STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. CaseNos. 2007002106 (Cond.) 2007002105 (Fine) DELTA HEALTH GROUP, INC., d/b/a MAITLAND HEALTH CARE CENTER, 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 DELTA HEALTH GROUP, INC., d/b/a MAITLAND HEALTH CARE CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing December 21, 2006 and ending January 17, 2007, and impose an administrative fine and survey fee in the amount of $38,500.00, based upon Respondent being cited for three State Class I deficiencies. JURISDICTION AND VENUE L. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative 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 II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4.° Respondent operates a 180-bed nursing home, located at 1700 Monroe Avenue, Maitland, FL 32751, and is licensed as a skilled nursing facility license number 14280961. 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. FACTS COMMON TO ALL COUNTS 6. That on or about December 21, 2006, the Agency conducted an Annual Survey at Respondent’s facility. 7. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number thirteen (13) during the survey and noted the following: a. That the resident was admitted to the facility on August 15, 2006 with diagnoses including congestive heart failure, bacteremia, cellulitis and abscess to left lower extremity, coronary artery disease, cerebrovascular disease, diabetes, hypertension, and morbid obesity; b. That the resident was admitted with a vascular stage Il wound on the shin of the left leg, lateral aspect, and pressure ulcers to left and right posterior thighs; c. That the resident was referred to a wound care specialist upon admission in August 2006 and was seen on August 22 and 29, 2006 but since then has refused to be treated by the wound care team which comes to the facility weekly; That the resident allows facility staff to perform wound treatments; That the resident was noted on the care plan as resistive to care and treatment and refused daily wound care; That on the day of review, the resident agreed only to have the left leg wound dressed and refused the other wounds sites to be seen and treated; That on December 12, 2006, the left leg wound measured 25 centimeters (cm.) by 14.7 cm. and depth of 0.2 cm. That the resident’s physician's orders for wound care of November 22, 2006 provided, "Cleanse left leg with Normal Saline apply Mepilex, wrap with Kling, cover with dry dressing every 3 days and as needed.” 8. That the Petitioner’s representative observed the resident number thirteen (13) during wound care by the nurse to the left lower leg on December 20, 2006 at 9:20 a.m. and noted as follows: That the resident was in bed, alert, oriented and verbally responsive to communication; That the nurse gathered all necessary supplies for the dressing change and started the procedure by first cutting the soiled gauze dressing on the left lower leg and placing the contaminated scissors on top of the treatment cart without any. barrier; That the old dressing was dark in color, dried and stuck to the skin; That while the nurse removed the soiled dressing, the resident moaned and verbalized how painful it was; e. That the resident had been administered a pain medication twenty (20) minutes prior to start of the dressing change; f. That when the soiled dressing was removed, a foul odor was noted from the wound and there was a copious amount of bleeding noted; g. That the resident further stated that every time nurses perform wound care, the ’ wound would always bleed; h. That the old dressing was saturated with dried blood and some cream colored purulent discharge; i. That the nurse patted/dabbed the wound with gauze, wet with normal saline and proceeded to obtain wound cultures with the use of a sterile cotton swab; j. That the nurse dried the wound with a dry gauze dressing without fully cleansing the wound with normal saline as ordered by the physician; k. That the wound bed and slough was dark red with some bright red areas, bled continuously in a pulsating manner, and dripped onto the blue pad under the resident's left leg; 1. That during the procedure, the nurse opened two (2) drawers of the treatment cart with soiled gloves on, looking for more needed supplies; m. That the wound was then covered with Mipelex dressing, a thick gauze, followed with ABD pads and wrapped with Kling; n. That the nurse failed to clean the back of the leg where blood had dripped and failed to clean surrounding areas of the wound. 