STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2006003572 2006003571 GREENBROOK NH, LLC, d/b/a APOLLO HEALTH & REHAB CENTER, Respondent. a) (, “2 if Y ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against GREENBROOK NH, LLC, d/b/a APOLLO HEALTH & REHAB CENTER, (hereinafter “Respondent”), pursuant to §§ 120.569 and 120.57 Fla. Stat. (2005), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing March 30, 2006, impose an administrative fine in the amount of $20,000.00 and a survey fee in the amount of $6,000.00, based upon Respondent being cited for two State Class I deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2005). re) Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Respondent operates a 120-bed nursing home, located at 1000 — 24" Street N., St. Petersburg, FL 33713, and is licensed as a skilled nursing facility license number 11830962. 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. COMMON FACTUAL ALLEGATIONS 6. That on or about March 30, 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 three (3) on March 30, 2006, and noted the following: a. That the physician's admission orders dated March 13, 2006 recited diagnoses of back pain, diabetes mellitus, hypertension, anemia, chronic renal insufficiency, and degenerative joint disease with orders for physical therapy for ambulation; b. That the Nursing Admission Data Review dated March 13, 2006 memorialized that the resident was alert and oriented and required limited assist for transfers and ambulation and was continent of bowel and bladder; c. That a nurse's note dated March 14, 2006 noted that the resident was able to make needs known; d. That an undated Social Service Assessment documents that the resident plans to return home after rehabilitation; That there existed no Advanced Directives in the record, nor was there a request for a “Do Not Resuscitate Order” (hereinafter “DNR”), and the resident was deemed to be a full code for resuscitative purposes; That nurse's notes dated March 19, 2006 memorialized the following: 1, iii. vil. viii. That the physician had been in to assess the resident that day between 10:00 and 11:00 a.m. and ordered lab work to be done the next day; That at 11:30 a.m., the physician was called and orders were obtained to catheterize the resident because the resident was having difficulty voiding: That at 2:00 p.m., the physician was called and notified that the resident was not drinking and complained of abdominal pain; That the nurse asked if the labs should be done stat and the physician indicated that the lab work could be done in the morning; That the resident was catheterized for 150 cubic centimeters (cc) of urine; That at 2:45 p.m., vital signs were stable and resident was resting "in bed with eyes open. No distress noted." That between 4:00 and 5:00 p.m., the licensed practical nurse (hereinafter “L.P.N.”) on the unit and the registered nurse supervisor (hereinafter “R.N.”) checked the resident at the request of the certified nursing assistant; That vital signs and oxygen saturation levels were within normal limits; The resident was given two Percocet tablets at 5:00 p.m. for pain that was described as "vague" and "pain is all over." That at 5:00 p.m. a nurse charted that regular staff stated that the resident is not [him/herself] and that the resident was "alert and unresponsive to staff." xi. xii. xiii. xiv. XV. Xvi. xvii. xviii. That there was no indication that the physician was called at this time; That at 6:00 p.m., the nurse charted that the resident continued to moan and that the Percocet was ineffective; That no vital signs were documented, nor was there documentation that the physician was notified of the resident's condition and that the pain medication was ineffective; That a nurse’s entry at 7:15 noted that the nurse was summoned to the resident’s room by the certified nursing assistant where the resident was "taking last breaths." That there was no documentation or indication that the nurse or other staff called an ambulance, the resident’s physician, the Respondent’s on-call R.N., or the family, nor was there any documentation that the resident was provided comfort, oxygen or emergency care; That at 7:25 p.m., the nurse charted that the resident had no pulse or blood pressure; That the nurse then called the family and the physician; That there was no documentation that the nurse called any other nurse or medical professional for assistance and/or guidance, or that any emergency care and treatment, including but not limited to cardio pulmonary resuscitation, had been performed. 8. That the Petitioner’s representatives interviewed the Respondent’s certified nursing assistant on March 27, 2006 who indicated the following: a. That she worked the 3 p.m. to 11 p.m. shift on March 19, 2006; b. That she cared for resident number three (3) on that date; c. That when she first checked on resident number three (3) at approximately 3:30 p.m. she noticed that the resident was not [his/her] usual self, not alert or responding and was calling out "mother, mother." d. That she notified the nurse in charge of the changes in the resident and of the resident's disorientation; @ That the nurse checked the resident and voiced that the resident did not look too good. 9. That the Petitioner’s representative’s interviewed the Respondent’s R.N. supervisor on March 28, 2006 who indicated the following: a. b. d. That she works twelve (12) hour shifts; That she left the Respondent facility at 6:11 p.m. on March 19, 2006 as her shift was completed; That she had checked resident number three (3) on that date between 4:00 and 5:00 p.m.; That at that time resident number three (3) was alert and capable of being aroused. 