STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2011006711 v. Return Receipt Requested: 7009 0080 0000 0586 4450 RAPHA MANOR, INC. d/b/a RAPHA MANOR, INC.., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Rapha Manor, Inc. d/b/a Rapha Manor, Inc. (hereinafter “Rapha Manor, Inc.”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes, (2010), and alleges: NATURE OF THE ACTION 1. This is an action to impose a revocation of license pursuant to Sections 408.815(1) (b), 429.14(1) (e)1, and 429.14(1) (a), Florida Statutes, an administrative fine of $12,000.00 pursuant to Section 429.19(2)(a), Florida Statutes (2010), for the protection of the public health, safety and welfare and $183.00 survey fee pursuant to Section 429.19(2) (b), and 429.19(7), Florida Statutes (2010). Filed November 2, 2011 4:57 PM Division of Administrative Hearings JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 429, Part I, Florida Statutes (2010), and Chapter 58A-5, Florida Administrative Code. 5. Rapha Manor, Inc. operates a S-bed assisted living facility located at 4555 41%* Avenue, Vero Beach, Florida 32967. Rapha Manor, Inc. is licensed as an assisted living facility license number AL11000, with an expiration date of April 17, 2013. Rapha Manor, Inc. was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I RAPHA MANOR, INC. FAILED TO MAINTAIN THE MINIMUM STAFFING HOURS PER WEEK OF 168 HOURS FOR SOME RESIDENTS Rules 58A-5.019(4) (a)1, 58A-5.019(4) (c), Florida Administrative Code (STFFING STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 5/26/2011 and based on observation, staff interview, and record review it was determined that the facility failed to maintain the minimum staffing hours per week of 168 hours for 1-4 sampled residents (resident.#1, #2, #3, #4). 8. During the entrance conference conducted on 05/26/2011, with the current Administrator (in person) and the owner (via telephone), beginning at approximately 9:00 AM, the surveyor was informed that caregiver #2 was arrested on a charge of aggravated battery on an adult 65-years or older on 05/19/2011 and she was informed by DCF (Department of Children and Families) that caregiver #2 cannot be around Resident #1. The owner stated that the former Administrator had been removed from her position prior to resident #1's medical appointment. 9. Additionally, the owner reported that 2 other residents were removed from the facility by DCF on 05/17/2011, and temporarily placed in other facilities. The current Administrator reported that resident #3 was admitted to the facility on 05/17/2011. A review of the facility's admission and discharge log indicated that a male resident died on 05/17/2011. 10. The current Administrator was asked to provide the current staffing hours for May 2011. Caregiver #2, noted as the live-in staff member, was still listed on the schedule despite the 3 DCF admonition to the Administrator that Caregiver #2 could not be in contact with the residents effective 05/19/2011. 11. A review of the staffing schedule indicated the following deficiencies: - 05/19/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; 8.5 hours for a 24-hour period (15.5 hours understaffed) ~ 05/20/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4 scheduled 7:30 AM-12:00 PM; owner's hours not indicated; unable to determine coverage for 3:30 PM-7:00 AM - 05/21/2011: Owner's hours not indicated; unable to determine 24-hour coverage - 05/22/2011: Owner's hours not indicated; unable to determine 24-hour coverage - 05/23/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4 scheduled 7:30 AM-12:00 PM; Owner's hours not indicated; unable to determine coverage 3:30 PM~7:00 AM - 05/24/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4's hours not indicated; Owner's hours not indicated; unable to coverage determine 3:30 PM-7:00 AM ~ 05/25/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4 scheduled 7:30 AM-12:00 PM; Owner's hours not indicated; unable to determine coverage 3:30 PM-7:00 AM ~ 05/26/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4 hours not indicated; oriented noted for paperwork; unable to determine coverage 3:30 PM-7:00 AM - 05/27/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4 scheduled 7:30 AM-12:00; unable to determine coverage 3:30 PM- 7:00 AM : - 05/28/2011: Caregiver #4 scheduled 7:30 AM-12:00 PM; unable to determined coverage 12:00 PM-7:30 AM - 05/29/2011: Caregiver #4 scheduled 7:30 AM-3:30 PM; unable to determine coverage 3:30 PM-7:30 AM ~ 05/30/2011: Caregiver #1 scheduled 7:00 AM-3:30 PM; Caregiver #4 scheduled 7:30 AM-12:00 PM; unable to determine coverage 3:30 PM-7:00 AM 12. A review of the May 2011 staff schedule indicated Caregiver #2 as the 24-hour live-in staff and Caregiver #1 as the 7:00 AM-3:30 PM (Monday-Friday) Administrator. 13. During an. interview with the current Administrator, conducted on 05/27/2011 at approximately 11:50 AM, she stated that she had brought resident #3 home with her last night and she plans to take resident#3 home with her for the weekend because the facility does not have enough staff to provide 24-hour coverage. .14. Based on the foregoing, Rapha Manor, Inc. violated Rules 58A-5.019(4) (a)1 and 58A-5.019(4) (c), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. COUNT II RAPHA MANOR, INC. FAILED TO ENSURE THAT ALL STAFF DOCUMENT OBSERVATIONS ON THE APPROPRIATE RESIDENT’S RECORD AND REPORT THE OBSERVATIONS TO THE RESIDENT’S HEALTH CARE PROVIDER Section 429.255(1) (a), Florida Statutes, and/or Rule 58A-5.019(2) (b), Florida Administrative Code CLASS II VIOLATION 15. AHCA re-alleges and incorporates paragraphs (1) through (S) as if fully set forth herein. 