STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, V. AHCA No. 201 3006661 SA PG GAINESVILLE, LLC d/b/a PALM GARDEN OF GAINESVILLE, Respondent. ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration ( hereafter “the Agency”), files this Administrative Complaint against the Respondent, SA PG Gainesville, LLC d/b/a Palm Garden of Gainesville (hereafter “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 April 4, 2013, and ending May 4, 2013, and impose an administrative fine in the amount of two thousand five hundred dollars ($2,500.00), based upon Respondent being cited for one State Class I] deficiencies, 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 TV, Subtitle C (as amended), Chapters 400, Part H, and 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 120 bed nursing home, located at 227 SW 62™4 BLVD, Gainesville, Florida 32607 and is licensed as a skilled nursing facility, license number 1408096, 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 6. The Agency re-alleges and incorporates by reference allegations 1 through 5. 7. Section 400. 022(1)(1), Florida Statutes states in pertinent part: 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. 8. On or about April 4, 2013, the Agency conducted a survey of the Respondent. 9. Based on interview and record review the skilled nursing facility failed to ensure that residents received adequate/appropriate health care to promote the physical, mental and psychosocial well-being by failing to ensure that 1 (#1) of 8 sampled residents received the i) necessary care and services for pain management and timely transfer to a facility of higher care. Resident #1 was identified to have complaints of mouth pain on 03/23/13. An x-ray on 03/26/13 revealed a fractured jaw of unknown origin; however, the resident was not transferred Out to the hospital until 03/28/13 for treatment. The resident expressed significant mouth pain throughout the 5 days prior to transfer to the hospital. 10. Record review for Resident #1 revealed that the resident was admitted to the skilled nursing facility on 3/18/13 after a hospital stay. The resident's admitting diagnosis list included: severe dementia. ll. On 3/22/13, 9:00 PM, the nurse noted that resident #1's lower lip appeared swollen. The physician's assistant (PA) was notified and Benadryl 12.5 milligrams (mg) was ordered and given for possible food/medication allergy. The nurse indicated that the lip continues to appear swollen. . 12. On 3/23/13, at 5:30 AM, the resident was found on the floor sitting on her buttocks between the bed and the chair. She reported that her arms and leg were hurting. The nurse noted that there was an abrasion on her back and bruises on her right and left shoulder. 13. On 3/23/13, at 8:29 AM, the resident was complaining of mouth pain. Her lips were red and swollen. The PA examined the resident and found that she had a half-dollar sized knot on her right lower jaw which was warm to the touch. He ordered Tylenol 325 mg two tablets every 6 hours, as needed for pain, and Tramadol 50 mg one tablet every 6 hours as needed for pain. 14. On 3/23/13, at 1:15 PM, the PA was notified that the resident's condition was worsening. The right side of her face was swollen and her bottom lip was swollen. 15. On 3/23/13, at 1:40 PM, the PA examined the resident and diagnosed her with a we dental abscess. He ordered Amoxicillin 250 mg, three times a day, for 7 days and Culturelle twice a day for 10 days. 16. On 3/24/13 to 3/25/13, the notes indicate that the resident continued to have jaw swelling and complaints of pain. She continues to receive her antibiotics and pain medications as ordered. 17. On 3/26/13, at 9:25 AM, the PA visited the resident and ordered an x-ray of the mandible, The x-ray revealed that the resident had a "comminuted fracture of the left mandible for which further evaluation was suggested,” 18. On 3/28/13, at 8:30 AM the resident was transferred by Emergency Medical Services (EMS) to an area hospital. 19. Review of the As needed (PRN) pain medication administration record revealed the following: 20. On 3/23/13 at 8:40 AM- Tramado! 50 mg by mouth was given for right jaw pain of "7 out of 10". After 30 minutes, the pain is documented as " 6 out of 10." After 1 hour, the pain is documented as "3 out of 10. 