‘eee : STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, Case Nos. 2011002396 (Fine) 2011002397 (Cond.) CRESTWOOD NURSING CENTER, INC., d/b/a CRESTWOOD NURSING CENTER, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Crestwood Nursing Center, Inc., d/b/a Crestwood Nursing Center (“the Respondent”), pursuant to sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $2,500.00 and assign conditional licensure status on the Respondent, a nursing home. PARTIES 1. The Agency is the licensing and regulatory authority that oversees nursing homes and enforces the applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to Chapters 408, Part II, and 400, Part Il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 2. The Respondent was issued a license (License Number 1454096) by the Agency to operate a nursing home located at 601 South Palm Avenue, Palatka, Florida 32177, was at all times material times required to comply with all applicable regulations, statutes and rules, 1 Filed April 18, 2011 1:58 PM Division of Administrative Hearings COUNTI 3. Under Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: .... (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. § 400.022(1)(1), Fla. Stat. 4, Under Florida law, in addition to the grounds listed in Part I 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. § 400.102(1), Fla. Stat. 5. On January 10-13, 2011, the Agency conducted a survey of the Respondent and its facility. 6. Based upon resident record review and interview, the Respondent failed to ensure that care and services were provided in accordance with the resident's comprehensive assessment related to restorative nursing for pain management, and the administration of pain medication as needed related to range of motion, for 1 of 15 sampled residents. (Resident #20) 7. The Respondent’s failure to provide Resident #20 with pain medication as needed during range of motion therapy resulted in the Resident crying out in pain, crying, moaning, and refusing to complete passive range of motion. 8. A review of Resident #20's clinical record revealed that the Resident was referred to physical therapy on April 29, 2010, for a re-evaluation. 2 9. A review of the physical therapy notes revealed that the Resident was originally referred by physical therapy to restorative nursing on December 9, 2009, with recommendations. for range of motion therapy 6 times a week for 12 weeks, then decreased to 3 times a week. 10. The physical therapy department re-evaluated the Resident on April 29, 201 0, and decided that the Resident would continue with the original orders for restorative nursing. 11. A review of the rehabilitation referral/screening form revealed: "pt demonstrates increased tone throughout lower extremities likely leading to complaint of pain. Previous attempt at therapy have been unsuccessful. Pt is dependent for all care and screams with all movement. It is my recommendation that pt continue with restorative range of motion program and pain meds as needed as there are no functional deficits for therapy to address at this time," 12. During the interview with the Respondent’s restorative aide on January 13, 2011, at 9:40 a.m., the aide stated that she had discharged the Resident from restorative nursing on December 24, 2010, 13. The aide further stated that she never informed or requested from a nurse pain medication for the Resident during or before range of motion therapy. 14, The interview further revealed that the aide did not did not inform nursing or the therapy department that she had discharged the Resident from restorative nursing. 15. A review of Resident #20 restorative nursing services narrative progress notes revealed the following: a. January 21, 2010 -- Resident crying during range of motion therapy. b. July 27, 2010 -- Resident still doing ok with passive PM, although at first she does cry with her right arm. c. September 20, 2010 -- Resident tolerated range of motion OK, she cried out in the beginning but seemed to get better with it. 3 } } d. November 9, 2010 -- Resident was OK at first with range of motion, then started to get fussy. e. November 11, 2010 ~ Resident did only a few range of motion on arms, none on her legs due to she had started crying. f. December 6, 2010 -- did a full body massage with lotion, did a few range of ; motion on arms she did fine until tried to do legs, she started to moan in discomfort so | let her be. g. December 20, 2010 -- Resident was very whining today, she acted as if she was not feeling well. 16. There was no documentation in the Resident's record that the restorative aide had informed the nursing staff that the Resident was experiencing pain during the range of motion exercises, 17. A review of the restorative documentation revealed that staff was not available to assist the Resident with range of motion on September 30, 2010, October 1, 4, 8-10, 14, 28;- November 9, December 10-11, 16, 20, and 24, 2010, for a total of 14 days. 18. A review of the Resident's minimum data sets (MDS) dated July 21, 2010, and October 21, 2010, revealed that the Resident was not coded as receiving restorative nursing. 19. During the interview with the Respondent’s Therapy Director on January 12, 2010, at 11:20 a.m., the Therapy Director stated that the Resident was referred to restorative nursing for pain management. The Resident is to receive restorative nursing on a routine basis for pain management as long as the Resident lives in the facility. 20. A continued interview revealed that restorative staff should not have discharged the Resident without first notifying the therapy department. 21. | During the interview with the Respondent’s MDS Coordinator on January 12, 4 } j 2010, at 1:00 pm, the MDS Coordinator stated that she did not code the Resident as réceiving restorative nursing because the facility does not have a nurse to supervise the program. 