16. During the complaint investigation conducted on 5/26/2011 and based on observations, record review, and interview, it was determined that the facility failed to ensure that all staff exercise their responsibilities, consistent with their qualifications, to observe residents, to document observation on the appropriate residents’ record and to report the observations to the residents’ health care provider for 2 of 4 sampled records (resident #1 and resident #3). 17. During an interview conducted with the owner of record, who is ‘also ae RN (Registered Nurse), on 05/26/2011 at approximately 3:40 PM, (since 04/05/2007) she was informed (via telephone) that the current Administrator could not find any documentation for resident #1 related to significant weight loss or complaints of pain. The May 2011 MOR (Medication Observation Record) reflected resident #1 weighed 82 pounds. The RN insisted that weights were noted in the record and reported to the resident's physician. County Health Department records from 02/03/2009-04/05/2011 did not indicate any weight concern. The health history form, dated 04/05/2011, notes recent weight change (losing). 18. On 04/14/2011 and 04/21/2011 the physician attempted to contact the Owner/RN to discuss the use of antibiotics and to request that the caregiver bring the "blue book" medical chart so she can review resident #1's medications. During the 05/04/2011 physician's visit at the County Health Department, Caregiver #5 failed to bring any records more recent than 2009. The physician's visit indicated Resident #i's weight as 82 pounds (04/05/2011 weight as 95.4) for a loss of 13 pounds. The Owner/ (Caregiver #3) was listed on the April 2011 schedule as a caregiver 6 times during the month. Since this resident’s relocation to another facility, her weight has increased dramatically. 19. A review. of resident #2's, physical exam (form 1823) dated 02/11/2010, indicated that he requires assistance with bathing. He resided at Rapha Manor from 02/25/2010-05/17/2011. This resident was removed by DCF (Department of Children and Families) and transferred to another ALF (Assisted Living Facility) on 05/17/2011. During an interview of Caregiver #5 (at this receiving facility), conducted on 05/31/2011 at approximately 9:40 AM, she stated, "Resident #2 almost beat me to the car" when I picked him up from Rapha Manor. 20. The Resident Observation Log, dated 05/24/2011, noted and Caregiver #5 reported on 05/31/2011 at approximately 9:40 AM, that the staff had to throw away 3 washcloths after bathing this resident because of the amount of debris that came off of this resident. She stated that the staff said resident #2's hygiene was very poor and that they were concerned about his toes "sticking together". Caregiver #5 stated that she proceeded to soak this resident's feet in warm and soapy ‘water. She stated she had to use the edge of the washcloth between the toes and then she had to scrub a large amount of debris from under the toes. Caregiver #5 stated that resident #2's toenails were curled under and extended way past the end of the nail bed. She stated that she contacted a podiatrist and the podiatrist reported to her that resident #2's nail growth appeared to be about 2~years-old. 21. Resident #2's podiatrist visit, dated 05/24/2011, indicated the following: ~ Chief complaint is of pain on the bilateral foot. - History of Present Illness: The problem has been present for several months. The area of the chief complaint is painful. The pain in the area is constant. The problem is exacerbated by weight bearing. The patient states the pain came on gradually. The patient denies trauma to the area. - Orientation: to person, place, and time. - Nail evaluation: The patient's nails are highly incarnated with chronically painful borders. The nails are excessively long. Palpation of this area of the nail is painful. Diagnoses were noted as: Paronychia of toe: skin infection around the nail Onychocryptosis: ingrown nail Onychogryphosis: fungus on nail Painful Foot 22. During.a review of resident #2's record at Rapha Manor, conducted on 05/26/2011, there was no documentation regarding the resident’s hygiene or the condition of his toenail. Caregiver #1, on 05/26/2011 at approximately 3:40 PM, acknowledged Rapha Manor's records do not contain notations related to the condition of the residents, and do not document staff contacting the health care providers or the family members to advise them of significant changes to the residents’ health. 23. Based on the foregoing, Rapha Manor, Inc. violated Section 429.255(1) (a), Florida Statutes, and/or Rule 58A- 5.019(2) (b), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. COUNT III RAPHA MANOR, INC. FAILED TO PROVIDE A SAFE AND DECENT LIVING ENVIRONMENT, FREE FROM ABUSE AND NEGLECT 5 Section 429.28(1), Florida Statutes Rule 58A-5.0182, Florida Administrative Code (RESIDENT CARE STANDARDS) CLASS I VIOLATION 24. