oO. 54I| STATE OF FLORIDA ap » AGENCY FOR HEALTH CARE ADMINISTRATION / Agk! Keds a o STATE OF FLORIDA, Sag ittay. AGENCY FOR HEALTH CARE RAY ADMINISTRATION, Petitioner, vs. Case Nos. 2008009767 (Fines) 2008009773 (Cond.) CROSS CREEK. HEALTH CARE : ASSOCIATES, LLC, d/b/a University Hills 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 CROSS CREEK HEALTH CARE ASSOCIATES, LLC, d/b/a University Hills Health and Rehabilitation (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing July 19, 2008, and impose an administrative fine in the amount of $7,500.00, based upon Respondent being cited for one State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2008). 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 408, Part If and Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 120-bed nursing home, located at 10040 Hillview Road, Pensacola, Florida 32514, and is licensed as a skilled nursing facility (license number 1111096). 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: ¢ TREAT RESIDENTS COURTEOUSLY; e PROVIDE THE NECESSARY CARE AND SERVICES TO PREVENT DEVELOPMENT OF AND PROMOTE HEALING OF A PRESSURE ULCER AND PROVIDE MEDICALLY NECESSARY ANTIBIOTIC THERAPY; e ENSURE PROPER CARE RELATED TO INFECTION CONTROL e ENSURE THAT A RESIDENT RECEIVED ADEQUATE CARE, SUPPORT SERVICES AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS AND INJURIES; AND ¢ FOLLOW PHYSICIAN ORDERS REGARDING RESIDENT MEDICATION. §§ 400.102(1), 400.022(1)(), 400.022(1)(n), 400.022(1)(0) Florida Statutes (2008) and Rule 59A-4.107(5), Florida Administrative Code WIDESPREAD CLASS II DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. Florida law provides the following: Section 400.102(1), F.S.: “Tn 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: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility...” Section 400.022(1)(1), F.S.: “All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the _ resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.” Section 400.022(1)(n), F-.S.: “All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis.” _ Section 400.022(1)(0), F.S.: “All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents _ in accordance with the provisions of that statement. The statement shall assure each _Tesident the following: 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, for punishment, or for reasons other than resident protection or safety.” Rule 59A-4.107(5), F.A.C.: “All physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift.” 8. The Agency conducted a re-licensure survey starting on July 14, 2008 and ending July 19, 2008; specific deficiencies in violation of ss. 400.102(1), 400.022(1)(n), and 400.022(1)(0) Florida Statutes and Rule 59A-4.107(5), Florida Administrative Code, were identified as a result of the recertification survey. 9. Based on observation and interview with staff the facility failed to treat residents courteously for 3 (residents # 42, 115 and 101) of 17 residents interviewed, failed to provide the necessary care and services to prevent development and promote healing of a pressure ulcer and provide pain management and provide medically necessary antibiotic therapy for 2 of 9 residents ° . (residents #48 & #197), failed to ensure proper infection control practices were followed for one resident (resident #197) , failed to ensure 1 of 4 sampled residents (resident #196) received adequate supervision and assistive devices to prevent accidents, and failed to follow physicians orders regarding resident medication for 1 of 10 observed residents in medication pass observations (resident #96). The findings related to the facility’s failure to prohibit abuse are: 1. During an interview with resident #42 on 7/15/08 at approximately 9:30 a.m., it was revealed that some of his/her caregivers had told him/her to "shut up and get dressed" and had rushed him/her while he/she was being toileted. The resident also stated that it did no good to report such treatment because the facility did not do anything. Review of the Grievance Log revealed that as recently as 6/25/08 resident #42 complained of staff's maltreatment; the Director of Nursing talked to staff as a result of the resident’s grievance. During an interview with the resident's Licensed Practical Nurse (LPN) on 7/17/08 at approximately 9:45 a.m. the nurse acknowledged that the resident's care was compromised and agreed that staff did not always treat the resident as they should and she was aware that staff did "rush" the resident during toileting. An interview with the facility social worker on 7/17/08 at approximately 12:15 p.m. revealed that she was unaware the resident still had concerns about maltreatment by care givers. She immediately went to speak with the resident and reported back to the surveyor "he/she says things are a little better." 