STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case Nos. 2010004175 (Revoc) 2010004852 (Fine) TALLAHASSEE FACILITY OPERATIONS, LLC 2010004851 (CL) d/b/a CONSULATE HEALTH CARE OF TALLAHASSEE, 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 Tallahassee Facility Operations, LLC, d/b/a Consulate Health Care of Tallahassee (hereinafter “Respondent’’), pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate a nursing home in the State of Florida pursuant to §§ 408.815 (1)(c), 400.102(4) and 400.121(1)(a), Florida Statutes (2009), impose an administrative fine of five thousand dollars ($5,000) based upon the citation of one (1) Class Il deficiency pursuant to §§400.102(1) and 460.23(8)(b), Florida Statutes (2009). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing April 6, 2010. 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. 1 Filed June 24, 2010 12:57 PM Division of Administrative Hearings. 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 IT, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a ]2(-bed nursing home, located at 1650 Philips Road, Tallahassee, Florida 32308, and is licensed as a skilled nursing facility license number 1019096. 5. Respondent was at all times materia! 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 Tag N216 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to section 400.102(1), Florida Statutes, Florida law states: 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: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility; 8. That from April 5, 2010 through April 6, 2010, the Agency conducted an unannounced complaint investigation (CCR 2010003116) at the Respondent’s facility. 9. That based on interviews and record review the facility failed to provide adequate assistance to prevent accidents resulting in injury and delayed treatment for 1 of 5 sampled residents (#4) and failed to provide adequate supervision to ensure a safe environment for | of 5 sampled residents (#3). Resident # 4 10. —- That during an interview conducted on 4/5/2010 at approximately 10:43 am Resident #4 stated having a recent accident. 11. That the resident said an accident occurred in the bathroom using the mechanical sit/stand lift and one staff member. Resident #4 stated his/her left hand was injured during this accident and required an X-ray. The resident reported that one person usually transfers them and sometimes two assist. 12. That when interviewed at approximately 2:15 PM, Resident #4 stated they reported pain in the left hand/wrist since the date of the fall on 3/12/10. 13. That the x-ray was ordered and taken 4/1/10, twenty days after the accident. 14. The Minimum Data Set (MDS) assessment reference date 3/13/2010 assessed resident #4 for transfer and toilet use with extensive assistance and 2+ persons physical assist. 15. That a review of the Nurse Tech Information Kardex (not dated) revealed Resident #4 is to transfer using 2 person assist and does not include the mechanical sit/stand lift. 16. That the care plan for falls dated 2/23/10 lists falls on 3/9/2010 and 3/12/2010. 17. That the care plan was revised on 3/12/2010 and does not include the use of the mechanical sit/stand lift. 18. That further record review indicated the accident occurred on 3/12/2010. 19. That nurse progress note and medication administration record dated 3/15/10 reflect the resident complained of left arm/shoulder and finger pain due to the fall. 20. That physician orders for left hand x-ray regarding the fall to rule out fracture is dated 4/1/10. 21. As of the date of the record review, 4/5/10. the x-ray results are not available in the medical record. When questioned, the nurse contacted the diagnostic center and had the results faxed to the facility. The radiologist report dated 4/1/10 revealed no acute fracture. 22. That the radiographer’s comments included ring finger contracted since fall- pt. (patient) straightens-out. 23. That on 4/5/10 at approximately 2:45 PM the certified nursing assistant said staff use the mechanical lift and one person to transfer and toilet Resident #4. 24. During an interview at approximately 2:50 PM the attending nurse said sometimes one person and sometimes two people assist Resident #4 with transfers using the mechanical lift. Resident #3 25. That record review revealed Resident #3 admitted in the facility on 7/22/09 with diagnoses to include Dementia, Severe agitation and Psychosis. 26. That physician orders, medication administration records and the medication care plan reviewed indicate Resident #3 requires the use of the following antipsychotic medications: Haldol for severe agitation, Zyprexa and Seroquel for dementia and pscyhosis. 27. That nurse progress notes dated 3/11/10 at 2000 documented observation of a male resident in resident #3 's room with his hands inside resident #3 's blouse on the residents chest. 28. That the note indicated the certified nursing assistant entered room to assist to remove the male resident said Resident #3 had been in the male resident's room " all evening" and was returned twice to correct room. 29. That a statement written by the certified nursing assistant, dated 3/12/10, document removing resident #3 from the male residents room prior to finding the male resident in resident #3 's room with his " hand in her top touching (resident #3) breast area " . 