9. That the Petitioner’s representative reviewed the Respondent’s care plans and clinical records regarding resident number thirteen (13) during the survey ending December 21, 200 and noted as follows: a, That the care plans did not reflect a resident assessment regarding levels of pain despite the fact that the resident was receiving pain medications almost daily as needed when the resident was in pain; That there were no care plans or interventions regarding pain experienced by the resident during wound care; That the effectiveness of the administered medication was not documented in the resident's medical record; That nursing staff had not assessed the resident’s level of pain; That during wound care, the nurse did not stop the procedure and ask the resident if the resident was able to tolerate the pain before proceeding with the dressing change; That the resident’s Minimum Data Set (MDS) reflected that the resident was coded. as "2,2" on the “pain” section, meaning the resident was having moderate pain daily; That the care plans did not reveal care plans regarding monitoring of the anticoagulant medication, coumadin, that the resident was receiving; That care plans for the monitoring of signs and symptoms for adverse reactions to Coumadin were not in the resident's medical record. 10. That the Petitioner’s representative interviewed the Respondent’s nurse who provided wound care to the resident on December 20, 2006 who: a. Confirmed that care plans regarding pain and anticoagulant monitoring were not in the resident's medical record; Confirmed that a Prothrombin Time (PT)/ International Normalization Ratio (INR), a laboratory (lab) blood test to determine how thin the blood is, had not been conducted November 27, 2006 as ordered; Asked the Agency surveyor if she should obtain a stat blood test; Expressed a lack of awareness as to what to do after observing a copious amount of bleeding from the resident’s wound. 11. That the Petitioner’s representative noted the following in the records of resident number thirteen (13) during the survey ending December 21, 2006: a. That the Physician's Order Sheet (POS) dated November 25, 2006 contained an order to increase "Coumadin medication to 7.5 mg. (milligrams) daily from 5 mg. and re check in one week;" That a pharmacist's communication of November 9, 2006 revealed that "this resident is receiving Warfarin (Coumadin) ... without routine Jab monitoring. Due to potential bleeding problems when toxic, please evaluate ~ and consider a protime with INR to be done monthly;" * That A PT and INR testing was completed on November 27, 2006 with results of PT at 20.5 (normal value = 11.5-14.9 seconds) and INR at 1.74 (normal value = 0.8-1.2, routine therapeutic range = 2.0-3.0 & high risk therapeutic range = 2.5-3.5); That the resident’s physician was notified and a repeat PT/INR was ordered to be completed in one week from November 27, 2006; That though the resident had received Coumadin 7.5 mg. since November 25, 2006, a PT/INR had not been done since November 27, 2006. 12. That the Petitioner’s representative interviewed the Respondent’s nurse and assistant director of nursing on December 20, 2006 who were unable to explain why the ordered repeat PT/INR test had not been administered since November 27, 2006 or the reason that further lab monitoring had not occurred/. 13. That a PT/INR test was completed on resident number thirteen (13) on December 20, 2006 at 5:45 PM at the time of the survey and after the observation of the resident's wound care the results of which reflected a PT at 92.1, a critical value, and INR at 12.25, a high value. 14. That the physician of resident thirteen (13) was notified at 7:45 p.m. who ordered a Vitamin K 10 mg. via subcutaneous injection to prevent bleeding, immediately placed coumadin on hold, and ordered a repeat PT/INR the next day. The physician did not order a complete blood count including a hematocrit and hemo globin to determine if the resident had lost a significant amount of blood. 15. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number twenty-four (24) during the survey and noted the following: a. That the resident was admitted to the facility on February 11, 2006 with diagnoses of senile dementia, hypertension, and diabetes; b. That physician's orders of December 6, 2006 status post hospitalization for fracture of the patella, revealed an order for coumadin 5 mg. every other day for prevention of deep vein thrombosis; c. That the physician ordered a PT/INR to be done in one week; d. That the resident’s medical record did not reveal the lab test completed on December 13, 2006 or any other day after that; e. That the treatment administration record (TAR) revealed the nurse's initials next to the lab test, indicating that the test was done. f. “That there was no further follow-up or monitoring by the staff or the physician . regarding anticoagulant therapy according to current standards of practice. g. That the resident continued to receive coumadin up to the date of December 21, 2006; h. That review of the care plans did not reveal any interventions or assessments on what to monitor and watch for while the resident was receiving anticoagulant therapy. 