2. An interview with resident #115 on 7/15/08 at approximately 10:20 a.m. revealed ‘the resident stated staff often treated him/her in an abusive manner to include speaking to him/her in a demeaning and rude manner. At breakfast on 7/18/08 resident stated a staff person shouted “What you want?” The resident stated that he/she was not afraid for himself/herself but he/she was afraid for some of the other residents that could not speak out for themselves. 3. During an interview with resident #101 on 7/15/08 at approximately 11:40 AM, the resident stated that some staff have been rough with his/her arm when transferring him/her and that some staff act like they don't want to offer help at times when asked to help. When asked if he/she had ever felt afraid because of the way they had observed other residents being treated, the resident stated he/she had seen staff (Certified Nurse Assistants - CNA) tell residents not to do things that they are doing and this has frightened him/her. The resident became tearful and began crying at this point. During further interview on 7/18/08 beginning at 9:30 AM, resident #101 stated that about a week ago a staff member was rough with him/her. The resident further stated that at the time of the incident the staff was trying to help him/her dress and the . resident told the CNA that she was hurting his/her arm. According to the resident, the CNA responded, "I don't care what is hurting." The resident stated he/she is not reporting these incidents because they do not know which nurse to tell. The findings related to failed to provide the necessary care and services to prevent development and promote healing of a pressure ulcer, provide pain management and provide medically necessary antibiotic therapy include: 4. At approximately 9:15 a.m. on 7/17/08, a staff member came to the Nursing Station to voice concerns to surveyors related to care and services surrounding resident #48. This staff person stated that the resident could be heard yelling out on a _ daily basis which staff thought might be due to a sore or sores on the resident's buttocks because staff had heard that resident #48 had sores on his/her buttocks and the staff observed were that resident #48 was left on his/her back in the same position a lot. Interview and observations with resident #48 on 7/17/08 at 9:25 a.m. found him/her in the room yelling out over and over, "Oh, I hurt", stating he/she hurt between the legs, that he/she had sores in that area and that the resident was given medication that only reduced the pain rather than relieved the pain. ___ The surveyor requested a nurse evaluate skin while the surveyor observed. An interview with nurse who assisted in observations and evaluation of the resident's skin on 7/17/08 at approximately 9:30 a.m. found that the resident had skin issues in the past but the nurse thought the resident's skin was clear now and without any open areas. Observations when the resident’s diapers were taken off found a bowel movement around the groin area and buttocks with noted redness and excoriation. The resident did have an open area between legs just under scrotum area and the resident was yelling loudly complaining of pain stating "it hurt down there" during the cleaning. The CNA's used what looked like baby wipes but did not get all the bowel movement off the resident and used a large rough looking towel and wash cloth to clean the resident even though resident continued to yell out in pain. Review of the resident’s chart found resident #48 had diagnoses to include: Diabetes- Insulin dependent and Urinary Frequency, both diagnoses compromise the resident's skin condition with documentation that the resident had-been identified at risk for skin impairment as noted on the resident’s care plan. Record review revealed no documentation of current open areas even though the observation revealed an open area. Nursing documentation 3/28/08 noted 2 small break down areas when changing the resident’s diaper, one on crease of left buttocks and one in the groin area and noted that the resident complained of pain when he/she sat in his/her wheelchair. On 7/17/08 at 11:40 a.m., an interview with the Unit Manager/Licensed Practical Nurse (LPN) regarding frequency of skin checks found that the hall nurses had the responsibility to do skin sweeps to check for skin impairment, stating she (unit manager) did not routinely conduct them on every new admission. A through skin assessment should be done on admission to note any probblems, so that appropriate care can be implemented. The Unit Manager is ultimately responsibe for the care on the unit. Further chart review of the July 2008 TAR (treatment administration record) found only one application of Nystatin cream to groin even though it was ordered twice daily as needed; again the Unit Manager/LPN also stated that it is responsibility of the hall nurse to apply the