STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE - ADMINISTRATION, Cl S 3 x < Petitioner, AHCA Nos. 2007010195 (Fine) 2007010196 vs. (Conditional License) HEARTHSTONE SENIOR COMMUNITIES, INC., d/b/a BAY CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through undersigned counsel, and files this administrative complaint against HEARTHSTONE SENIOR COMMUNITIES, INC., d/b/a BAY CENTER, , (hereinafter “Facility” or “Respondent”), pursuant to §§ 400, Part II, 408, Part II, 120.569 and 120.57, Fla. Stat. (2007). NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of two thousand five hundred dollars ($2,500) based upon Respondent being cited for one isolated Class II deficiency, pursuant to § 400.102(1)(a), Fla. Stat. (2007), (AHCA No. 2007010195). Additionally, this is an action to impose a conditional licensure rating from July 19, 2007, through September 5, 2007 pursuant to §400.23(7)(b), Fla. Stat. (2007) (AHCA No. 2007010196). JURISDICTION AND VENUE 2. The Agency has jurisdiction pursuant to §§ 120.569, 120.57, 120.60, 400.062, and 408.813, Fla. Stat. (2006). 3. Venue lies in Bay County, pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 4. The Agency is the enforcing authority with regard to skilled nursing facilities licensure pursuant to § 400, Part II, Fla. Stat. (2007), and Fla. Admin. R.5S9A-4. 5. Respondent operates a skilled nursing facility located at 1336 St. Andrews Blvd., Panama City, Florida 32405, having been issued license number 10340961. 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. COUNTI RESPONDENT’S FACILITY FAILED TO INVESTIGATE INJURIES OF UNKNOWN ORIGIN AND PROTECT RESIDENTS FROM POTENTIAL INJURY FOR FOUR OF TWENTY-SEVEN RESIDENTS, AND NEGLECTED TO PROVIDE CARE AND SERVICES TO PREVENT WORSENING OF A PRESSURE ULCER FOR ONE RESIDENT § 400.102(1)(a), Fla. Stat. (2007) ISOLATED CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That an off-hours entry re-certification survey was conducted starting on Sunday, July 15, 2007 at approximately 5:00 p.m. through July 19, 2007. The facility was not in compliance with 42 CFR 483 & 488 requirements for Long Term Care Facilities. 8. Based on observation, record review and interview the facility failed to investigate injuries of unknown ongin and protect residents from potential injury for 4 of 27 residents (#5, 16, 25, 26); and neglected to provide care and services to prevent worsening of a pressure ulcer for 1 of 27 residents #17. The findings include: 1. A review of the abuse "Self-Paced Learning Module" given to employees during orientation did not include training in identification and investigation of injuries on unknown source. 2. An observation of the resident # 16 on 7/18/07 at 12:55 P.M. the right side of the resident's face was black, purple and brown from the hairline to the bottom of the neck. The bruising covered the complete right side of the resident's face and across the bridge of the nose. The resident's right eye was red and almost swollen shut. An interview with the resident at this time stated “isn't it ugly" indicating her face. The resident pulled back her hair and displayed a large raised area to her head at the beginning of her hair line on the right side. The area was approximately 2 cm raised and 2 cm in diameter. The resident stated the "man with a big stick hit me." A review of the medical record revealed on 7/8/07 at 11:00 P.M. the nurse documented the "resident was found on floor, upper torso under bed. Resident had arms wrapped around bar under bed, had urinated on self. Resident babbling, holding onto bar, tried to undo amns, resident screaming to leave her alone. Staff gently unwrapped arms from pole and slid her out from under bed. Large hematoma noted right forehead around temple area." The resident was sent to the Emergency Room. The medical record did not contain a report from the Emergency Room. The nurse’s note 7/9/07 at 5:30 A.M. stated the Emergency Room staff called and papers were sent with the resident. The resident was to be awaken every 3-4 hours x 24 hours due to “head trauma.” An interview with the LPN on 7/18/07 at 3:30 P.M. stated the resident #16 had no other bruising to her body or other injuries, except to the head and face. An interview with the C.N.A. on 7/19/07 at 6:30 A.M. stated on 7/8/07 she was making rounds at approximately 10:00 P.M. and resident #16 was not in her bed. The C.N.A. found the resident under the bed holding on to the bar under the bed. The C.N.A. and nurse attempted to assist the resident out from under the bed. The resident began screaming "Why did you do this to me?" among other things. The resident had a knot on her head and it took about 10 minutes to