STATE OF FLORIDA ky gl AGENCY FOR HEALTH CARE ADMINISTRATION aa STATE OF FLORIDA, AGENCY FOR lG7) HEALTH CARE ADMINISTRATION, OD -\ 68 | vs. AHCA NO: 10-00-026-ALF Petitioner, ST. CATHERINE’S TLC, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of $3,050.00 upon St. Catherine’s TLC. As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part III, Florida Statutes. 2. Respondent, St. Catherine’s TLC, is licensed by the Agency to operate an assisted living facility at 9990 NW 41" Street, Cooper City, Florida 33024 and is obligated to operate the assisted living facility in compliance with Chapter 400 Part III, Florida Statutes, and Rule 58A-5, Florida Administrative Code. 3. On March 21, 1997 a survey team from the Agency’s Area 10 Office conducted a survey and the following Class II and Class III deficiencies were cited. 3A. Pursuant to Rules 58A-5.0182(6) and S8A-5.0182(6)(a)l, F.A.C., the method for management of a resident’s medications, whether self-administration, self- administration with supervision, or administration by licensed personnel, shall be as directed by the health care provider in the health assessment report required pursuant to 58A-5.0181, F.A.C., or as prescribed on new orders. Residents who are capable of taking their own medication are encouraged to do so. A resident may keep his own medication on his person or in his own room or apartment, which is kept locked when the resident is absent or in a secure place, which is normally out of sight of other residents. This standard was not met as evidenced by the following observations: (1) Resident #2 is an 86 year old male with Diabetes and gangrene on the leg, under Hospice care, residing in the unlicensed facility. The resident had no health assessment, Hospice care plan, nor records of how his medications were being managed. (a) During an interview with the caretaker at 3:30 p.m., it was stated to surveyor that the administrator of St. Catherine’s ALF gives out the medication. (b) — The resident’s pills, which consisted of Trental, Glucotrol, Plendil, Percocet, Darvon, Cipro, and a handful of pink tablets that were unlabeled, were stored unlocked in a kitchen cabinet. (c)_ The resident later on complained to surveyors of pain in the lower leg extremity. Resident #2 was examined by paramedics at the request of surveyors, and was sent via ambulance to Memorial Hospital for emergency treatment of gangrene to the leg at approximately 7:00 p.m. that evening. (2) Resident #1 is an 81 year old female with a colostomy and tumor on the left side of the stomach area, residing in the unlicensed facility. According to her family member, the resident had a recent psych evaluation, which resulted in a diagnosis of Paranoid Schizophrenia. The family member went on to say that the resident’s behavior was difficult to manage at times and sometimes bizarre. (a) There was no health assessment, progress notes, nor were there any records of medication management for this resident. 3B. (3) Resident #3 is an elderly female resident found lying in bed in the unlicensed facility with ants crawling on her upper extremities. The staff stated that the resident has cancer of the nose. Surveyors observed that the nose bridge was decayed and appeared reddened, revealing cartilage and white secretions. (a) | There was no health assessment, progress notes, nor was there any records of medication management for this resident. (4) Based on observations and interview with staff, residents and family members, it was determined that the facility violated Rule 58A- 5.0182(6), F.A.C., for failing to ensure that residents in the unlicensed facility received management of their medications. Pursuant to Rule 58A-5.0182(2), F.A.C., the facility shall ensure that residents receive services appropriate to their needs. Personal supervision is offered as appropriate for each resident. This standard was not met as evidenced by the following observations: (1) Resident #1 is a female with a colostomy and tumor on the left side of the stomach area. According to her family member, the resident had a recent psychological evaluation and the physician informed them the resident was Paranoid Schizophrenic. (a) The family member further stated the resident had problems due to a colostomy: “My mother does not want anyone to see or care for the colostomy, the only thing she does is place sanitary napkins over it. After meals, she sticks her fingers in her mouth to induce vomiting to prevent the colostomy bag from being soiled.” (b) Interview with the staff of the unlicensed section revealed the administrator of the facility had not addressed the behavior problems. There were no records, progress notes, or evidence that the resident was receiving medical supervision. (2) Resident #2 is a male with Diabetes and gangrene on the leg receiving Hospice care. This resident was observed limping and had a dirty dressing on the leg. The resident also had a dressing on the right middle finger. According to his spouse, the resident slammed his finger on the bedroom door. (3) (a) During the complaint investigation, surveyors called 911 