cream if needed. In the TAR book for each individual resident there was a notation card to indicate which shift and the date the skin sweep is required; the card for resident #48 revealed that his/her weekly skin sweep was to be done weekly on Tuesdays by the 7-3 nurse. However, review of the weekly skin sweep found the chart noted a skin sweep had not been done since 6/3/08 and noted no new skin impairments at that time. The weekly skin sweep was found to be updated on 7/17/08 after requesting the nurse to assist surveyor in observing resident #48's skin to evaluate for open areas. The nurse noted on 7/17/08 a small open area found between groin and leg. Review of the care plan reveald that resident #48 was identified as having daily discomfort and pain located in back and joints with interventions to include positioning to comfort. On 7/18/08 from 9:00 a.m. to 10:30 a.m. resident #48 was observed for at least on hour and a half sitting up in a wheelchair near nursing station with head positioned on his chest, eyes closed, dozing. Staff did not make any attempts at repositioning him/her, laying him/her down, or asking him/her if he/she might like to go to bed. Review of the Nursing Progress notes revealed that the resident had a recent history of pain when in a wheelchair for long periods of time, as noted in nursing documentation 5/24/08 and 5/25/08 notes reflecting the resident having discomfort in his/her wheelchair. The 5/25/08 12:00 p.m. nursing notes indicate that the resident complained of discomfort in his/her wheelchair and that the resident needs to be repositioned every 20 - 30 minutes to relieve discomfort. Long periods in his/her wheelchair without the resident’s position being changed, as well as nursing not following through with weekly skin sweeps compromised resident #48's skin condition, caused an open area between the resident’s legs and under scrotal area which caused the resident even more unrelieved pain. 5. Review of resident #197 record indicated an admission date of 11/07 with diagnosis of Diabetes Mellitus. From 11/07 the resident was admitted to the hospital seven times. Upon one return form the hospital the resident was noted to have a neurotic area to left toe which eventually resulted in amputation of left foot. Gangrene developed and later the resident had above the knee amputation. Review of history and physical dated 1/30/08 indicated a diagnosis of Diabetes Mellitus, Osteomyelitis, Above Knee Amputation (AKA) (1/9/08), Gangrene, Methicillin Resistant Staph Auresus (MRSA), Severe Peripheral Disease and Diffuse bilateral Vascular Disease to both lower extremities on left side. All of the diagnoses listed are severe risk factors for MRSA infection. However, the facility failed to utilize the infection control standard of practice for a resident with MRSA. Observation 7/17/08 2:05 PM noted a sign on the door directing visitors to see the nurse, no isolation cart present outside of the room, no trash can in the room or in the bathroom and no barrels for soiled linen. Residents can be properly cared for if appropriate infection control practices are followed, which this facility was not following. Observation 7/18/08 8:15 a.m. noted a sign on the door directing visitors to see nurse, no isolation cart present outside of room, no trash can in room or in the bathroom in the room and no barrels for soiled linen. Interview with wound nurse at the same time revealed that the nurse was not sure if the resident hd MRSA. When asked ; again she stated the manager said the resident had MRSA in wounds. Record review. _ did not indicate an order for contact isolation. Review of the most current MDS dated 5/13/08 indicated surgical wounds with infection. Interview with nurse 7/18/08 4:00 PM stated that the policy is to have signs on doors, to have cart outside the door for supplies, and to bag items inside the room if a resident has MRSA. Record review of the most current care plan noted plan of care for wounds. Physician orders dated 7/08 indicated to give antibiotic Merrem 0.5 grams IV every 6 hours (12AM, 6AM, 12N, 6PM) for wound infections. The resident is currently receiving IV antibiotics to treat the MRSA infection; however, the resident did not receive medications as ordered because the staff was administering the medication every eight (8) hours instead of every six (6) hours. Interview with director of nursing 7/18/08 at 3:30 p.m. stated there has been no tracking and trending of infections from 1/08 through 5/08 and data has not been investigated and the facility has not initiated interventions. Review of the aides’ plan of care Kardex lacked evidence of isolation and wound problems. Observation of resident 7/17/08 2:05 p.m. noted two bags of intravenous (IV) Merrem 500 milligrams. One bag had approximately 25% of the antibiotic remaining. The surveyor asked