; STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION OY. OUTS STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008005799 (Fines) 2008005800 (Cond.) OAK TERRACE HEALTH CARE ASSOCIATES LLC, d/b/a Governors Creek Health and Rehabilitation, 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 OAK TERRACE HEALTH CARE ASSOCIATES, LLC, d/b/a Governors Creek Health and . Rehabilitation, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing April, 23, 2008, impose an administrative fine in the amount of $60,000, and a survey fee in the amount of $6,000, based upon being cited for four widespread State Class I deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2007). 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 120-bed nursing home, located at 803 Oak Street Green Cove Springs, Florida 32043, and is licensed as a skilled nursing facility license number 1181096. 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. COUNT I RESPONDENT’S FACILITY FAILED TO MONITOR AND ENSURE THE IMPLEMENTATION OF ITS SMOKING POLICY AND PROCEDURES IN ORDER TO PROTECT THE RESIDENTS. §§ 400.141(1) and 400.20, Fla. Stat. (2007) WIDESPREAD CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That Florida Law provides the following: Section 400.20, Fla. Stat. (2007) Licensed nursing home administrator required.--No nursing home shall operate except under the supervision of a licensed nursing home administrator, and no person shall be a nursing home administrator unless he or she is the holder of a current license as provided in chapter 468. Section 400.141, Fla. Stat. (2007) Administration and management of nursing home facilities.--Every licensed facility shall comply with all applicable standards and rules of the agency and shall: (1)Be under the administrative direction and charge of a licensed administrator. 8. That on April 22, 2008 through April 23, 2008, the Agency conducted an unannounced Complaint Investigation. The complaint allegation was confirmed and citations were issued as a result of this investigation. 9. . Based on record review of 8 sampled residents, staff interviews, review of the Facility's Smoking Policy and Procedures, review of the grievance log and a review of the December 2007 Resident Council meeting, the facility failed to monitor and ensure the implementation of its Smoking Policy and Procedures in order to protect the residents of the facility. This failure contributed to the facility's lack of appropriately intervening, including Residents #1, #2, #3 and #5, and preventing a resident with poor decision making skills from smoking in his/her room while using oxygen which resulted in the death of Resident #1. The Governing Body failed to demonstrate adequate supervision and assistance with smoking for residents at risk with smoking and thereby created an immediate jeopardy situation for all residents in the facility. The findings include: ~ 1. Despite awareness that Resident #1 lacked safety awareness, needed assistance with lighting his/her cigarette, was non-compliant with keeping a lighter in his/her possession and required redirection from smoking in his/her room or other parts of the facility, the facility failed to prevent Resident #1 from injuring him/herself or other residents in the facility. A smoking screen was conducted 3 days after this resident was found in his/her room smoking. The screen was inaccurate and completed by the Risk Manager (RM); however, he/she did not sign off as having completed the screen. During an interview on 4/23/08 at 8:53 a.m. and in the presence of the Director of Nursing (DON), when asked why she didn't sign the document she completed, she stated she was told by the Regional Management Team not to sign anything as the RM. This same screen, which was inaccurate, was signed by the Social Service Director who confirmed he/she never read the document he/she had signed. Interviews conducted during the survey with licensed nurses and CNA's, Certified Nursing Assistants, (Refer to F 323) revealed residents, both alert and confused, kept cigarettes and lighters in their possession. Same interviews confirmed staff was aware Resident #1 repeatedly attempted to smoke in his/her room and in bed. Review of the current list of residents who smoked in the facility provided by the Director of Nurses for the date of 4/22/08 revealed residents who smoked resided in both the East and West wing portions of the facility. Residents on both sides of the facility maintained lighters and cigarettes in their possession. An interview conducted with an alert and oriented resident who smoked on 4/22/08 at 9:30 a.m. revealed residents carried cigarettes and lighters on themselves. He/she stated everyone knew Resident #1 would smoke in his/her room. During an interview with the Regional Nurse Consultant on 4/23/08 at 1:00 p.m., she confirmed the system was broke and quarterly smoking screens were not being completed on those residents who smoked. 2. Despite awareness of Resident #3's distributing cigarettes and lighters to residents in the facility, interventions were not in place to prevent Resident #3 from distributing lighters and cigarettes to other residents which ultimately Jed to another resident 's death and placed the entire facility in jeopardy. 3. An interview with Resident #5 on 04/23/08 at 2:30 PM revealed that prior to the incident on 04/19/08 the facility allowed him/her to keep his/her own cigarettes and lighter. Medical record review on 04/23/08 of the Nursing Progress notes revealed that on 04/22/08 at 10:32 p.m. Resident #5 had been out on the patio to smoke. The Administrator reported during an interview on 04/23/08 at 2:30 PM residents were not allowed on the Smoking Patio after 9:00 p.m. Despite residents not being allowed on the patio after 9:00 p.m., a resident was out on the patio after hours. 4. Review of Resident #2's medical record revealed the resident was a smoker on 08/12/05. A Smoking Safety Screen was completed 04/20/08; approximately 2 years and 8 months after identifying the resident smoked. A Care Plan to include smoking was not completed by the facility until 04/19/08 at 11:21 PM; once again approximately 2 years and 8 months after the facility identified the resident smoked. 5. Review of the 01/06/08 Grievance Log revealed an unsampled resident initiated a complaint to the Social Services Director reporting a lost lighter. The Social Services Director reported in conclusion of the Complaint that the lighter had been found and returned to the resident and the resident was advised to report lost items in a timely manner. 