stated she just received a C&S obtained on 1/19/07, so the result of 1/16/07 should be in the medical record. The Staff Developer phoned the lab which stated they did not receive the specimen. The Risk Manager on 1/15/07 at 3:30 P.M. brought the surveyor a stool sample test dated 1/19/07 for resident #58. The test did include a C&S for C-Diff. A review of the facility's policy titled Clostridium Difficile: Preventing Spread; states Clostridium Difficile (C-diff) is a spore-forming gram-positive anaerobic bacillus that produces at least two exotoxins. The organism causes gastrointestinal infections that range in severity from asymptomatic colonization to severe diarrhea. ' f. An interview with a CNA on 1/25/07 at 12:20 P.M. stated she is assigned to the 100 Hall. A review of her current assignment sheet with 9 residents listed. The CNA stated 6 of these residents have experienced diarrhea. (#16, 18, 20, 27, 15,58) The CNA stated 2 of the residents have experienced Nausea and Vomiting. (#65 and #3) The CNA stated only one resident has not developed Gastrointestinal Symptoms. The CNA stated the symptoms began approximately 1 and 1/2 weeks ago. The symptoms began with resident #58 and then spread to the other residents. The resident #58 is ambulatory and the CNA stated "goes all over the.building." g. An interview with a CNA on 1/25/07 at 4:00 P.M. stated she has just returned to work after experiencing Diarrhea with nausea and vomiting. The CNA stated last Thursday (1/18/07) began feeling sick at work. The CNA notified the nurse and another CNA was brought in to assist her with the completion of her shift. The CNA stated she told the nurse she had the same symptoms as the residents. The CNA stated could not work on Friday (1/19/07) and notified the facility of Gastrointestinal Symptoms, The CNA stated the Gastrointestinal symptoms began on the 100 Hall with resident #58. The symptoms then spread to the resident's roommate (#59). The symptoms then spread to resident #20, 64, 27, 32, 13, and then #15. The CNA stated resident #13 has had diarrhea for 10 days. The CNA stated another CNA currently can not work due to having caught the same symptoms. She stated the residents on the -00-Hall-are-mostly-ambulant. There are some residents which prefer to stay in theirroom. The 100 Hall also has residents with tracheostomy and bed-bound residents. The CNA stated the symptoms seem to last a couple of days and resident #27 was up in her wheelchair throughout the facility when she was experiencing the symptoms. h. An interview was conducted with Resident #15 at approximately 09:15 a.m. on 1/26/07. The resident is coded as a 0 on the MDS for cognition indicating no cognitive impairment. The resident was asked if he was aware of anyone who is currently exhibiting signs of being sick such as nausea, vomiting, or diarrhea. The resident stated that his nurse last night told him she was too sick to do his dressing change, and she would have to get another nurse to do it. The resident thought the nurse went home sick. i. On 1/25/07 at approximately 2:00 P.M. the January Infection Control-Log was requested. The Risk Manager/Infection Control Coordinator stated she did not have the log. The infection control information was not collected until the end of the month. . An interview with the Risk Manager/Infection Control Coordinator on 1/25/07 at 2:45 P.M. gave the two surveyors a map of the facility layout with rooms of residents identified with the gastrointestinal symptoms indicated. The Infection Control Log does not contain information of the Gastrointestinal symptoms. The Coordinator stated had determined it was a "self-limiting virus." The Coordinator stated had determined this because the symptoms resolve in 24 to 48 hours. The Coordinator stated was "keeping up with who has symptoms." The Coordinator _ gave the surveyors a hand written list of residents from each hall. The list contained no further information, such as, dates of onset, resolution and symptoms. The Coordinator stated has begun this week "reinforcing" hand- washing with nurses and CNA's. The Coordinator has not addressed other staff, such as, dietary and therapy. The Coordinator stated she had notified the Department of Health of the Gastrointestinal Symptoms yesterday (1/24/07). The Coordinator was unable to provide details of whom she spoke with and time. Upon further questioning the Coordinator stated she did not actually. call the Department of Health. She stated the DON had called, but she had no further information. The Coordinator continuously referred to the illness as a virus, but was unable to conclusively describe how she arrived at this diagnosis. The Coordinator was unable to provide evidence the facility attempted to rule out food ” borne illness, C-Diff or other bacterial infection. The Risk Manager was asked if aware the C-Diff C&S was not completed on 1/16/07 for resident #58. She stated was unaware the test was not completed. The resident is listed on the January Infection Control Log. The Coordinator was asked if any staff had missed work due to symptoms. The Coordinator stated "don't know." The Coordinator stated "will begin" monitoring employee health as part of Infection Control, but is not currently reviewing this information. The Risk Manager stated the Gastrointestinal symptoms first came to her attention on 1/22/07. The only intervention to the outbreak of Gastrointestinal symptoms by the Risk Manger has been "paying attention.” An interview with the DON on 1/25/07 at 3:25 P.M. stated had left a message with the Department of Health on 1/24/07 but did not speak with the agency until today 1/25/07. The Department of Health will be to the facility on 1/26/07 to investigate the outbreak. The agency stated the symptoms seem to indicate possibly a Norovirus. The DON has no written report of the information reported to the Department of Health. The DON stated the virus usually lasts 24 to 36 hours with a gestation period up to 48 hours before symptoms are demonstrated. The DON stated had spoken with staff about washing hands and the facility will keep residents in the room "as much as possible.” An interview with the DON on 1/25/07 at 3:40 P.M. with a review of a report of a C&S of the stool from resident #58 dated 1/19/07 does not contain a C&S for C- - Diff. The DON confinns this and stated would check on the culture. (There was not further evidence provided during the survey.) A review was made with the DON of the list given by the Risk Manager of residents with symptoms, which does not include the symptoms identified and a date of onset or resolution. The DON stated those 27 residents no longer have symptoms and there is currently no one in the building experiencing Diarrhea, Nausea or Vomiting. The DON stated interviewed every staff member and resident and there is currently no resident or staff member with symptoms. The DON brought in the facility's CNA assignment sheet which lists bowel movement. The DON stated the assignment sheet is a legal document.and signed by the CNA. She stated the facility keeps these sheets. The DON stated the assignment sheets do not state any diarrhea. A review of the assignment sheets only list bowel movements of medium, large, or extra large. The sheets do not state how many bowel movements, the time of the movements, or further analysis of the consistency. Many residents are listed as "Self" without any further documentation. An interview with the DON on 1/25/07 at 4:05 P.M. stated she had obtained no further information on the Norovirus. The facility has no printed information of CDC guidelines on the virus. The DON stated the virus is difficult to kill and . there are no current "person" in the building with the symptoms. . . An interview with the resident #44 on 1/25/07 at 4:45 P.M. stated he has been experiencing diarrhea but has not had any today. The resident stated he is still nauseated. j. An interview with the DON on 1/26/07 at 10:25 A.M. stated the medical director and nurses had reviewed each of the residents the night of 1/25/07. The DON stated each resident was given treatment if indicated and an Infection Control Survelliance sheet was completed. The surveyor requested.a list of the residents exhibiting symptoms. The DON stated did not keep a list and would --—have-to-pull-each-medical-_record.