calm the resident, 3. An interview with the Risk Manager/Assistant Director of Nursing (ADON) on 7/18/07 at 12:30 P.M. stated the bruising to resident #16 is "better." She stated the event was recorded as an observation on the floor under bed at 11:00 P.M. by aC.N.A. with arms wrapped around the bed frame under the bed. She stated the C.N.A. was making walking rounds and discovered the resident on the floor. The resident was not seen or heard prior to being found on the floor. She stated it took "several" staff members to get the resident out from under the bed. The resident had a large bruise to the right side of face. She stated the resident was screaming when staff attempted to get her out from under the bed. The resident was "thinking someone was going to hurt her." She stated the facility did not have a copy of the Emergency Room report to review the physician's findings and discharge instructions. The ADON stated she did not investigate the injury any further because of the resident's dementia. The incident was attributed to Dementia. She stated the staff take such good care of the residents, are caring and would not abuse the resident. The ADON stated did not "even approach from an abuse" prospective. The ADON was unable to explain how dementia would cause a large knot to the head with a hematoma. She stated was unaware of any other injuries to residents which were not witnessed. Resident #5 (also on the same locked unit with resident #16) on 6/24/07 was found at 2:15 A.M. with a hematoma to left temple. The ADON stated this injury was not investigated as an abuse investigation. This injury was also un-witnessed and both residents had no other injuries to their bodies. The ADON stated had not put the two incidents together until questioned by the surveyors. Both of these residents are on a Locked Unit with 27 other residents. A review of the facility's Immediate Abuse Reports from 1/1/07 to 7/18/07 revealed no reports of Injuries of Unknown Source. 4. An observation of the resident #5 on 7/19/07 at 9:10 A.M. revealed the resident with healing hematoma over left eye. A review of the medical record revealed a nurse note dated 6/24/07, the nurse documented at 2:15 A.M. "resident awoke when room mate was being cared for...was lying on his left side. When he sat up a C.N.A. saw a moderate sized hematoma just above left brow with some darkening under left eye...mild swelling. This nurse asked resident if he fell or bumped his head, he stated ‘don't know’, asked him if he knew what had happened. He again stated ‘don't know’. No other injury noted." An interview with the DON on 7/18/07 at 11:15 A.M. confirmed the resident was found in bed with a hematoma over the left eye. The injury was not listed as a fall. An interview with the LPN on 7/18/07 at 3:30 P.M. stated the injury to resident #5 was a "strange one." The nurse went into the room at 2:00 A.M. to assist the roommate and the resident #5 sat up in the bed. The nurse noted the resident with a hematoma over his left eye. The resident had no other bruising to his body or other injuries. The resident could not tell the staff how the injury occurred. The resident will usually yell "call the police" whenever someone is bothering him and can indicate what happened. An interview with the ADON on 7/18/07 at 11:35 A.M. stated the injury was recorded as an injury of unknown source. The ADON stated the nurse noted the hematoma to the forehead during the night. The resident was unable to tell how the injury occurred. The resident has a history of seizures. The ADON contributed the injury to a seizure or "walking into the bathroom door at night." The resident is on 3 medications for seizures. The ADON stated the resident was not witnessed having a seizure but it was assumed that is what happened. The facility did neuron-checks after the injury was discovered which were all normal. This is not consistent with normal findings of a resident after a seizure. The ADON had no explanation for this. The ADON stated after the injury the resident’s psychotic medications were assessed and the resident's Abilify was discontinued. A review of the medical record revealed the Abilify was actually discontinued on 5/1/07, over a month before the injury. The ADON was unable to explain this discrepancy in her investigation. The ADON stated to the 2 surveyors present during this interview, that an investigation was not conducted to tule out abuse due to the injury occurred during the middle of the night and the facility felt the injury was due to a seizure. 