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. During the complaint investigation conducted on 5/26/2011 and based on observation, interviews, and record reviews, it was determined that the facility failed to provide a safe and decent living environment, free from abuse and neglect for 2 of 3 sampled residents (Resident #1 and #2). 26. Caregiver #2 utilized profanity and yelled at residents, staff members were rough with residents, and residents indicated that they feared retaliation by the staff if they were to speak- up. 27. During an interview with an APS (Adult Protective Services) Investigator, conducted on 05/25/2011 at approximately 9 2:00 PM, she stated that resident #1 reported to her that Caregiver #2 removed her from her wheelchair, shook her violently and placed her in bed. The APS Investigator reported that this resident had a hip fracture when it was reported to APS on 05/04/2011. She stated that resident #1 indicated that she had made Caregiver #2 aware of the pain, but she was told to shut up by this caregiver. Resident #1 also stated the facility does not provide her with enough food. 28. During an interview with the Detective, conducted on 05/27/2011 at approximately 8:30 AM, he relayed his interview with the physician that discovered resident #1's hip fracture. Resident #1 was complaining to the physician of hip pain while attempting to get up on the exam table. When asked what happened, resident #1 informed the physician that Caregiver #2 picked her up,. shook her like a milk carton, and threw her on the bed. The resident stated that the hip pain began immediately following this incident which occurred about 2 weeks ago. 29. During a review of resident #1's records and an interview with the current Administrator on 05/26/2011 at approximately 4:00 PM, the Administrator could not provide an explanation as to why MORs (Medication Observation Records) were missing for this resident. She obtained some documents from the staff only area and began to make a pile of MORs. She then sorted them by year. One sheet of the (handwritten) May 2011 MOR only indicated meal percentages, Ensure, and monthly weights. One page 10 of the MOR, (printed by the pharmacy) for May 2011 was located and reviewed. The MOR did not indicate that pain medication was administered to Resident #1. The same documents were located for April 2011 and the use of pain medication was noted for Resident #1. 30. A review of the facility's incident report regarding the 05/04/2011 incident, documented the owner’s interviews with the staff. Caregiver #5 stated that she was unable to confirm whether the resident had complaints of pain in the past 2 weeks. This caregiver worked the 7:30 AM - 12:00 PM shift on the April 2011 schedule. 31. A review of Resident #1’s documentation at the County Health Department indicated the following: . - 05/04/2011: Referral to emergency room form noted severe pain and unable to bear weight. - 04/15/2011: Annual exam noted weight as 95.4 thin. - 05/09/2011: Surgical Pathology Report indicated osteonecrosis (impaired blood supply to the bone) - 05/04/2011: Radiology report noted sub capital fracture of the right hip; large amount of fecal matter throughout the colon - 04/21/2011: Physician's note reflected calling the owner for over 1 week in order to discuss the provision of the antibiotics. : -05/04/2011: Physician's note indicated weight as 82 pounds; lost 13 pounds; does not know medications this resident is on and has requested the "blue book"; only records through 2009 were provided. 32. A review of the hospital record for Resident #1 revealed the following: - 05/04/2011: Critical care consultation indicated this resident looks chronically wasted. - 05/13/2011: Rehabilitation consultation noted she had a bipolar hemiarthroplasty and physical examination reflects chronic wasting. - 05/04/2011: The history and physical (problem list) reflects this appears to be an old nonunion hip fracture. 33. Resident #1's Weight Record from Rapha Manor reflected the following: 04/01/2009: 100 10/01/2009: 101 04/01/2010: 99.1 10/01/2010: 99.8 02/01/2011: 98 04/01/2011: 100 05/04/2011: 85 34. On 05/26/2011 at approximately 4:30 PM, the surveyor reviewed resident #1's Resident Observation Logs, which were identified by the Administrator as the document the staff would use to note changes to the residents’ health, when family or the physician is contacted. The Resident Observation Logs for Resident #1 on the chart were dated 02/28/2008-10/23/2008. The Administrator was questioned regarding the 2008-2011 records and indicated that she did not know where they were located. The owner was contacted (via telephone), on 05/26/2011 at approximately 5:00 PM, and was asked what, if any, attempts the staff had made to address resident. #1's weight loss. She indicated that there isn't really anything we can do because she has AIDS and has cachexia. The owner was interviewed as to whether or not alternate foods or extra snacks were offered, or if the physician was notified and asked for recommendations. She replied that the physician was aware of her weight. Resident #1's weight on 05/04/2011 recorded at the health department was noted as 85 pounds (last day as resident of Rapha Manor). 35. During a tour of the facility conducted on 05/26/2011 at 9:45 AM, the AHCA poster (containing the Abuse hotline number) was not posted and she was not aware of the need to have it posted for residents to see it. Additionally, the portable phone was not in working order so residents could call for help if needed. 