6. On 4/22/08 the minutes of the December 2007 Resident Council meeting revealed a resident had requested the facility place smoke detectors in each resident's room. An interview with the Maintenance Director on 4/23/08 at 2:30 p.m. revealed the resident that requested the smoke detector's in each resident's room was a non-smoking resident that was concerned because other resident's were known to smoke in their rooms. The Director stated the previous Risk Manager requested an automatic cigarette lighter be purchased and placed out on the patio where the residents smoke. The purpose of this was to prevent the resident from having lighters in their possession. He stated that after taking several months to purchase the device, he did not see it being used because the residents still had lighters on them and it was a safety issue. He stated families would bring in lighters for residents. d 10. The above constitutes a violation of §§ 400.141(1) and 400.20, Fla. Stat. (2007), and constitutes a widespread Class I deficiency pursuant to § 400.23(8)(a), Fla. Stat. (2007). ll. The Agency provided Respondent with a mandatory correction date of April 28, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT II RESPONDENT’S FACILITY FAILED TO IMPLEMENT AN EFFECTIVE QUALITY ASSESSMENT AND ASSURANCE PROCESS, Fla. Admin. Code R. 59A-4.109(1) WIDESPREAD CLASS I DEFICIENCY 12. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11), as if fully set forth herein. 13. That Florida Law provides the following: ° Rule 59A-4.109, Fla. Admin. Code (1) 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) A complete, 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. 14. Based on record review, observation and interview, the facility failed to accurately reflect the smoking status of 4 (#1, #3, #2, #4) of 8 sampled residents identified for smoking. This was evidenced by: 1.) Failing to accurately assess Resident #1's use of oxygen and non-compliant behavior of smoking in his/her room which resulted in the death of the resident. The facility failed to have the appropriate health professional assess the resident as evidenced by failing to notify the physician of the resident's repeated attempts at smoking in his/her room. 2.) Facility failed to accurately complete the smoking safety screen for Resident #1. 3.) Facility failed to accurately assess the residents (#1, #3, #2, #4) smoking habits which prevented the completion of a comprehensive care plan to assure the residents’ safety needs were being met. The facility's failure to accurately and comprehensively assess residents who smoke created an Immediate Jeopardy, endangering the health, safety of all residents in the facility and the death of Resident #1. The findings include: 1. Clinical record review reveals Resident #1 was readmitted to the facility on 9/09/06 with multiple diagnoses including, Dementia, Excessive Alcohol and Drug Abuse, Chronic Nicotine Abuse, and history of CVA (Cerebral Vascular Accident) with left sided weakness, Seizure disorder. Review of the Nursing Data Collection tool dated 9/09/06 acknowledged the resident smoked and used oxygen. An Activity note dated 12/18/06 revealed the resident needed assistance (from staff) to light his/her cigarettes. Review of nursing summary dated 3/25/08, 12/02/07, and 11/04/07 revealed the resident was alert, orientation fluctuated and lacked awareness of own needs. Information reviewed on the 12/02/07 summary revealed this resident was anxious, easily upset, hostile frequently, refused care and sat by self in smoking porch-did not initiate conversations, kept curtain drawn in room, and insisted door be closed. Information on the 11/04/07 summary revealed the resident was verbally aggressive, used oxygen while in room and had been observed increasing the oxygen concentration settings up to 4-5 liters. Staff indicated they provided numerous reminders not to adjust settings. Nursing summary dated 10/07/07 revealed the resident was non-compliant with oxygen and continued to "bump up" the concentration to 5 liters during the night. Review of nursing notes dated 7/18/07, 10:30 a.m., revealed the resident was found in the West Wing hallway with a lighted cigarette. The resident was redirected to the porch and was told not to have a cigarette lighter in his/her possession. Review of the Social Service (SS) quarterly note dated 9/20/07 revealed the resident frequented the smoking patio and she had spoken to him/her (the resident) about smoking in his/her room. An interview was conducted on 4/22/08 at 9:30 a.m with an alert and oriented resident who currently resides in the facility. This resident stated he/she would provide cigarettes and lighters to this resident (#1). He/she stated it was a well known fact within the facility that the resident (#1) would smoke in his/her room. The interdisciplinary team conducted a Significant Change in Status assessment of the resident on 6/10/07. Review of the RAPS (Resident Assessment Protocols) affiliated with this assessment did not reflect the resident's smoking habits, whether he/she was safe to smoke or required assistance from staff. Subsequent MDS's (Minimum Data Assessments) thereafter dated 9/05/07, 12/05/07 and 3/05/08 failed to address the resident's use of tobacco and smoking while in his/her room as well as the use of oxygen. Review of the most recent assessment dated 3/05/08 revealed the resident was verbally abusive and resisted care daily. This behavior was not easily altered. In addition, the assessment revealed the resident was dependent on staff for ADL's (Activities of Daily Living). The assessment revealed Dementia with Behavioral Disturbances had a direct relationship to his/her current ADL, cognitive, mood and behavior status. The intent of completing a comprehensive assessment was part of an ongoing process through which the facility identified the resident's functional capacity and health status. The facility was responsible for addressing all needs of the resident regardless of whether the issue was included in the MDS or RAPS. The interdisciplinary team failed to address the smoking needs and behaviors associated with unsafe smoking of Resident #1. Review of the nursing progress notes dated 4/14/08 at 2:50 p.m. reveal upon entering the resident's room, the nurse saw the resident smoking a cigarette. According to the notes, when the resident saw the nurse, the resident put the cigarette in a urinal. The nurse explained that smoking was not allowed in the facility. The nurse "notified the House Supervisor and the SSD of situation. Lighter was removed from the resident's possession. Will continue to monitor the situation." Review of the clinical record revealed Nurse's notes dated 4/19/08 at 11:15 p.m. (5 days after the resident was witnessed smoking in his/her room) that there had been a fire at the facility and Resident #1 had "died". An interview was conducted with the Director of Nurses (DON), Activity Director (AD) and Social Service Director (SSD) on 4/22/08 at 2:00 p.m. which _ revealed they were not aware the resident was not assessed for smoking or oxygen use, Interview with the Regional Risk Manager and Director of Nurses on 4/22/08 at 4:30 p.m. revealed the resident expired as a result of smoking in his/her room in bed. Because the interdisciplinary team failed to assess the resident's smoking habits and address his/her behavior of smoking in his/her room while using oxygen, a comprehensive care plan was not developed in an attempt to keep the resident safe which contributed to the resident's death and placed the other residents in the facility at risk for serious harm, injury and/or death. 