Mi bee es gf UES IA LD STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, ; Case Nos. (Fine) 2010007838 (Conditional) 2010007839 13455 MANAGEMENT, LLC, d/b/a : CROSSWINDS HEALTH AND REHABILITATION CENTER, Respondent ; / ADMINISTRATIVE COMPLAINT COMES NOW, the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, 13455 Management, LLC, d/b/a Crosswinds Health and Rehabilitation Center (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of one thousand dollars ($1,000.00) and assign a conditional licensure status beginning on July 8, 2010, and ending on July 12, 2010, based on one isolated class ITI deficiency. PARTIES 1, The Agency is the licensing and regulatory authority that oversees skilled nursing facilities in Florida and enforces the applicable federal and state statutes, regulations and rules, governing skilled nursing facilities. Ch. 408, Part II, and Ch. 400, Part Il, Fla. Stat.; Ch. 59A-4, F.A.C, The Agency may deny, suspend, or revoke a license issued to a skilled nursing facility, Filed January 5, 2011 4:13 PM Division of Administrative Hearings and impose administrative fines pursuant to Sections 400.121, 400.23, 408.813 and 408.81 5, Fla. Stat.; assign conditional licensure status pursuant to Section 400.23(7), Fla. Stat; and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Fla. Stat. 2. The Respondent was issued a license by the Agency (License No. 1438096) to operate a 58-bed skilled nursing facility located at 13455 West U.S. Highway 90, Greenville, Florida 32331, and was at all material times required to comply with the applicable federal and state regulations, statutes and rules. COUNT I Failure to Follow Physician Orders 3. Under Florida law, 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, R. 59A- 4.107(5), F.A.C, 4. On or about April 29, 2010, the Agency conducted an annual re-licensure survey of the Respondent and its Facility. 5. Based upon observations, interviews, and record review, the Respondent failed to follow physician orders for 3 of 16 sampled residents by failing to provide wound treatment and dressing care for Resident #30, failing to apply compression stockings as ordered for Resident #34 and failing to use a personal alarm as ordered for Resident #49. Resident #30 6. On the afternoon of April 27, 2010, Resident #30 was observed in bed. 7. The resident showed the surveyor his/her wounds of the right lower leg; the wounds were uncovered and did not have a dressing over them. 8. The resident stated that the staff dressed the leg yesterday evening but the dressing came off during bathing and no one ever put another dressing on the wound. 9. A record review of Resident #30’s current physician orders for wound care was conducted. The physician orders were written on April 7, 2010 and ordered the discontinuation of the silvadene cream to-the right lower leg wound and directed cleaning the right lower leg wound with normal saline, apply hydrogel, and cover with telfa dressing daily until healed. 10. A review of the resident’s current treatment record revealed treatment being done to the right lower leg wounds. The wounds were cleaned with normal saline, hydrogel and the . telfa dressing were applied as documented on the 3-11 ‘shift. 11. Record review of the resident’s current care plan revealed, “Treatments as ordered.” 12. On the afternoon of April 27, 2010, observation of the resident’s wounds with the nurse confirmed that the wounds were not covered by a dressing as per current physician’s orders. 13. An interview with the resident’s nurse on the afternoon of April 27, 2010, revealed that she was aware the resident did not have the dressing on his/her leg but decided to leave the area open to air. 14. The resident’s nurse confirmed that this was not the current physician wound care orders and; therefore, that physician’s orders were not followed. Resident #34 15. A record review for sampled Resident #34 revealed a physician order dated February 23, 2009 for knee length compression stockings. 16. Observation of the resident on April 27, 2010 revealed the resident in bed on his/her back with feet elevated on pillows and no compression stockings on the resident’s legs. 17. Observation on April 28, 2010 revealed the resident sitting in a wheelchair at the nurses’ station. The resident had on a pair of tan socks and shoes, but no compression stockings. 18. An interview conducted on April 28, 2010 with the resident’s certified nursing assistant (“C.N.A.”) revealed that the resident has a pair of compression stockings but does not like to wear them. However, the C.N.A. stated that he/she did not ask the resident that morning if the resident wanted to put them on because the resident has been refusing the stockings. | 19. A review of the treatment record for-Resident #34 revealed that the staff. were _ putting on the compression stockings at 7 A.M. and removing them at 3 P.M. However, Resident #34 refused the stockings on April 22, 2010 through April 25, 2010. 20. An interview on April 28,'2010 with Resident #34’s nurse revealed that staff should be offering and applying the stockings, if allowed by the resident, as ordered by the physician. 21. In an interview on April 28, 2010 the Director of Nursing agreed that the physician’s orders should be followed. Resident #49 22. A record review was conducted regarding Resident #49. 23. On April 24, 2010 a telephone order was issued for Resident #49 that required non-skid socks to be worn at all times if shoes are off (order two pair), a bed alarm for patient safety and a chair alarm. 24, On April 28, 2010, the resident was observed in his/her room eating breakfast. Then the resident got up off the bed and sat in his/her wheelchair. The chair alarm was on the wheelchair but was not attached to the resident. 