nurse who was attempting to hang bag two why the entire antibiotic was not infused, she did not know the answer. The two bags were not marked with a time to be delivered. The nurse stated that the IV pump did not work and that the facility did not have a backup so the nurse used a dial-a-flow meter to infuse the medication. The nurse also indicated Merrem was ordered every 8 hours and that the medication was due now at 2:00 p.m. However, review of the medication record (MOR) indicated Merrem 500 mg was to be given every 6 hours (at 12 am., 6 a.m., 12 p.m.,, and 6 p.m.) and the 12:00 p.m. dose, which was not signed as administered, was being given 2 hours late. Further review of the MOR noted that starting on 7/8/08, 8 doses were not signed by nurse and therefore there is no proof that the medicine was administered. Also, administration of a Merrem IV was not signed as given on 7/17/08 at 6:00 p.m. or on 7/18/08 at 6:00 a.m. An interview with the nurse confirmed the findings. Observation of the medication room 7/18/08 at 9:00 a.m. noted 20 bags of Merrem antibiotic for resident #197 for 3 stage IV wound infections with delivery dates 7/11 and 7/18. There were 20 bags, but the nurse stated that there should only have been 8 bags of antibiotics left. The findings indicating that the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents and injuries includes: 6. Resident #196 was admitted to the facility on 7/1/08 following a hospitalization for Failure to thrive with frequent falls and weakness at home. At the time of admission, the resident was to receive further evaluation for gait disturbances. Review of the resident's clinical record revealed an initial nursing progress note on 7/1/08 at 11:00 p.m. which reads, “Patient at risk for falls - Alarm placed on patient. Call bell in reach." Additional documentation at 11:10 p.m. reads, "Patient constantly getting out of bed after frequent instructions not to do.so. Will continue to monitor. Patient placed in wheelchair with PA (personal alarm) and seat belt." Further review of the resident's record revealed a "Falls Risk Identification and Plan of Care" was written on 7/1/08 which identified the resident as requiring assistance with transferring and ambulation. Care plan approaches included: provide assistance for unsteady gait; distant supervision for ambulation; and provide appropriate safety and enabler devices. A therapy screen conducted on 7/2/08 identified the resident as being at risk for falls with deviations in gait and unsteady, inconsistent step length and stride. Recommendations included using a gait device with hand held assist for ambulation distances less than 15 feet. Additional documentation in the resident's record on 7/3/08 at 1:30 AM reads, "Resident sat down to floor out of wheelchair in hallway, with PA (personal alarm) intact. No injuries noted, accompanied back to chair, faxed report to doctor, will continue to monitor prior to notifying family." Following the resident's fall on 7/3/08, a Fall Action Team Fall Review was completed on 7/7/08. The review concluded that the resident "has history of poor safety awareness, restless, constantly attempting to get up. Has unsteady gait with multiple falls. Approaches: PA (personal alarm), Velcro Belt, ARNP (Advanced Registered Nurse Practitioner) & Pharmacy review, Psych (psychiatrist) consult, and PT (physical therapy) screen. Observations on 7/16/08 at 3:45 PM revealed the resident ambulating down the hallway past the nursing station pushing his/her wheelchair in front of him/her. The resident's personal alarm was dangling from the back of the wheelchair instead of attached to the resident. Further documentation in the nurses progress notes on 7/17/07 at 1:30 a.m. reveal the resident was up walking to go smoke with CNA's (certified nursing assistant) assistance and turned too quickly, falling and bumping his/her head and his/her left frontal area. The resident's glasses were also broken. X-rays taken on 7/17/08 confirmed the resident sustained a fractured right clavicle. However, there was no evidence that staff was using a gait device with a hand held assist as recommended by therapy staff for safe ambulation. Facility staff failed to provide the necessary assistive devices and supervision in order to prevent the resident from falling. The findings demonstrating that the facility failed to follow physician orders for resident medication for residents in medication pass observations include: 7. The surveyors observed Nurse #1, on Hall 2, on 7/14/08 at 12:37 p.m. during an accu check (blood sugar evaluation) on resident #96. The accu check at that time revealed that the resident’s blood sugar level was 281. An interview with the nurse at this time revealed that the rise in blood sugar required a sliding scale coverage of Novolog Insulin ordered by physician. Upon returning