16. That the Petitioner’s representative interviewed the Respondent’s assistant director of. nursing on December 21, 2006 vio indicated that the respondent was unable to locate the lab result for the resident as had been annotated as having been taken and confirmed that the resident had not been care plained in tegards to coumadin therapy. . 17... That'the Petitioner’s representative reviewed the Respondent’s clinical records regarding resident number RS twenty-three (23) during the survey and noted the following: a. That the resident’s diagnoses included peripheral vascular disease, anemia, end. stage renal disease with dialysis and history of deep vein thrombosis; b. That the medication administration record indicated the resident had been receiving coumadin at 2.5 mg. since November 6, 2006; c. That lab results of November 10, 2006 documented prothrombin time (PT) 20.1 seconds (normal range = 11.5-14.9) and INR 1.69 (routine therapeutic range = 2.0-3.0), both outside normal Tanges; d. That lab results on November 17, 2006 reflected PT of 33.4 seconds and INR was 3.28, both in excess of therapeutic range; e. That a telephone order dated November 17, 2006 decreased coumadin to 2 mg. per day and repeat PT/INR in one (1) week; £ That on November 24, 2006, the lab results for the PT was 16.4 and 1.3 for the INR; g. That the physician ordered the PT/INR to be repeated in one (1) week; h. That no documentation in the clinical record reflected the subsequently ordered PT/INR testing and no lab results were present for PT/INR for the month of December 2006; i, That Respondent’s lab book did not reflect any slips available for resident the resident for any PT/INR testing for the month of December 2006; j. That interview on 12/20/06 at approximately 3 p.m. with the Keys unit manager revealed that the tests were not completed and that she was not aware that it needed to be done; 18. That the Petitioner’s representative interviewed the Respondent’s Keys unit manager on December 20, 2006 who indicated the she was unaware of the necessity for PT/INR testing be conducted for resident number twenty-three (23). COUNT T 19. The Agency re-alleges and incorporates paragraphs one (1) through eighteen (18), as if fully set forth herein. 20. That pursuant to Florida law, the nursing home facility shall have sufficient nursing staff, on a 24-hour basis to provide nursing and related services to residents in order to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility will staff, at a minimum, an average of 1.7 hours of certified nursing assistant and .6 hours of licensed nursing staff time for each resident during a 24 hour period. R. 59A-4.108(4), Florida Administrative Code. 21. That pursuant to Florida law, the agency shall adopt rules providing minimum staffing requirements for nursing homes. These requirements shall include, for each nursing home facility: . a. A minimum certified nursing assistant staffing of 2.6 hours of direct care per resident per day beginning January 1, 2003, and increasing to 2.7 hours of direct care per resident per day beginning January 1; 2007. Beginning January 1, 2002, no facility shall staff below one certified nursing assistant per 20 residents, and a minimum licensed nursing staffing of 1.0 hour of direct care per resident per day but never below one licensed nurse per 40 residents. b. : Beginning January 1, 2007, a minimum weekly average certified nursing assistant staffing of 2.9 hours of direct care per resident per day. For the purpose of this sub-paragraph, a week is defined as Sunday through Saturday §400.23(3)(a)(1), Florida Statutes (2006). 22. That‘on or about December 21, 2006, the Agency conducted an Annual Survey at Respondent’s facility. 23. ‘That ’based upon the review of records and interview, the Respondent failed to provide sufficient nursing staff in its failure to provide adequate supervision of nursing services conceming monitoring tesidents on anticoagulant medication, for three (3) of eleven (11) sampled residents, to ensure that the highest practicable level of.care and well-being was maintained, the same being contrary to law. 10 24. That the Petitioner’s representative reviewed the clinical records for residents numbered thirteen (13), twenty-three (23), and twenty-four (24) who all were receiving anti-coagulant therapy and noted that Respondent’s nursing staff failed to follow physician's orders to re-check laboratory tests on (PT/INR) to determine the therapeutic levels. 