2. Observation of Resident #3 on 4/22/08 at 9:30 a.m. revealed the resident outside on the patio sitting in an electric wheelchair smoking a cigarette. The resident confirmed a long term nicotine habit. He/she stated he/she would go to the store for him/herself and the other residents who smoked and purchase cigarettes and lighters and would bring them back for them. The resident stated he/she had stopped smoking for a little while, but, had picked up the habit again. During the interview with Resident #3 it was revealed that the resident supplied cigarettes and lighters to another resident (#1) in the facility that had recently passed away due to smoking in bed. 10 In an interview with the DON on 4/22/08, she confirmed Resident #3 had given the resident who passed away his/her smoking materials. She stated the resident passed away as a result of smoking in bed while using oxygen. Interviews with an LPN (Licensed Practical Nurse) and CNA (Certified Nursing Assistant) on 4/21/08 between 2:00 and 2:45 p.m. confirmed Resident #3 would leave the facility and buy cigarettes and lighters for other residents. They stated the residents would give Resident #3 a couple dollars in return for doing this. The LPN confirmed some of the residents who had lighters were demented. During an interview with the Director of Nursing on 4/21/08 at 4:00 p.m., he/she confirmed Resident #3 was permitted to leave the facility unsupervised and was aware the resident had been supplying other residents in the facility with lighters and cigarettes. Clinical record review revealed the resident was admitted to the facility on 3/16/04 with multiple diagnoses including, not limited to, Nicotine Addiction, Type II Diabetes, and Anxiety. The Social Service Notes dated 2/22/07 through 2/21/08 were reviewed to determine whether any interventions were in place to prevent Resident #3 from supplying residents with cigarettes and lighters. The notes did not reveal he/she was even aware the resident was providing smoking materials to other residents. A comprehensive MDS (Minimum Data Set) was conducted on 2/10/08. This assessment and accompanying RAPS (Resident Assessment Protocols) did not address the resident's smoking habits and the fact he/she would leave the facility, buy cigarettes and lighters, then retum back to the facility and distribute cigarettes and lighters to other residents. Because the interdisciplinary team failed to assess the resident's smoking habits and acknowledge the resident was distributing cigarettes and lighters to other residents in the facility, a plan of care had not been developed by the interdisciplinary team. Interventions were not in place to prevent Resident #3 from distributing lighters and cigarettes to other residents in the facility which contributed to the death of Resident #1 and placed the other residents’ lives in jeopardy. 3. On 04/22/08 review of the active medical record of Resident #2 revealed he/she was readmitted to the facility on 05/12/07 with multiple diagnoses including Convulsions, Encephalopathy, Alcohol abuse, Psychosis, Febrile Convulsions, Cerebral palsy, Difficulty walking, General muscle weakness, and Speech disturbances. Review of the Social/Psychosocial Data Collection and Evaluation dated 8/12/05 revealed Resident #2 was able to self-propel in wheelchair and smoked at times. Review of the initial Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) provided by the facility's Medical Records department dated 8/25/05 did not reveal Resident #2 used tobacco products at least daily. The Annual MDS and RAP dated 03/30/07 did not reveal Resident #2 smoked. The Quarterly MDS dated 12/28/07 did not reveal Resident #2 smoked. The Annual Review of the Nursing Data Collection dated 3/23/06 revealed Resident #2 did not smoke. Review of the Plan of Care section of the medical record revealed a Care Plan identifying the resident as a smoker on 4/19/08 at 11:21 PM. The active medical record revealed a Smoking Safety Screen dated 4/20/08 that indicated Resident #2 requires supervision with smoking. Review of the medical record revealed an order from the physician dated 04/20/08 for Resident #2 that a smoking apron was to be on when the patient was outside smoking with a family member. On 4/22/08 the Director of Nursing provided a list of the smokers currently residing in the facility which did include Resident #2. An interview with Resident #2 on 04/23/08 at 2:15 PM confirmed he/she smoked cigarettes. 4. On 4/22/08 during review of the closed medical record it was revealed that Resident #4 was readmitted to the facility on 4/08/08 with multiple diagnoses including Pulmonary Hypertension, Obesity, and Depression with Psychotic features. Review of the initial Minimum Data Set dated 01/30/03 revealed Resident #4 used tobacco products at least daily. Review of the Nursing Data Collection dated 04/08/08 revealed Resident #4 received.oxygen continuously at 3 liters per minute, was a smoker and there were not any safety concerns related to smoking. Review of the Initial Care Plan initiated 04/08/08 for Resident #4 did not reveal Resident #4 was a smoker. Review of Social/Psychosocial Data Collection and Evaluation completed 4/14/08 revealed Resident #4 smoked. Smoking Safety Screen dated 4/17/08 revealed Resident #4 was able to smoke independently. During an interview with the Regional Nurse Consultant (RNC) on 4/23/08 at 1:00 p.m., she indicated the smoking assessments (screens) are completed by 13 observing the resident, staff report and chart review. The instructions at the top of the Smoking Safety Screen guide the assessor to "ask the resident/patient to demonstrate smoking." Then, to "answer questions by checking "Yes" or "No". Provide comments to all "No" answers." Further review revealed a physician's order dated 04/19/08 to discharge Resident #4 to another skilled nursing facility. Following the discharge, a second Care Plan dated 04/19/08 at 11:21 PM revealed Resident #4 as a smoker and included goals and approaches to the problem. The record also revealed another Smoking Safety Screen completed after Resident #4 was discharged, dated 4/20/08, revealing Resident #4 required supervision with smoking because the resident smoked with an oxygen on. The nurse completing the screen did not observe the resident as per the instructions on the screen and per the 4/23/08 interview with the RNC. During an interview with the Nurse Consultant on 4/23/08 at 1:00 PM it was revealed that the 04/20/08 the Smoking Safety Screen had been updated based on knowledge of Resident #4, not an actual observation as instructed on the screen. 5. Review of the facility's Smoking Policy under "Procedure", directs the staff to evaluate the resident for smoking safety. This evaluation will include but was not limited to, the Nursing Data Collection, Smoking Safety Screen, the RAI/MDS, and Physician's Orders. It also revealed the resident should be re-evaluated for smoking safety quarterly, and with change in clinical condition. The facility failed to consistently use the RAI/MDS to evaluate residents who smoke in the facility. An interview was conducted with the RNC on 4/23/08 at 1:00 p.m. When asked whether the residents who smoked in the facility had quarterly smoking screens completed, she stated that it wasn't done. 15. The above constitutes a violation of Fla. Admin. Rule 59A-4.109(1), and constitutes a widespread Class I deficiency pursuant to § 400.23 (8)(a), Fla. Stat. (2007). 