—_On-1/26/0Lat-10:30.A.M..the Risk Manager ~and Unit Manager-were observed pulling each medical record to obtain the names of resident's currently exhibiting symptoms. The facility did not maintain a list of residents to track and trend the gastrointestinal symptoms within the facility. On 1/26/07 at 10:45 A.M. the DON brought a list of 6 residents with Gastrointestinal symptoms identified by the facility: - #76- 1/25/07 - #73- 1/25/07 and 1/26/07 - #22- 1/25/07 - #78- 1/25/07 and 1/26/07 - #75- 1/25/07 . 10 - #72- 1/25/07 and 1/26/07. k. An interview with the LPN on Hall 1 on 1/25/07 at 12:10 P.M. stated resident #11, #13, and #32 are experiencing Diarrhea. A review of the medical records on Hall 1 experienced the following symptoms: - #58 had experienced diarrhea 1/16/07 with a C-Diff ordered which was not completed. ; - #59 Diarrhea on 1/17/07. - #20 Diarrhea on 1/18/07. - #13 Diarrhea- receiving Imodium. - #60 Nausea/vomiting and Diarrhea 1/18/07. - #61 Nausea/vomiting and Diarrhea 1/18/07. - #63- Nausea and vomiting. - #64- Nausea and vomiting and Diarrhea. (Currently in Hospital) 1. An interview with the LPN on Hall 3 on 1/25/07 at 1:50 P.M. stated resident #44 and #66 are currently experiencing diarrhea with nausea and vomiting. A review of the Hall 3- 24 hour reports stated on 1/23/07 the resident #44 experienced nausea and vomiting 8 times. A review of the medical records for Hall 3 the following residents experienced the following: - #45- Vomiting - #44- nausea, vomiting and diarrhea. - #67- 1/2/07 nausea and vomiting. m. A review of the medical records for Hall 4 - 24 hour reports on 1/13/07- resident #36 with nausea and vomiting, on 1/14/07 resident #42 with nausea and vomiting and diarrhea leading to his death that morning then on 1/15/07 - resident #56- with 3 large watery bowel movements, resident #7 - with 3 large watery bowel movements, and resident #57 with 2 large watery bowel movements. n. On 1/25/07 beginning at 12:15 P.M. the following residents were interviewed related to Gastrointestinal Symptoms: ~= #13 stated had: diarrhea o on Sunday 1/21/07-- -#32 stated had vomiting about 1 week ago -#64 stated, "Yeah, I had both vomiting and diarrhea. “My wife came and visited and now she has it - starting last night - both vomiting and diarrhea." - #71 stated had vomiting and diarrhea for 2 or more days within the last week or sO. -#59 stated had vomiting and diarrhea starting last Friday and lasting until Monday (1/22/07) - #31 stated had cramping of the stomach and diarrhea about a week ago. - #72 stated had both vomiting and diarrhea about 2 weeks ago. - #52 stated had diarrhea 2 days ago on Tuesday (1/23/07). - #50 stated had vomiting and diarrhea about a week and a half ago. - #51 stated had diarrhea for 2-3 days about 2 weeks ago. - #15 stated had 2 days worth of diarrhea and was very nauseated within the last few days. - #16 stated had 3 days of diarrhea about 5 days ago. 0. During the initial tour of the facility on 1/22/07 at approximately 9:00 a.m. the following observations were made: --In room 136 a blue cushion for a wheelchair lying on floor ; --Outside room 115, three bags of soiled pads and trash in hallway --In'room 220 a'soiled towel on floor and water basin on floor unlabeled --In room 211 a denture cup without a top sitting on window sill --In room 206, bed A, Nebulizer tubing lying on floor .--Used syringe laying on top of sharps container on Medication cart instead of being placed in the sharps container --In room 220 a soiled towel on floor --In room 123 a urinal on floor, urinal % filled --In room 124, % full urinal sitting on top of dresser --In room 122, a blue pad standing up.on floor next to wall During a tour of the facility was conducted on 1/23/07 at approximately 7:30 a.m., the following observations were noted: --In room 209 (shared by 4 residents) toilet extender has yellow and brown substance ~ --In shower room on 2™ hallway, a foot rest lying on floor On 1/44/07 at approximately 2:00 p.m. resident # 30 was observed walking down the 100 hallway from the toilet at the end of the hallway with a % full urinal. Resident # 30 was observed entering into his room, 121. An interview was conducted with the Director of Nursing (DON) on 1/24/07 at approximately 2:05 p.m. The DON stated, “Resident # 30 is very weird. I will _ooomtake:care- oft" ae yippee cee ee On 1/24/07 this surveyor entered into resident # 30's room, 121, and observed 4 urinals sitting on a table behind multiple items. One of the urinals was % full with urine. An observation was conducted of Resident #3 on 1/23/07 at approximately 8:40 AM. This observation occurred in the resident's bedroom. Upon entering the resident's room this surveyor noted strong urine like smell. It was noted that there was a yellow colored puddle under the bedside commode which was located to the right of the resident's bed. An interview with the resident at this time stated that he/she had used to commode this morning and thought he/she must have spilt some urine. The resident stated that the urine had been on the floor about a half hour. An additional observations of this resident on 1/23/07 at approximately 9:20 AM and at approximately 11:00 AM revealed the yellow puddle remained on the floor under the bedside commode. p. An interview was conducted with the Staffing Coordinator on 1/125/07 at approximately 3:00 p.m. When the Staff coordinator was questioned about staff calling in sick due to gastrointestinal symptoms, she stated the call in 's were as following: 1/19/07 1C.N.A. related to virus 1/20/07 1 Licensed Practical Nurse (LPN) related to virus ; 1/21/07 2 Certified Nursing Assistants (C.N.A.) related to a virus 1/22/07 4C.N.A.s.(3 related to a virus) : 1/23/07 2 C.N.A:s related to a virus 1/24/07 2 CN.A. related to a virus 1/25/07 1 related to a-virus q. A review of the Centers for Disease Control (CDC) report dated 8/3/06 stated diarrhea and vomiting can be caused by a virus, bacteria, medical conditions, or medications. The physician should determine the cause of Gastrointestinal Symptoms. These symptoms are serious for persons who are unable to drink enough fluids to replace what they lose through vomiting or _ diarrhea. Persons who are unable to care for themselves, disabled, or elderly are at risk for dehydration from loss of fluids. Immune compromised persons are at risk for dehydration because they may get a more serious illness, with greater vomiting or diarrhea. They may need to be hospitalized for treatment to correct or prevent dehydration. The viral gastrointestinal symptoms are contagious and are spread through close contact with infected persons, for example, by sharing food, water, or eating utensils, or eating or drinking contaminated foods or beverages.” The disease is diagnosed on the basis of symptoms, medical examination, and laboratory testing of a stool specimen. Persons can reduce their chance of getting infected by frequent hand-washing, prompt disinfection of contaminated surfaces with household chlorine bleach-based cleaners, and prompt washing of soiled: articles of clothing- ——— ~~ According to an article by the CDC "Empiric Use of Airbome, Droplet, or Contact Precautions" the risk of nosocomial transmission of infection may be highest before a definitive diagnosis can be made. The routine use of Standard Precautions for all patients should reduce this risk for conditions other than those requiring Airborne, Droplet, or Contact Precautions. While is is not possible to prospectively identify all patients needing these enhanced precautions, certain clinical symptoms (Diarrhea/Vomiting) carry a sufficiently high risk to warrant the empiric addition of enhanced precautions while a more definitive diagnosis is pursued. To ensure the appropriate empiric precautions are implemented the facility must have a system in place to evaluate residents. I. A review of the facility policy Infection Prevention and Control Program the facility is to strive to prevent and contro] endemic and epidemic nosocomial infections for the protection of residents, staff, and visitors. The goal is to identify and reduce the risks of acquiring and transmitting infections among residents, staff, and visitors. The facility utilizes nationally recognized organizational standards and procedures, such as, the CDC. The process is designed to lower the risks and improve the trends and rates of epidemiologically significant infections. The process includes: prevention, Surveillance, and control. The facility utilizes various sources of data for infection surveillance including; employee absenteeism report, Infection tracking log, Laboratory data, and medical records, and Interdisciplinary 24 hour reports. The facility failed to implement an effective Infection Control