21. "On 3/23/13 at 1:40 PM -Tylenol 650 mg by mouth for right jaw pain of "4 out of 10". After 30 minutes, the pain is documented as "3 out of 10." After 1 hour, the pain is documented as "1 out of 10." 22, On 3/23/13 at 6 PM- Tramadol 50 mg by mouth was given for right jaw pain of " 6 out of 10". After 30 minutes, the pain is documented as "3 out of 10." After 1 hour, the pain is documented as "1 out of 10." 23. On 3/24/13 at 7:50 AM -Tylenol 650 mg by mouth for right jaw pain of "4 out of 10". After 30 minutes, the pain is documented as “3 out of 10." After 1 hour, the pain is documented as "1 out of 10. " 24. On 3/24/13 at 12 PM- Tylenol 650 mg by mouth for right jaw pain of " 7 out of 10". After 30 minutes, the pain is documented as "5 out of 10." After 1 hour, the pain is documented as "2 out of 10," 25. On 3/24/13 at 12 PM- Tramadol 50 mg by mouth was given for right jaw pain of "7 out of 10". After 30 minutes, the pain is documented as "5 out of 10." After | hour, the pain is documented as "2 out of 10," 26. On 3/24/13 at 6 PM- Tramadol 50 mg by mouth was given for right jaw Pain of " 8 out of 10". After 30 minutes, the pain is documented as "2 out of 10." After 1 hour, the pain is documented as "1 out of 10. 27. On 3/24/13 at 9:30 PM- Tylenol 650 mg by mouth for right jaw pain of " 8 out of 10". After 30 minutes, the pain is documented as "2 out of 10." Afier 1, hour the pain is documented as "1 out of 10." 28. On 3/25/13 at 4:18 AM- Tramadol 50 mg by mouth for right jaw pain of "8 out of 10". After 30 minutes, the pain is documented as "6 out of 10." After 1] hour, the pain is documented as "5 out of 10." 29, On 3/25/13 at 10:30 AM- Tramadol 50 mg by mouth for right jaw pain of "8 out of 10". There was no documentation noted for intensity of pain for 30 minutes and for J hour after intervention. 30. On 3/26/13 at 7:25 AM- Tramadol 50 mg by mouth for right jaw pain of "6 out of 10". After 30 minutes, the pain is documented as "5 out of 10." After 1 hour, the pain is documented as "2 out of 10," 31. On 3/26/13 at 7:25 AM -Tylenol 650 mg by mouth for right jaw pain of "6 out of 10". After 30 minutes, the pain is documented as "5 out of 10." After 1 hour, the pain is documented as "2 out of 10." 32. Late entry: On 3/26/13 at 1:10 AM Tramadol 50 mg by mouth for right jaw pain of "9 out of 10". After 30 mimutes, the pain is documented as "6 out of 10." After ] hour, the pain is documented as "4 out of 10, " 33. On 3/27/13 at 7:10 AM- Tramadol 50 mg by mouth for right jaw pain of "$ out of 10". After 30 minutes, the pain is documented as "4 out of 10." After 1 hour, the pain is documented as "2 out of 10." 34. On 3/27/13 at 3:30 PM- Tramadol 50 mg by mouth for right jaw pain of "8 out of 10". After 30 minutes, the pain is documented as " 8 out of 10." After 1 hour, the pain is documented as "7 out of 10." 35. On 3/27/13 at 6 PM- Dilaudid 2 mg subcutaneous injection for right jaw pain of " 7 out of 10". After 30 minutes, the pain is documented as "3 out of 10." After | hour the pain, is documented as " 0 out of 10." 36. There is no documentation of pain medication being administered between 3/27/13 at 6 PM until EMS arrived on 3/28/13 at 8:36 AM. 37. Interview with the Risk Manager on 4/4/13 at 1:00 PM revealed that Resident 41 was initially sent to the hospital for evaluation because she was not eating; not as a result of the fall. 38. On 4/4/13, at 1:30 PM, the Administrator stated that nurse caring for Resident #] was unavailable for interview on the day of the survey. She also stated that the PA involved in Resident #1's care was out of the country. She stated that she placed a call to the resident's physician, who is also the facility's medical director, but he has not returned her calls. 