16. The Agency provided Respondent with a mandatory correction date of April 28, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT I RESPONDENT?’S FACILITY FAILED TO DEVELOP COMPREHENSIVE CARE PLANS FOR RESIDENTS THAT SMOKED TOBACCO. Fla. Admin. Code R. 59A-4.109(2) WIDESPREAD CLASS I DEFICIENCY 17. The Agency re-alleges and incorporates paragraphs one (1) through sixteen (16), as if fully set forth herein. 18. That Florida Law provides the following: 59A-4.109 Resident Assessment and Care Plan. (2) The facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment. . 15 19. That on April 22, 2008 through April 23, 2008, the Agency conducted an unannounced Complaint Investigation. The complaint allegation was confirmed and citations were issued as a result of this investigation. 20. Based on medical record review, interview of residents and facility staff the facility failed to develop Comprehensive Care Plans for 5 (Resident #1, #2, #3, #4 and #6) of 8 sampled residents that smoked tobacco. Failure to develop a Comprehensive Care Plan to identify smoking risks, implementing safety interventions and monitoring for safety compliance places all residents and staff within the facility at risk for injury, illness and/or death. The failure by the facility to develop a care plan for Resident #1, who smoked, created an Immediate Jeopardy situation that put the resident at risk, resulting in the resident's death. The failure of the facility to care plan Resident #1's safety placed all residents residing in the facility at risk, since the fire has the potential to impact everyone. The findings include: 1. Clinical record review for Resident #1 revealed he/she was readmitted to the facility on 9/09/06 with multiple diagnoses including, Dementia, Excessive Alcohol and Drug Abuse, Chronic Nicotine Abuse, and history of CVA (Cerebral Vascular Accident). Review of the Nursing Data Collection tool dated 9/09/06 acknowledged Resident #1 was a smoker. An Activity note dated 12/18/06 revealed Resident #1 needed assistance (from staff) to light his/her cigarettes. Review of nursing summary dated 3/25/08, 12/02/07, and 11/04/07 revealed Resident #1 as alert, orientation fluctuated and lacked awareness of own needs. 16 Review of nursing notes dated 7/10/07 at 2:00 p.m. revealed another resident witnessed Resident #1 fall out of his/her wheelchair in the smoking area. Review of nursing notes dated 7/18/07, 10:30 a.m., revealed Resident #1 was found in the West Wing hallway with a lighted cigarette. Resident #1 was redirected to the porch and was told not to have a cigarette lighter in his/her possession. Review of the Social Service quarterly note dated 9/20/07 revealed Resident #1 frequented the smoking patio and had been spoken to by staff about smoking in his/her room. Review of the nursing progress notes dated 4/14/08 at 2:50 p.m. revealed upon entering the resident's room, the nurse saw Resident #1 smoking a cigarette. The resident put out the cigarette in a urinal. The nurse explained to Resident #1 smoking was not allowed in the facility and the lighter was removed from the resident's possession. The nurse indicated the situation would continue to be monitored. There were no interventions documented in Resident #1's medical record related to how the facility would monitor the resident. The interdisciplinary team conducted a Significant Change in Status assessment of Resident #1 on 6/10/07. This assessment did not include that Resident #1 smoked cigarettes and required assistance from staff. Review of the care plan section of the chart did not include a plan of care addressing Resident #1's tobacco use. Despite notes acknowledging Resident #1 lacked safety awareness, needed assistance with lighting his/her cigarette, was non-compliant with keeping a lighter in his/her possession and required redirection from smoking in his/her room or other parts of the facility, the interdisciplinary team failed to develop a comprehensive plan of care to prevent Resident #1 from injuring him/herself or other residents and staff in the facility. 17 Interview with the Social Service Director, Activities Director and Director of Nursing (DON) on 4/22/08 at 2:00 p.m. revealed they were not aware that there had been no current plan of care in the resident's record. On 04/22/08 at 2:30 p.m., the Director of Nurses (DON) presented a "smoking" care plan for Resident #1 dated 9/20/07.. The DON stated this care plan for smoking was printed out of the computer today because the original care-plan could not be found. The DON confirmed it was outdated and never revised. Nurse's notes dated 4/19/08 at 11:15 p.m. revealed there had been a fire at the facility and Resident #1 had "died". Interview with the Regional Risk Manager and Director of Nurses on 4/22/08 at 4:30 p.m. revealed Resident #1 expired as a result of smoking in bed in his/her room. 2. Observation of Resident #3 on 4/22/08 at 9:30 a.m. revealed the resident outside on the patio sitting in an electric wheelchair smoking a cigarette. An interview with Resident #3 revealed a long term nicotine habit. Resident #3 revealed he/she would go to the store for him/herself and the other residents who smoked and purchase cigarettes and lighters and would bring them back to the facility. Resident #3 revealed he/she had stopped smoking for a little while, but, has picked up the habit again. During the interview on 4/22/08 at 9:30 a.m. with Resident #3, he/she revealed he/she had supplied cigarettes and lighters to Resident #1 in the facility that had recently passed-away due to smoking in bed. Interviews with a Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) on 4/21/08 between 2:00 and 2:45 p.m. confirmed Resident #3 would leave the facility and buy cigarettes and lighters for other residents. They stated the residents would give Resident #3 a couple dollars in return for doing this. The LPN confirmed some of the residents who had lighters were confused. During an interview with the Director of Nursing on 4/21/08 at 4:00 p.m., she confirmed Resident #3 was permitted to leave the facility unsupervised and was aware Resident #3 had been supplying other residents in the facility with lighters and cigarettes. Clinical record review reveals Resident #3 was admitted to the facility on 3/16/04 with multiple diagnoses including, Nicotine Addiction, Type II Diabetes, and Anxiety. The Social Service Notes dated 2/22/07 through 2/21/08 did not reveal any interventions were in place to prevent Resident #3 from supplying residents with cigarettes and lighters. The notes did not reveal she was even aware Resident #3 was providing smoking materials to other residents. The medical record revealed a comprehensive MDS (Minimum Data Set) was conducted for Resident #3 on 2/10/08. This assessment did not address Resident #3's smoking habits or that he/she would leave the facility and distribute cigarettes and lighters to other residents. Review of the care plan section of Resident #3's medical record did not reveal a plan of care addressing the resident's tobacco use after the comprehensive assessment was completed on 02/10/08. ‘A plan of care was not revealed in the medical record addressing Resident #3's smoking habits and distributing cigarettes and lighters to residents in the facility. 