Process utilizing these sources of data to identify and prevent the transmission of Gastrointestinal Symptoms. s. An observation and interview was conducted with Resident #13 on 1/22/07 at approximately 11:20 AM. The resident was located in his/her bedroom lying supine in bed. The resident confirmed that he/she has a pressure sore on his/her coccyx. The resident stated that he/she goes to Dialysis on Tuesday, Thursday and Saturdays. Resident #13 stated that "lots of people are sick in here". He/she stated that for a few days multiple people including him/herself have been sick on their stomaché and having diarrhea. The resident stated that a few days ago he/she "sat in poop" at Dialysis. He/She stated that the facility ‘was aware of that and that he/she had reported it to the staff. Record review for Resident #13 was conducted 1/22/07- 1/25/07. The medical record review revealed the resident currently has a’ Stage 3 decubitus to his/her coccyx. The medical record revealed a Telephone Physician Order dated 12/19/06 to cleanse coccyx wound with normal saline and apply preppies skin barrier wipe to peri wound area, lightly pack with curagel gauze and cover with Telfa Island every day. Review also revealed a Telephone Order dated 1/8/07 for resident to receive Imodium for diarrhea. Review of the resident care plan for the coccyx wound updated date of 1/4/07 revealed the facility interventions were to complete weekly and as needed skin _—--grid-with skin assessments, and toreport.changes in the.siteto.the Physician. Review of the Skin Grid for this resident revealed the last assessment recorded on the form was 1/14/07. The facility documented the coccyx wound on 1/14/07 as a Stage 3, length was 3 centimeters, width was 1.6 centimeters and the depth was 2 centimeters. Prior to this assessment date of 1/14/07, the facility completed an assessment on 1/7/07 and documented the coccyx wound as a Stage 3, length was 2 centimeters, width was 1.0 centimeters and width was 1.5 centimeters. No assessment was documented as completed on 1/21/07. From this skin grid review it was noted by this surveyor that the coccyx wound increased in length from 2 centimeters to 3 centimeters, increased in width from 1.0 centimeters to 1.6 centimeters and increased in depth from 1.5 centimeters to 2 centimeters from the dates of 1/7/07 to 1/14/07. | 8 @ Review of the Nurses Noted revealed a note dated 1/20/07 at 12 noon that the "resident returned from Dialysis full of BM (diarrhea) front and back up to the waist. Resident has been sitting in BM since 6 AM Resident has wound on coccyx + Dsg was soiled with BM Dsg removed wound cleaned + redressed"{sic]. Nurses Notes on 1/20/07 11:00 PM to 7:00 AM also revealed that the resident had 2 loose stools. Nurses Notes on 1/21/07 at 11:00 AM revealed resident was complaining of diarrhea and Imodium was given. Nurses Notes on 1/22/07 11:00 PM to 7:00 AM revealed the resident was given Imodium for diarrhea , Review of Resident #13's medical record failed to reveal any interventions provided by the facility or any physician notification when the wound got worse from 1/7/07 to 1/14/07, also failed to reveal any physician notification of the resident returning home from Dialysis in diarrhea. Review also failed to reveal -any documented coordination of care for Resident #13 with the Dialysis Center related to him/her sitting in BM. An interview was conducted with the R.N. Unit Manager for this resident on 1/24/07 at approximately 5:15 PM. during this interview. 9. Based on record review, observations, resident and staff interviews it was determined the facility failed to ensure the medical director assumed responsibility for coordination of medical care to implement an effective Infection Control program, ensure employee health was - implemented into the Infection Control program, implement a system to identify, investigate, control and prevent Gastrointestinal symptoms of residents, and assist the facility in resolving a conflict affecting resident care and medical care related to provision of care for fifty-seven (57) out of eighty-four (84) sampled residents. (#2, #3, #7, #9, #11, #13, #14, #15, #16, #18, #20, #22, #23, #26, #27, 29, #30, #31, #32, #36, #42, #43, #44, HAS, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, 475, #76, #77, #78) Immediate jeopardy was identified on 1/26/07 and removed on 2/10/07. Scope and severity was reduced to an F. The findings include: a. A review of the medical records and interviews with staff and residents on 1/25/07 and 1/26/07 the following residents were noted to have experienced Gastrointestinal symptoms of diarrhea and/or nausea and vomiting in January 2007: 1) #67- (room 307A)- 1/2/07 2) #36- (room 415A) - 1/13/07 3) #42-(room 402B)- 1/13/07. The resident died 1/14/07. 4) #45- (room 312A)- 1/14/07 5) #56-(room 401A)- 1/15/07 and 1/17/07. 6) #7- (room 412A)- 1/15/07 7) #57- (room 413B)- 1/15/07 8) #51- (room 201B- 1/16/07 . 9) #58- (room 129A) - 1/16/07 Emergency Room 1/24/07 with a decline in condition. ; 10) #44- (room 311A)- 1/16/07, 1/17/07, 1/23/07, 1/24/07, 1/25/07. (A Protime with a critical value on 1/25/07.) 11) #59- (room 129B)- 1/17/07, 1/19/07, 1/22/07, 1/24/07. 12) #69 (room 111) 1/17/07, 1/18/07 13) )}#13- (room 120B) - 1/8/07, 1/19/07, 1/20/07, 1/21/07, 1/26/07. . 14) #46 - (room 208A)- 1/18/07, 1/21/07. 15) #20- (room 122)- 1/18/07 16) #60- (room 131A)- 1/18/07 17) #61- (room 132A)- 1/18/07. 18) #64- (room 130A)- 1/18/07, 1/20/07 (Spouse/Visitor with symptoms ) 19) #49- (room 215B)- 1/18/07, 1/21/07 20) #63 (room 136)1/18/07, 1/19/07, 21) #43- (room 301A)- 1/19/07, 1/20/07 22) #71 (room 109A) 1/19/07 23) #62 (room 132C) 1/20/07 24) #23- (room 206A)- 1/21/07 25) #11- (room 216A)- 1/21/07 26) #50 - (room 215A)- 1/21/07 27) #26- (room 201A) - 1/21/07 28) #2- (room 206B) - 1/21/07- 29) #29 - (room 114) - 1/21/07 —_ Hospitalized on 1/22/07. 30) #47 - (room 219B)- 1/22/07- Hospitalized 1/23/07 with critical Protime value. 31) #48- (room 216B)- 1/22/07 32) #53- (room 220A)- 1/22/07, 1/24/07 33) #55- (room 209B)- 1/22/07, 1/23/07, 1/24/07 34).#54- (ro9m.209A)- 1/23/07, 1/24/07, _ -- 35) #52- (room 218) - 1/23/07. ~ . 36) #72- (room 101)- 1/25/07, 1/26/07. 37) #78- (room 213B)- 1/25/07, 1/26/07. 38) #73- (room 307) - 1/25/07, 1/26/07. 39) #74- (room 309) - 1/26/07. 40) #22- (room 204) - 1/25/07, 1/26/07 41) #75- (room 205) - 1/25/07, 1/26/07. 42) #76- (room 312)- 1/25/07, 1/26/07. 43) #77- (room 210B)- 1/26/07. The 100 Hall - 22 residents exhibiting Gastrointestinal Symptoms. The 200 Hall - 19 residents exhibiting Gastrointestinal Symptoms. The 300 Hall- 8 residents exhibiting Gastrointestinal Symptoms. The 400 Halil- 5 residents exhibiting Gastrointestinal Symptoms. 54 residents of a current census of 129 exhibited Gastrointestinal Symptoms of Nausea/Vomiting and/or Diarrhea during the month of January 2007. (42%) b. An interview with the Director of Nurses (DON) on 1/25/07 at 8:40 A.M. stated the facility Lab and Infection Control process includes: - Nurse observes signs and symptoms of an infection and contacts the physician. - The nurse writes the physician order and completes an infection control sheet - The infection control sheet goes to the DON who logs the information - The DON diagrams the rooms in a color code for the type of infection - If a pattern is noted the DON in services staff and reports to the monthly QA _ Meeting. Cc. The DON stated the she began reviewing all physician orders about 2 months ago. The DON reviews the infection control sheets, which are completed by the nurse, If the nurse did not complete an infection control sheet the DON would go to the nurse to complete the sheet. The DON, as the Risk Manager, would track and trend the infections. The DON was the Risk Manager until 12/25/06, when a new employee was hired. The DON stated the last Infection Control in service to all staff was in December 2006 on hand-washing. The DON stated the last trend identified was related to Urinary Tract Infections in residents with a catheter. The DON stated the infection rates have gone up. since the in service. But the DON stated the increase was related to increased reporting of infections by the staff. d. On 1/25/07 at approximately 2:00 P.M. the January Infection Control Log was requested. The Risk Manager/Infection Control Coordinator stated she did not have the log. The infection control information was not collected until the end of the month. An interview with the Risk Manager/Infection Control Coordinator on 1/25/07 at 2:45 P.M. gave the two surveyors