STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Petitioner, vs. AHCA 09-01-0004 ALF THE ELYSIUM OF BOCA RATON, | Oo ae 2 INCORPORATED, d/b/a ELYSIUM OF _ BOCA RATON, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after Twenty One (21) days from the receipt of this Complaint, the Agency for Health Care Administration (hereinafter referred to as the "Agency") intends to impose a civil penalty in the amount of Eleven Thousand Five Hundred (11,500) Dollars upon The Elysium of Boca Raton, Incorporated, d/b/a The Elysium of Boca Raton (hereinafter referred to as "Respondent"). As grounds for this civil penalty the Agency alleges as follows: 1. The Agency has jurisdiction over Respondent by virtue of the provisions of Chapter 400, Part III, Florida Statutes (F.S.). 2. Respondent is licensed to operate at 2600 NW Fifth Avenue, Boca Raton, Florida 33431 Florida 33308, as an assisted living facility in compliance with Chapter 400, Part III, F.S., and Chapter 58A-5, Florida Administrative Code (F.A.C.). 3. The Respondent has violated the provisions of Chapter 400, Part II, F.S., and the provisions of Chapter 58A-5, F.A.C., in that it failed to correct within the mandated time frame of May 3, 2000 (Section 400.419(3)(c)) F.S., (1) Class I, (3) Class II, (3) Class IH, and (1) Class IV deficiencies cited during the survey of April 3, 2000. These deficiencies set forth below were still uncorrected when a follow-up visit was made on May 4, 2000. (a) Tag 700. Based on interviews and observation the facility did not provide appropriate personal supervision to meet the individual resident’s ‘needs; did not note deviations in the resident’s normal appearance and state of well being; and did not contact the resident’s guardian in an emergency. (1) On 3/21/00 at approximately 8:00 a.m. when Resident #1’s private duty CNA reported to the facility that the resident stated she/he was sexually assaulted “last night” (sometime between 8:45 p.m. on 3/20/00 and 8:00 a.m. on 3/21/00). The facility administrator wrote an incomplete incident report, a copy of which was in the resident’s clinical record. The administrator did not notify the resident’s guardian, case manager, family, physicians, abuse hot line, or local law enforcement. (2) | When the guardian and case manager learned of the incident, they immediately contacted the local police who began an investigation on 3/21/00. They also arranged to have private duty help with the resident 24 hours a day until the resident could be transferred out of the facility. (3) The surveyor first saw the resident on 3/22/00 at approximately 6:00 p.m. The resident was in his/her room in bed. The resident grabbed the surveyor’s hand and in a shaky, tearful voice asked, “are you here to protect me?” (4) When the surveyor asked the resident what had happened, the resident stated that a tall black female, possibly called “mama”, had come into the room sometime during the night, lifted up the nightgown and fondled the resident. The resident also reported wearing different adult briefs and different nightclothes the next morning. The resident also stated that the brother-in-law of the man who cleans came to his/her room at the end of this shift and told the resident to leave the door oper! and he would come back to visit later. The resident stated that she/he was very nervous about this remark. During an interview with the private duty CNA the CNA stated that the resident was dressed in evening adult briefs and 2 the top of a sleep wear set. Interviews with all staff present on all shifts between 8:00 p.m. on 3/20/00 and 8:00 a.m. on 3/21/00 failed to find anyorie who knew anything about who changed the resident and when. The private duty found the first nightgown in the laundry. The surveyor was able to identify 3 staff members on duty that fit the description of a tall black female. The resident’s case manager and private duty and some staff members identified the employee called “mama”. This individual stated to the surveyor that the resident calls everyone “mama”. During an individual interview with each staff member, they all denied being in the resident’s room and/or changing the resident. (5) During interview on 3/22/00 the resident also told the surveyor that a male who cleans the rooms had stopped by before leaving work on 3/20/00 and told the resident to “leave the door open tonight so I can come to visit you”. The resident stated that this made him/her very nervous. During an interview with this employee on 3/23/00, he denied coming up at night to see the resident and did not know how the resident got changed. (2a) This deficiency remained out of compliance during the 5/04/00 revisit, based on the following information: (1) During interview, the facility administrator was not able to explain to the surveyor the proper procedure for reporting abuse. (2) The facility policy and procedure for reporting incidents did not state - that it is to be coinpletéd by the Person having first administrator i in all cases. (3) ‘The facility did not prepare a plan of correction for this tag. The Statements made and submitted as a plan of correction were only statements contradicting the survey findings. The facility did not have documentation to support statements. 