3. The initial tour on 4/22/08 at 10:00 a.m. revealed Resident #6 in his/her room and in bed. Resident #6 revealed he/she had smoked cigarettes for years and often times would wake up at 5:00 a.m. to go out to the patio to smoke to "calm his/her nerves". Clinical record review revealed Resident #6 was admitted to the facility on 1/20/08 with multiple diagnoses including, Bipolar Disease, Altered Mental Status, Cirrhosis and Anxiety. A Nursing Data Collection tool was completed on 1/20/08 which acknowledged when Resident #6 had difficulty sleeping he/she would smoke. A comprehensive Minimum Data Set (MDS) with an assessment referenced date of 1/31/08 had been completed and addressed the finding that Resident #6 smoked on a daily basis. Review of the care plan section of Resident #6's medical record did not reveal a plan of care addressing Resident #6's smoking habits after the initial comprehensive assessment had been completed. Resident #6's medical record revealed a care plan related to the smoking that was developed on 4/19/08, approximately 3 and % months following Resident #6's admission to the facility. During an interview with the DON on 4/22/08 at 3:00 p.m., she was questioned as to why care plans addressing smoking were not completed after the comprehensive assessments. The DON revealed she was new to the facility and recognized the facility had a problem in not completing smoking assessments or care plans for those residents who smoked. The DON revealed that after the death of a resident from smoking in bed, the facility immediately placed care plans in all of the charts of the residents who smoked. 4. On 4/22/08 review of the active medical record for Resident #2 it was revealed he was readmitted to the facility on 05/12/07 with multiple diagnoses including convulsions, encephalopathy, alcohol abuse, psychosis, febrile convulsions, cerebral palsy, difficulty walking, general muscle weakness, and speech disturbances. 0 Review of the Social/Psychosocial Data Collection and Evaluation dated 8/12/05 revealed Resident #2 was able to self-propel in wheelchair and smoked at times. Review of the initial Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) provided by the facility's Medical Records department dated 8/25/05 did not reveal Resident #2 used tobacco products at least daily. The annual MDS and RAP dated 3/30/07 did not reveal Resident #2 smoked. The quarterly MDS dated 12/28/07 did not reveal Resident #2 smoked. The annual Review of the Nursing Data Collection dated 03/23/06 revealed Resident #2 did not smoke. Review of the Plan of Care section of the medical record revealed a Care Plan identifying Resident #2 as a smoker on 4/19/08 at 11:21 PM. The active medical record revealed a Smoking Safety Screen dated 4/20/08 that indicated Resident #2 required supervision with smoking. Review of the medical record revealed an order from the physician dated 4/20/08 for Resident #2 that a smoking apron was to be on when outside smoking with a family member. During an interview with the DON on 4/22/08 at 3:00 PM, the DON revealed she was new to the facility and recognized the facility had a problem in not completing smoking assessments or care plans for those residents who smoked. The DON stated after the death of a resident from smoking in bed, the facility immediately placed care plans in all of the charts of the residents who smoked. An interview with Resident #2 on 04/23/08 at 2:15 PM confirmed he/she smoked cigarettes. 21 5. On 4/22/08 during review of the closed medical record it was revealed that Resident #4 was readmitted to the facility on 04/08/08 with multiple diagnoses including Pulmonary Hypertension, Obesity, and Depression with Psychotic features. Review of the initial Minimum Data Set dated 01/30/03 revealed Resident #4 used tobacco products at least daily. Review of the Nursing Data Collection dated 04/08/08 revealed Resident #4 received oxygen continuously at 3 liters per minute, was a smoker and there were not any safety concems related to smoking. Review of the Initial Care Plan initiated 04/08/08 did not reveal Resident #4 was a smoker. Review of Social/Psychosocial Data Collection and Evaluation completed 4/14/08 revealed Resident #4 smoked. Smoking Safety Screen dated 4/17/08 revealed Resident #4 was able to smoke independently. The closed medical record revealed a physicians order dated 04/19/08 to” discharge Resident #4. Following Resident #4's discharge a Care Plan dated 4/19/08 at 11:21 PM revealed the resident as a smoker and should smoke under supervision only. The record also revealed another Smoking Safety Screen completed on 04/20/08 at 11:21 PM, after Resident #4 was discharged, that revealed Resident #4 required supervision with smoking because he/she smoked with his/her oxygen on. During an interview with the Director of Nursing (DON) on 4/22/08 at 3:00 PM, the DON stated she was new to the facility and recognized the facility had a problem in not completing smoking assessments or care plans for those residents a9 who smoked. The DON stated after the death of a resident from smoking in bed, the facility immediately placed care plans in all of the charts of the residents who smoked. 21. The above constitutes a violation of Fla. Admin. Rule 59A-4.109(2), and constitutes a widespread Class I deficiency pursuant to § 400.23 (8)(a), Fla. Stat. (2007). 22. The Agency provided Respondent with a mandatory correction date of April 28, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT IV RESPONDENT’S FACILITY FAILED TO ENSURE THE ENVIRONMENT REMAINS AS FREE OF ACCIDENT HAZARDS AS POSSIBLE. §§ 400.022(1)() and 400.102(1), Fla. Stat. (2007) WIDESPREAD CLASS I DEFICIENCY 23. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22), as if fully set forth herein. 24. That Florida Law provides the following: Section 400.022, Fla. Stat. (2007) (1)AIl 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: 23 1) 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 Section 400.102, Fla. Stat. (2007) In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (i) An intentional or negligent act materially affecting the health or safety of residents of the facility; 25. That on April 22, 2008 through April 23, 2008, the Agency conducted an unannounced Complaint Investigation. The complaint allegation was confirmed and citations were issued as a result of this investigation. 