a map of the facility layout with rooms of residents identified with the gastrointestinal symptoms indicated, The Infection Control Log does-not-contain information of-the-Gastrointestinal symptoms. The... Coordinator stated she had determined it was a "self-limiting virus." The Coordinator stated had determined this because the symptoms resolve in 24 to 48 hours. The Coordinator stated was "keeping up with who has symptoms." The Coordinator gave the surveyors a hand written list of residents from each hall. The list contained no detailed information, such as, dates of onset, resolution or symptoms. The Coordinator stated has begun this week "reinforcing" hand- washing with nurses and CNA's. The Coordinator has not addressed other staff, such as, dietary and therapy. The Coordinator stated she had notified the Department of Health of the Gastrointestinal Symptoms yesterday (1/24/07). The Coordinator was unable to provide details of whom she spoke with and time. Upon further questioning the Coordinator stated she did not actually call the Department of Health. She stated the DON had called, but she had no further information. The Coordinator continuously referred to the illness as a virus, but was unable to conclusively describe how she arrived at this diagnosis. The Coordinator was unable to provide evidence the facility attempted to rule out food borne illness, C-Diff or other bacterial infection. The Risk Manager was asked if aware the C-Diff C&S was not completéd on 1/16/07 for resident #58. She stated was unaware the test was not completed. The resident is listed on the January Infection Control Log. . The Coordinator was asked if any staff had missed work due to symptoms. The Coordinator stated "I don't know." The Coordinator stated "will begin" . monitoring employee health as part of Infection Control, but is not currently reviewing this information. The Risk Manager stated the Gastrointestinal symptoms first came to her attention on 1/22/07. The only intervention to the _ outbreak of Gastrointestinal symptoms by the Risk Manger has been “paying attention." €. An interview with the DON on 1/25/07 at 3:25 P.M. stated had left a message with the Department of Health on 1/24/07 but did not speak with the agency until today 1/25/07. The Department of Health will be to the facility on 1/26/07 to investigate the outbreak. The agency stated the symptoms seem to indicate possibly a Norovirus. The DON has no written report of the information reported to the Department of Health. The DON stated the virus usually lasts 24 to 36 hours with an incubation period up to 48 hours before symptoms are demonstrated. The DON stated she had spoken with staff about washing hands and the facility will keep residents in the room "as much as possible." f. An interview with the DON on 1/25/07 at 3:40 P.M. with a review of a report of a C&S of the stool from resident #58 dated 1/19/07 does not contain a C&S for C-Diff. The DON confirms this and stated would check on the culture. (There was not further evidence provided during the survey.) A review was made with the DON of the list given by the Risk Manager of residents with symptoms, which does not include the symptoms identified and a date of onset or resolution. The DON stated those 27 residents no longer have symptoms and ...._there.is. currently no one in the building ‘experiencing Diarrhea, Nausea or Vomiting. TheDON stated every staff member. and resident was interviewed and - there is currently no resident or staff member with symptoms. B. An interview with the DON on 1/26/07 at 10:25 A.M. revealed the medical director and nurses had reviewed each of the residents the night of 1/25/07. The DON stated each resident was given treatment if indicated and an Infection Control Survelliance sheet was completed. The surveyor requested a list of the residents exhibiting symptoms.’ The DON stated she did not keep a list and would have to pull each medical record. On 1/26/07 at 10:30 A.M. the Risk Manager and Unit Manager were observed pulling each medical record to obtain the names of resident's currently exhibiting symptoms. The facility did not maintain a list of residents to track and trend the gastrointestinal symptoms within the facility. : On 1/26/07 at 10:45 A.M. the DON brought a list of 6 residents with Gastrointestinal symptoms identified by the facility: - #76- 1/25/07 - #73- 1/25/07 and 1/26/07 - #22- 1/25/07 * ~~ #78- 1/25/07 and 1/26/07 - #75- 1/25/07 - #72- 1/25/07 and 1/26/07. h. An interview with the LPN on Hall 1 on 1/25/07 at 12:10 P.M. stated resident #11, #13, and #32 are experiencing Diarrhea. A review of the medical records on Hall 1 experienced the following symptoms: - #58 had experienced diarrhea 1/16/07 with a C-Diff ordered which was not completed. - #59 Diarrhea on 1/17/07. - #20 Diarrhea on 1/18/07. - #13 Diarrhea- receiving Imodium. - #60 Nausea/vomiting and Diarrhea 1/18/07. - #61 Nausea/vomiting and Diarrhea 1/18/07. - #63- Nausea and vomiting. - #64- Nausea and vomiting and Diarrhea. (Currently in Hospital) i. An interview with the LPN on Hall 3 on 1/25/07 at 1:50 P.M. stated resident #44 and #66 are currently experiencing diarrhea with nausea and vomiting. A review of the Hall 3- 24 hour reports stated on 1/23/07 the resident #44 experienced nausea and vomiting 8 times. A review of the medical records for Hall 3 the following residents experienced the following: 2 #45- Vomiting - #44- nausea, vomiting and diarrhea. - #67- 1/2/07 nausea and vomiting. : A review of the medical-records-for Hall 4 --24 hour reports on 1/13/07- resident #36 with nausea and vomiting, on 1/14/07 resident #42 with nausea and vomiting and diarrhea leading to his death that morning then on 1/15/07 - resident #56- with 3 large watery bowel movements, resident #7 - with 3 large watery bowel movements, and resident #57 with 2 large watery bowel movements. k. An interview was conducted with the Staffing Coordinator on 1/125/07 at approximately 3:00 p.m. When the Staff coordinator was questioned about staff calling in sick due to gastrointestinal symptoms, she stated the call in's were as following: 1/19/07 1 CN.A. related to virus 1/20/07 1 Licensed Practical Nurse (LPN) related to virus 1/21/07 2 Certified Nursing Assistants (C.N.A.) related to a virus 1/22/07 4C.N.A:s (3 related to a virus) 1/23/07 2 C.N.A.s related to a virus 1/24/07 2 C.N.A. related to a virus 1/25/07 1 related to a virus 1. A review of the Centers for Disease Control (CDC) report dated 8/3/06 stated diarrhea and vomiting can be caused by a virus, bacteria, medical conditions, or medications. The physician should determine the cause of Gastrointestinal Symptoms. These symptoms are serious for persons who are unable to drink enough fluids to replace what they lose through vomiting or diarrhea. Persons who are unable to care for themselves, disabled, or elderly are at risk for dehydration from loss of fluids. Immune compromised persons are at risk for dehydration because they may get a more serious illness, with greater vomiting or diarrhea. They may need to be hospitalized for treatment to correct or prevent dehydration. The viral gastrointestinal symptoms are contagious and are spread through close contact with infected persons, for example, by sharing food, water, or eating utensils, or eating or drinking contaminated foods or beverages. The disease is diagnosed on the basis of symptoms, medical examination, and laboratory testing of a stool specimen. Persons can reduce their chance of getting infected by frequent hand-washing, prompt disinfection of contaminated surfaces with household chlorine bleach-based cleaners, and prompt washing of soiled articles of clothing. According to an article by the CDC "Empiric Use of Airborne, Droplet, or Contact Precautions” the risk of nosocomial transmission of infection may be highest before a definitive diagnose can be made. The routine use of Standard Precautions for all patients should reduce this risk for conditions other than those requiring Airborne, Droplet, or Contact Precautions. While is not possible to prospectively identify all patients needing these enhanced precautions, certain clinical symptoms (Diarrhea/Vomiting) carry a sufficiently high risk to warrant the empiric addition of enhanced precautions while a more definitive diagnosis is --—_pursued-—To-ensure-the.appropriate-empiric-precautions.are.implemented the . - facility must havea system in place to evaluate residents...