CASE | DECISION |JUDGE | FOOTNOTES

Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
IN THE CASE OF  


SUBJECT:

Windsor Health Care Center,

Petitioner,

DATE: July 10, 2003
                                          
             - v -

 

Centers for Medicare & Medicaid

 

Docket No.C-01-519
Decision No. CR1066
DECISION
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DECISION

Petitioner, Windsor Health Care Center (Petitioner or Facility), is a long-term care facility certified to participate in the Medicare and Medicaid programs as a provider of services. Petitioner challenges the Centers for Medicare & Medicaid Services' (CMS's) determination that, from November 30, 2000 until December 21, 2000, it was not in substantial compliance with program participation requirements. For the reasons set forth below, I conclude that, from November 30, 2000 until December 21, 2000, the facility was not in substantial compliance with Quality of Care requirements. Petitioner also challenges the amount of the Civil Money Penalty (CMP) imposed, $550 per day. I conclude that the amount of the CMP is reasonable.

I. Background

As a condition for participation in the Medicare and Medicaid programs, skilled nursing facilities (SNFs) (Medicare) and nursing facilities (NFs) (Medicaid) periodically undergo surveys to determine whether they are in substantial compliance with program participation requirements, and the Secretary of Health and Human Services (Secretary) contracts with state survey agencies to conduct those surveys. Social Security Act (Act), section 1864(a); 42 C.F.R. § 488.20. The regulations require that each facility be surveyed at least once every 12 months, and more often if necessary, to ensure that identified deficiencies are corrected. 42 C.F.R. § 488.20(a).

In July 2000, a facility resident (Resident No. 49) suffered a broken leg under questionable circumstances. The facility reported the incident to the Ohio Department of Health (State Agency), which forwarded the information to its Akron district office "for their information and possible review" during the facility's next annual survey. Petitioner's Exhibit (P. Ex.) 7, at 2-10. For reasons that are not explained in this record, the State Agency did not immediately investigate. However, after completing the facility's standard compliance survey on November 30, 2000, the State Agency, citing the circumstances surrounding Resident No. 49's broken leg as well as other incidents, determined that the facility was not in substantial compliance with program requirements. Among other deficiencies, the State Agency found that the facility did not meet requirements for Quality of Care, 42 C.F.R. § 483.25(h)(2). CMS Ex. 3. It advised CMS of its survey findings, and, by letter dated January 23, 2001, CMS advised the facility that it agreed with the State Agency's findings. Specifically, CMS found that the facility was not in substantial compliance with federal requirements for participation in the Medicare and Medicaid programs, and that the facility's most serious deficiencies constituted actual harm that was not immediate jeopardy. CMS also concurred with the State Agency recommendation to impose a denial of payment for new admissions (DPNA), effective March 2, 2001. CMS noted the State Agency's recommendation that it impose a CMP of $600 per day, effective November 30, 2001, and agreed that a CMP was appropriate, but imposed a lesser amount, $550 per day. Finally, CMS advised Petitioner that the imposition of a CMP would continue until the facility either reached substantial compliance or its provider agreement was terminated. CMS Ex. 1.

The State Agency conducted a follow-up survey on December 21, 2000. By letter dated March 1, 2001, CMS advised Petitioner that it had achieved substantial compliance as of December 21st; neither the DPNA, nor termination would be imposed. The CMP of $550 per day was discontinued as of December 21, 2000, the day the facility achieved substantial compliance. The CMP was thus imposed for 21 days, and totaled $11,550. CMS Ex. 2.

The facility timely appealed, and the case has been assigned to me. CMS has moved for summary judgment. Petitioner opposes, arguing that "material issues of fact remain with respect to the relief request by CMS," and that "issues remain with respect to CMS's allegation of substandard quality care under Quality of Care tag F-324." Windsor Health Care Center's Response to Respondent's Motion for Summary Affirmance of the Civil Money Penalty (P. Response) at 1. The parties have submitted proposed exhibits. Petitioner has submitted 11 exhibits (P. Exs. 1-11). CMS has submitted 31 exhibits, but for purposes of summary judgment relies on 11 exhibits, CMS Exs. 1-5, 7, 20-24, and 31. In addition, CMS has submitted three declarations, marked CMS MSJ Exs. A, B, and C. For purposes of this summary judgment ruling, I admit P. Exs. 1-11, CMS Exs. 1-5, 7, 20-24, and 31, and CMS MSJ Exs. A, B, and C. (1)

II. Issues

I consider first whether summary judgment is appropriate.