25. That the Petitioner’s representative interviewed the Respondent’s director of nursing on December 21, 2006, who indicated that the respondent had no nursing supervisory staff on the Keys wing of the facility, where the three coagulant therapy residents resided, for a period of three (3) months and that the staff nurses on the unit failed follow-up or monitor lab tests ordered on the residents receiving the anti-coagulant medication, coumadin. 26. That the Petitioner’s representative noted that in addition to the failure to conduct ordered laboratory testing, nursing staff failed to ensure the completion of care plans for those residents regarding the use of anti-coagulant medications, and that the facility did not have a policy and procedure for nursing staff to refer to for caring for residents on anticoagulant therapy. 27. That the failure to provide adequate nursing to ensure that residents of a wing of the facility receive physician ordered treatment and that care plans as required for a resident’s medical and other needs are met is in violation of law. 28. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 29. The Agency provided Respondent with the mandatory correction date for this deficient practice of December 23, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $12,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT II 30. The Agency re-alleges and incorporates paragraphs one (1) through eighteen (18), as if fully set forth herein. 31. That pursuant to Florida law, each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A preliminary nursing evaluation with physician’s orders for immediate ' care, completed on admission. . (c) | Acomplete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment. R. 59A-4.109(1), Florida Administrative Code. 32. That on or about December 21, 2006, the Agency conducted an Annual Survey at Respondent’s facility. 12 33. That based upon the review of records and interview, Respondent failed to develop care plans for two (2) of eleven (11) residents receiving coumadin therapy, and failed to develop a plan of care for pain management for one (1) of twenty-one (21) sampled residents, said failures being contrary to the requirements of law. 34. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number thirteen (13) during the survey and noted the following: a. That the resident was admitted to the facility on August 15, 2006 with diagnoses including congestive heart failure, bacteremia, cellulitis and abscess to left lower extremity, coronary artery disease, cerebrovascular disease, diabetes, hypertension, and morbid obesity; b. That the resident was admitted with a vascular stage II wound on the shin of the left leg, lateral aspect, and pressure ulcers to left and right posterior thighs. 35: That the Petitioner’s representative observed the resident number thirteen (13) during wound care by the nurse to the left lower leg on December 20, 2006 at 9:20 a.m. and noted as follows: a. That the resident was in bed, alert, oriented and verbally responsive to communication; b. That the nurse gathered all necessary supplies for the dressing change and started the procedure by first cutting the soiled gauze dressing on the left lower leg and placing the contaminated scissors on top of the treatment cart without any barrier; c. That the old.dressing was dark in color, dried and stuck to the skin; d. That while the nurse removed the soiled dressing, the resident moaned and verbalized how painful it was; That the resident had been administered a pain medication twenty (20) minutes prior to start of the dressing change; That when the soiled dressing was removed, a foul odor was noted from the wound and there was a copious amount of bleeding noted; That the resident further stated that every time nurses perform wound care, the wound would always bleed; That the old dressing was saturated with dried blood and some cream colored purulent discharge; That the nurse patted/dabbed the wound with gauze, wet with normal saline and proceeded to obtain wound cultures with the use of a sterile cotton swab; That the nurse dried the wound with a dry gauze dressing without fully cleansing the wound with normal saline as ordered by the physician. 