-. - - we m. A review of the facility policy, Infection Prevention and Control Program the facility is to strive to prevent and control endemic and epidemic nosocomial infections for the protection of residents, staff, and visitors. The goal is to identify and reduce the risks of acquiring and transmitting infections among residents, staff, and visitors. The facility utilizes nationally recognized organizational standards and procedures, such as, the CDC. The process is designed to lower the risks and improve the trends and rates of epidemiologically significant infections. The process includes: prevention, Surveillance, and control. The facility utilizes various sources of data for infection surveillance including; employee absenteeism report, Infection tracking log, Laboratory data, and medical records, and Interdisciplinary 24 hour reports. The facility failed to implement an effective Infection Control Process utilizing these sources of data to identify and prevent the transmission of Gastrointestinal Symptoms. Review of the facility policy states Standard Precautions includes hand-washing. The hands are to be washed whether or not gloves are worn when touching body fluids, secretions, and contaminated items. The hands are to be washed when gloves aré removed, between resident/patient contact, as indicated to avoid transfer of microorganisms to other resident/patient or environments, and between tasks and procedures on the same resident to prevent cross-contamination. The gloves are to be changed between tasks on the same resident after contact with material that may contain a high concentration of microorganisms. n. Review of the clinical record for resident #2 revealed a telephone order to draw a Basic Metabolic Profile (BMP) on 1/11/07. Review of the lab revealed a collection date of 1/11/07 at 6:00 a.m. and a report date to the facility of 1/11/07 at 12:04 p.m. The lab's abnormal value was Patassium 5.7 (High) Normal 3.4-5.5 and Osmo-calculated as 274 (normal 275-300). Further review of the lab revealed a hand written notation of faxed to physician 1/11/07 at 3:30 p.m. An interview was conducted with the staff nurse on 1/22/07 at approximately 5: p.m. to determine why the attending physician had not responded to the abnormal lab. The staff nurse stated, "this physician is very slow to respond. I have faxed things to him 11 times and ‘he still doesn't respond". When asked what she does when the attending physician doesn't respond, the staff nurse stated she calls the Medical director. The staff nurse stated she called the medical director and received an order to have the lab redrawn 1/12/07. An interview with the DON on 1/24/07 at approximately 8:30 a.m. confirmed resident #2's attending physician is slow to respond tot he nurses and stated the issue has been discussed at the Quality Assurance meeting with the medical director. ; __o. _.. _Aninterview was conducted with the Medical Director on 1/25/07 at approximately 1:00 p.m-prior-to a scheduled-QA meeting:--The-Medical Director asked this surveyor if the survey revealed any issues.’ This surveyor stated the survey team was looking at infection control issues related to the Gastrointestinal Symptoms. This surveyor asked the Medical Director if he was aware of the outbreak of gastrointestinal symptoms of diarrhea through the building. The Medical Director stated he was aware of one resident with C-Diff but wasn't aware of the other residents experiencing diarrhea and nausea and vomiting. When this surveyor asked the Medical Director if he was aware of a resident experiencing the Gastrointestinal symptoms in the evening and moming of 1/13/07 and expiring on 1/14/07, the Medical Director stated he was not aware of 21 this situation but he doesn't review the other physician's chart. The Medical Director stated, "this area has a difficult time getting good nurses. This facility has to use Agency nurses and that is not good for continuity of care. The Medical Director stated he would discuss this in QA On 1/26/07 at approximately 6:45 a.m., the Medical Director spoke to this surveyor over the telephone to state, "I am a very busy doctor and I stated at the facility until] 10:00 p.m. last night evaluating every resident experiencing Gastrointestinal symptoms. I am aware of every resident who is currently with these symptoms and who had these symptoms recently". 10. The above constitutes a violation of Section 400.121(1){a), Florida Statutes (2006). 11. | The above constitutes a widespread Class I deficiency, for which a fine of $15,000 is authorized pursuant to Section 400.23(8)(a), Florida Statutes (2006). COUNT I Facility’s Administrator failed to maintain an active role in the facility’s internal risk management and quality assurance program in contravention of Chapter 400.147(2), Florida Statutes (2006) 12. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 13. That on J anuary 26, 2006, an annual licensure survey of the Respondent facility was - conducted, - eH ren me te ere a 14. Based on record review, observations, resident and staff interview and policy review the facility failed to ensure ADMINISTRATION effectively administered the facility to ensure the residents were able to maintain the highest practicable physical and psychosocial well-being through the implementation of an effective Infection Control Program to ensure laboratory tests for culture & sensitivity were completed as ordered by the physician; failed to ensure employee health was implemented into the Infection Control] Program; failed to implement a system to identify, investigate, control, and prevent Gastrointestinal Symptoms of residents, failed to ensure the environment was free of Infection Control hazards; failed to ensure the . implementation of policies to _prevent food bore illness for For 57 out of 84 sampled residents (#2, #3, #7, #9, #11, #13, #14, #15, #16, #18, #20, #22, #23, #26, #27, #29, #30, #31, #32, #36, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, H61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78). Immediate jeopardy was identified on 1/26/07 and removed on 2/10/07. Scope and severity was reduced to an F. The findings include: a. A review of the medical records and interviews with staff and residents on 1/25/07 and 1/26/07 the following residents were noted to have experienced Gastrointestinal symptoms of Diarrhea and/or nausea and vomiting in January 2007: 1) #67- (room 307A)- 1/2/07 2) #36- (room 415A) - 1/13/07 _ 3) #42-(room 402B)- 1/13/07, The resident died 1/14/07. 4) #45- (room 312A)- 1/14/07 5) #56-(room 401A)- 1/15/07 and 1/17/07. 6) #7- (room 412A)- 1/15/07 7) #57- (room 413B)- 1/15/07 8) #51- (room 201B- 1/16/07 9) #58- (room 129A) - 1/16/07 Emergency Room 1/24/07 with a decline in condition. 10) #44- (room 311A)- 1/16/07, 1/17/07, 1/23/07, 1/24/07, 1/25/07. @ Protime - ———— With a-critical-value:onl/25/07) ===> = = T1)-#'59- (room '129B)- 1/17/07, 1/19/07, 1/22/07, 1/24/07. 12) #69 (room 111) 1/17/07, 1/18/07 13) }#13- (room 120B) - 1/8/07, 1/19/07, 1/20/07, 1/21/07, 1/26/07. 14) #46 - (room 208A)- 1/18/07, 1/21/07. 15) #20- (room 122)- 1/18/07 16) #60- (room 131A)- 1/18/07 17) #61- (room 132A)- 1/18/07. 18) #64- (room 130A)- 1/18/07, 1/20/07 (Spouse/Visitor with symptoms ) 19) #49- (room 215B)- 1/18/07, 1/21/07 20) #63 (room 136)1/18/07, 1/19/07, 21) #43- (room 301A)- 1/19/07, 1/20/07 23 22) #71 (room 109A) 1/19/07 23) #62 (room 132C) 1/20/07 24) #23- (room 206A)- 1/21/07 25) #11- (room 216A)- 1/21/07 26) #50 - (room 215A)- 1/21/07 27) #26- (room 201A) - 1/21/07 28) #2- (room 206B) - 1/21/07- 29) #29 - (room 114) - 1/21/07 —- Hospitalized on 1/22/07. 30).#47 - (room 219B)- 1/22/07- Hospitalized 1/23/07 with critical Protime value. woe . 31) #48- (room 216B)- 1/22/07 32) #53- (room 220A)- 1/22/07, 1/24/07 33) #55- (room 209B)- 1/22/07, 1/23/07, 1/24/07 34) #54- (room 209A)- 1/23/07, 1/24/07. 35) #52- (room 218) - 1/23/07. 36) #72- (room 101)- 1/25/07, 1/26/07. 37) #78- (room 213B)- 1/25/07, 1/26/07. 38) #73- (room 307) - 1/25/07, 1/26/07. 39) #74- (room 309) - 1/26/07. 40) #22- (room 204) - 1/25/07, 1/26/07 41) #75- (room 205) - 1/25/07, 1/26/07, 42) #76- (room 312)- 1/25/07, 1/26/07. . 43) #77- (room 210B)- 1/26/07. . The following resident information was obtained via staff and resident interview which confirmed symptoms of Nausea/Vomiting and/or Diarrhea. The medical record was incomplete and did not specify the dates or specific Gastrointestinal symptoms. 