25. Later that morning, the resident was observed outside in the smoking area in his/her wheelchair and the chair alarm was not attached to the resident. An aide was observed outside with the residents in the smoking area. 26. At mid-morning, the resident was observed in the hallway in his/her wheelchair bending over in the chair and the chair alarm was not attached to the resident. 27. Also on April 28, 2010, Resident #49 was observed in the dining area during activities sitting in his/her wheelchair and the chair alarm was not attached to the resident. Two nurses were observed in the dining room when this occurred. 28. An interview with the nurse was conducted. The nurse stated that they did not notice that Resident #49’s chair alarm was not attached to him/her this morning. 29. The Respondent's practice constituted a class III deficiency in that it would result in no more than minimal physical, mental or psychosocial discomfort to the resident or has the . potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. § 400.23(8)(c), Fla, Stat. 30. The Agency cited the Respondent with a class III deficiency and provided a mandatory correction date of May 29, 2010. ) 31. On or about July 8, 2010, the Agency conducted a revisit to the re-licensure survey of the Respondent and its Facility. 32. Based upon observation, interview and record review, the Respondent failed to follow physician orders for 2 of 5 sampled residents by failing to provide the prescribed diet for Resident #52 and failing to provide skin assessments and wound care for Resident #54. Resident # 52 33, Resident #52 was observed in the dining room on July 8, 2010 eating lunch. The tray card read no concentrated sweets, unsweetened tea. 34, A review of Resident #52’s care plan revealed an update on April 29, 201 0, with a physician’s order that read: add milk and juice at each meal to promote weight stabilization at or above his/her ideal body weight record. 35. . On July 8, 2010 during an interview with Resident #52 and his/her spouse, the resident stated, “T have milk with breakfast, but 1 do not have it on my tray at lunch or dinner.” 36. When asked about the milk and juice at each meal for Resident #52, the Food Service Director replied, “we offer him milk, but he does not always want it.” The Food Services Director was asked if the milk and juice should come on the tray since the physician order was written for it, and the Food Services Director agreed that it should be on the tray. 37. A review of the medication administration record of Resident #52 for April, ‘May and June failed to reveal a carry-over for the physician’s diet order change written on April 29, 2010. 38. An interview was conducted with the Minimum Data Set (“MDS”) coordinator. The care plan is implemented by the MDS coordinator, She was asked what the process is for making sure physician orders are implemented. The MDS coordinator explained that the order dated May 29, 2010 was a recommendation by the registered dietician. The nurse then discussed the recommendation with the physician and an order was obtained from Resident #52’s doctor, The nurse would then transfer the new order to the medication administration record then fax the order to pharmacy that would then make sure the medication administration record is updated each month with the new dietary order. 39. Another interview was conducted with the Food Service Director who stated that dietary has the order for fruit juice and milk with each meal. When questioned about the diet card that read no concentrated sweets, unsweetened tea, the Food Service Director stated, “That was an old card.” The Director had diet sheets which showed milk and juice with each meal, Resident #54 40. A record review for Resident #54 was conducted on July 8, 2010. 41. Physician’s orders dated May 25, 2010 directed the application of Mepilex border dressing to the left and right buttocks three times weekly and as needed until healed. 42. The treatment record also indicated the application of Mepilex border dressing to the left and right buttocks three times weekly and as needed until healed as prescribed by the physician on May 25, 2010. 43. The last documented dressing change on the treatment record was initialed by the nurse as being done on July 2, 2010, with the next dressing changes due on July 5, 2010, and July 7, 2010. 44, The last two dressing changes were not initialed as being done. 45. These findings were confirmed by the Director of Nursing. 46. Observation of Resident #54’s buttocks, in the presence of the Director of Nursing, on July 8, 2010, revealed a healed wound area on the left buttock and an undressed Stage 2 ulcer on the right buttock. 47. The physician order for Resident #54 dated March 30, 2010 indicated skin checks weekly on the Tuesday, 3-11 shift. . 48. The Skin and Wound Weekly Quality Assurance Tracking Log dated June 23, 2010 documented a Stage 2 pressure ulcer to the left buttock of the resident measuring 2em x 2cm x superficial depth and a Stage 2 pressure ulcer to the right buttock measuring 2cm x lcm x superficial depth. There are no other wound measurements or documentation regarding the wounds since June 23, 2010. 49, An interview with the Director of Nursing confirmed that neither the wound measurements nor the skin check documentation had been done since June 23, 2010. 