to the medication cart to draw up the Insulin, the nurse could not find resident's insulin. The nurse went to the phone and called the pharmacy to get instructions as to what to do about there being no medication. The pharmacy staff and was instructed to take the medication out of the EDK (Emergency Drug Kit) in the medication room. Upon going to the EDK on Hall 2, the nurse could not find any Novolog Insulin. She then went to Hall 1's medication room to check for the Insulin in their EDK. There was no Novolog Insulin in their EDK either. At 1:02 p.m. Nurse #1 called the Pharmacy again to let them know there was no Novolog in either of the EDK' s in the building and she could not administer the Insulin for the raised blood sugar. At this time, pharmacy staff told her they would send the medication from the back up pharmacy and it should be there within the hour. Resident #96 did not receive the ordered Novolog Insulin 4 units until approximately 2:30 p.m., which is approximately 2 hours after the resident was evaluated, when it was received from the back up pharmacy. Review of the current physician orders revealed Accu checks ordered for AC & HS (before meals and at bedtime) with a Sliding Scale for blood sugars between 251- 300 requiring 4 units of Novolog Sliding Scale insulin for resident's diagnosis of Diabetes Mellitus If as ordered on July 2008 Physician Orders signed 6/30/08. An interview with Unit Manager/LPN on 7/18/08 at approximately 3:00 p.m. found she was not sure if Insulin had not been ordered by the Nurses or if Pharmacy had not delivered the medication timely and that the facility did have problems sometimes with pharmacy delivery of medications. 10. The Respondent had a legal duty to treat residents courteously and fairly and to ensure that residents were not mentally abused pursuant to ss. 400.022(1)(m) and 400.022(1)(0), FS. The Respondent had a legal duty to provide adequate and appropriate health care to prevent and treat pressure ulcers, to properly address resident infection, provide pain management and provide medically necessary antibiotic therapy pursuant to s. 400.022(1)(I),F.S. The Respondent had a legal duty to provide adequate care, supervision and support services, and _ assistive devices to prevent accidents and injuries pursuant to s. 400.022(1)(1), F.S. Finally, the Respondent had a legal duty to follow physician orders regarding patient medication administration pursuant to Rule 59A-4.107(5), F.A.C. The Respondent failed, either intentionally or negligently, to fulfill its duty to treat residents courteously and fairly when its staff told resident #42 to “shut up”, when it rushed resident #42 while the resident was being toileted, when staff verbally demeaned resident #115, when staff were physically rough with resident #101, and when staff ignored resident #101’s statement that they were hurting the resident. The Respondent’s actions violated ss. 400.022(1)(n) and 400.022(1)(0), F.S., and materially affected the residents mental health in the form of intimidation and discomfort from rough treatment. . The Respondent failed, either intentionally or negligently, to fulfill its duty to. provide adequate care related to pressure sores, provide pain management and provide medically necessary antibiotic therapy when it failed to change resident #48’s position frequently enough to prevent pressure ulcers and pain, when they failed to properly clean excrement from the resident #48’s body around area of the pressure ulcer, when they failed to regularly assess the resident’s skin impairments, and when it failed to properly and adequately administer antibiotic medication to resident #48’s according to the frequency required resident’s medication record. The Respondents actions violated s. 400.022(1)(1), F.S., and materially affected a residents health in the form of pressure ulcers and pain. The Respondent failed, either intentionally or negligently, to fulfill its duty to provide adequate care related to properly address resident infections. If a resident has MRSA then the facility should have made trash cans, gowns, gloves, bags available for staff to use to prevent exposure and contamination from draining wounds and other body fluids. MRSA is easily transmitted in the nursing home. Residents can be properly cared for if appropriate infection contro] practices are followed, which this facility was not following. Linens and trash should be red bagged in the room and removed. The red bag indicates to staff that the contents are contaminated and need to be handled differently. The Respondents actions violated s. 400.022(1)(1), F.S., and materially affected a residents health in the form of potentially exposing other residents to infection. The Respondent failed, either intentionally or negligently, to fulfill its duty to provide adequate supervision and assistive