STATE OF FLORIDA Oo, 8a ee AGENCY FOR HEALTH CARE ADMINISTRATION;< me if Le STATE OF FLORIDA, woe Og AGENCY FOR HEALTH CARE 0 < Od| ( ADMINISTRATION, Petitioner, vs. Case Nos. (fines) 2006013298 (conditional) 2006013299 SCG GRACEWOOD, LLC, d/b/a GRACEWOOD REHABILITATION AND NURSING CARE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, SCG Gracewood, LLC, d/b/a Gracewood Rehabilitation and Nursing Care (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges as follows: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of two thousand five hundred dollars ($2,500.00) and assign conditional licensure status beginning on September 27, 2007, and ending on October 17, 2007, based upon one Class II deficiency. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Florida Statutes (2007). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees skilled nursing facilities, more commonly referred to as nursing homes, in Florida and enforces the applicable federal regulations and state statutes and rules governing such facilities. Chs. 408, Part II, 400, Part II, Fla. Stat. (2007); and Ch. 59A-4, Fla. Admin. Code. The Agency is authorized to deny an application for licensure, revoke or suspend a license, and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or the applicable tules. §§ 408.813, 408.815, 400.121, 400.23. Fla. Stat. (2007). In addition, the Agency may assign conditional licensure status and assess costs related to the investigation and prosecution of this case. §§ 400.23(7), 400.121(8), Fla. Stat. (2007). 5. The Respondent was issued a license (License No. 1538096) to operate a 120-bed skilled nursing facility located at 8600 U.S. Highway 19 North, Pinellas Park, Florida 33782, and was at all times material times required to comply with the applicable federal regulations and state statutes and rules governing such facilities. "Nursing home facility" means any facility which provides nursing services as defined in Part I of Chapter 464, Florida Statutes, and which is licensed according to this Part. § 400.021(12), Fla. Stat. (2007). COUNTI The Respondent Failed to Ensure That Residents Were Accurately Assessed And Reassessed And That Physician Orders Were Obtained For The Appropriateness Of Physical Restrictions Or Restraints And Received Adequate And Appropriate Health Care And Protective And Support Services In Violation Of F.S. 400.022(1) 6. The Agency re-alleges and incorporates by reference paragraphs 1 through 5. 7. Under Florida law, 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. § 400.022, Fla. Stat. (2007). 8. Under Florida law, the resident’s rights statement shall assure each resident the right to be adequately informed of his or her medical condition and proposed treatment, unless the resident is determined to be unable to provide informed consent under Florida law, or the right to be fully informed in advance of any non-emergency changes in care or treatment that may affect the resident's well-being; and, except with respect to a resident adjudged incompetent, the right to participate in the planning of all medical treatment, including the right to refuse medication and treatment, unless otherwise indicated by the resident's physician; and to know the consequences of such actions. § 400.022(1)(j), Fla. Stat. (2007). 9. Under Florida law, the resident’s rights 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)(), Fla. Stat. (2007). 10. Under Florida law, the resident’s rights statement shall assure each resident the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, punishment, or reasons other than resident protection or safety. § 400.022(1)(o), Fla. Stat. (2007). 11. On or about September 27, 2007, the Agency conducted an annual health and life safety survey of the Respondent and its Facility. 12. Based upon observation, interview and record review, the Respondent failed to ensure that residents were accurately assessed and/or reassessed and that physician orders were obtained for the appropriateness of a physically restrictive environment and/or restraints, and received adequate and appropriate health care and protective and support services, which resulted in the inappropriate physical restriction, restraint and/or seclusion of 2 of 33 sampled residents (Residents #16 and #11). Resident #16 13. During the initial tour of the Facility on September 24, 2007, from approximately 9:24 am. to 10:15 a.m., Resident #16 was observed to be housed in the secured unit of the Facility. 14. The access to and from the secured unit was controlled by locked doors, which could be opened with a five digit code that must be activated by staff. 15. A patio and outdoor seating area also has its access controlled by a locked door, which must be activated by staff. 16. The patio and outdoor area are surrounded by a six-foot high chain-link fence, which prevents ingress and egress by residents. 17. During an interview on September 25, 2007, at approximately 3:05 p.m., with the Resident, the Resident stated that he or she felt like a prisoner in this place. 18. The Resident further stated that he or she was locked in here, taken by the staff to the dining room to eat, allowed to go outside only if someone unlocks the door, and must remain outside in the fenced area at such times. 