Emergency Medical Services for the resident. When the paramedics arrived at the unlicensed section of the ALF, the resident’s leg was examined. After the evaluation, the paramedics determined that transportation of the resident by ambulance to Memorial Hospital for immediate attention was required. (b) The Protective Investigator from Aging and Adult Services informed the surveyor by telephone on March 24, 1997, that the doctors recommended the leg be amputated. This resident did not receive timely appropriate services and supervision for his medical condition. Resident #3 was observed by surveyors lying in bed with ants crawling on her upper extremities. The resident is alert but did not answer to surveyors questions. The resident was observed to have her nasal area structure decayed, reddened and exuding white secretions. (4) (a) Staff stated the resident had cancer of the nose. The resident’s fingernails were encrusted with the secretions. Surveyors observed the resident picking the nasal area. According to an interview conducted by the protective investigator, the resident stated “I don’t want to live anymore.” (b) An interview with the administrator and caretaker revealed this resident had been in the licensed ALF and was transferred to the unlicensed section of the facility approximately two nights ago. (c) Review of the admission and discharge log revealed the resident had been admitted to the ALF on February 21, 1997. The facility had no records or progress notes of the resident’s medical status or level of care needed. Resident #4 was observed by surveyors to be in a locked room. The door had to be opened by the police officer after several attempts at knocking on the door with no response. The resident was found lying ina hospital bed with full rails, on continuous oxygen due to breathing problems and a diagnosis of Emphysema. (a) A plate of half eaten mashed potatoes was left on a TV table near the bed. Surveyors observed ants crawling throughout the leftover food and the bed. This resident is known to surveyors from a previous complaint investigation of St. Catherine’s ALF in October 1996, at which time he was deemed inappropriate for continued residency in the licensed ALF. 4. (b) During the revisit to that investigation in November 1996, the administrator reported to surveyor that the resident’s guardian took him home. An interview with the guardian revealed that this resident had been transferred to the unlicensed facility four months ago by the administrator of the licensed ALF. (c) The facility had no progress notes of the resident’s medical condition or level of care. (5) Resident #5 was observed during the tour of the unlicensed section of the facility to be alert and confused. The resident was in a wheelchair in the living room area unsupervised. The resident’s hands shook violently. The resident stated to the surveyor: “Why don’t we have something to eat, I’m hungry.” (a) Review of the admission and discharge log revealed the resident had been admitted to the ALF in April of 1996. The administrator stated that a volunteer had taken the resident for a walk to the unlicensed section of the ALF. The alleged volunteer could not be found by surveyors for an interview. (6) Based on observations, interviews and record review, it was determined that the facility violated Rule 58A-5.0182(2), F.A.C., for failing to provide the appropriate services and personal supervision to residents who require special needs in the unlicensed section of the ALF. On April 8, 1997 a survey team from the Agency’s Area 10 Office conducted a survey and the following Class III deficiency was cited. 4A. Pursuant to Rule 58A-5.024(1)(b), F.A.C., the incident report shall be made by the individuals having first hand knowledge of the incident, and shall contain: a) a clear description of each accident or incident involving dangerous behavior of resident or staff member involved b) the time c) the place the incident occurred d) the names of the individuals involved e) witnesses if injuries were sustained f) nature of injuries g) cause of the accident, if known h) a description of medical or other services provided i) who provided services, and j) any steps taken to prevent recurrence. This standard was not met as evidenced by the following observations: 5. (1) Based ona tour of the facility at 2:00 p.m. in the common area of the facility, Resident #2 was observed with a bruise around the left eye area. The administrator stated it was a result of a fight with her roommate. (a) _ Review of the incident report on file revealed that there was no documentation of the dangerous behavior of the residents involved, nor an accurate description of the nature of the injury sustained. (2) Based on an interview with the administrator and record review, it was determined that the facility violated Rule 58A-5.024(1)(b), F.A.C., for failing to have the required information reported on the incident. On December 10, 1997 a survey team from the Agency’s Area 10 Office conducted a survey and the following Class III deficiency was cited. SA. Pursuant to Section 400.428(1) and (3), F.S. and Rule 58A-5.0182(7), F.A.C., interviews with residents and consultation with the ombudsman council in the district verify that resident’s rights and freedoms are protected and facilitated in accordance with the Resident Bill of Rights. This standard was not met as evidenced by the following observations: 6. (1) Based on observations made during the initial tour of the facility, the men’s bathroom on the northeast side of the facility had no curtain or covering on it. The glass in the window was not frosted, therefore, there was no privacy for anyone using that bathroom. (2) Based on observations, it was determined that the facility violated Section 400.428(1) and (3), F.S. and Rule 58A-5.0182(7), F.A.C., for failing to ensure that resident’s rights and freedoms were protected and facilitated in accordance with the Resident Bill of Rights. On May 20, 1999 a survey team from the Agency’s Area 10 Office conducted a moratorium appraisal visit. There were three Class III and two Class I deficiencies cited. 6A. Pursuant to Rule 58A-5.024(1)(b), F.A.C., the incident report shall be made by the individuals having first hand knowledge of the incident, and shall contain: a) a clear description of each accident or incident involving dangerous behavior of resident or staff member involved b) the time c) the place the incident occurred d) the names of the individuals involved e) witnesses if injuries were sustained f) nature of injuries g) cause of the accident, if known h) a description of medical or other services provided i) who provided services, and j) any steps taken to prevent recurrence. This standard was not met as evidenced by the following observations: qd) During a tour of the facility, it was noted that Resident #2 had a bruise around his/her right eye and a laceration above the right eyebrow. An interview with the staff member on duty revealed that this injury had occurred from a recent fall. (a) Further investigation and a review of the facility’s accident/incident reports revealed that an incident report had been completed for this resident on May 16, 1999, however, the report did not contain the nature or extent of the resident’s injuries, a description of the medical treatment that was provided, and steps taken to prevent recurrence. (2) Based on record review, it was determined that the facility violated Rule 58A-5.024(1)(b), F.A.C., for again failing to provide a clear description of an incident involving a resident. 6B. Pursuant to Rule 58A-5.024(2)(c)3B-e, F.A.C., the facility shall maintain a record of resident height and weight at admission and semiannually thereafter for residents receiving personal care services, as well as the following additional health information: a) the name, address, and telephone number of the resident’s health care provider b) a description of the resident’s overall condition and level of care required, updated as needed, and c) reports of resident illness and medical attention provided. This standard was not met as evidenced by the following observations: 6C. (1) During a tour of the facility, Resident #1 and Resident #3 were interviewed and revealed that they did not care for the taste or the quality of the food being served. In addition, general observations of the five (5) facility residents revealed that one (1) of the two (2) residents interviewed appeared to be thin and frail. (a) A review of Resident #1’s clinical record revealed that this resident’s most recent recorded weight was 155 lbs. on March 10, 1999. Upon surveyor request, this resident was re-weighed on May 20, 1999 and found to weigh 136 Ibs. (a weight loss of 9 Ibs). (b) Further investigation and a review of Resident #3’s record revealed that his/her last recorded weight was 210 Ibs. on March 10, 1999. This resident was also re-weighed on May 20, 1999, in the presence of a surveyor, and found to weigh 197.5 Ibs. (a weight loss of 12.5 Ibs). (c) An interview with the facility’s administrator revealed that she was unaware of these unplanned weight losses and therefore, had not documented any changes in these residents conditions. (2) Based on observation, interview and record review, it was determined that the facility violated Rule 58A-5.024(2)(c)3b-e, F.A.C., for failing to maintain a description of the resident’s overall condition, which is updated as necessary. Pursuant to Rule 58A-5.0182(6), F.A.C., the method for management of a resident’s medications, whether self-administration, self-administration with supervision, or administration by licensed personnel, shall be as directed by the health care provider in the health assessment report required pursuant to 58A-5.0181, F.A.C., or as prescribed on new orders, This standard was not met as evidenced by the following observations: (1) During a review of Resident #1’s clinical record, it was noted on the health assessment that this resident is to self-administer their medications with supervision. Further review of the record revealed that the resident had progress notes-dated from October 6, 1998 thru April 27, 1999, which indicate that this resident often refuses medication. (a) Aninterview with the staff member on duty at 9:45 a.m. on May 20, 1999 revealed that when this resident refuses medication, she and other staff members will mix the resident’s medications into his/her food. (2) (b) Further interview with this staff member revealed that she is a home health aid and has no license that would permit her to administer medications to a resident. Based on record review and interview, it was determined that the facility violated Rule 58A-5.0182(6), F.A.C., for again failing to follow the correct method for management of medications as directed by the resident’s health care provider. 