5. A review of the medical record for resident #25 revealed the resident was found on 6/26/07 with skin tears to left hand. The skin tear to the back of the wrist was 1.8 cm x .5 cm and to base of forefinger 0.5 cm diameter. The resident stated his roommate (#27) hit him. The roommate denied the allegation. A review of the medical record for the roommate (resident #27) the nurse documented on 6/18/07 the resident's Depakote was increased because of aggressive behavior, combativeness, and threatening others with a cane. The medical record contained no entry related to the allegations by resident #25 on 6/26/07. The nurse notes stated the resident was evaluated by Therapy on 6/26/07 and the cane was taken away. A review of both medical records (#25 and #27) contained no further investigation of the un-witnessed injuries to resident #25 or measures to protect the resident. A review of the facility's Immediate Reports revealed no report filed for the Injury of Unknown Source. An interview with the LPN on 7/18/07 at 3:30 P.M. stated the resident #27 would swing his cane at staff. The cane was taken away, but the resident was given a walker a couple of days after the cane was taken. An observation of the resident #27 on 7/19/07 at 2:15 P.M. the resident was observed ambulating in the locked unit with walker folded and held in the right hand as a cane. An interview with the LPN on 7/19/07 at 11:00 A.M. confirmed resident #25 had un-witnessed skin tears. The resident #25 would "point" to resident #27 when asked what happened. The resident #25 would indicate a long item with his hands. The cane of resident #27 was at the end of the bed. The LPN stated the staff moved the resident #25 to another room after the incident. A review of the medical record revealed no documentation of this move to another room. The LPN was unsure of the date the resident was moved to another room. The LPN did not see resident #27 hit the resident #25, but "there was suspicion that he hit" the resident #25. An interview on 7/19/07 at 1:20 P.M. with the DON, ADON, and Regional Corporate Nurse stated the ADON is the Abuse Coordinator. Resident #27 was upset due to resident #25 urinated on the resident, which lead to the episode on 6/26/07. This information/behavior was not documented in either of the resident's medical record. They stated the resident #25 was moved to another room but are unsure of date the resident was moved. There was no further investigation into the incident to confirm the resident was abused by his roommate and no intervention to protect the residents from the resident #27 except the removal of the cane. The resident #27 currently has a walker and a new roommate. 6. On 07/18/07 at approximately 5:30 p.m. resident #26 was observed lying in bed, partially covered. Three (3) large bruises were visible from the hallway on resident #26's right arm. These injuries were of a suspicious nature and were not new injuries. On 07/18/07 at approximately 6:00 p.m. an LPN was asked to examine resident #26's right arm. The LPN observed the three large bruises with this surveyor. The bruise on the upper arm was large and roundish and was equal in size to the width of resident #26's arm. The bruise on the elbow extended from above the elbow, over the elbow to below the elbow, and also covered the entire outer view of resident #26's arm. The bruise on the wrist was smaller and round only covering about half of resident #26's arm width. Resident #26 was unable to state how the bruises occurred. An interview was conducted with the LPN at that time. The LPN states that she was previously unaware of the bruising. The LPN stated that the bruising should be documented in resident #26's medical record. The LPN further stated that skin sweeps are done weekly on every resident. Stated that the bruising would either be documented on the ‘Weekly Skin Check’ form, or in the Nurse's Notes. Record review revealed no identification of bruising on resident #26. Nurse's notes from 05/28/07, through the most current entry of 07/07/07 did not mention any bruising or injury. On 06/30/07 a nurse documented, "Skin check performed per weekly routine schedule. No interruptions in skin integrity noted." On 07/07/07 a nurse documented, "Skin check performed per weekly schedule. No interruptions in skin integrity noted." On a form entitled 'Weekly and PRN Skin Check" a nurse documented "No new areas of skin impairment" on 06/30/07, 07/07/07, and 07/14/07. No further documentation was made on this form. An interview on 7/19/07 at 1:20 P.M. with the DON, ADON, and Regional Corporate Nurse stated the resident #26 had now been assessed and the appropriate State forms completed and an investigation was completed today to rule out abuse. The staff is to be in-serviced on recognizing injuries of unknown source to report to the Risk Manager. 