44) #32 (room 120A) 45) #16 (room 127) 46) #15 (room 125B) 47) #27 (room 118) 48) #65 (room 123) 49) #3 (room 126) ~-- 50) #18 (room 128)-- rm : - 51) #66 (room 302A) 52) #68 (room 106B) 53) #70 (room 113A) 54) #31 (room 217A) The 100 Hall - 22 residents exhibiting Gastrointestinal Symptoms. The 200 Hall - 19-residents exhibiting Gastrointestinal Symptoms. The 300 Hall- 8 residents exhibiting Gastrointestinal Symptoms. The 400 Hall- 5 residents exhibiting Gastrointestinal Symptoms. 24 54 residents of a current census of 129 exhibited Gastrointestinal Symptoms of Nausea/Vomiting and/or Diarrhea during the month of January 2007. (42%) b. An interview with the Director of Nurses (DON) on 1/25/07 at 8:40 A.M. stated the facility Lab and Infection Control process inchides: - Nurse observes signs and symptoms of an infection and contacts the physician. - The nurse writes the physician order and completes an infection control sheet = The infection contro] sheet goes to the DON who logs the information - The DON diagrams the rooms in a color code for the type of infection - If a pattern is noted the DON in services staff and reports to the monthly QA meeting. The DON stated the she began reviewing all physician orders about 2 months ago. The DON reviews the infection control sheets, which are completed by the nurse. If the nurse did not complete an infection control sheet the DON would:go to the nurse to complete the sheet. The DON, as the Risk Manager, would track and trend the infections. The DON was the Risk Manager until 12/25/06, when a new employee was hired. The DON stated the last Infection Control in service to all staff was in December 2006 on hand-washing. The DON stated the last trend identified was related to Urinary Tract Infections in residents with a catheter. The DON stated the infection rates have gone up since the in service. But the DON stated the increase was related to increased reporting of infections by the staff. c, An interview of the DON on 1/25/07 at 8:40 A. M. revealed the Quality Assurance system to ensure physician lab orders are completed includes the _ medical records staff member to audit the medical records monthly for completion of labs, orders, complete charts, The medical records staff member gives a list of Jabs missed to the DON and Risk Manager. The Unit Managers do separate lab audit. The 11-7 shift completes the lab paperwork, places a copy of the lab request in a lab manual, the lab person comes in each morning, the results of the lab are faxed to the 300 Hall which distributes the results to the nurses. The Unit Managers audit the lab book each day and remove the Jab request as the results are received. The Unit Managers, DON, and Risk Manager review the 24 hour report each moming. The nurses document any stat or extra labs which were ordered. ‘The nurses-fax the lab results to the physician, If no response in 24 ‘hours then the-nurse-contacts the physician again. -If still no-response the nurse-is to contact the Medical Director. An interview with the Medical Records staff member on 1/24/07 at 12:55 P.M. stated she audits the medical record for routine labs. She does not audit for stat or other unscheduled Jabs. d. A review of the Jab request form book for the Unit 100 Hall contains lab requests from 10/06 until 1/25/07. The Unit has a Jab tracking book and lab request book do not match. hw cory Resident #14 had an order for a repeat urinalysis dated 12/23/06 which was not done, resident #58 had an order dated 1/16/07 for a stool culture for C-Diff which was not done. e. An interview with a CNA on 1/25/07 at 12:20 P.M. stated she is assigned to the 100 Hall. A review of her current assignment sheet with 9 residents listed. The CNA stated 6 of these residents have experienced diarrhea. (#16, 18, 20, 27, 15,58) The CNA stated 2 of the residents have experienced Nausea and Vomiting. (#65 and #3) The CNA stated only one resident has not developed Gastrointestinal Symptoms. The CNA stated the symptoms began approximately 1 and 1/2 weeks ago. The symptoms began with resident #58 and then spread to the other residents. The resident #58 is ambulatory and the CNA stated "goes all over the building." f. An interview with a CNA on 1/25/07 at 4:00 P.M. stated she has just returned to work after experiencing Diarrhea with nausea and vomiting. The CNA stated Jast Thursday (1/18/07) began feeling sick at work. The CNA notified the nurse and another CNA was brought in to assist her with the completion of her shift. The CNA stated she told the nurse she had the same symptoms as the residents. The CNA stated could not work on Friday (1/19/07) and notified the facility.of Gastrointestinal Symptoms. The CNA stated the Gastrointestinal symptoms began on the 100 Hall with resident #58. The symptoms then spread to the resident's roommate (#59). The symptoms then spread to resident #20, 64, 27, 32, 13, and then #15. The CNA stated resident #13 has had diarrhea for 10 days. The CNA stated another CNA currently can not work due to has caught the same’symptoms. She stated the residents on the 100 Hall are mostly ambulant. There are some residents which prefer to stay in their room. The 100 Hall also has residents with tracheostomy and bed-bound residents. The CNA stated the symptoms seem to last a couple of days and resident #27 was up in her wheelchair.throughout the facility when she was experiencing the symptoms. B. On 1/25/07 at approximately 2:00 P.M. the January Infection Control Log was requested. The Risk Manager/Infection Control Coordinator stated she did —not have the log. The infection control information was not collected until the end of the month. An interview with the Risk Manager/Infection Control Coordinator on 1/25/07 at 2:45 P.M. gave the two surveyors a map of the facility layout with rooms of residents’identified with the gastrointestinal symptoms indicated. The Infection Control Log does not contain information of the Gastrointestinal symptoms. The Coordinator stated had determined it was a "self-limiting virus." The Coordinator stated had determined this because the symptoms resolve in 24 to 48 hours. The Coordinator stated was "keeping up with who has symptoms.” The Coordinator gave the surveyors a hand written list of residents from each hall. The list contained no further information, such as, dates of onset, resolution and symptoms. The Coordinator stated has begun this week "reinforcing" hand- 26 washing with nurses and CNA's. The Coordinator has not addressed other staff, such as, dietary and therapy. The Coordinator stated she had notified the Department of Health of the Gastrointestinal Symptoms yesterday (1/24/07). The Coordinator was unable to provide details of whom she spoke with and time. - Upon further questioning the Coordinator stated she did not actually call the Department of Health. She stated the DON had called, but she had no further information. The Coordinator continuously referred to the illness as a virus, but was unable to conclusively describe how she arrived at this diagnosis. The Coordinator was unable to provide evidence the facility attempted to rule out food borne illness, C-Diff or other bacterial infection. The Risk Manager was asked if aware the C-Diff C&S was not completed on 1/16/07 for resident #58. She stated was unaware the test was not completed. The resident is listed on the January Infection Control Log. ” The Coordinator was asked if any staff had missed work due to symptoms. The Coordinator stated "don't know." The Coordinator stated "will begin" monitoring employee health as part of Infection Control, but is not currently reviewing this information. The Risk Manager stated the Gastrointestinal symptoms first came to her attention on 1/22/07. The only intervention to the outbreak of Gastrointestinal symptoms by the Risk Manger has been "paying attention." h. An interview with the DON on 1/25/07 at 3:25 P.M. stated had left a message with the Department of Health on 1/24/07 but did not speak with the agency until today 1/25/07. The Department of Health will be to the facility on 1/26/07 to investigate the outbreak. The agency stated the symptoms seem to indicate possibly a Norovirus. The DON has no written report of the information reported to the Department of Health. The DON stated the virus usually lasts 24 to 36 hours with a gestation period up to 48 hours before symptoms are demonstrated. The DON stated had spoken with staff about washing hands and the facility will keep residents in the room "as much as possible." i. An interview with the DON on 1/25/07 at 3:40 P.M. with a review of a report of a C&S of the stool from resident #58 dated 1/19/07 does not contain'a C&S for C-Diff. The DON confirms this and stated would check on the