4 ‘The facility had not taken any action to ensure the residents’ health, safety, physical and emotional well being now and in the future. This is in violation of Rule S8A- >: 01821Xb-), F A.C. Class I deficiency. $7,500 - civil penalty. d knowledge of the incident, not the (b) Tag 206. Based on record review, the facility incident reports were inaccurate and incomplete: qd) The clinical record for Resident #1 contains an incident report of possible rape dated 3/21/00 prepared by the facility administrator. The incident report did not contain a clear description of the incident; any medical services provided, and steps taken to prevent recurrence. Additionally, there were many items on the form that have been left blank including: was the person a resident, employee, or visitor; resident’s condition before the incident; physician and family notified; person seen by a physician or taken to a hospital; names of witnesses; and follow-up. The narrative portion of the incident report is not consistent with the information provided to the surveyor by witnesses. (la) The facility incident report states that the incident happened at 8:30 p.m. The nurse on duty told the surveyor that she gave the resident the evening medication at approximately 8:45 p.m. and did not notice anything unusual. The resident stated to the surveyor that the incident happened sometime after the private aid left after the evening medication was given. (1b) The incident report stated hat the private aide came back to the facility at 8:30 p.m. Interviews with the resident, private aide, and guardian revealed that the private aide worked a later shift that day and finished work sometime between 8 & 8:30 p.m. after getting the resident ready for bed by putting on the night-time adult brief and nightgown. (ic) The incident report stated that the private aide examined the resident on 3/21 and found no evidence of abuse. When the resident reported the incident to the private aide and case manager on the morning of 3/21, the case manager called the police. The private aide and a female police officer examined the resident. There was no mention of the police in the incident report. During interviews, staff stated that the police did not leave a card and told them that there would not be a police report because the case was closed. During an interview on 3/26/00 with the detective, she/he stated that she/he left a card with 4 the nurse on duty and would be able to make a positive identification of the nurse. The detective also stated that the case was not closed. On 3/26/00 the officers had not completed the investigation. (1d) During interview, the resident, private aide, and case manager stated that the next morning (3/21/00) the resident was wearing different adult briefs and the top of a 2-piece sleepwear set with the top partially pulled up, exposing the resident. During further interviews with all the staff on duty on the 3-11 and 11-7 shifts on 3/20 and 3/21, no one knew anything about how, when, and who changed the resident’s briefs and clothing. The private aide Jater found the nightgown in the laundry. (le) During interviews with the resident, the resident stated that the facility has been repeatedly telling him/her that it was all a bad dream and to forget about it. (1f) The facility did not notify the resident’s physician, guardian, family, or the abuse hot line (1-800-96-ABUSE) (lg) The incident report stated that the resident had made many remarks about sex, but there was no documentation of this i in the resident’s clinical record. one Q) The clinical record for Resident #1 contained an incident report date 3/10/00 prepared by the facility administrator. The incident report did not include prevent recurrence. Additionally, there were many items on the form that have been left blank including was the person a resident or visitor; location of incident; condition of the resident; property/equipment involved; witnesses; and follow-up. 3) During interviews with Resident #1, the resident’ s guardian, and the ~ resident’s- case manager, all stated to the- ‘surveyor that the resident had had 2 telephones, pieces of costume jewelry, and cases of adult briefs missing from the resident’s room. Review of the resident clinical record revealed that there were no incident reports in the resident records and staff interviewed was not aware if any incident reports were available for these incidents/missing items. bead (2b) Based on record review, it was determined that the facility incident reports were inaccurate and incomplete. Findings include: (1) The facility policy and procedure for reporting incidents did not state that the incident report was made by the individuals having first hand knowledge of the incident. (2) During interview, the facility administrator was not able to relate to the surveyor what types of incidents were abuses and what the proper procedure is for reporting suspected cases. (3) “The facility