7: Areview of the facility's policy on Guidance for Conducting Investigations of abuse stated the Injuries of Unknown Source must meet 2 conditions: 1) source of injury was not observed by any person or the source of the injury could not be explained by the resident AND 2) injury is suspicious because of the extent of the injury or the location of the injury (e.g. its location in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The residents #5, 16, 25, and 26 would meet this criteria related to the location of the injuries and extent of the bruising which was not witnessed and could not be explained by the resident. The implementation of this policy would necessitate the investigation into these injuries to rule out abuse by another resident or other person. The facility's policy further stated "conducting a thorough investigation" included, the type of allegation, documentation of the details of the incident, documentation of the injury, interview and obtain statements of each staff member with any knowledge of the incident, interview any visitors or anyone who might have knowledge of the incident, interview staff on other shifts, interview residents in the same room or vicinity, identify the cognitive status of the victim and other residents, review the behavior of the perpetrator (if known), describe any actions taken by the facility to protect residents and to prevent a reoccurrence, identify any medications that may cause the resident to bruise easily or may in any way be related to the nature of the injury, review facility procedures, review and identify any nurse's notes or other facility records that may contain information about the incident. The facility failed to provide evidence during the survey that this policy was implemented and followed for the resident's #5, 16, 25, and 26. 8. A review of the medical record for resident #17 revealed a wound culture of a pressure sore to the sacrum was completed on 6/7/07. The nurse’s notes confirm the culture was from the wound due to abnormal drainage from the sacral wound. The results revealed +3 growth of the microorganism of P. Mirabilis. The physician ordered on 6/12/07 for the resident to begin the antibiotic Augmentin. The pharmacy notified the nursing staff the patient was allergic to Augmentin. The nurse phoned the physician and a phone order was received for Macrobid for 14 days on 6/12/07, The Culture and Sensitivity report does not list Macrobid (Nitrofurantoin) as a medication in which the microorganism is sensitive. The Drug Information Handbook for Nurses stated the medication Macrobid is indicated in the treatment of Urinary Tract Infections, not wound infections. The facility did not clarify the medication order with the physician or complete a follow up wound culture upon the completion of the antibiotics. The wound continued to drain foul smelling drainage after completion of the antibiotic. The last assessment on 7/17/07 lists the drainage as gray/brown with a foul smell. The medical record contained no communication with the physician of the continued foul smelling drainage. A review of the Skin Gnd the area to the Sacrum was identified on 5/15/07 as a Stage II, with measurements of 3 cm x 6 cm with a depth of less than 0.1. On 6/19/07 the wound increased in size from a Stage II to a Stage III with measurements of 6 cm x 9 cm with tunneling of 2 cm (unable to assess depth of wound). On 6/22/07 the nurse documented the wound was not stageable. The wound was measured weekly and continued to reveal an increase in wound size with a foui yellow/green drainage and black wound bed. The last measurements on 7/17/07 revealed the wound was not stageable, the length is increased to 8.8 cm, width increased to 14.2 cm, and depth increased to 2.4cm. The drainage is gray/brown with a foul odor. The wound bed is gray. The tunneling is increased to 2.4 cm. A review of the nurse notes for 6/19/07". ...... Govumented the decline in the status of ie Wound. The nuise wid not document communication with the physician of the decline in the wound from a Stage II to a Stage III with continued foul smelling yellow/green drainage. On 6/27/07 the resident requested to be sent to the Wound Care center for debridement of the wound. The physician approved of this request. The nurse documented the wound care center was notified and stated Medicaid would not pay for the treatment. There is no further documentation of follow up of this request. The wound care was changed on 6/29/07. The facility protocol is for wound care once a day, The resident requested the wound care be performed twice a day, but later notified the nurse he would comply with the once a day