19. A review of the Face Sheet in the medical record for Resident #16 revealed that the Resident had been originally admitted to the Facility on August 23, 2007, signed out against medical advice on August 25, 2007, and returned to the Facility on August 28, 2007. 20. The Cumulative Diagnosis Sheet, the Physician's Order Sheet dated August 28, 2007, and the Physician's Progress Notes dated September 22, 2007, reflected medical diagnoses for the Resident that included Hypertension, Congestive Heart Failure, Mood Disorder and Transverse Myelitis with Paraplegia. 21. The Resident Data Collection form dated August 28, 2007, described the Resident as "alert, oriented, angry, friendly, cooperative, talkative, with quick comprehension." 22. The Nurses Notes dated August 28, 2007, at 2:00 p.m. stated: "Resident arrived via stretcher - ambulance, alert and oriented X 3, was admitted last week, left against medical advice, now returned court ordered, continent of bowel and bladder, makes needs known, needs minimal assistance, transfers by self." 23. The Resident was also noted to require a wheelchair (self propel) for ambulation related to lower extremities weakness and problems with muscular coordination. 24. On August 29, 2007 (the day after Resident #16 was admitted), the physician signed a “Statement of Physician” form which stated that the physician had examined the Resident and determined that the Resident has the capacity to provide informed consent and make medical decisions. 25. A hand written report dated August 31, 2007, and signed by a professional consultant related to behavioral concerns, revealed that the Resident was: Alert. Oriented x 4. Appearance - well groomed; Attitude - cooperative; Thought processes - intact; Judgment - intact; Insight - impaired; Orientation - fluctuating time; Can resident make appropriate medical decisions at this time - yes; If accessible, resident should be considered for an Alzheimer's wing: none circled; Harmful to self - no; Harmful to others- no. 26. Nurses Notes dated September 8, 2007, at 11:00 a.m., indicated that the Resident wanted to leave. 27. The Resident indicated that he or she was going to live with his or her friend or family member, 28. | When the Resident was told by the Facility staff that he or she could not leave because there was a court order mandating his or her staying in the Facility, the Resident called the case worker. 29. The Nurses’ Notes dated September 8, 2007, at 12:00 noon documented: "case worker told the resident that it was her decision not court ordered." 30. The Nurses Notes also reflected that the Resident was given an option to provide a telephone number and address of the person who would provide housing, and the caseworker would make arrangements for the discharge. 31. | The Nurses' Notes do not reflect this was provided. 32. On September 27, 2007, at approximately 9:50 a.m., during a telephone interview with the Resident's caseworker, she related that she was very familiar with Resident #16. 33. She stated that she had spoken to a Facility Manager on September 8, 2007, in response to Resident #16 wanting to leave the Facility at that time, and explained that there was no court order in place. 34. She further related that if the Resident had a place to live, he or she could leave the Facility. 35. She further stated that she had asked the Facility to contact her if the Resident left, but said that no one ever did. 36. She further related that she was still continuing her efforts to find suitable placement for the Resident. 37. A review of the Nursing Notes for the Resident's stay did not reveal any documentation of exit seeking behavior. 38. On September 26-27, 2007, interviews with three CNAs and an Activities Assistant confirmed that they were all aware that Resident #16 had expressed his or her desire to reside somewhere other than the Facility. 39. A review of the Resident's medical record revealed no initial assessment of the Resident related to the need to reside in a secured unit and no ongoing assessment of the Resident for the continuing need to reside in the secured unit. 40. __ A review of all the Physician's Orders in the record for Resident #16 did not include an order to be admitted to the Special Care Unit, which is a secured unit within the Facility. 41. On September 26, 2007, at approximately 3:20 p.m., the Administrator provided a document which appeared to be an e-mail dated August 29, 2007, with Subject: "Special Care Unit Adm. & Disch. Criteria", titled: "Special Care Unit." 42. A review of this document revealed under the heading of "Admission Criteria”: "1. Must have a diagnosis of Alzheimer's Disease, Dementia, or other related disorders. 2. Have a physician's order." 43. The Administrator confirmed that these criteria apply to all residents. 44, During an interview with the Facility’s Unit Manager on September 26, 2007, at approximately 4:50 p.m., it was revealed that the Facility did not reassess the Resident's capability of living in a less restrictive unit in the Facility. Resident #11 45. A record review for Resident #11 revealed that on June 12, 2007, at 12:00 p.m. the Resident was found on his or her knees in front of the wheelchair. 