On the merits, this case presents the following questions:

1. Whether, from November 30, 2000 until December 21, 2000, the facility was in substantial compliance with program participation requirements, specifically 42 C.F.R. § 483.25 (Quality of Care); and

2. If the facility was not in substantial compliance, is the amount of the CMP imposed, $550 per day (for a total of $11,500), reasonable?

III. Statutory and Regulatory Background

The Act sets forth requirements for long-term care facility participation in the Medicare and Medicaid programs, and authorizes the Secretary to promulgate regulations implementing the statutory provisions. Act, sections 1819 and 1919. The Secretary's regulations governing long-term care facility participation in the Medicare and Medicaid programs are found at 42 C.F.R. Part 483.

To participate in the Medicare and Medicaid programs, facilities periodically undergo surveys to determine whether they comply with applicable statutory and regulatory requirements for Medicare SNFs and/or Medicaid NFs. They must maintain substantial compliance with program requirements and, to be in substantial compliance, a facility's deficiencies may pose no greater risk to resident health and safety than "the potential for causing minimal harm." 42 C.F.R. § 488.301.

Under the statute and "Quality of Care" regulation, each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care. Act, section 1819(b); 42 C.F.R. § 483.25. Specifically, the facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 42 C.F.R. § 483.25(h)(2).

If a facility is not in substantial compliance with program requirements, CMS has the authority to impose one or more of the enforcement remedies listed at 42 C.F.R. § 488.406, which include imposing a CMP. See Act, section 1819(h). CMS may impose a CMP for the number of days that the facility is not in substantial compliance with one or more program requirements, or for each instance that a facility is not in substantial compliance. 42 C.F.R. § 488.430(a).

In situations where the deficiencies do not constitute immediate jeopardy, but have caused actual harm or have the potential for more than minimal harm, CMS may impose a CMP in the lower range of $50 to $3,000 per day. In setting the amount of the CMP, CMS considers: 1) the facility's history of noncompliance; 2) the facility's financial condition; 3) factors specified in 42 C.F.R. § 488.404; and 4) the facility's degree of culpability, which includes neglect, indifference, or disregard for resident care, comfort, or safety. The absence of culpability is not a mitigating factor. 42 C.F.R. § 488.438(f). The factors at 42 C.F.R. § 488.404 include: 1) the scope and severity of the deficiency; 2) the relationship of the deficiency to other deficiencies resulting in noncompliance; and 3) the facility's prior history of noncompliance in general and specifically with reference to the cited deficiencies.

IV. Discussion

A. Summary Disposition is appropriate because Petitioner has not demonstrated any dispute over genuine issues of material fact. (2)

Unless the parties raise a genuine issue of material fact, an administrative law judge (ALJ) may decide a case on summary judgment, without an evidentiary hearing. Carrier Mills Nursing Home, DAB No. 1883 (2003); Livingston Care Center, DAB No. 1871 (2003); Crestview Parke Care Center, DAB No. 1836 (2002); Everett Rehabilitation and Medical Center, DAB No. 1628, at 3 (1997); Carmel Convalescent Hospital, DAB No. 1584, at 27 (1996). The Board recently reiterated in Livingston Care Center, that:

CMS is entitled to summary judgment if it has (1) made a prima facie showing that [the facility] was not in substantial compliance with one or more participation requirements, and (2) demonstrated that there is no dispute about any material fact supporting its prima facie case and that it is otherwise entitled to judgment as a matter of law. CMS is not entitled to summary judgment if [the facility] has proffered evidence that would permit an ALJ to conclude that it was in substantial compliance with Medicare participation requirements during the relevant time.

(Emphasis added). Livingston Care Center at 6. In attempting to defeat a motion for summary judgment, a party may not rely on the denials of its pleadings, but is required to tender evidence of specific facts in the form of affidavits and/or admissible discovery material, in support of its contention that a dispute exists. Crestview at 6 (citing Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586, n. 11 (1986)).