36. That the Petitioner’s representative reviewed the Respondent’s care plans and clinical records regarding resident number thirteen (13) during the survey ending December 21, 200 and noted as follows: a. That the care plans did not reflect a resident assessment regarding levels of pain despite the fact that the resident was receiving pain medications almost daily as needed. when the resident was in pain; That there were no care plans or interventions regarding pain experienced by the resident during wound care; That the effectiveness of the administered medication was not documented in the resident's medical record; 14 That medical staff had not assessed the resident’s level of pain; That during wound care, the nurse did not stop the procedure and ask the resident if the resident was able to tolerate the pain before proceeding with the dressing change; That the resident’s Minimum Data Set (MDS) reflected that the resident was coded as "2,2" on the “pain” section, meaning the resident was having moderate pain daily; That the care plans did not reveal care plans regarding monitoring of the anticoagulant medication, coumadin, that the resident was receiving; That care plans for the monitoring of signs and symptoms for adverse reactions to Coumadin were not in the resident's medical record. 37. That the Petitioner’s representative interviewed the Respondent’s nurse after the wound care procedure on December 20, 2006 who verified that there were no care plans regarding pain and anticoagulant monitoring. 38. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number twenty-four (24) during the survey and noted the following: a. That the resident was admitted to the facility on February 11, 2006 with diagnoses of senile dementia, hypertension, and diabetes; * That physician's orders of December 6, 2006 status post hospitalization for fracture of the patella, revealed an order for coumadin 5 mg. every other day for prevention of deep vein thrombosis; That the physician ordered a PT/INR to be done in one week; That the resident’s medical record did not reveal the lab test completed on 15 December 13, 2006 or any other day after that. 39. That the Petitioner’s representative interviewed the Respondent’s assistant director of nursing on December 21, 2006 who indicated that the laboratory could not find the results, but noted that in the resident’s treatment administration record (TAR), the nurse has initialed that the test was done and confirmed that care plans were not completed in regards to coumadin therapy monitoring for the resident. 40. That there was no evidence of further follow-up or monitoring by the staff or the physician regarding anticoagulant therapy according to current standards of practice. 41. That the resident continued to take coumadin up to the survey end of December 21, 2006. 42. That the Petitioner’s representative reviewed the care plans of resident number twenty- four (24) and noted no interventions or assessments on what to monitor and watch for while the resident was receiving anticoagulant therapy. 43. That this action or inaction of the Respondent and its failure to develop care plans for residents in a timely manner is in violation of Florida law. 44. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 45. The Agency provided Respondent with the mandatory correction date for this deficient practice of December 23, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). 16 COUNT I 46. The Agency re-alleges and incorporates paragraphs one (1) through eighteen (18), as if fully set forth herein. . 47. That pursuant to Florida law, an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. § 400.102(1)(a), Florida Statutes (2006). 48. That Florida law provides that all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following. ..the right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan...the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints... § 400.022, Florida Statutes (2006). 49. That on or about December 21, 2006, the Agency conducted an Annual Survey at Respondent’s facility. 50. That based upon observation, interview, and the review of records, Respondent failed to adequately monitor two (2) of eleven (11) residents receiving anticoagulant therapy thereby failing to provide adequate and appropriate health care and protective and supportive services in that the failure to monitor may result in appropriate therapeutic levels of anticoagulants, 51. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number thirteen (13) during the survey and noted the following: a. That the resident was admitted to the facility on August 15, 2006 with diagnoses including congestive heart failure, bacteremia, cellulitis and abscess to left lower extremity, coronary artery disease, cerebrovascular disease, diabetes, hypertension, and morbid obesity; b. That the resident was admitted with a vascular stage II wound on the shin of the left leg, lateral aspect, and pressure ulcers to left and right posterior thighs. 