46. As a result, the nurse notified the physician and a doctor's order was received "May use lap buddy while in wheelchair." 47. | The order remained and was found on the current September 2007 physician's order sheet. 48. A further review of the record revealed that no assessment for the use of this mechanical restraint had been completed and that there was no documentation that the Resident's legal representative had provided informed consent for the use of this type of restraint. 49. Based on observations of Resident #11 on September 24, 2007, at approximately 12:35 p.m. and 1:52 p.m., September 25, 2007, at approximately 8:15 a.m., and September 26, 2007, at approximately 9:02 a.m., it was revealed that the resident was seated in a wheelchair with a lap buddy in place. 50. During an interview with the Resident's Certified Nursing Assistant on September 26, 2007, at approximately 10:30 a.m., and Licensed Practical Nurse on September 26, 2007, at approximately 11:10 a.m., it was represented that the Resident needed the lap buddy to prevent him or her from getting up. 51. | They both acknowledged that while the Resident is able to remove the lap buddy at times, the Resident is unable to remove it at will. 52. During an interview with the Facility’s Minimum Data Set coordinator on September 26, 2007, at approximately 11:15 a.m., it was confirmed that she was responsible for performing physical restraint assessments after a referral from physical therapy or nursing. 53. She stated that the process requires a pre-screening assessment for restraints and a decision by the interdisciplinary team. 54. | She acknowledged the assessment had not performed for Resident #11. Sanctions 55. The Respondent’s actions or inactions constitute a class II deficiency. 56. Acclass II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. § 400.23(8)(b), Fla. Stat. (2007). 57. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8)(b), Fla. Stat. (2007). 58. In this instance, the Agency is seeking a fine in the amount of two thousand five hundred dollars ($2,500.00), as an isolated state class II deficiency. COUNT II Assignment of Conditional Licensure Status Pursuant to F.S. 400.023(7)(b) The Agency re-alleges and incorporates by reference paragraphs | through 5. The Agency re-alleges and incorporates by reference the allegations in Count I. 61. The Agency is authorized to assign a conditional license status to skilled nursing facilities pursuant to section 400.23(7), Florida Statutes (2007). 62. Due to the presence of a class II deficiency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes (2007), or the rules adopted by the Agency. 63. A conditional licensure status means that a Facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the Agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the Facility has no class I, class II, or class III deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. 64. The Agency assigned the Respondent conditional licensure status with an action effective date of September 27, 2007. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. 65. The Agency assigned the Respondent standard licensure status with an action effective date of October 17, 2007. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the Respondent conditional licensure status for the period between the assignment of the conditional license and the standard. license pursuant to section 400.23(7), Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of two thousand five hundred dollars ($2,500.00.). 3. Assign the Respondent conditional licensure status for the period between the assignment of the conditional license and the standard licese 4. Assess costs related to the investigation and py§é 5. Florida Bar No. 709311 Agency for Health Care Administration Office of the General Counsel Sebring Building, Suite 330D 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 NOTICE The Respondent is notified that it has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873. 11 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form have been served to: Cindy L. Daughters, Administrator, Gracewood Rehabilitation and Nursing Care, 8600 U.S. Highway 19, North, Pinellas Park, Florida 33782, by U.S. Certified Mail, Return Receipt No. 7007 0719 December, 2007. Agency for Health Care Administration Office of the General Counsel Sebring Building, Suite 330D 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 Copies furnished to: Cindy L. Daughters, Administrator Thomas M. Hoeler, Senior Attorney Gracewood Rehabilitation and Nursing Care Agency for Health Care Administration 8600 U.S. Highway 19 North 525 Mirror Lake Drive North, Suite 330D Pinellas Park, Florida 33782 St. Petersburg, FL 33701 (Certified U.S. Mail) (Interoffice Mail) Rebecca G. Thorn, Registered Agent Patricia R. Caufman, Field Office Manager SCG Gracewood, LLC Agency for Health Care Administration 1240 Marbella Plaza Drive 525 Mirror Lake Drive, 4th Floor Tampa, Florida 33619 St. Petersburg, Florida 33701 (U.S. Certified Mail) (Interoffice Mail) 12 Exhibit A Original Certificate of Conditional License For SCG Gracewood, LLC d/b/a Gracewood Rehabilitation and Nursing Care Certificate No. 14879 License No. SNF1538096 13

Docket for Case No: 08-000311