26. Based on record review, interviews and observations, the facility failed to ensure the environment remains as free of accident hazards as possible for 6 (#1, #2, #3, #4, #6, #7) of 8 sampled residents identified as residents who smoked in the facility. The facility failed to effectively remove and secure smoking materials as outlined in their facility policy and procedure for smoking which resulted in Resident #1 smoking in bed while using oxygen which resulted in the death of the resident. In addition, the facility failed to determine whether these residents were safe to smoke and develop an individualized plan of care addressing their smoking needs. The facility failed to implement their system of securing smoking items which created a fire hazard for all residents in the facility. 24 In addition the failure of the unsprinklered facility to place battery operated smoke detectors in each resident's sleeping room resulted in Immediate Jeopardy. This systemic breakdown placed all residents in the facility in danger of serious injury or death. The findings include: 1. Clinical record review revealed Resident #1 was readmitted to the facility on 9/09/06 with mu!tip!c diugudsus ine!sting, Dementia, Excessive Alcohol and Drug Abuse, Chronic Nicotine Abuse, and history of CVA (Cerebral Vascular Accident) with left sided weakness, Seizure disorder. Review of the Nursing Data Collection tool dated 9/09/06 acknowledged the resident smoked and used oxygen. An Activity note dated 12/18/06 revealed the resident needed assistance (from staff) to light his/her cigarettes. Review of nursing summary dated 3/25/08, 12/02/07, and 11/04/07 revealed the resident was alert, orientation fluctuated and lacked awareness of own needs. Information reviewed on the 12/02/07 summary revealed this resident is anxious, easily upset, hostile frequently, refused care and sat by self in smoking porch-does not initiate conversations, keeps curtain drawn in room, insisted door be closed. Information on the 11/04/07 summary revealed the resident is verbally aggressive, used oxygen while in room and had been observed increasing the oxygen concentration settings up to 4-5 liters. Staff indicate they provide numerous reminders not to adjust settings. Nursing summary dated 10/07/07 reveal the resident was non-compliant with oxygen and continued to "bump up" the concentration to 5 liters during the night. 25 Review of the physician's orders for the month of March 2008 revealed the resident could use oxygen at 2 liters per nasal cannula as needed for shortness of breath. Review of nursing notes dated 7/10/07 at 2:00 p.m. revealed another resident witnessed Resident #1 fall out of his/her wheelchair in the smoking area. Review of nursing notes dated 7/18/07, 10:30 a.m., revealed the resident was found in the West Wing hallway with a lighted cigarette. The resident was redirected to the porch and was told not to have a cigarette lighter in his/her possession. The record did not reflect staff removed the lighter from the resident's possession. Review of the Social Service (SS) quarterly note dated 9/20/07 revealed the resident frequented the smoking patio and she had spoken to him (the resident) about smoking in his/her room. Despite this known history of the resident smoking in other areas of the building and in his/her room, there were no other SS notes addressing any interventions other than "speaking" to the resident regarding his/her non-compliant smoking behaviors. An interview was conducted on 4/22/08 at 9:30 a.m with an alert and onented resident who currently resides in the facility. This resident stated he/she would provide cigarettes and lighters to this resident. He/she stated it was a well known fact within the facility that the resident (#1) would smoke in his/her room. The interdisciplinary team conducted a Significant Change in Status assessment of the resident on 6/10/07. Subsequent MDS's (Minimum Data Assessments) thereafter dated 9/05/07, 12/05/07 and 3/05/08 failed to address the resident's use 6 of tobacco and smoking while in his/her room. The RAPS (Resident Assessment Protocols) failed to address this non-compliant behavior. Review of the most recent assessment dated 3/05/08 revealed the resident was verbally abusive and resisted care daily. This behavior was not easily altered. In addition, the.assessment revealed the resident was dependent on staff for ADL's (Activities of Daily Living). The assessment revealed Dementia with Behavioral Disturbances had a direct relationship to his/her current ADL, cognitive, mood and behavior status. Review of the care plan section of the medical record failed to include a plan of care addressing the resident's tobacco use. Despite notes acknowledging the resident lacked safety awareness, needed assistance with lighting his/her cigarette, was non-compliant and kept a lighter in his/her possession and required redirection from smoking in his/her room or other parts of the facility and repeatedly attempted to increase his/her oxygen while in his/her room, the interdisciplinary team failed to develop a comprehensive plan of care to prevent the resident from injuring him/herself or other residents in the facility. Interview with the Social Service Director (SSD), Activities Director (AD) and Director of Nursing (DON) on 4/22/08 at 2:00 p.m. revealed they were not aware that there had been no current plan of care in the resident ' s record. At 2:30 p.m., the DON presented a "smoking" care plan dated 9/20/07. She stated they printed this care plan out of the computer because they couldn't find the original care plan. She confirmed though from the computer, it was outdated and never revised. Review of the nursing progress notes dated 4/14/08 at 2:50 p.m. reveal upon entering the resident's room, the nurse saw the resident smoking a cigarette. According to the notes, when the resident saw the nurse, the resident put the 7 cigarette in a urinal. The nurse explained that smoking was not allowed in the facility. The nurse "notified the House Supervisor and the SSD of situation. Lighter was removed from resident's possession. “Will continue to monitor the situation." There were no interventions documented by nursing as to how they were monitoring the resident. There were no notes entered by the SSD or House Supervisor related to being notified of the resident smoking in his/her room. An interview was conducted with the SSD on 4/22/08 at 1:50 p.m. who confirmed she was made aware the resident was found smoking in his/her room on 4/14/08. She could not confirm any interventions were put into place to prevent the resident from injuring him/herself. Interviews were conducted on 4/22/08 between 2:00 and 3:43 p.m. with CNA's and Licensed Nursing staff who were familiar with the resident. The interviews confirmed the resident repeatedly smoked and attempted to smoke in his/her room. One of the CNA's commented the resident at one point in time had been found with ashes on top of his/her sheets and smoke in the room. She confirmed those residents that smoked lived in different parts of the building. The interview revealed residents, both alert and confused, would keep lighters and cigarettes on their person, or, in bedside tables. Staff stated within the past 3 months, they (Administration) started to attempt to have better control on the lighters kept by the confused residents and would try to keep the cigarettes and lighters at the nurses' station, but, this was not always possible. One of the nurses stated she was "surprised there wasn't something (process) firmer in place." 