39. Telephone interview on 4/16/13, at 7:44 AM, with the daughter (Power of Attorney) of Resident #1 confirmed that she is the medical POA (Power of Attorney) for the resident. She stated that she is listed on the skilled nursing facility paperwork to call as the primary contact. She stated that she was notified that her mother fell at the skilled nursing facility. She stated that she and her family alerted the skilled nursing facility that her mother's face and lips were swollen and inverted. She stated that the nurses alerted the PA of the family's concerns each time an issue was brought to their attention. She stated that her sister questioned the PA as to how her mother could have an abscessed tooth when she did not have any teeth, She stated that once the x-ray results returned the PA told her that her mother's jaw was “cracked. "She stated that he was attempting pain management. She stated that she was not given any other treatment options. No one spoke with her concerning G-tube placement as the resident was not eating. She stated that she does not know why the skilled nursing facility or the PA waited two additional days after identification of the Jaw fracture (3/26/13) to transfer her mother to the hospital when she was not able to eat during this time and she was in pain. She stated that the hospital physicians had to stabilize her mother's blood pressure prior to repairing her jaw fracture. She stated that since her mother has been in the hospital she has had 2 surgeries. One surgery was to repair the fracture by placing 2 metal plates and screws to each side of her lower jaw. The other surgery was to place a G-tube for nourishment. . 40. Review of the EMS record of Resident #1 revealed that on 3/28/13, at 8:46 AM EMS arrived to the skilled nursing facility to transport the resident to the hospital. The skilled nursing facility staff informed EMS that Resident #1 fell out of bed on 3/22/13. The staff informed the EMS that the resident had a fractured Jaw and was not eating or taking her medications for the past 2 days, They also told EMS that they contacted Resident #1's physician and he wanted her evaluated for not eating or taking her medication. EMS administered 5 m 2 morphine sulfate intramuscularly to the resident's right deltoid muscle for complaints of pain of "8 out of 10" upon arrival to the skilled nursing facility. 41. Review of the hospital record for Resident #1 revealed that the patient was admitted to the hospital on 3/28/13, at 9:12 AM with a diagnosis of altered mental status and jaw fracture. The physician documented that Resident #1 was alert, incoherent, mumbling, but it was clear that she was in pain. Review of the operative report revealed that on 4/1/13, Resident #1 had an open reduction internal fixation of bilateral mandibular body fractures using a matrix 8- hole plate with 6 bicortical locking screws and 2 positional screws. Review of the consultation reports revealed that Resident #1 also had an enteric feeding tube placement. 42. The Respondent's actions or inactions constituted an isolated Class II deficiency. 43. A Class II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. §400.23(8)(b), Fla. Stat. (2012). 44, A Class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. 45. A fine shall be levied notwithstanding the correction of the deficiency. §400.23(8)(b), Fla. Stat. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $2,500.00 against the Respondent. COUNT II 46. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein, 47. Based upon the Respondent's 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)(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 April 4, 2013 and ending May 4, 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. Specifie 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 Admin istration 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 to the below named persons/entities by the method designated on this 9th day of August 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 Kriste Mennella Kala Fuhrmann Field Office Manager Administrator (Electronic Mail) Palm Garden of Gainesville 227 SW 62™ BLVD Gainesville, Florida 32607 (U.S. Certified Mail: 7011 1570 0000 3003 1957) Bernard Hudson Long Term Care Unit Manager ( Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: SA PG GAINESVILLE, LLC d/b/a ACHA No. 2013006661 PALM GARDEN OF GAINESVILLE 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 reccived 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 Chapter! 20, 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 — EEE ST OF THESE 3 OPTIONS OPTION ONE (1) I 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. | 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 proposed 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 Respondent (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) I 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: 13-003718