Where Petitioner tenders evidence that raises factual disputes, the judge determines whether such disputes are material by resolving them in favor of the non-moving party, in this case, Petitioner. If, after so resolving all factual disputes, CMS establishes substantial noncompliance that justifies the penalties imposed, the disputed facts are not material and CMS is entitled to summary judgment. Thus, in Carmel Convalescent, where the petitioner had the opportunity to present its case with briefs and supporting documentation, but did not demonstrate a genuine dispute of material fact, an appellate panel of the Departmental Appeals Board (Board) affirmed summary disposition. Carmel Convalescent Hospital, DAB No. 1584, at 22 (1996). See also Glenburn Home, DAB No. 1806, at 17 (2002) ("[I]n reviewing a case where an ALJ failed to either obtain a written waiver or hold an oral hearing, we may nonetheless uphold the decision if the affected party either had conceded all of the material facts or proffered testimonial evidence only on facts which, even if proved, clearly would not make any substantive difference in the result."); Cherrywood Nursing and Living Center, DAB CR845, at 4 (2001) ("While inferences made from facts which are averred to support a motion must be made in a manner most favorable to the party that opposes the motion, it is not sufficient for a party simply to state that it disputes allegations of fact in order to avoid possible entry against it of summary disposition. That party must describe the asserted facts credibly in order to establish a dispute.")

Here, Petitioner has ignored the requirement that it tender evidence of specific facts to support its contention that a dispute exists. Instead, it suggests, generally, that CMS's proffered surveyor affidavits are not credible, accuses CMS of relying on hearsay (in fact, "hearsay, upon hearsay, upon hearsay") and states, in conclusory fashion, that substantial evidence "negates CMS's assertions of non-compliance." P. Response at 9. Petitioner does not identify what that "substantial evidence" might be, stating that it "will not reiterate herein all of the factual evidence in support of its argument on this point," and that "the declaratory and documentary evidence for its position is contained within Windsor's Informal Dispute Resolution (IDR) statement of which CMS has attached to its motion." Id. (3) As discussed below, careful review of the factual assertions and evidence contained in what appear to be Petitioner's IDR submissions does not demonstrate any material dispute. Indeed, CMS cites liberally to these documents to establish its own case.

CMS has set forth, in considerable detail, the specific facts upon which it relies in determining substantial noncompliance. Petitioner was afforded ample opportunity to show, through argument and supporting documentation, the bases for its challenges to those facts. As discussed in more detail below, Petitioner has not demonstrated the existence of a dispute of material fact, and therefore summary judgment is appropriate.

B. From November 30, 2000 until December 21, 2000, the facility was not in substantial compliance with program participation requirements, specifically 42 C.F.R. § 483.25 (Quality of Care).

In order to meet the overall Quality of Care requirement that it provide what is necessary for each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being, the facility must ensure that its supervision is adequate to prevent accidents. This requirement does not amount to strict liability or require absolute success in an obviously difficult task. Using an outcome-oriented approach, facilities have the flexibility to use a variety of methods, but they are responsible for achieving the required results. In ensuring adequate supervision, the facility is not required to do the impossible or be a guarantor against unforeseeable occurrence, but it "is required to do everything in its power to prevent accidents." 42 C.F.R. § 483.25(h) (emphasis added); Asbury Center at Johnson City, DAB No. 1815, at 12 (2002); Koester Pavilion, DAB No. 1750, at 25-26 (2000); Woodstock Care Center, DAB No. 1726, at 25 (2000).

That two facility residents suffered accidents and were injured while in the care of facility staff is uncontroverted. On July 24, 2000, Resident No. 49's leg was broken, and on November 28, 2000, Resident No. 57 fell from her shower chair, sustaining a head injury that required stitches.

Resident No. 49

The survey team reported that Resident No. 49 sustained a fracture of the distal shaft of her right tibia. Quoting the facility documents, the team reported that "on July 24, 2000, on the 3:00 p.m. to 11:00 p.m. shift, a nursing assistant wheeled this resident into his/her room in a hurried manner, bumping the resident's leg on the footboard to the bed." CMS Ex. 3, at 10-11. In its motion for summary judgment, CMS reviews, in painstaking detail, the facility's reports and other investigative documents relating to this incident. The documents could be read as providing conflicting accounts of the incident. However, certain factors are common to all the accounts and, under any of them, the facility was not providing supervision and/or assistance devices necessary to prevent accidents.