52. That the Petitioner’s representative observed wound care to resident number thirteen (13) on December 20, 2006 and noted the resident’s wound with a large amount of dark old blood in the soiled dressing, a copious amount of bright red blood dripping from the wound, and the wound was observed bleeding in a pulsating manner. 53. That the Petitioner’s representative noted the following in the records of resident number thirteen (13) during the survey ending December 21, 2006: a. ' That the Physician's Order Sheet (POS) dated November 25, 2006 contained an order to increase "Coumadin medication to 7.5 mg. (milligrams) daily from 5 mg. and re check in one week;" b. That a pharmacist's communication of November 9, 2006 revealed that "this resident is receiving Warfarin (Coumadin) ... without routine lab monitoring. Due to potential bleeding problems when toxic, please evaluate and consider a protime with INR to be done monthly;" c. That a PT and INR testing was completed on November 27, 2006 with results of PT at 20.5 (normal value = 11.5-14.9 seconds) and INR at 1.74 (normal value = 0.8-1.2, routine therapeutic range = 2.0-3.0 & high risk therapeutic range = 2.5-3.5); 18 d. That the resident’s physician was notified and a repeat PT/INR was ordered to be completed in one week from November 27, 2006; e. That though the resident had received Coumadin 7.5 mg. since November 25, 2006, a PT/INR had not been done since November 27, 2006. 54, That the Petitioner’s representative interviewed the Respondent’s nurse and director of nursing on December 20, 2006 who were unable to explain why the ordered repeat PT/INR test had not been administered since November 27, 2006 or the reason that further lab monitoring had not occurred. 55. That the Respondent’s pharmacist returned to the facility to complete a drug regimen review from December 6 through 8, 2006 but did not follow up on the PT/INR ordered to be done one week after November 27, 2006 which should have been done between December 4 and 5, 2006. 56. That the Petitioner’s representative interviewed the Respondent’s pharmacist on December 21, 2006 who stated, "I could have missed it. I don't know why. It is normally something I would address.” 57. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number twenty-four (24) during the survey and noted the following: - a. That the resident was admitted to the facility on February 11, 2006 with diagnoses of senile dementia, hypertension, and diabetes; b. That physician's orders of December 6, 2006 status post hospitalization for fracture of the patella, revealed an order for coumadin 5 mg. every other day for prevention of deep vein thrombosis; c. That the physician ordered a PT/INR to be done in one week; 19 d. That the resident’s medical record did not.reveal the lab test completed on December 13, 2006 or any other day after that; e. That the treatment administration record (TAR) revealed the nurse's initials next to the lab test, indicating that the test was done. f. That there was no further follow-up or monitoring by the staff or the physician regarding anticoagulant therapy according to current standards of practice. g. That the resident continued to receive coumadin up to the date of December 21, 2006; h. That review of the care plans did not reveal any interventions or assessments on what to monitor and watch for while the resident was receiving anticoagulant therapy. 58. That the Petitioner’s representative interviewed the Respondent’s assistant director of nursing on December 21, 2006 who indicated that the respondent was unable to locate the lab result for the resident as had been annotated as having been taken and confirmed that the resident had not been care planned in regards to coumadin therapy. 59. That this action or inaction of the Respondent is a failure to provide adequate and appropriate health care and protective and support services entrusted to the Respondent’s care and is contrary to law. 60. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 20 61. | The Agency provided Respondent with the mandatory correction date for this deficient practice of December 23, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00. against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT IV 62. The Agency re-alleges and incorporates paragraphs one (1) through sixty-one (61) as if fully set forth herein. 