STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 2013003621 PENSACOLA FACILITY OPERATIONS, LLC d/b/a CONSULATE HEALTH CARE OF PENSACOLA, Respondent. / ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against the Respondent, Pensacola Facility Operations, LLC d/b/a Consulate Health Care of Pensacola (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing March 20, 2013 and ending April 12, 2013, and impose an administrative fine in the amount of one thousand dollars ($1,000.00), based upon Respondent being cited for one uncorrected State Class III deficiency’ JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2010). 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), Chapters 400, Part II, and 408, Part Ty, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. : Respondent operates a 120 bed nursing home, located at 235 West Airport Blvd. Pensacola, Florida 32505 and is licensed as a skilled nursing facility, license number 130470965. 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. COUNTI Resident Rights Violation 6. . The Agency re-alleges and incorporates by reference allegations 1 through 5. 7. Under Florida law, 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. § 400.22(1)(), Fla. Stat. (2012). 8. On or about February 8, 2013, the Agency conducted a standard survey of the Respondent. 9, Based on record reviews and interviews the facility failed to follow care plans for 3 of 26 sampled residents (#128, 43, 123) in regards to providing restorative nursing program, monitoring psychotropic medications, and not completing a quarterly fall risk assessment. 10. Record review for sampled resident #128 revealed the resident was admitted to the nursing home on 09/16/12. The resident received physical therapy services. The resident was discharged from physical therapy on 12/12/12 to the restorative nursing program (RNP), Review of the Therapy Communication to Restorative Nursing Program by the Physical Therapist dated 12/13/12 revealed the RNP was to perform lower extremity range of motion exercises using 2 pound weights times 3 sets of 15. Also to ambulate the resident using a gait belt and front wheel walker with wheelchair in tow 250 feet and 100 feet with patient requiring reminders to keep knees extended and increase strides, requires rest breaks and use of oxygen per at 2 liters. These recommendations are to be done three times a week for 12 weeks. 11. Interview with the resident on 2/6/13 at approximately 2:00PM revealed that she stated the staff are to assist her to walk with her walker three times a week but they are only doing it one time a week, 12. Record review of the restorative notes for J: january 2013 revealed the last time the resident was assisted with ambulation and range of motion was on 1/25/13. The record fails to reveal any documentation of the restorative program being done the rest of the month for January and revealed the restorative program has not been done any of the month of February. 13. Review of the restorative care plan for this resident revealed the intervention of ambulation with gait belt and front wheel walker three times a week for 12 weeks initiated on 12/13/12. 14, Interview with sampled staff #A, C.N.A. (nurse aide) and the restorative C.N.A. on 2/7/13 at 2:02PM revealed she has worked three days this week and has not provided ambulation assistance or range of motion to this resident. Review of the resident's restorative notes with this restorative C.N.A. confirmed the last range of motion exercises and ambulation done with this resident was on 1/25/13 and none have been done so far in February. 15. Interview with the DON 2/7/13 at 2:29PM confirmed the findings of no restorative nursing program done on this resident since 1/25/13 and should be done 3 times a week. 16. Interview with DON again on 2/7/13 at 3:44PM confirmed the care plan was not being followed. 17. . Record review for sampled resident #43 revealed a physician order of 1/1/13~ 131/13 for Xanax 0.5 mg give one tablet by mouth every 8 hours as needed for anxiety. Record review revealed the resident required the medication on 1/1/, 1/5, 1/6 and 1/21/13. Record review of the January 2013 behavior monitoring sheet for the Xanax failed to reveal any staff documented behaviors which required the use of the Xanax. The staffing did not document any other interventions tried prior administering the medication. And record review revealed no documentation of the effectiveness of the medication either on the medication administration record or in the nurses notes or on the behavior monitoring sheet. Interview with the DON on 2/713 at 10:43AM revealed the nursing staff are to record the resident 's behavior on the behavior monitoring sheet and should attempt and document non pharmaceutical interventions and then administer the antianxiety medications. The staff should assess and record the effectiveness of the antianxiety medication. Continued interview with the DON on 2/7/13 at 10:56AM confirmed the nursing staff did not adequately monitor the antianxiety medication. 18. Review of the psychotropic medication care plan for the antianxiety medication revealed 12/17/12 intervention for the nursing staff to monitor behavior and mood every shift and document. Interview with the DON on 2/7/13 at approximately 11:04AM confirmed the care plan was not followed. 19. During Stage 1 Staff Interview with LPN Unit Manager for G & R on 2/4/13 about 4:34 pm she revealed Resident #123 had "thrown himself out of bed" on 1/6/13 on the 3- 11 shift, The resident's care plan was reviewed during Stage II for falls. The care plan inchuded an intervention to complete fall risk assessment on admission/Quarterly. 20. . A review of the assessments in Resident #123 clinical record revealed that the last Fall Risk Assessment was completed on the resident on 7/6/12. 21. An interview was conducted with the LPN Unit Manager of G&R on 2/5/13 about 2:45 pm. She was asked to provide the last fall risk assessment for Resident #123. She stated, "The last one I see in the chart is 7/6/12, let me check my office." After checking her office with the surveyor she confirmed the last fall risk assessment was completed on 7/6/12. . 22. The Respondent’s actions and/or inactions constituted a class III violation. 23, A class III deficiency is a deficiency that the agency determines will 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, (2012), 24, A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class IIL-deficiency is corrected within the time specified, a civil penalty may not be imposed. § 400.23(8)(c), Fla. Stat. (2012). 