According to the facility's investigation report, Resident No. 49 stated that during the 3 to 11 p.m. shift on July 24th, Nurse Aide (NA) Gail Gordon wheeled her "really fast" from the smoking lounge to her room, bumping her right leg on the foot board of her bed. The aide apologized. P. Ex. 7, at 4-5. In an incident report dated July 24, 2000, the registered nurse (RN) on duty, Pearl Strong, noted that an aide came to her and said that "while she was putting [Resident No. 49] to bed the wheelchair hit the side of [the] bed." P. Ex. 7, at 3. (4) In a written statement dated July 28, 2000, NA Gordon offers this account:

[Resident No. 49] was in South Feeding Lounges smoking. About 6:50 p.m., she was ready to go to bed. [Resident No. 54] (5) started pushing her, I told him to stop because he was running her into the wall.

I took her to her room, and I pushed her in the room. I pushed [Resident No. 49]'s bed over by the window, so I could get around to put her in bed.

She said the wheel bump (sic) the bed, I did not see that. She said her leg was hurting. I reported it to the nurse so that she could come and look at it.

P. Ex. 7, at 10.

In the July 31, 2000 report of a neglect investigation, the then facility administrator reiterates the resident's statement that the aide wheeled her into her room and bumped her leg against the footboard of her bed. Subsequent x-ray showed a fracture of the right distal tibia without displacement. The facility completed the report, taking statements from the resident and staff. The facility concluded "suspect that an abuse/neglect/misappropriation incident occurred, but were unable to confirm it," and that the wrongdoer could not be determined. P. Ex. 7, at 8-9; CMS Ex. 20, at 8-9. (6)

In addition, CMS submits other facility documents setting forth Resident No. 49's version of the events. Dated July 27, 2000, and signed by the facility social worker, social services notes read as follows:

Social Services asked [Resident No. 49] what happened to her leg. At first she said that she rolled her wheelchair against her foot board. Social Services asked [her] how is that possible when you don't wheel your own wheelchair.

[Resident No. 49] then began to tell me what happened. She said on Monday between 7:00 p.m./8:00 p.m. Gail rolled her from the smoking room. She was going fast, rolled her into the room and ran into the foot board on the bed. [Resident No. 49] says they both heard a bone crack. Gail told [Resident No. 49] that she didn't mean to do it. [Resident No. 49] told her she was alright.

According to [Resident No. 49], Gail then put her into bed. [Resident No. 49] says Gail was rough with her. [Resident No. 49] then said that she was in pain. [Resident No. 49] says that Gail started to yell at her. Gail said it doesn't hurt as bad as you pretend. [Resident No. 49] says she yelled so loud people outside heard. She knows this because [Resident No. 54] came in to check on her. He heard the yelling. Her window was cracked.

[Resident No. 49] says that Gail is telling people [Resident No. 54] was pushing her and did this.

A couple of days later, [Resident No. 49] asked Johanna for a pain pill. That is when she told someone she was hurt.

CMS Ex. 20, at 1.

In yet another account, found in the surveyor notes and purportedly copied from the facility's investigation record, NA Gordon said that [Resident No. 54] pushed [Resident No. 49] into her room, wedging her chair between the two beds. When NA Gordon attempted to "unwedge" the chair, the resident's wheelchair hit the footboard. She said that she was "unaware" that the resident's leg hit the footboard, although she reported the incident to Nurse Pearl, who assessed the resident. CMS Ex. 20, at 2.

The evidence thus sets forth several possible scenarios resulting in Resident No. 49's broken leg. (7) Although the details and emphasis vary, the scenarios are generally consistent. In none of her statements did NA Gordon deny that, while under her care, Resident No. 49's leg bumped the footboard, which most likely caused the fracture. Either she herself carelessly pushed the resident's wheelchair, or she allowed Resident No. 54 to push the wheelchair in a reckless fashion, or both. I agree with CMS that no matter which of these incidents resulted in the resident's leg fracture, the facility was not exercising an adequate degree of supervision. Under none of the proffered scenarios did the facility do everything in its power to prevent the accident.