50. The physician order for Resident #54 dated une 23, 2010 indicated to apply warm water compresses to the legs for 20 minutes two times per day. A review of the resident’s treatment record for July 1, 2010 through July 7, 2010, indicated that warm compresses were applied only one time per day. 51. The Respondent’s practice constituted a class II deficiency in that it would result in no more than minimal physical, mental or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services, § 400.23(8)(c), Fla. Stat. 52. The Agency cited the Respondent with a class III deficiency and provided a mandatory correction date of August 8, 2010. Sanction 53. The Respondent’s actions or inactions constituted an uncorrected class III deficiency. 54. An uncorrected class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. § 400.23(8)(c), Fla. Stat. (2009), 55. Under Florida law, in addition to any other sanction imposed under this part or part II of chapter 408, in any final order that imposes sanctions, the agency may assess costs related to the investigation and prosecution of the case. § 400.121(8), Fla. Stat. (2009), WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose and administrative fine against the Respondent in the amount of one thousand dollars ($1,000.00). COUNT Assignment of Conditional Licensure Status 56. The Agency re-alleges and incorporates by reference the allegations in Count I. 57. . The Agency is authorized to assign conditional licensure status to skilled nursing facilities pursuant to Section 400.23(7), Fla. Stat. 58. Due to the presence of a class III deficiency that was not corrected within the time established by the Agency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part I, Fla. Stat., and the rules adopted by the Agency. 59. A conditional licensure status means that a Facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the Agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. If the facility has no class I, class II, or class III deficiencies at the time of the follow-up survey, a standard licensure status ~ may be assigned. 60. The Agency assigned the Respondent conditional licensure status with an action effective date of July 8, 2010. The original conditional license certificate is attached as Exhibit A and is incorporated by reference, . 61. The Agency assigned the Respondent standard licensure status with an action effective date of July 12, 2010. The original standard license certificate is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose conditional licensure status on the Respondent for a period between the assignment of the conditional license and the standard license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a final order against the Licensee that: 1, Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. 3. Assesses costs related to the investigation and prosecution of this case. Respectfully submitted this | Shays October, 2010. . Jones, Senior Attorney Fforida Bar No. 732291 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, Florida 32308 Phone: (850) 412-3630 Fax: (850) 921-0158 NOTICE The Respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, and to be represented by counsel or other qualified representative. Specific options for the administrative action are set out within the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency’ Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. 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 9364 to: Administrator, Crosswinds Health and Rehabilitation Center, 13455 West U.S. Highway 90, Greenville, Florida 32331, on October £57 Ka, Florida Bar No. 732291 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, Florida 32308 Phone: (850) 412-3630 Fax: (850) 921-0158 Copy furnished to: Barbara Alford, Field Office Manager Agency for Health Care Administration Administrator Crosswinds Health and Rehabilitation Center 13455 West U.S. Highway 90 Greenville, Florida 32331 EXHIBIT A Original Certificate For Conditional License With An Effective Date Of July 8, 2010 EXHIBIT B Original Certificate For Conditional License With An Action Effective Date Of July 12, 2010 13 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST ELIZABETH DUDEK GOVERNOR INTERIM SECRETARY October 7, 2010 CROSSWINDS HEALTH AND REHABILITATION CENTER 13455 W US HWY 90 GREENVILLE, FL 32331 Dear Administrator: The attached license with Certificate #16468 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, t Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management 3 - EXHIBIT 4 LORIDA FE —_—— GCOMPEARIE EP ARE Health Care in the Sunshine ahca 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 www.FloridaGompareCare.gov State of Florida | AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE NURSING HOME CONDITIONAL This is to confirm that 13455 Management, LLC has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: CROSSWINDS HEALTH AND’ REHABILITATION CENTER 13455 W US HWY 90 GREENVILLE, FL 32331 TOTAL: 58 BEDS STATUS CHANGE EFFECTIVE DATE: 07/08/2010 EXPIRATION DATE: 03/31/2011 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST ELIZABETH DUDEK GOVERNOR INTERIM SECRETARY October 7, 2010 CROSSWINDS HEALTH AND REHABILITATION CENTER 13455 W US HWY 90 GREENVILLE, FL 32331 Dear Administrator: The attached license with Certificate #16469 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 Standard Sincerely, Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management LORIDA COMPARE CARE Health Care ja the Sunshine 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 www.FtorldaCompareCare.gov exmresence | LICENSE #: SNF1438096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE ~ NURSING HOME STANDARD RONG ah Ven rae a This is to confirm that 13455 Management, LLC has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: . CROSSWINDS HEALTH AND REHABILITATION CENTER 13455 W US HWY 90 GREENVILLE, FL 32331 TOTAL: 58 BEDS STATUS CHANGE EFFECTIVE DATE: 07/12/2010 EXPIRATION DATE: 03/31/2011 , Agency for Health Care Administration sa gescite COMPLETE THIS SECTION

Docket for Case No: 11-000020