culture. (There was not further evidence provided during the survey.) A review was -—made-with the-DON-of-the-list-given-by-the-Risk-Manager-of-residents with symptoms, which doesnot include the symptoms identified and a date of onset or resolution. The DON stated those 27 residents no longer have symptoms and there is currently no one in the building experiencing Diarrhea, Nausea or Vomiting. The DON stated interviewed every staff member and resident and there is currently no resident or staff member with symptoms. The DON brought in the facility's CNA assignment sheet which lists bowel movement. The DON stated the assignment sheet is a legal document and signed by the CNA. She stated the facility keeps these sheets. The DON stated the assignment sheets do not state any diarrhea. A review of ihe assignment sheets only list bowel movements of medium, large, or extra large. The sheets do not state how many bowel movements, the time of the movements, OF further analysis bh ~ of the consistency. Many residents are listed as "Self without any further documentation. An interview with the DON on 1/25/07 at 4:05 P.M. stated she had obtained no further information on the Norovirus. The facility has no printed information of CDC guidelines on the virus. The DON stated the virus is difficult to kill and there is no current "person" in the building with the symptoms, oo j. An interview with the DON on 1/26/07 at 10:25 A.M. stated the medical director and nurses had reviewed each of the residents the night of 1/25/07. The DON stated each resident was given treatment if indicated and an Infection Control] Surveillance sheet was completed. The surveyor requested a list of the residents exhibiting symptoms. The DON stated did not keep a list and would have to pull each medical record. On 1/26/07 at 10:30 A.M. the Risk Manager _ and Unit Manager were observed pulling each medical record to obtain the names of resident's currently exhibiting symptoms. The facility did not maintain a list of residents to track and trend the gastrointestinal symptoms within the facility. On 1/26/07 at 10:45 A.M. the DON brought a list of 6 residents with Gastrointestinal symptoms identified by the facility: - #76- 1/25/07 - #73- 1/25/07 and 1/26/07 - #22- 1/25/07 - #78- 1/25/07 and 1/26/07 - #75- 1/25/07 ~ #72- 1/25/07 and 1/26/07. k. An interview with the LPN on Hall 1 on 1/25/07 at 12:10 P.M. stated resident #11, #13, and #32 are experiencing Diarrhea. A review of the medical records on Hall 1 experienced the following symptoms: - #58 had experienced diarrhea 1/16/07 with a C-Diff ordered which was not completed. - #59 Diarrhea on 1/17/07. ~—--#20-Diarrhea.on-1/1.8/07. + #13 Diarrhea- receiving Imodium. - #60 Nausea/Vomiting and Diarrhea 1/18/07. - #61 Nausea/Vomiting and Diarrhea 1/18/07. - #63- Nausea and vomiting. - #64- Nausea and vomiting and diarrhea. (Currently in Hospital) 1, An interview with the LPN on Hall 3 on 1/25/07 at 1:50 P.M. stated resident #44 and #66 are currently experiencing diarrhea with nausea and vomiting. A review of the Hall 3- 24 hour reports stated on 1/23/07 the resident #44 experienced nausea and vomiting 8 times. A review of the medical records for Hall 3 the following residents experienced the following: 28 - #45- Vomiting - #44- nausea, vomiting and diarthea. - #67- 1/2/07 nausea and vomiting. m. A review of the medical records for Hall 4 - 24 hour reports on 1/13/07- resident #36 with nausea and vomiting, on 1/14/07 resident #42 with nausea and vomiting and diarrhea leading to his death that morning then on 1/15/07 - resident #56- with 3 large watery bowel movements, resident #7 - with 3 large watery bowel movements, and resident #57 with 2 large watery bowel movements. n. During the initial tour of the facility on 1/22/07 at approximately 9:00 a.m. the following observations were made: --In room 136 a blue cushion for a wheelchair lying on floor --Outside room 115, three bags of soiled pads and trash in hallway --In room 220 a soiled towel on floor and water basin on floor unlabeled --Used syringe laying on top of sharps container on Medication cart instead of being placed in the sharps container --In room 123 a urinal on floor, urinal % filled --In room 124, % full urinal sitting on top of dresser During a tour of the facility was conducted on 1/23/07 at approximately 7:30 am., the following observations were noted: --In room 209 (shared by 4 residents) toilet extender has yellow and brown substance --In shower room on 2" hallway, a foot rest lying on floor n. An interview was conducted with the Staffing Coordinator on 1/125/07 at approximately 3:00 p.m. When the Staff coordinator was questioned about staff calling in sick due to gastrointestinal symptoms, she stated the call in 's were as following: 1/19/07 1 C.N.A. related to virus —1/20/07-—-—---1. Licensed Practical Nurse (LPN) related to virus 1/21/07 2 Certified Nursing Assistants (C.N.A.) related to a virus 1/22/07 4 C.N.A.s (3 related to a virus) 1/23/07 2 C.N.A.s related to a virus 1/24/07 2 C.N.A. related to a virus 1/25/07 1 related to a virus 0. An observation of the resident refrigerator, freezer, countertop and cabinets in the dining area of the hall 4, locked unit on 1/24/07 starting at 12:30 pm revealed: Refrigerator: (There are no temps recorded by staff.) -Roast beef in ziplock is molded with a white creamy substance covering the beef -Unlabeled date on ziplock bag containing cheese slices and sandwich -2 loose oranges in the bottom of the refrigerator. The refrigerator smelled of a foul odor with spilled substances on the shelves. -Open ' Power Aid ' without date. -Container with brown liquid noted. No label, no date. -2 lunches in the bottom. Not labeled or dated -Sliced Bread in a ziplock, not labeled or dated. Freezer: An unlabeled bag containing seven dumpling-like items Staff 'Weight Watcher ' meal and frozen Dr. Pepper, which are not labeled or dated. Countertop: ~ an unlabeled and undated container of liquid Cabinets: -Large unlabeled and undated open Styrofoam cup containing white powdery substance There was no lid on the cup. -Bottle of undated old appearing hot sauce that is nearly empty -Open box of 'Cheez It’ -One large bag of unlabeled substance that expires January 2007. The unit manager states he/she is unsure of the contents - Open popcorn bag on top of the refrigerator. -One locked cabinet opened by the unit manager contained: Open, undated bag of ‘Fig Newtons’, 5 unlabeled, undated individual bags containing cookies; Open, undated box of vanilla wafers, and an open partially empty can of 'Sam's Cola’. A review of the facility policy titled, Storage states dry goods are to be placed in bags and sealed or placed in plastic containers. The goods should be dated and stored no longer than 3 months. Refrigerated Items should be labeled with date received. Left over foods should be stored in containers which are impervious and labeled with-month,-date.and. year...Discard refrigerated leftovers.afier 48 hours. The temperatures are to be recorded on all refrigeration units each shift. Foods from outside sources are prohibited. 15. The above constitutes a violation of Section 400.147(2), Florida Statutes (2006). 16. The above constitutes a widespread Class I deficiency, for which a fine of $15,000 is authorized pursuant to Section 400.23(8)(a), Florida Statutes (2006). 30 COUNT I Respondent failed to ensure the implementation of its processed to ensure the prevention of abuse and provide a safe and comfortable environment . resulting in physical and mental mistreatment and abuse for one (1) of eighty- four (84) sampled residents, contravention of Chapter 415.102, Florida . Statutes (2006) 17. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 18. That on January 26, 2006, an annual licensure-survey of the Respondent facility was conducted. 19. Based on interview, observation, and record review, it was determined the facility failed to ensure the implementation of their processes to ensure the prevention of abuse and provide a safe and comfortable environment resulting in physical and mental mistreatment and abuse for one (1) of eighty-four (84) sampled residents. (#75) The findings include: | On 1/24/07 at approximately 8:00 a.m. the Maintenance Director tested the temperatures in the 200 Hall Shower room. The Maintenance Director allowed the hot water run over 5 minutes. The Maintenance Director stated the temperature he recorded with his digital temperature gauge was 98.8. The Maintenance Director stated the facility has 4 showers and one shower per month is checked for water temperatures. The Maintenance Director could not provide -documentation-of-the-shower-water-being-checked-monthly.