did not prepare a plan of correction and had not taken steps to ensure that this type of incident did not occur again. The facility submitted as a plan of correction statements contradicting the survey findings, but had no documentation to support these statements. . This is in violation of Rule 58A-5.024(1)(d), F.A.C., Class II deficiency. $1,000 civil penalty. (c) Tag 214 On 4/03/00, based on interview, the facility did not have background screening on two contract employees who have direct contact with residents. () During an interview with the bookkeeper, the surveyor was informed that the Facility had not conducted background screening on 2 contract employees who clean the common areas of the facility as well as the resident rooms a ad bathrooms. (2c) On 05/04/00, based on interview, the facility did not have background Screening 0 on vall contract employees who have direct contact with residents. “() i “A housekeeper ‘who. ‘has started working in ‘the ‘facility after the complaint investigation conducted on 4/03/2000 did not have a background screening. The facility Stated that the inf rmation had not been submitted. Thi sctio 1 400.4: 4275(2), F. S., and Rules SBA. 0190), and S8A- 5: onsniays FAC. _Class Il deficiency. $300 civil penalty (ad) Tag 512. On 4/03/00 the facility did not have sufficient staff to provide the required level of care offered and to evacuate residents in case of emergency. (1) When the surveyor arrived at the facility on 3/27/00 at 9:45 p.m. a person later identified as the CNA for the 2™ floor locked unit was sitting in his/her car in the parking lot. The CNA retumed to the facility approximately 10:00 p.m. The surveyor went to the 2™ floor at 10:20 p.m. and entered the locked unit. The surveyor was not able to locate the CNA on the unit. (2) On 3/27/00 at approximately 10:20 p.m. and 10:30 p.m. the surveyor spoke with a male resident wandering the halls on the unlocked portion of the 2™ floor. The | male resident stated that it was 10:00 a.m. and he wanted to know where breakfast was. . There was no nurse or CNA on duty on this part of the 2™ floor. (3) There were 2 staff members at the 1“ floor nurses’ Station on 3/27/00 when the surveyor arrived at approximately 10:00 p.m. until they went off duty at approximately 11:15 p.m. One of the nurses identified him/herself as the second floor nurse. (4) The surveyor observed the 2™ floor locked unit CNA get off the . _ elevator at the 1* floor at approximately 10:40 p.m. and wait by the nurse time clock visiting with the next shift until it was time for the shift change. The nurses were both at the 1" floor nurses” station, leaving the entire a floor, including the locked ‘unit, _ Unsupervised for approximately 20 minutes. — cet (5) When the surveyor arrived at the facility on 3/27/00, the bell to the emergency entrance was not working. The surveyor walked around the outside of the kek building and tried the door at the far south end. The door was unlocked, but an alarm, . . ; , sounded when the ‘surveyor opened the door. ‘The alarm was silenced, but no one came to a t check the door. The surveyor entered the facility and located the hallway Jeading to the: 7 nurses” s $ not yisible from the urses’ station. The surveyor walked to the nurses’ Station and informed the 2 nurses that the south door was just been used as an entrance. _ One nurse stated, “You can’t come in that door, is locked”. When the surveyor asked if the nurses had heart and silenced the alarm. They stated, “Yes, we thought it went off by mistake.” The surveyor took the nurses down the hall to show them that the door was not locked. (2d) The facility did not have sufficient staff to provide or arrange services for residents as required. The findings were as follows: (1) During the tour of the facility, the surveyor did not observe a nurse or CAN on the unlocked portion of the second floor. This is in violation of Rules 58A-5.0182(1), and 58A-5.019, F.A.C. Class II deficiency. $1,000 civil penalty. (e) Tag 610. On 3/27/00 at approximately 10:30 p.m. and 10.50 p.m. the surveyor observed that the door to the medication room was left half open. The surveyor entered the medication room at 10:30 p.m. when there were no nurses within sight and found that the refrigerator contained opened cans of soda in addition to medications. There was a box of bubble pack medications on the counter, the treatment cart was unlocked, and the medication drawer was open. The surveyor found the same conditions at 10:50 p.m. when 2 nurses were sitting at the nurses’ station in front of the medication room. When the first floor nurse saw the surveyor leave the medication room, the nurse closed the door slightly more, but not enough to lock it. i F “Qe) On 5/04/00 the medications were not stored properly. The findings were as ' : qd) "The cover letter with the statement of deficiencies stated that asa - ‘ result of this tag cited as a Class II, the facility was required t: to have a consultant Pharmacist "do an on- ‘site ‘consultation visit within 71 ‘working days and a ‘get a corrective plan of action . , Prepared, signed