28 The record revealed a "Smoking Safety Screen" signed by the SSD on 4/17/08 for Resident #1; 3 days after the resident was found smoking in his/her room. This assessment revealed the resident demonstrated and complied with smoking in approved smoking areas, demonstrated and complied with keeping smoking materials in a safe location designated by facility and the resident is cognitively intact and demonstrated consistently good decision making (e.g. no diagnosis of dementia or other related disorders). This is in direct conflict with physician's diagnosis of dementia, staff observations of resident's non-compliance of smoking in his/her room and resident's failure to consistently demonstrate good decision making skills. On 4/23/08 at 8:08 a.m., the SSD was interviewed. She stated she did not do the Smoking Safety Screen. She stated the Risk Manager (RM) completed screen and the SSD signed off on it. When the SSD was asked whether she reviewed the assessment before signing it, she stated, "No" and wasn't aware of the errors that were put on the screen. Interview with the RM on 4/23/08 at 8:53 a.m. confirmed she was aware Resident #1 had a diagnosis of dementia and the resident did not have good decision making skills. She could not confirm why she inaccurately completed the screen. When asked why she didn't sign the screen as he/she was the one who completed it, the RM stated, "I was told by the Regional Team not to sign anything as RM". Review of the facility's Smoking policy and procedure provided at the time of the investigation revealed residents who smoke will be identified and evaluated for smoking safety. The procedure includes the following: 1.) Identify the resident/patient who requests to smoke. Instruct resident/patient on smoking policy. 29 The clinical record did not demonstrate evidence the resident was instructed on the components of the smoking policy. 2.) Evaluate the resident/patient for smoking safety. 3.) The evaluation will include, but is not limited to, the Nursing Data Collection Smoking /safety Screen, the RAI/MDS, and Physician's orders. 2 This was not done as evidenced by the Interdisciplinary team’s failure to use the RAI/MDS to evaluate the resident's smoking routine as well as assess the resident's ability to safely smoke and whether the resident required assistance from staff to smoke (as indicated by the activity note of 12/18/06). The Smoking Safety Screen was inaccurately completed 1 and 1/2 years after the resident begin residing in the facility. 3.) Determine reasonable accommodations the resident would require to smoke safely. Accommodations may include, but are not limited to, set up assistance, staff supervision, staff assistance, and adaptive or protective equipment. There was no indication the resident was adequately supervised as evidenced by his/her repeated episodes of smoking in his/her room and increasing his/her own oxygen levels. There was no indication the resident was provided adaptive or protective equipment as evidenced by ashes in his/her bed and cigarette butts in the urinal. . 4. Develop an individualized smoking plan with interventions that addresses the risk factors of unsafe smoking. Risk factors may include, but are not limited to: Cognitive Impairment, Diagnosis of dementia or related disease, Physical limitations, Medication side effects, Factors that impact safety awareness. 30 The facility failed to develop a comprehensive individualized smoking plan of care. The policy further reveals the resident should be re-evaluated for smoking safety quarterly and with a change in clinical condition and monitor the environment for unsecured smoking materials, and secure if located. The facility failed to re-evaluate Resident #1's ability to safely smoke on a quarterly basis and when he/she changed in status and failed to adequately secure the lighters and cigarettes of the those residents, including Resident #1, who smoked in the facility. Further review of the clinical record reveals Nurse 's notes dated 4/19/08 at 11:15 p.m. (5 days after the resident was witnessed smoking in his/her room) that there had been a fire at the facility and Resident #1 had "died". Interview with the Regional Risk Manager and Director of Nurses on 4/22/08 at 4:30 p.m. revealed the resident expired as a result of smoking in his/her room in bed. A meeting was held with the Director of Nurses and on 4/22/08 at 9:34 a.m. who stated Resident #1 had been given smoking material’by another resident. She stated she was new to the facility and the smoking policy system was "broken". She wasn't sure who had a smoking screen or whether the residents who smoked had individualized plans of care. She was unaware that the RM and SSD were completing the screens and when she found out they were being done incorrectly, stopped them from doing so. The surveyors reviewed a sample of 8 residents who smoked. None of the records who required quarterly safety screens were completed. Two of the six smoking screens initiated by the RM and SSD were inaccurate. Five of the eight 31 re records, Resident #2, #3, #4, #6 and #7, reviewed failed to have individualized care plans developed after the initial and subsequent comprehensive assessments. Five of seven residents had the same care plan and the same interventions put into place on the same date; the plans of care were not individualized. Review of the current list of residents who smoked in the facility provided by the Director of Nurses for the date of 4/22/08 revealed residents who smoke reside in both the East and West wing portions of the facility. It was learned through the interviews conducted on 4/22/08 with licensed and certified staff, as well as alert and oriented residents who smoked, residents on both sides of the facility would have lighters and cigarettes in their possession. A meeting was held with the Administrator (ADM) and DON on 4/22/08 at 5:40 p.m. regarding the failure of the staff to adequately supervise and monitor residents who smoke in the facility which ultimately contributed to Resident #1's death. The ADM, in an attempt to keep all of the residents in the facility safe, stated the patio area where the residents smoke will only be open from 6:30 a.m. to 9:00 p.m. Immediate room searches were conducted. The door to the patio has been changed. A code is required to go out after 9:00 p.m. Any resident can still go and smoke after 9:00 p.m. but must be escorted and supervised by staff. A designated staff person (CNA) has been assigned to monitor the area during that time frame. Residents and families are being educated to the new protocol of not being permitted to have cigarettes and lighters in their possession and must be kept with the designated CNA who will in turn keep the cigarettes and lighters for the residents bagged and in a