protocol. Since the wound care was changed on 6/29/07 the wound has continued to decline with increased measurements, foul odor, and increased tunneling. There was not documentation of communication with the physician of the continued decline of the wound. The resident was documented as being non-compliant with treatment because he refuses to go to bed and prefers to stay up in the wheelchair. The nurse documented on 7/17/07 that the resident uses his hand to reposition self in the wheelchair during the day. The resident was observed on 7/16/07 at 2:00 P.M. during a group meeting repositioning himself in his chair to periodically relieve pressure. The resident's care plan stated the resident is non-compliant with treatments. The facility's July 1-18, 2007 TAR does not list any days as wound care missed or refused by the resident. The resident was to receive a whirlpool each day on 11-7. A review of the July 1- 18 TAR, revealed the resident was to receive a whirlpool each day on the shift 11- 7. The nurse TAR is blank on the dates 7/1, 7/2, 7/7, 7/11, 7/13, 7/14, 7/16 and 7/17. The dates of 7/3, 7/4, 7/6, 7/8, 7/12, and 7/15 are circled, which indicated the treatment was not given and the reason would be documented on the back of the TAR. Only one of these days(7/10) is documented on the back of the TAR. On 7/3/07 and 7/10/07 the nurse documented the resident refused the whirlpool but allowed the dressing change. On 7/13/07 at 4:00 a.m. the nurse documented the resident refused the whirlpool. It is not documented if the nurse offered the whirlpool at a later time. There is no further documentation of refusal of the whirlpool. There is no further documentation of the daily completion of the whirlpool for the treatment of the pressure sore or notification to the physician of the resident's refusal or failure to receive the whirlpool! daily as ordered. During an interview with the resident on 7/19/07 at 12:45 P.M. with review of his Treatment Administration Record (TAR) for 7/07, resident #17 was questioned on the whirlpool. The resident was to receive a whirlpool daily on 11-7 shift for pressure sore. The resident stated he does not refuse the whirlpool every day. The resident stated the facility is using Agency nurses, who state they do not know how to do the whirlpool. The resident stated there is a problem with agency nurses doing the required wound care. The resident stated he is aware his pressure sore is getting worse. The facility's MDS lists the resident's cognition as a"0" or no impairment. 9. The above findings constitute a violation of § 400.102(1)(a), Fla. Stat. (2007), an isolated Class II deficiency, for which a fine of $2,500 is authorized pursuant to §§ 400.23(8)(b) and 408.813, Fla. Stat. (2007). COUNT II DUE TO THE CITED UNCORRECTED CLASS III DEFICIENCY, AN IMPOSITION OF A CONDITIONAL LICENSE IS WARRANTED §§ 400.19(3) and 400.23(7)(b), Fla. Stat. (2006) 10. | The Agency re-alleges and incorporates paragraphs (1) through (9) as if fully set forth herein. 12. Based upon Respondent’s cited isolated State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under § 400, Part II, Fla. Stat. (2007), or with rules adopted by the Agency, a violation subjecting it to assignment of conditional licensure status pursuant to § 400.23(7)(b), Fla. Stat. (2007). 13. Due to the presence of an isolated Class II deficiency, a conditional license certificate number 14762 was issued to Respondent with an effective date of July 19, 2007. Respondent was issued a standard license certificate number 14763 with an effective date of September 5, 2007 (Exhibits 1 and 2). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I and Count II; (B) Recommend administrative fines against Respondent in the amount of $2,500 for Count I; (C) Assess attorney’s fees and costs; and (D) 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 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter, 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. ft Respectfully submitted this a day of October 2007. /y| A Bart O. Moore, Esquire Fla. Bar. No. 0768715 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7004 2890 0000 5526 7810 to: Facility Administrator, Rodney C. Watford, 1336 St. Andrews Blvd., Panama City, FL 32405, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 7827 to: Owner Hearthstone Senior Communities, Inc., 1333 Wayne Street, Reading, PA 19601, and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 7834 to Registered Agent Spector Gadon & Rosen, PA, 360 Central Avenue, Suite 1550, St. Petersburg, Florida 33701on October Dib 2007: i / ! : O. Moore, Esquire Copy furmished to: Barbara Alford, FOM 11

Docket for Case No: 07-005383