25. The Agency cited the Respondent for a class III violation. 26. The Agency provided a mandated correction. 27. The mandated correction was before March 20, 2013. 28. On or March 20, 2013, the Agency conducted a survey of the Respondent. 29. Based on staff interview and clinical record review the facility failed to monitor ‘as needed’ medications for anxiety and pain control, The facility. failed to provide any ‘documentation of need’ nor did the facility monitor the effectiveness of the ‘as needed' medications for 2 of 3 (#43 and #83) residents reviewed for unnecessary medications. 30. The Behavior/Intervention Monthly Flow Record for resident #43 was reviewed for behaviors. The form indicated the resident had anxiety on 3/12/13 on the day shift. The form indicated the resident was redirected and 1:1 occurred on the day shift..The form does not show any behaviors occurring on the day shift any other day. The Medication Administration Record (MAR) was viewed. It indicated that the alprazolam (Xanax) for anxiety was not given. The sign out sheet for the controlled drug alprazolam (Xanax) 0.5 mg one tablet every 8 hours as need for anxiety was cross referenced. The sign out sheet indicated the resident received the medication on 3/12/13 and 3/14/13 both at 8 am. 31. A review of Resident #43's nurses! notes indicated the last note was written on 3/11/13. A review of the weekly progress note indicated this was last completed on 2/21/13. The care plan for resident #43 for psychotropic medications stated: interventions monitor for behaviors and side effects, and monitor the effectiveness of psychotropic drugs. 32. An interview was conducted with the LPN (Licensed Practical Nurse) Unit Manager for the 100, 200, and 300 hallway on 3/19/13 about 1:30 pm. She was asked to explain the policy for as needed medications, She stated, "The behaviors are charted on the Behavior/Intervention Monthly Flow Record". She was asked where the 'as needed! medication should be charted when administered. She said, "On the MAR", She confirmed that the Xanax was not charted as being given on 3/12/13 or 3/14/13. She also confirmed there was no documentation of the effects of the medication on the MAR. We teviewed the chart's nurses’ notes and there were no notes for 3/12/13 or 3/14/13 confirmed by the LPN Unit Manager. There had been no weekly progress note written since 2/21/13 which was also confirmed by the LPN Unit Manager. 33. Resident # 83's clinical record MAR, Physician Order Sheet (POS), and Pain Flow Record was viewed for as needed medications for pain. The MAR and POS revealed orders for Tylenol Extra Strength 500 mg one as needed every 12 hours for headache, oxycodone- acetaminophen (Percocet) 5-325 mg give % tablet as needed every 6 hours for pain levels 1-3 and oxycodone-acetaminophen (Percocet) 5-325 mg 2 (1/2) tablets every 6 hours as-needed for pain greater than 3. The MAR indicated the resident received the Percocet 5-325 mg 2 (1/2) tablets medication several times daily except March 16 and 17, the Percocet 1 (1/2) tablet and the Tylenol extra strength had not been given . The purple Pain Flow Record was blank with no entries for the month of March, 34, Further review revealed no entries on the MAR for the dates, times, and effectiveness of the Percocet 2 (1/2) tablets. The nurses’ notes revealed the last entry was made on 11/29/12 and the last weekly progress note was dated 1/24/13. 35. An interview was conducted with LPN (Employee B) on 3/20/13 about 10:48am regarding the purple Pain Flow Record. She confirmed the Pain Flow Record was blank for Resident #83. We reviewed Resident #83's record and she confirmed the last nurses' note was dated 11/29/12, and last weekly progress note was dated 1/24/13. She stated, "The pain flow sheet should be completed for pain medications, there should be another pain sheet because she uses it so much". We both reviewed the chart for another pain flow sheet but none was found. She then stated, "Yes, ] know it should have been done." 36. The Respondent’s actions or inactions constituted an uncorrected class IIT violation. 37. The Agency cited the Respondent for a class III violation. 38. A class III deficiency is a deficiency that the agency determines will 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. (2012), 39.. A 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. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $1,000.00 against the Respondent. COUNT U 40. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein. 41. Based upon. the Respondent’s uncorrected State Class IIT 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)(a), Florida Statutes (2012). 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 (2012) commencing March 20, 2013 and ending April 12, 2013. ) Respectfully Submitted, /s/ John E. Bradley John E. Bradley Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John.Bradley@ahca.myflorida.com NOTICE The Respondent is notified of the right to request an administrative hearing pursuant to Sections 120,569 and 120.57, Florida Statutes. The Respondent has the right to hire and be represented by an attorney in this matter at the Respondent’s cost. Specific options for administrative action are set out in 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 THEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated on this 29th day of May 2013. /s/ John E. Bradley John E. Bradley Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John.Bradley@ahca.myflorida.com Donah Heiberg Field Office Manager (Electronic Mail) Jason Duplantis Administrator Pensacola Facility Operations, LLC 235 West Airport Blvd Pensacola, Florida 32505 (U.S. Certified Mail: 7011 1570 0000 3003 1766): Berard Hudson Long Term Care Unit Manager (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: PENSACOLA FACILITY OPERATIONS, LLC ACHA No. 2013003621 d/b/a CONSULATE HEALTH CARE OF PENSACOLA ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued. imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapterl20, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) J admit to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this ptoposed agency action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Resporident (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) T hereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title:

Docket for Case No: 13-002428