22, During the interview with the Director of Nursing on January 12, 2010, at 1:30 pm, the Director of Nursing confirmed that the facility did not have a nurse to supervise the restorative nursing program. 23. A review of the facility's restorative nursing program policy and procedures revealed that the restorative nursing program requires a licensed practical or registered nurse to develop restorative plans of care, meet with the restorative aides on a weekly basis, document progress notes and assess residents for therapeutic needs. 24, The Respondent’s actions and/or inactions constituted a violation of the above- referenced provision of law and amount to. an isolated Class II deficiency pursuant to section 400.23(8)(b), Florida Statutes. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $2,500.00. COUNT I 25. The Agency re-alleges and incorporates by reference Count I. 26. Based upon the above cited state class II deficiency, the Respondent was not in substantial compliance with criteria established under Chapter 400, Part II, Florida Statutes, or the rules adopted by the Agency, subjecting the Respondent to assignment of a conditional licensure status under Section 400.23(7)(b), Florida Statutes. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assign conditional licensure status to Respondent commencing January 13, 201 1, and ending February 23, 2011. “gic CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1, Makes factual and legal findings in favor of the Agency, 2. Imposes the relief set forth above. Respectfully submitted on this M, d day of Muck , 2011. (la age D. Carlton Enfinger, Esquj Assistant General Counsel Florida Bar No. 793450 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5407 Telephone: 850-412-3640 Facsimilie: 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 Administrative Complaint and Election of Rights Form were served by U.S. Certified Mail, Return Receipt No. 7009 0960 0000 6 4 x 2 i 3708 3291 to Barbara M. Engelkes, Administrator, Crestwood Nursing Center, 501 South Palm Avenue, Palatka, Florida 32177, and by U.S. Mail to John F. Gilroy, UII, Registered Agent, John F, Gilroy, Ill, P.A., 1695 Metropolitan Blvd., Suite 2, Tallahassee, Florida 32308 on this 29 day of MNosch. 2011: D. Carlton Enfinger, Esquire Assistant General Coulfsel Florida Bar No, 793450 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5407 Telephone: 850-412-3640 Facsimilie: 850-921-0158 Copy: Kris Mennella, Field Office Manager FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION. RICK SCOTT ELIZABETH DUDEK GOVERNOR INTERIM SECRETARY March 7, 2011 CRESTWOOD NURSING CENTER. 5301 S$ PALM AVE PALATKA, FL 32177 Dear Administrator: The attached license with Certificate #16662 is being issued for the operation of your facility, Please review it thoroughly to ensure that all information is correct and consistent with your tecords, 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 cc; Medicaid Contract Management 2727 Mahan Drive, MS#33 COMPARE RARE Visit AHCA online at Tallahassee, Florida 32308 Health Care In the Sunshine ahca.myflorida.com £f www.FloridaCompareCare.gov wonensimmupy erp tpjeay Joy Aouasy “Asmotoeg WSU] Z102/0€/90 ‘ALVG NOILVUIdXA TIOZ/E1/10 -ALV ALLOA AONVHO SOIVIS Saag 69 “IVLOL LLIZE Td VALVIVd SAV Wivd § 10S UALNAD ONISYNN COOMISAYO :SuLmoy[o} au3 oyerado 03 pozoyNE st sasueol}] oy} se pue ‘sqqnqeis BpUOLy ‘II Wed ‘Or to1deyD ul pezuoyne ‘ONENSUILIpY s1eD W[eoy Joj Aouesy “epuopy jo ae1g ety Sq paydope suopemnsar pure sop ot TIM perduioo sey ONT UALNAO ONISUNN COOMLSAAD G3 TUYUOS 0} St SIT, qINOH ONISMAN AFONVUNSSV ALITVNO HLTVH JO NOISIAIC NOLLVULSININGV duvo HLTVaH YOd AONAOV VPLIO],] JO 9JLIG C999 *# ALVOIILYAO ino! FLORIOA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT GOVERNOR March 7, 2011 CRESTWOOD NURSING CENTER 501 $§ PALM AVE PALATKA, FL 32177 Dear Administrator: ELIZABETH DUDEK INTERIM SECRETARY The attached license with Certificate #16663 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 cc: Medicaid Contract Management 2727 Mahan Drive, MS#33 COoOMeARE CARE Tallahassee, Florida 32308 Health Care In the Sunshine www.FloridaCompareCare.gov Visit AHCA online at ahca.myflorida.com vopeNsTaTUpY are tyes} Joy Aouasy “piaioeg Wi ZIOZ/0E/90 ‘ALVG NOLLVUIEX 110Z/¥2/20 -ALVG FAILOFAIT AONVHO SO.LVLS saad $9 “IVLOL LLITE Td VALVTVd AAV Wivd § 10S ULNA ONISUNN GOOMISAAD :BuLMoT]o oy) a1e10do 0} pazomne st sesueoy] oy} se pue ‘saimerg epOly ‘T] Wed “OOP so\deyp Ul pezuoyyne ‘uonensTuTMpy eeD yee} 10,4 Aouedy “epnoly Jo arerg ou Aq perdope suoyejngor pue saqnz og) Ws perjduios sey ONI UALNFO ONISUNN COOMILSAAO 1H} UAYUOS 03 ST SHYT CavaNnvis AINOH ONISHOIN AONVUYNSSV ALITVNO HLTVaH AO NOISIAIG NOLLVULSININGYV Fav) HLIVAH WOd AONYDOV VPLIOL] JO 93¥IS 960~STIANS *# ASNAOIT ; , €9991 -# ALVOIILadD OFFICIAL USE Postage | $ Cartitied Fee Return Receipt Fee Postmark (Endorsement Required) Here Restricted Delivery Feo {Endorsement Required Totat Postage & Fees is 7004 O5b0 boo0 3706 3291 : SENDER: COMPLETE THIS SECTION m™ Complete items 1, 2, and 3, Also complete item 4 if Restricted Delivery is desired. m 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, CO Addresses B, Recelved by ( Print Name) C. Qate of Delivery Nan. ‘ ay) D. Is delivery address different from item 1? _O Yes if YES, enter delivery address below: [No 1. Article Addressed to: . eat Type Certifled Mait 2 Express Mall 1D Registered C1 Return Receipt for Merchandise i O Insured Mail 1 6.0.0. : 4, Restricted Delivery? (Extra-Fee) O Yes SQ Sa Bhan Aaeint, “Peoade AL BAVA PS Form 3811, February 2004 Domestic Return Recelpt 102595-02-M-1840 { . _ raed

Docket for Case No: 11-001934