devices to residents in order to prevent accidents when it failed to follow its own care plan for the resident by failing to use an assistive device during ambulation, which resulted in a fall and fractured right clavicle. The Respondent’s actions violated s. 400.022(1)(1), F.S., and materially affected a resident’s health, causing a fractured clavicle. The Respondent failed, either intentionally or negligently, to fulfill its duty to follow physicians’ orders or record why it did not follow the orders when it failed to administer insulin to resident #96 in accordance with the resident’s medication orders based on its failure to administer the insulin until approximately two (2) hours after the resident was noted to have a blood sugar level which required insulin treatment. The Respondent also failed to follow physician’s orders regarding medication for resident #197 by failing to administer Merrem doses in their entirety as well as by failing to administer Merrem every six hours. The Respondent also failed to timely record the reason it did not follow the physicians orders for either resident. The Respondent’s actions violated Rule 59A-4.107(5), F.A.C., and materially affected a resident’s health by placing resident #96 at risk for complications from diabetes and dangerous blood sugar levels and by placing resident #197 at risk for complications and affects of insufficiently treated MRSA infection. Pursuant to s. 400.102(1), F.S., any intentional or negligent act that materially affects the health or safety of a resident is grounds for administrative action. The Respondent has been cited for multiple acts, international or negligent, that materially affected the health or safety of its residents. The Agency has supported its citations with specific factual findings that support the alleged deficiencies. Furthermore, the Respondent’s acts effected a wide enough population of residents to be considered a widespread deficiency pursuant to s. 400.23(8), F.S., which defines a widespread deficiency as “a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents.” The deficiencies alleged regarding the facilities treatment of residents affected not only the residents specifically identified in this Complaint, but also other residents the facility according the residents who were interviewed. Also, several of the deficiencies alleged herein relate to the facilities staff following resident care plans and doctors orders. Ignoring resident care plans and doctors orders for multiple residents and in multiple areas of care demonstrate a systemic failure of the Respondent to adequately follow the appropriate care for any resident and that failure that has the potential to affect a large portion of the facility’s residents. Finally, the treatment of the resident identified as having a contagious diagnoses (MRSA) failed to meet the standard of practice and placed the residents and staff at risk for infection. Therefore, the Agency appropriately categorized the alleged Class II deficiency as widespread. 11. The Agency provided Respondent with the mandatory correction date for this deficient practice of August 29, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $7,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Florida Statutes (2008). COUNT II 12. The Agency re-alleges and incorporates Counts I of this Complaint as if fully set forth herein. 13. Based upon Respondent’s cited widespread State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part Il of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment ofa conditional licensure status under § 400.23(7)(b), Florida Statutes (2008). 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 (2008) commencing July 19, 2008. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Heaith Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I, and II; (B) Recommend an administrative fine against Respondent in the amount of $7,500 for Count I, a widespread Class II deficiency; (C) Assign a conditional licensure status commencing July 19, 2008 (D) Assess attorney’s fees and costs; and . (E) 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. Respectfully submitted this 1° day of October, 2008. Tek Heal, Mark Hinely . Fla. Bar.48084 Agency for Health Care Administration 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 8701 to: Facility Administrator Rebecca Simmons, University Hills Health and Rehabilitation, 10040 Hillview Road, Pensacola, Florida 32514, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8718 to: Owner Cross Creek Health Care Associates, LLC, 303 Perimeter Center North, Suite 500, Atlanta, Georgia 30346, and. by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8725 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301 on October 1%, 2008: , Mark Hinely Copy furnished to: Barbara Alford, FOM

Docket for Case No: 08-005411