63. Respondent has been cited for three (3) State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes (2006). . WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of $6,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2005). COUNT V. 64. The Agency re-alleges and incorporates paragraphs one (1) through sixty-one (6 1) as if fully set forth herein. 65. Based upon Respondent’s three cited State Class I deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part I of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2006). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida 21 Statutes (2006) commencing December 21, 2006 and ending January 17, 2007. Respectfully submitted this 2 day of May, 2007. Agency or Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2005), Respondent shall post the most current license in a prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be:represented by an attorney in this matter. 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: 7004 1350 0004 2776 0840 on May _2 _, 2007 to: Tunecia Sheffield, Administrator, Maitland Health Care Center, 1700 Monroe Avenue, Maitland, FL 32751 and by U.S. Mail to Kimberly A. Seith, Reg. Agent, Delta Health Group, Inc., 2 North Palafox St., Pensacola, FL 32502. 22 Copies furnished to: Tunecia Sheffield, Administrator Maitland Health Care Center 1700 Monroe Avenue Maitland, Florida 32751 (U.S. Certified Mail) Joel Libby Field Office Manager Hurston South Tower 400 W. Robinson, Suite $309 Orlando, FL 32801 (U. S. Mail Kimberly A. Seith Registered Agent Delta Health Group, Inc. 2 North Palafox Street Pensacola, Florida 32502 (U.S. Mail) Thomas J. Walsh, I, Esquire Senior Attomey Agency for Health Care Admin. 525 Mirror Lake Dr, 330G St. Petersburg, Florida 33701 teroffice) 23 t FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST GOVERNOR March 15, 2007 MAITLAND HEALTH CARE CENTER 1700 MONROE AVENUE MAITLAND, FL 32751 Dear Administrator: ANDREW C. AGWUNOBI, M.D. SECRETARY The attached license with Certificate #14213 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for status change to Conditional. Sincerely, Orbe 0.000 Agency for Health Care Administration Division of Health Quality Assurance Enclosure cc; AHCA Area Office 07 Long Term Care Section file Medicaid Contract Management Certificate of Need FLORIDA COMPARE GARE Health Gare in the Sunshine 2727 Mahan Drive, MS#33 - Tallahassee, Florida 32308 # wiw.FloridaGompareCare.gov Visit AHCA online at http://ahca.myflorida.com SCH O8T “IVIOL:. he é a Mitra: the a HT j eae t iigg othe {sori sete. if Stn, ) 1 'paztidipne , Par FLORIDA AGENCY FOR HEALTH CARE ADMINSTRATION CHARLIE CRIST GOVERNOR March 15, 2007 MAITLAND HEALTH CARE CENTER 1700 MONROE AVENUE MAITLAND, FL 32751 Dear Administrator: ANDREW C. AGWUNOBI, M.D. SECRETARY The attached license with Certificate #14214 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 The previously issued Standard license, Certificate #13989 must be retumed to the Agency because at the time of renewal your status was Conditional. Sincerely, . gency for Health Care Administration Division of Health Quality Assurance Enclosure ce: AHCA Area Office 07 Long Term Care Section file Medicaid Contract Management Certificate of Need : RIDA MPARE GARE Haalth Care in tha Sunshine 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 www.FlorldaGomparaCare.gov Visit AHCA online at http://ahca.myflorida.com L002/T0/10 *ALVG HALLO NOLLOV i SGHd 081 “IVIOL VICPT 3# ELVOMILLO ; FLORIDA AGENCY FOR HEALTH CARE ADMINGTRATION ANDREW C, AGWUNOBI, CHARLIE CRIST M.D. GOVERNOR. SECRETARY March 15, 2007 MAITLAND HEALTH CARE CENTER 1700 MONROE AVENUE MAITLAND, FL 32751 Dear Administrator: The attached license with Certificate #14215 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for a status change to Standard. Sincerely, Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: AHCA Area Office 07 Long Term Care Section file Medicaid Contract Management wa A Certificate of Need Arloripa SSS PB COMPARE CARE Visit AHCA online at Health Cara in the Sunatina http://ahca.myflorida.com 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 ff www.FloridaComparaGara.gov hit } Likes NE? Hage re SCHd 08T “IVLOL REST COMPLETE THIS SI iON ON DELIVERY” m@ Complete Items 1,2, and 3. Also complete item 4 if Restricted Delivery is desired. m@ Print your name and address on the reverse so that we can return the card to you. ™ Attach this card to the back of the mallpiece, or on the front if space permits. Sinner as C1 Registered” << Fi Retum Receipt for Merchandise™» insured Maiti — 1 G.0.D- 2, Article Number 7oo4, aS 0004 2?77b 840 (TaSICE FO Se ————$——— PS Form 3811, February 2004 Domestic Return Receipt i ve” “igpsgs-02-M-1540 wae Se at et mete eee . vee atimetiy’

Docket for Case No: 07-002686