10. ‘That the Petitioner’s representative interviewed the Respondent’s LPN on March 28, 2006 who indicated the following: a. b. That she was the LPN who worked the 3 to 11 shift on March 19, 2006; That she checked the chart of resident number three (3) at approximately 3:15 p.m. and saw what she believed to be a DNR on a white piece of paper in the chart; That on March 19, 2006, she had not contacted the physician of resident number a three (3) at any time during the shift until after the resident had expired; d. That on March 19, 2006, she had not contacted the Respondent’s on-call nurse regarding resident number three (3) at any time during the shift; e. That on March 19, 2006, she had not administered oxygen, performed cardio pulmonary resuscitation, or taken any other actions as she believed that resident number three (3) was the subject of a DNR; f. That had she not seen a DNR in the chart of resident number three (3) she would have contacted the resident’s physician; g. That she was the employee of an agency and had not worked in the Respondent facility for several months; h. That she had not received an orientation to the Respondent facility or its policies and procedures. 11. That the Petitioner’s representative provided the Respondent’s records for resident number three (3) to the LPN who had been on duty on March 19, 2006 and requested that the resident’s DNR be identified. 12. That the Respondent’s LPN could not locate a DNR for resident number three (3). 13. That the Petitioner’s representative interviewed the Respondent’s administrator on March 27, 2006 who indicated the following: a. That after review of records, the administrator confirmed that there was no DNR. in the medical records of resident number three (3); b. That the Respondent does not perform orientation of agency staff; c. That staff are expected to perform cardio pulmonary resuscitation on residents if the resident does not have a DNR in the resident’s chart. 14. That the Petitioner’s representative interviewed the physician of resident number three (3) by phone on March 28, 2006 who indicated that it was his expectation that cardio pulmonary resuscitation would have been administered on resident number three (3) and that the resident would be sent to the hospital. 15. That the Petitioner’s representative interviewed the Respondent’s medical director on March 29, 2006 who indicated that “pain is the fifth vital sign" and he would expect that the pain as noted for resident number three (3) would be reported to the resident’s attending Physician. COUNT I 16. The Agency re-alleges and incorporates paragraphs one (1) through fifteen (15), as if fully set forth herein. 17. That pursuant to Florida law, all licensees of nursing homes 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 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, with established and recognized practice standards within the community, and with rules as adopted by the agency. § 400.022(1)(1), Fla. Stat. (2005). 18. That Florida law provides the following: “Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of iliness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(b), Fla. Stat. (2005). 19. That the Respondent failed to provide for the rights of its residents in the Respondent’s failure to provide adequate and appropriate health care and protective and support services in the following: a. The Respondent failed to provide adequate and appropriate health care in its failure to notify the health care provider of resident number three (3) that the resident was experiencing a change in condition including complaints of pain and unresponsiveness; The Respondent failed to provide adequate and appropriate health care in its failure to notify the health care provider of resident number three (3) that the resident was experiencing a change in condition including continued observations that the resident was experiencing pain after having been administered pain medication; The Respondent failed to provide adequate and appropriate health care in its failure to provide comfort or assist in pain management after observing the resident’s continued pain; The Respondent failed to provide emergency care, including but not limited to resuscitative care such as cardio pulmonary resuscitation or oxygen, after identifying the resident’s medical distress identified as “last breaths;” The Respondent failed to provide adequate and appropriate health care in its failure to contact emergency services after identifying the resident’s medical distress identified as “last breaths;” f. The Respondent failed to provide adequate and appropriate health care in its failure to notify the family of resident number three (3) that the resident was experiencing a change in condition including complaints of pain and unresponsiveness. 20. ‘That these multiple failures resulted in the death of-resident number three (3) without the resident having received interventions to address the resident’s ongoing complaints of pain and without the resident’s receipt of medical interventions or efforts to resuscitate the resident when the resident was identified as experiencing medical distress, said failures being in violation of law and below recognized professional standards of nursing. 