and dat d by the pharmacy consultant and submitted to: the area Office. The scent puattn vn ; have a plan of correction. (2) During the tour of the facility the surveyor observed a covered plastic container. in the medication refrigerator. The container did not have a label or date and appeared to contain some type of fruit or coffee beverage. (3) An unmarked cardboard box was on the counter of the medication room. It contained several bubble packs of medications. When the surveyor asked why these medications were left on the counter, the reply was that they were the ones to be Teturned to the pharmacy. ; | This is in violation of Rule 58A-5.0185(6)(d)3,a, F.A.C., Class II deficiency. $1,000 civil penalty. (f) Tag 013. Based on observation, the facility advertised without the ALF license number. On 4/03/00 during a review of a local newspaper revealed that the facility had a large advertisement on 2/27/00, 3/12/00, and 3/26/00. None of the advertisements contained the facility ALF license number.: (2f) This deficiency remained out of compliance when the 5/04/00 revisit took place. The facility continued to run newspaper advertisements without the ALF license number. The administrator stated that the license number was no longer necessary based Lon - information received in core update training. However, during interview with the ate Department of Elder Affairs (DOEA), representative who conducts the training sessions, the surveyor was informed that the Florida Statutes 400. 441(7) have not t changed and the license ne ‘number i is still required i in all advertising. ‘This is in violation of Section 400. 447(7), F.S., Class IV deficiency. $100 civil . penalty. ; a (g) Tag 213. During the survey of 4/03/00 and based on interviews, it was . determined that the facility did not have personnel records for contract employees providing services to 0 residents i in their rooms and i m common areas. Findings include: oe at - (1) “The facility contracts with t two men to clean the - common areas of the . facility and clean the resident rooms and bathrooms. During an interview with the 9 bookkeeper, the surveyor learned that the facility did not have any personnel information such as: references, verification of freedom from communicable disease, verification of freedom from TB, and no licenses, certification, insurance, or bonding on these 2 contract workers. (2g) This remained out of compliance during the 5/04/00 revisit, based on the following information: qd) The facility had files for 4 contract housekeepers. Review of these files revealed that one housekeeper who was in the facility at the time of the survey had no documentation of verification of freedom from TB. . (2) There is a new housekeeper in the facility whose file had no documentation of verification of freedom from TB. This is in violation of rule 58A-5.019(2)(a), F.A.C., Class II deficiency. $300 civil penalty. (h) Tag 902. On the survey of 3/03/99 it was observed that the facility did not maintain the furnishings in good repair. The findings include: 69) On the first floor, outside of rooms 135, 136 and 137, there i isa chair with a large stain, almost covering the sitting a area. “Outside of rooms 122, 123 and 124, there . is a pink upholstered chair with a large brown stain covering all of the seat. The chairs inthe activity room all had noticeable stains of t varying sizes. © Qh) “On “4/03/00 and based: on observation, the facility furniture ‘and | furmishings were not clean and i in good: repair. (1) On all visits to the facility, the surveyor found it difficult to find a chair that did not have dried urine spots or noticeable dampness on the seats. This is in violation of rule 58A-5. 022(1)(C), FA. c. Class III deficiency. $300 civil penalty. 4. The above referenced violations constitute ground to levy this civil penalty pursuant to Section 400.419(3)(c), (F.S.), in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and regulations for the operation of an Adult Living Facility. 5. Notice was given in writing to the Respondent of each of the above violations and the time frame for correction. 6. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, &S); to be represented by counsel (at its expense); to take testimony, to call and 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, your request for an administrative hearing must conform to the requirements in Rule 28- 106. 201, 2 A C. ), and must state which i issues of material fact you dispute. Failure to dispute material i issues of fact in your request for a hearing may be treated _ by the Agency as an election by you of an informal proceeding under Section 120.57(2), FS.) ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED “7. RESPONDENT IS FURTHER NOTIFIED THAT F. FAILURE T TO ) REQUEST A . HEARING TWENTY ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Retum Receipt Requested to Claire Bojanoski, Administrator, The Elysium of Boca Raton, 2600 NW 5" Avenue, Boca Raton, Florida 33431, and to John L. Fiorilla, Registered Agent, 2600 NW 5" Avenue, Boca Raton, Florida 33431, on this Lay of , f }