6D. Pursuant to Rules 58A-5.0182(1), (2) and (2)(f), F.A.C., the facility shall ensure that residents receive services appropriate to their needs. Personal supervision is offered as appropriate for each resident. The facility shall contact the resident’s family, guardian, health care surrogate, or health care provider and case manager or mental health case manager when a resident exhibits a significant change or when there is an emergency, in accordance with written procedures. This standard was not met as evidenced by the following observations: (1) During a tour of the facility, Resident #2 was noted to have a bruised right eye and a laceration above the right eyebrow. An interview with the staff member on duty revealed that these injuries were sustained from a recent fall. (2) (a) Further investigation and a review of the incident report for this resident revealed that he/she had fallen on May 16, 1999 and was taken to the emergency room. This report had no documentation to indicate that this resident’s family or health care provider had been contacted regarding this resident’s condition. (b) The clinical record for Resident #2 was also reviewed and revealed no evidence that this resident’s family or health care provider had been contacted following this fall. Based on record review, it was determined that the facility violated Rules 58A-5.0182(1), (2) and (2)(f), F.A.C., for failing to contact the resident’s family or health care provider when a resident has an emergency. 6E. Pursuant to Section 400.428(1) and (3), F.S., interviews with residents and consultation with the ombudsman council in the district verify that resident’s rights and freedoms are protected and facilitated in accordance with the Resident Bill of Rights. This standard was not miet as evidenced by the following observations: qd) A review of Resident #1’s record revealed progress notes dating from October 6, 1998 thru April 27, 1999, which indicated that this resident often refused medications. An interview with the staff member on duty at 9:45 a.m. on May 20, 1999 revealed that this resident continues to refuse medications, therefore, to ensure the resident receives the prescribed medication, she and other staff members mix the medications into the resident’s food. (a) Further investigation and interview with the staff member revealed that this is done without the resident’s consent. (2) Based on record review and interview, it was determined that the facility violated Section 400.428(1) and (3), F.S., for violating one (1) of five (5) residents right to make independent personal decisions. 7. Based on the foregoing, St. Catherine’s TLC has violated the following: (a) Tag A206 incorporates Rule 58A-5.024(1)(b), F.A.C. (b) — Tag A301 incorporates Rule 58A-5.024(2)(c)3b-e, F.A.C. (c) Tag A600 incorporates Rule 58A-5.0182(6), F.A.C. (d) Tag A700 incorporates Rule 58A-5.0182(1)(2)(f, F.A.C. (e) Tag A705 incorporates Section 400.428(1) and (3), F.S. for the aforementioned violations. 8. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.419, Florida Statutes, and Rule 58A-5.033, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of an Assisted Living Facility. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: R.S. Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403, with a copy sent to Christine T. Messana, Esquire at the same address. All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identify the AHCA number and facility name that is referenced on page | of this complaint. All payment of fines should be sent to the Agency for Health Care Administration, Attention: Christine T. Messana, Staff Attorney, General Counsel’s Office, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Issued this 3 velday of Ape ' — , 2000. ZA y Patricia i 277 Supervisor, Area 10 Agency for Health Care Administration Health Quality Assurance 1400 W. Commercial Blvd., Suite 110 Ft. Lauderdale, Florida 33309 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrator, St. Catherine’s TLC, 9990 NW 41® Street, Cooper City, Florida 33024 on this’3 vef day of Apes | , 2000. Christine T. Messana, Esquire Office of the General Counsel Copies furnished to: Christine T. Messana Staff Attorney Agency for Health Care Administration 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308-5403 Pete J. Buigas, Deputy Director Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403 Area 10 Office Gloria Collins, Finance & Accounting 13

Docket for Case No: 00-001677