30. That at 2130 the nurse placed the resident #3 on ] on 1. 31. That during an interview on 4/5/10 at approximately 11:50am the Director of Nursing (DON) said that Resident #3 is a wanderer and staff sit outside the resident ' s room in the hall all night. 32. That on 4/5/10 at approximately 4:20 pm an interview was conducted with the attending nurse for Resident #3. The nurse said Resident #3 is " fast as a whip". The nurse said the resident is confused at times and will wander the hall walking around if not sleepy when put to bed at might. 33, That on 4/5/10 at approximately 4:40 pm the certified nursing assistant was interviewed. The assistant reported that routinely three nursing assistants are on shift together and one of the three is always present to monitor residents. 34. That an interview was conducted with the Administrator and DON on 4/6/10 at approximately 12:45 pm regarding the incident and staff supervision. 35. That the DON said more than one aide is assigned to hall for constant monitoring and the aides do not take breaks at the same time. 36. That on the date of the incident, staff was present, aware of Resident #3 wandering behaviors into the male residents room prior to the incident. 37. That staff failed to provide adequate supervision to make sure all residents were in a safe environment. 38. That the Administrator and DON were questioned about overall staff supervision to ensure safety for cognitively impaired residents. Both advised that staff and the management team are very aware of both residents and are very aware of any type of behaviors and anything else that might be a problem for all residents. 39. The Agency provided Respondent with the mandatory correction date for this deficient practice of May 20, 2010. 40. The above findings reflect Respondent’s failure to provide adequate assistance to prevent accidents resulting in injury and delayed treatment and Respondent’s failure to provide adequate supervision to ensure a safe environment, thus the Respondent’s actions constituted an isolated Class I deficiency, pursuant of § 400.23(8)(b), Florida Statutes(2009). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(b), Florida Statutes (2009). COUNT Il 41, The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count | of this Complaint as if fully set forth herein. 42. Based upon Respondent’s cited State Class II deficiency, 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 (2009). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2009) commencing April 6, 2010 (Exhibit 1). COUNT I 43. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count | of this Complaint as if fully set forth herein. 44. That pursuant to section 400.102(4), Florida Statutes, Florida law states: In addition to the grounds listed in part Il of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (4) Fraudulent altering, defacing, or falsifying any medical or nursing home records, or causing or procuring any of these offenses to be committed. 45, That pursuant to section 400.121(1), Florida Statutes, Florida law states: The agency may deny an application, revoke or suspend a license, and impose an administrative fine, not to exceed $500 per violation per day for the violation of any provision of this part, part I] of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest: (a) A violation of any provision of this part, part I of chapter 408, or applicable rules; 46. That on 4/13/10 at 9:30 a.m. the nursing home administrator, Fate Brown, and the director of nursing, Benna Player, came to meet with the AHCA Field Office Manager, Barbara Alford, to present documentation for consideration to not issue a deficiency. 47. This visit was before the statement of deficiencies was issued and this is common practice. 48. The administrator and DON presented the AHCA Field Office Manager with a copy of the same residents care plan, however, this care plan had “mechanical lift” checked. 49. The care plan was altered/falsified after the survey. 50. That based thereon, the Agency seeks the revocation of the Respondent’s licensure as its primary relief. St. That should the Respondent admit the facts herein by action or inaction, the Petitioner shall enter an Order revoking the Respondent's license to operate an assisted living facility. 82. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate a nursing home in the State of Florida, pursuant to §§ 408.815, 400.102(4) and 400.121(1), Florida Statutes (2009) 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; B) Grant conditional licensure commencing April 6, 2010; C)Recommend revocation of Respondent’s license number 1019096; 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. 4 Respectfully submitted this 8 day of May, 2010 or Zioe/ D. Carlton Enfinger, If, Esq. Fla. Bar. No. 793450 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Retum Receipt No. 7004 2890 0000 5526 4673 to: Facility Administrator Fate Preston Brown, Consulate Health Care of Tallahassee, 1650 Phillips Road, Tallahassee, Florida 32308 and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4680 to Registered Agent pan Mason, 800 Concourse Parkway South, Suite 200, Orlando, Florida 32751 on May 6" 2010: D. Carlton fl in Copy furnished to: Barbara Alford, FOM

Docket for Case No: 10-003704