Resident No. 57

According to her treatment plan, Resident No. 57 suffered from Alzheimers, scoliosis, glaucoma and cataracts. She had a left knee contracture. She was non-ambulatory, at risk for falls, with a vision deficit. She had severe cognitive deficits, could not make her needs known, and did not understand others. She was not aware of safety issues. She was dependent for all her activities of daily living, and could be resistive to care, unable to understand the intentions of the caregiver. P. Ex. 8, at 3-4. According to the assessment on her Minimum Data Sheet (MDS), she was totally dependent on staff for transfers, requiring "two + persons physical assist," and she was totally dependent on staff for bathing, requiring "two + persons physical assist." P. Ex. 8, at 6-7. On the other hand, Petitioner includes with her records an unattributed handwritten note that says she

is indeed a 2 person assist for transfers only - not for hands on care. A two-person assist was provided for the transfer but not for the actual shower which is in the realm of her care plan.

P. Ex. 8, at 1. This unattributed submission falls short of the type of declaration generally required to establish a genuine dispute of fact for summary judgment purposes. However, in its plan of correction, Petitioner submits that the MDS assessment "is a recapitulation of the highest form of assistance required in the past seven days, not necessarily required at all times." CMS Ex. 3, at 11. I resolve any apparent conflict between the MDS and its other statements in Petitioner's favor, and find that Resident No. 57's care plan requires a two-person assist for transfers only, and not for the resident's actual shower.

This does not resolve the question as to whether the facility was doing everything in its power to prevent Resident No. 57 from having an accident. Petitioner submits no investigative report, notes, or other evidence to establish the circumstances surrounding the accident. For its part, CMS submits the declaration and notes of Nurse Surveyor Darlene Eddinger, who declares that she copied into her notes verbatim the investigative report. She also copied portions of the facility nursing note entries, MDS assessment, and care plan. (8) According to Nurse Eddinger, two nurse aides transferred Resident No. 57 to a shower chair. One aide then left the shower area, while the other remained to conduct the shower. The resident began to fall forward, the aide tried to secure her, but both fell to the floor. CMS MSJ Ex. B, at 3-4; CMS Ex. 22. Resident No. 57 suffered a laceration to the head, was taken to the emergency room, where she was given seven stitches. Id.; CMS MSJ Ex. C.

Thus, the record before me shows a seriously compromised individual, who was at high risk for falls, and suffered a serious fall while in the shower. The question then is: what was the facility doing to prevent accidents to this vulnerable individual, particularly while she was bathing. For its part, Petitioner presents neither declarations nor documentary evidence to counter CMS's case. Petitioner does not even specify which of the specific facts set forth in CMS's materials it challenges (if any). Petitioner has not proffered evidence that would permit me to conclude that it provided Resident No. 57 with adequate supervision and assistance devices to prevent accidents.

Because CMS has made a prima facie showing that the facility was not in substantial compliance with 42 C.F.R. § 483.25, and Petitioner proffers no set of facts which, if accepted, would establish its substantial compliance with 42 C.F.R. § 483.25, CMS is entitled to summary judgment on that issue. Livingston Care Center at 6.

C. The amount of the CMP imposed against Petitioner, $550 per day, is reasonable.

Having found a basis for imposing a CMP, I now consider whether the amount imposed is reasonable, applying the factors listed in 42 C.F.R. § 488.438(f). It is well-settled that, in reaching a decision on the reasonableness of the CMP, I may not look into CMS's internal decision-making processes. Instead, I consider whether the evidence presented on the record, concerning the relevant regulatory factors, supports a finding that the amount of the CMP is at a level reasonably related to an effort to produce corrective action by a provider with the kind of deficiencies found and in light of the other factors involved, i.e., financial condition, facility history, culpability. I am neither bound to defer to CMS's factual assertions, nor free to make a wholly-independent choice of remedies without regard for CMS's discretion. Barn Hill Care Center, DAB No. 1848, at 21 (2002); Community Nursing Home, DAB No. 1807, at 22 et seq. (2002); Emerald Oaks, DAB No. 1800, at 9 (2001); CarePlex of Silver Spring, DAB No. 1683, at 8 (1999).