21. 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 an isolated State Class I deficiency. 22. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 2, 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 8s 400.23(8)(a) and 400.102, Fla. Stat. (2005). COUNT I 23. The Agency re-alleges and incorporates paragraphs one (1) through fifteen (15), as if fully set forth herein. 24. 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), Fla. Stat. (2005). 25. That Florida law provides the following. “‘Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(b), Fla. Stat. (2005). 26. That the Respondent has and had a duty to perform adequate and appropriate health care for the resident’s of its facility. 27. That the Respondent has and had a duty to be aware of its resident’s records, including but not limited to whether a resident has indicated through a DNR whether life prolonging procedures. should be utilized. 28. That the Respondent either intentionally or negligently failed in meeting its duties in the following: a. That the Respondent intentionally or negligently failed to notify the health care provider of resident number three (3) that the resident was experiencing a change in condition including complaints of pain and unresponsiveness; b. That the Respondent intentionally or negligently failed to provide adequate and appropriate health care in its failure to notify the health care provider of resident number three (3) that the resident was experiencing a change in condition including continued observations that the resident was experiencing pain after having been administered pain medication; c. That the Respondent intentionally or negligently failed to provide adequate and appropriate health care in its failure to provide comfort or assist in pain management after observing the resident’s continued pain; d. That the Respondent intentionally or negligently failed to provide emergency care, including but not limited to resuscitative care such as cardio pulmonary resuscitation or oxygen, after identifying the resident’s medical distress identified as “last breaths;” e. That the Respondent intentionaily or negligently failed to provide adequate and appropriate health care in its failure to contact emergency services after identifying the resident’s medical distress identified as “last breaths.” 29. That the above, individually and collectively, materially affected the health and safety of resident number three (3). 30. That the intentional or negligent acts described above would cause or was likely to cause serious injury, impairment, or death to residents of the Respondent facility. 31. That the intentional or negligent acts or inactions of the Respondent are in violation of law. 32. That 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 an isolated State Class I deficiency. 33. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 2, 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, Fla. Stat. (2005). COUNT II 34. The Agency re-alleges and incorporates paragraphs one (1) through fifteen (15), seventeen (17) through twenty-two(22), and twenty-four (24) through thirty-three (33) as if fully set forth herein. 35, Respondent has been cited for two 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), Fla. Stat. (2005). 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), Fla. Stat. (2005). COUNT IV 36. The Agency re-alleges and incorporates paragraphs one (1) through five (5), (7) through (20), and (22) through (34) as if fully set forth herein. , 37. Based upon Respondent’s two cited State Class I deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part IT 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), Fla. Stat. (2005). 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), Fla. Stat. (2005) commencing March 30, 2006. Respectfully submitted this / } day of May, 2006. 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. 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, 323 08, (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 US. Certified Mail, Return Receipt No: 7004 2510 0005 4049 3288 on May > 2006 to: I HEREBY CERTIFY that a true and correct copy of the foregoing has F served by » EL 32789. Karen L. Goldsmith, Esq., 2160 Park Avenue North, Winter Pai Th alsh, II, Esquire Copies furnished to: Karen L. Goldsmith, Esq. 2160 Park Avenue North Winter Park, FL 32789 (U.S. Certified Mail) Thomas J. Walsh, II, Esquire Senior Attorney Agency for Health Care Admin. 525 Mirror Lake Dr, 330G St. Petersburg, Florida 33701 (Interoffice) FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR ALAN LEVINE, SECRETARY May 17, 2006 Karen L. Goldsmith, Esq. 2160 Park Avenue North Winter Park, FL 32789 RE: Agency for Health Care Administration v. Greenbrook NH, LLC Case numbers: 200603571 and 200603572 Dear Ms, Goldsmith: Please accept this letter as confirmation that you will accept service of the enclosed complaint on behalf of your client Greenbrook NH, LLC. In addition, you will take such steps as are necessary to amend that certain Petition for Formal Hearing filed on behalf of your client based upon correspondence from the Agency to reflect the same as responsive to this complaint. Thank you in advance for your cooperation. Very truly yours, . Walsh, I Visit AHCA online at wwuefdie.state flus 325 Mirror Lake Drive #330H St. Petersburg, FL 33701

Docket for Case No: 07-002715