locked box. Smoking receptacles are located on the patio as is the necessary fire prevention equipment. The CNA will dole out 1 cigarette at a time to the resident requesting to smoke; will keep track of how much is smoked; and the resident will not get another cigarette until the first one is completely put out. The ADM stated one of the facility's challenges was residents who are permitted to go out of the facility and families who bring cigarettes and lighters in for the residents who smoke. AD The DON was asked whether all of the staff at the facility was educated regarding the new policy. She stated not all of the staff had been educated. She was asked whether all of the family and friends of the residents received education regarding the new protocol and the ADM stated a resident smoking meeting was held 4/21/08 at 11:30 a.m. which included families that were in-house visiting. He stated a family council meeting was scheduled to be held "this Friday" and that some, not all letters had been sent out. The ADM confirmed not all of the families had been notified. The DON stated the smoking policy was going to be revised. She stated new care plans and screens have been completed on all of the residents who smoke. The ADM stated to date, there are no other residents that the facility is aware of that has attempted to smoke in his/her room and no one has smoking paraphernalia in his/her possession. Concerns were expressed by the surveyors that the new care plans placed in the residents charts state the residents were going to be educated about the safe use of the "lighter". The DON stated she would take a look at the care plans and revise. Observations of the patio where residents smoke on 4/22/08 at 9:30 a.m., 11:40 a.m., 12:50 p.m., 3:30 p.m. and 4:30 p.m. confirmed a designated CNA , supervising the smoking area and handing out cigarettes while lighting them for residents. The cigarettes and lighters were kept in a lock box. All appropriate fire extinguishing materials were in place. Observations on 4/23/08 at 8:00 a.m., 11:30 a.m., and 2:00 p.m. of the patio area did not reveal any concerns. An interview was conducted with the Regional Nurse Consultant (RNC) on 4/23/08 at 1:00 p.m. who stated the smoking safety assessments were being done daily since the incident; if they needed to be revised then it would be done. She stated the assessments were completed by observing the resident, staff report and 22 interview. The RNC was not aware the surveyor had just pulled a screen on a resident that was inaccurate and done after the resident was discharged from the facility. The RNC stated the smoking policy would not be changed; however, the protocol would be changed to fit the needs of the residents in the facility. When asked why the DON stated it would be changed, she stated the DON didn't realize because she was new. The RNC confirmed they were still in the process of educating the staff and family members. On 4/23/08 at 1:45 p.m., the Incident log was reviewed. The log revealed the facility had just found two residents with smoking material on them. One resident was found at 8:00 a.m. on 4/23/08 with cigarettes on her/him and another was found at 8:30 a.m. on 4/23/08 with a pipe in his/her room. Based on the staff still finding residents with smoking material on them, the facility's inability to educate and in-service all staff and all families and/or legal representatives involved with the residents, and review of an assessment performed after a resident was discharged from the facility, the jeopardy remained in effect and was not abated. 27. The above constitutes a violation of §§ 400.022(1)(1) and 400.102(1), Fla. Stat. (2007), and constitutes a widespread Class I deficiency pursuant to § 400.23 (8)(a), Fla. Stat. (2007). 28. The Agency provided Respondent with a mandatory correction date of April 28, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). QA COUNT V 29. The Agency re-alleges and incorporates Counts I through IV of this Complaint as if fully set forth herein. 30. Based upon Respondent’s four State Class I deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II 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 (2007). 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 Statutes (2007) commencing April 23, 2008. COUNT VI 31. The Agency re-alleges and incorporates Counts I through V of this Complaint as if fully set forth herein. 32. Respondent has been cited for four 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 (2007). 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 (2007). 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 through Count VL (B) Recommend an administrative fine against Respondent in the amount of $66,000 for Count I; I, TL, IV and VI; (C) Assess attorney’s fees and costs; and (D) Grant all other general and equitable relief allowed by law. Respectfully submitted this gh day of May, 2008. Mark Hinely, Esq. Fla. Bar. No. 48084 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Florida Statutes (2007), 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. 36 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, Ti allahassee, Florida, 32308, (85 0) 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 2890 0000 5526 8213 to Facility Administrator Gary S. Cooke, Governors Creek Health and Rehabilitation, 803 Oak Street, Green Cove Springs, Florida 32043, by USS. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8220 to Owner Oak Terrace Health Care Associates, LLC, d/b/a Govemors Creek Health and Rehabilitation, 10210 Highland Manor Drive, Suite 250, Tampa, FL 33610, and by US. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8237 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301-2525 on May GA 2008: Mark Hinely, E Copy furnished to: Nancy Marsh, FOM 7 I FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST GOVERNOR May 5, 2008 OX Ju J GOVERNORS CREEK HEALTH AND REHABILITATION 803 OAK STREET GREEN COVE SPRINGS, FL 32043 Dear Administrator: HOLLY BENSON Sy". SECRETARY, 47.4 > “eaten ELL ag he The attached license with Certificate #15177 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 Conditional. Sincerely, Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need FLO RIDA COMPARE DARE Health Care in the Sunshine 2727 Mahan Drive, MS#33 Tatiahassee, Florida 32308 g www.FloridaCompareCare.gov Visit AHCA online at http: //ahca.myflorida.com souvmmssy ATTEN? 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Is delivery address different from item 1? ET Yes if YES, enter delivery address below: [No O Retum Receipt for Merchandise O Insurea Mal = C.0.D, 4. Restricted Delivery? (Extra Fee) U.S. Postal Services CERTIFIED MAIL: RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Pata PS Form 3800; June’2002 er ss - SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse So that we can return the card to you, ® Attach this card to the back of the mailpiece, or on the front if space permits. 3. ice Type Certified Mail © Express Mail CO Registered CO Retum Receipt for Merchandise O Insured Mail (1. C.0.D.

Docket for Case No: 08-002675