CMS has imposed a penalty of $550 per day, which is at the lower end of the mandatory range for non-immediate jeopardy situations ($50 - $3,000 per day). With respect to the 42 C.F.R. § 488.438(f) factors, CMS cites findings from the facility's 1999 annual survey, the year immediately preceding the survey in issue here, which show that the facility was then out of compliance with the requirements of 42 C.F.R. § 483.25(h)(2). The agency document shows a level G deficiency - actual harm that is not immediate jeopardy. CMS Ex. 5, at 1; CMS MSJ Ex. C, at ¶ 15. Petitioner has not denied CMS's assertion.

CMS also submits evidence of the facility's financial solvency. (9) An income statement report for Calendar Year 1999, prepared from information contained in the facility's cost report, shows total revenues of $3,817,311, expenses of $3,779,387, and a net operating profit of $37,924. CMS Ex. 4. Again, Petitioner has not challenged CMS's assertion nor presented any evidence suggesting a different financial picture.

Applying the remaining factors, I find that the Quality of Care deficiencies cited were not insignificant. The deficiencies were serious, and the facility was culpable. Considering these factors, as well as the facility history and financial condition, I would not find unreasonable CMS's determination to impose a CMP that is significantly higher than the mandatory minimum.

V. Conclusion

For all of the reasons discussed above, I uphold CMS's determination that, from November 30, 2000 until December 21, 2000, the facility was not in substantial compliance with program participation requirements, specifically 42 C.F.R. § 483.25 (Quality of Care). The amount of the CMP imposed, $550 per day, is reasonable.

JUDGE
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Carolyn Cozad Hughes

Administrative Law Judge

FOOTNOTES
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1. CMS objects to the authenticity of one of Petitioner's documents, P. Ex. 8, at 1. For these purposes, I admit that document. For its part, Petitioner offers no objections to any particular exhibit, although it complains generally about the surveyor declarations and "notes made by unknown authors" in "what purport to be resident's records." I find these general complaints insufficient to justify my not admitting any of CMS's exhibits. At a minimum, an objection to the admissibility of an exhibit should identify the challenged exhibit. Moreover, as explained in the text, I need not rely on any of CMS's exhibits. Petitioner's exhibits, by themselves, justify a finding of substantial noncompliance.

2. I make Findings of Fact and Conclusions of Law (Findings) to support my decision in this case. I set forth each Finding in italics as a separate heading.

3. Although Petitioner does not cite to any specific exhibits, I presume it refers here to CMS Exs. 3 and 24.

4. I note that these are Petitioner's exhibits, which Petitioner identifies as "records, documents, and information for Resident No. 49." Windsor Health Care Center's Final List of Exhibits and Witnesses. Thus, even if I were to reject all of CMS's exhibits and declarations - which I am not required to do in the face of Petitioner's failure to present any credible challenge to them - what remains are documents establishing that Resident No. 49's leg was broken as a result of staff negligence or abuse. Moreover, the contents of the documents submitted by CMS - primarily social service notes - are not inconsistent with the facts contained in Petitioner's own exhibits.

5. See CMS Ex. 7, at 4 (Resident Roster). Resident No. 54 has a cognitive impairment, non-dementia mental illness, with behavioral symptoms and depression. He takes psychoactive medications, has contractures or limited range of motion, and a communication problem. Id.

6. Nevertheless, according to surveyor notes, on July 31, 2000, NA Gordon was given a verbal warning about her attitude, "yelling at a resident while providing care." The note says the "staff and residents state employee is very abrupt and rough." Also on July 31, 2000, NA Gordon was given a written warning for transporting Resident No. 49 in a careless manner, and "transferring resident to bed by self. Resident is 2-person (non-weight bearing)." CMS Ex. 21, at 1. Petitioner has not specifically denied this assertion, and presents no evidence to contradict it.

7. I note that Petitioner did not identify as a potential witness any of the individuals identified as having first (or even second) hand knowledge of these events, not NA Gordon, Nurse Strong, nor Debbie Carson, the social worker who interviewed Resident No. 49.

8. Comparing her notes to Petitioner's submissions (Care Plan and MDS) shows no inconsistency between her notes and Petitioner's submissions. Compare P. Ex. 8 with CMS Ex. 22.

9. Petitioner has not claimed that its financial condition makes the amount of the CMP unreasonable. See Community Nursing Home, DAB No. 1807, at 22, et seq.; Emerald Oaks, DAB No. 1800 (2001)

 

CASE | DECISION | JUDGE | FOOTNOTES