-- On 1/24/07 a Certified Nursing Assistant (C.N.A.) was observed assisting resident #75 with a shower. Resident # 75 stated to the C.N.A., "I am so cold". Resident #75, again, stated, “I'm so cold". The C.N.A. responded by saying, "we are almost done". The C.N.A. stated to this surveyor, "she is the first resident to be showered. I have let the water run for about a minute. J have the handle turned all the way over". This surveyor asked resident # 75 if the water was cold and the resident stated, "yes". The C.N.A. continued to shower resident #75. Resident # 75 stated, "that's enough, I am cold". This surveyor took the temperature of the water and noted the temperature as 98.2 This surveyor reported this incident to the Administrator, Corporation Staff member, and the Director of Nursing (DON)/Abuse Coordinator on 1/24/07 at approximately 9:15 a.m. This surveyor requested for the Abuse Coordinator and the Maintenance Director validate the water temperature taken by this surveyor. The Maintenance Director checked the 200 hallway shower temperatures again in the presence of this surveyor and the Abuse Coordinator on 1/14/07 at approximately 9:15 a.m. The Maintenance Director allowed the hot water for run > 5 minutes and the recordings were as: : Atiminute 95 degrees At2 minutes 97.5 degrees At5 minutes 99.5 degrees The hot water temperature did not exceed 99.5 after 5 minutes of allowing the hot water to run. On 1/24/07 at approximately 9:30 a.m., the Maintenance Director and this surveyor checked the hot water temperature at the water tank located in a closet. The hot water temperature was recording at 110 degrees. On 1/24/07 at approximately 9:35 a.m., the DON/Abuse Coordinator interviewed the C.N.A. in this surveyor’s presence in the 200 Hallway. The C.N.A. stated to the DON/Abuse Coordinator the water was cold after allowing the water to run about a minute. The C.N.A. stated she had the hot water handle tured all the way over. The C.N.A. acknowledged to the DON/Abuse Coordinator the resident stated she was cold but the resident had soap all over her, so the shower was completed. The DON/Abuse Coordinator stated to this surveyor, "I will take care of it". On 1/24/07 at approximately 10:45 a.m. the Corporate Staff member gave this surveyor a typed sheet of paper stating: "Bay Center Action Steps for allegation of "Abuse" re: shower temp on 1/24/07 qe CNA. immediately. interviewed wed and ‘suspended (Agency CN. Ay ‘Agency notified. 2. All shower rooms closed until investigation and/or repairs made. 3. Allegation reported to abuse coordinator and mandatory reporting completed. 4. Interview and statement from resident involved. 5. Met with maintenance director to review and validate temp monitoring procedures. 6. Resident interviews to be completed on resident regarding shower experiences. 7. Nursing staff in-serviced on monitoring resident shower tolerance and reporting of any complaints about water temps to charge nurse and/or maintenance director. 8. Nursing staff re-in serviced on "Bathing without a Battle”. 32 9. Investigations and findings to be reviewed with QAA”. Review of their Policy "Prevention and Reporting: Suspected Resident/Patient Abuse, Neglect, and/or Misappropriation of Property" Reporting: 1. Notify the shift supervisor immediately 2. Report the incident to Don and Administrator ; 3. Notify the appropriate State agency (s) immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to State- specific regulations. (Attach State-specific regulations as an addendum to this standard/procedure) . 4, Notify the legal guardian, spouse, or responsible family/members/significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property immediately (within 24 hours) 5. Notify the physician immediately (within 24 hours) 6. Initiate contact with the local law enforcement, immediately, when warranted, as required by State law. 7. Report results of investigation to the proper authorities as required by State law. . An interview was conducted with resident # 32 on 1/24/07, when questioned about the hot water being cold in the showers, resident # 32 stated, "the showers are cold sometimes and when it is cold water, I just don't take a shower". An interview was conducted with the Corporate Maintenance Director on 1/25/07 at approximately 9:30 a.m. The Corporate Maintenance Director stated the 200 Hallway shower needed a mixing valve that works.on keeping the water temperature consistent. The Corporate Maintenance Director stated he took the hot water temperature at the tank and recorded at 110 degrees but the 200 hallway shower was 98 degrees. Another surveyor with the Corporate Maintenance Director tested the hot water temperature in room 214 on 1/25/07 at approximately 9:45 a.m. The Corporate Maintenance Director allow the hot water to run > 5 minutes and recorded the __temperature.at 99.0. a An interview was conducted with resident # 19 and wife on 1/25/07 at approximately 10:50 am. Resident # 19 stated the hot water in the showers are normally cold. When this surveyor asked resident # 19 ifhe tells the C.N.A.s the water is cold, resident # 19 stated, "yes". When this surveyor asked resident # 19 what the C.N.A.s tell him when he complains the hot water is cold, resident # 19 stated, "they tell me I will be finished in a minute”. 20. The above constitutes a violation of Section 415.102, Florida Statutes (2006). 21. The above constitutes an isolated Class I deficiency, for which a fine of $5,000 is @ @ (B) Recommend administrative fines against Respondent in the sum of $35,000 for Count I, Count Il, and Count I, as well as a survey fee of $6,000, pursuant to Sections 400.23(8)(a) and 400.19(3), Florida Statutes (2006); , (C) Revoke Respondent’s Skilled Nursing Home License number 10340961; (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Makan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. 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 this of 0 H day of February, 2007. . Moore, Esq. 'L. BAR # 0768715 /Agency for Health Care Administration 2727 Mahan Drive, MS # 3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Retum Receipt No.7004 1160 0003 3739 8163 to Administrator Rodney C. Watford, 1336 St. Andrews Blvd., Panama City, FL 32405 and by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 8170 to Owner Hearthstone Senior Communities, Inc., 1333 Wayne Sireet, Reading, PA 19601 on FebruaryZo{* , 2007. Bart O. Mdore; Esquire Copies furnished to: Barbara Alford, FOM 5 me al O r m led m Postage | m a] Centilied Fee /Q >| oO Retum Reciept Fee Postar (Endorsement Required) Here =) restricted Detive ' A (Endorsement Readies a -+——__ | a i Total Postage & Fees | § lor ia ja ne f SENDER: COMPLETE THIS SECTION | @ Complete items 1, 2, and 3. Also complete : _ Item 4 If Restricted Delivery is desired. ; ® Print your name and address on the reverse ; so that we can return the card to you, ‘i Attach this card to the back of the mailpiece, or on the front if'space permits. i 1. Article Addressed to: Ww SOB WO DEW oe Cone ance VAL ee, \ Vu \ES 3 246. a. 3. Sepice ee Cy Sekses Certified Mail [2 Express Mall CO Registered D Return Receipt for Merchandise Ci Insured Malt 0 G.0.D. 4, Restricted Delivery? (Extra Fee) Yes 7004 1360 08063 3739 8170 ! BS OGL DA LA GO\ } i ; PS Form 3811, July 1999 Domestic Return Recelpt 402595-00-4.0952 Postage | Certified Fee Retum Reclep! Fee Postmark Here (Endorsement Required) Restricted Delivary Fe (Endorsement Required) Total Postage & Fees $ 7004 4160 0003 3739 a1b3 Rex eS PS'Farm:a800,;Uune gona sesh COMPLETE THIS SECTION ON DELIVERY SENDER: COMPLETE THIS SECTION £.Recelved by (Please Print Clearly) |B, Date of Delivery Asai? }), O Agent on TZ Meteo F Doe 0 Addrassee D. Is delivery atidress different from item 17 (1 Yes If YES, enter delivery address below: +] No @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse . ~ so that we can return the card to yous" im Attach this card to the back of the mailplece, or on the front if space permits. 1. Article Addressed to: Adan rnc arado't | Weducyc . Oa Sark (SAG SA Amahauss Rick. Powcauan, City FL E2405 a. Saat Certified Mail [1 Express Mall D Registered CO Retum Recelpt for Merchandise Ci insured Mail = 1.0.0. | 4: Restricted Delivery? (Extra Fee) Ol Yes 2" S004 Labo O003 3739 6263 7004 LbbO o003 3734 bubs 102595-00-M-0952 PS Form 3811, July 1999 Domestic Return Receipt

Docket for Case No: 07-001260