36. The facility did not provide resident #1 with a safe environment, free from abuse and neglect. The staff yelled, cursed, and handled residents in a rough manner resulting ina painful hip fracture that was not treated for 2 weeks. The facility neglected to provide resident #1 with sufficient nutrition and failed to appropriately address nutritional needs in order to prevent a significant weight loss. 37. A review of resident #2's record medical examination (form 1823), dated 02/08/2011, indicated he requires the assistance of a staff member for bathing. During an interview with Caregiver #4, conducted on 05/26/2011 at approximately 2:30 PM, she was asked whether this resident had any skin concerns and what kind of assistance with ADLs (Activities of Daily Living) he required. She replied that his skin was fine. She stated that she helps all of the residents with their ADLs because she likes to spoil them. 38. During an interview with an APS Investigator, conducted on 05/25/2011 at approximately 2:00 PM, she reported that resident #2 & resident #4 had been removed from this facility and placed at other ALFs. 39. During an interview with the Detective, conducted on 05/27/2011 at. approximately 8:30 AM, he stated that during an interview with resident #2 that the resident confirmed that Caregiver #2 used profanity and yelled. The Detective reported that Resident #2 refused to answer questions as to whether or not he had seen residents physically abused by the staff, stating that he was afraid of retaliation by the owner. 40. The use of profanity and yelling by caregivers and the fear of staff retaliations is a direct violation of each resident's right to live in a safe and decent living environment free from abuse and neglect. The facility neglected to provide basic personal hygiene and podiatry services necessary to prevent pain upon weight bearing for resident #2. 41. During an interview with the Administrator of the receiving facility for resident #2, conducted on 05/31/2011 at approximately 9:40 AM, she reported resident #2 was picked up by his wife on 05/28/2011. The Administrator described resident #2's lst. shower at this facility. She stated that 3 washcloths had to be used and then thrown away, because of the amount of debris that came off of his body. She then stated that her caregiver reported to .her that resident #2's toes were stuck together. The Administrator reported that she observed his toes and initially thought they may have been webbed. She said upon closer inspection it was determined they were so filthy (debris between and under toes) that she had to soak his feet in warm and soapy water and then use the side of the washcloth to work the debris from between and under the toes. The Administrator also mentioned that resident #2's toenails were extremely long and curled under. She stated she called the podiatrist. 42. The podiatry report, dated 05/24/2011, indicated resident #2's chief complaint is of pain bilateral foot. Orientation is noted as oriented to person, place, and time. The history of the present illness reflected this problem was present for several months. The pain is constant, the problem is exacerbated by weight bearing, and resident #2 denies trauma to the area. The nail evaluation section reflects the patient's nails generally are highly incarnated with chronically painful borders. The nails are excessively long. Palpation of this area is painful. The Administrator stated resident #2 provided permission for her and the Certified Ombudsman to observe his podiatry treatment. 15 43. The facility in which resident #2 resided until 05/19/2011, neglected to provide basic personal hygiene services (bathing) and podiatry services in order to prevent constant pain associated with "excessively long" toenails. -44, Based on the foregoing, Rapha Manor, Inc. violated Section 429.28(1), Florida Statutes, and/or Rule 58A-5.0182, Florida Administrative Code, a Class I deficiency, which carries, in this case, an assessed fine of $10,000.00, and revocation of the license. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I, II, and III. B. Revoke the Respondent’s license and assess an administrative fine of $12,000.00 and a survey fee of $183.00 against Rapha Manor, Inc. ALF on Counts I through III for the violations cited above. Cc. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2010). Specific options for administrative action are set out in the attached Election of Rights and 16 explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMP! WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMP] AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. LAINT LAINT If YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. ria Lawton-Russell Assistant General Counsel Agency for Health Care Administration 8333 NW 53*% Street Suite 300 Miami, Florida 33166 (305) 718-5907 Copies furnished to: Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Room 500 Delray Beach, Florida 33484 (Inter-office mail) V7 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has’ been furnished by U.S. Certified Mail, Return Receipt Requested to Camilla Minus, Administrator, Rapha Manor, Inc., 4555 aK Avenue, Vero Beach, Florida 32967 on 2011. — KY ria Lawton*Russell

Docket for Case No: 11-005640

Orders for Case No: 11-005640