Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: BEVERLY ENTERPRISES, FLORIDA, INC., D/B/A BEVERLY HEALTH & REHAB ENGLEWOOD
Judges: WILLIAM R. PFEIFFER
Agency: Agency for Health Care Administration
Locations: Punta Gorda, Florida
Filed: Feb. 21, 2002
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Wednesday, April 10, 2002.
Latest Update: Jan. 05, 2025
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be oB- 7ob/
STATE OF FLORIDA >
AGENCY FOR HEALTR CARR ADMINISTRATION“ /£p i
STATE Of FLORIDA
AGENCY FOR HEALTH CARE
ADMINISTRATION,
Petitioner,
vs. ABCA WO. 08-01-0020 NE
BEVERLY ENTERPRISES, FLORIDA, INC.,
d/b/a BEVERLY HEALTE & REHAB ENGLEWOOD,
Respondent.
/
ADMINISTRATIVE COMPLAINT
COMES NOW the Agency for Health Care Administration
(hereinafter “AHCA"), by and through the undersigned counsel,
and files this administrative Complaint against Beverly
Enterprises Florida, Inc., d/b/a/ Beverly Health & Rehab
Englewood (hereinafter “ Beverly-Englewood”) pursuant to 28-
106.201 Florids Administrative Code (2000) (F.A.C.) and Chapter
120, Florida Statutes ("F.S.") hereinafter alleges:
NATURE OF THE ACTION
1. This is an action to impose a civil penalty in the
amount of two thousand one hundred ($2,100) dollars pursuant To
Section 400.121 F.S.
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| SORTSDICTION AND VENUE
2. This court has jurisdiction pursuant to Section
420.569 and 120.57 F.S. end Chapter 28-106 F.A.c.
3. Venue lies in this Court, Department of Administrative
Hearings, pursuant to 120.57 £.S and Chapter 28 F.A.C.
PARTIES
4. BHCA, is the enforcing authority with regard tc
skilled nursing fadility licensure law pursuant to Chapter 400,
Part If, 8.5. and Rules 594-4 F.A.C.
5. Beverly-Englewood is a skilled nursing facility
located-at L112 Drury Lane, Englewood, Florida 34224 and is
licensed under Chapter 400, Part II, F.S. aad Chapter 59A-4.
PLAC.
count Tf
BEVERLY-ENGLEWOOD FAILED TO PROMOTE CARE IN AN ENVIRONMENT THAT
MAINTAINS OR ENHANCES EACH RESIDENT'S DIGNITY
400.022 (1} (n) F-S.
CLASS III
6. ACA realleges and incorporates (1) through (5) as if
fully set forth herein.
7., Based on observations, resident comments, staft
interviews/comments, the facility failed to promote care in an
environment that maintains or enhances each resident's dignity
and respect in full recognition ef their individuality for 7 of
oom
mere
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18 active plus 22 random sampled residents py: (1) by failing to
assist the residents to drink liquids provided io residents at
meals efter residents requested to drink the liquids; (2) by |
failing to assist residents after observing residents struggling
te open milk cartons; (3) by failing to respect the privacy of
residents needing care; and, (4) by failing to ensure that
residents received their meals together to enhance eating.
B. Surveyors observed, on 3/5/01 from 12:10 P.M. until
approximately 1:00 P.M, 13 residents sitting at tables with
milk cartons placed in front of them, but, facility steff did
not assist the residents with theix milk until the trays were
served at 1 P.M. |
9. Interviews with the Certified Nursing Assistants
(“CNA”) on the above date and time, revealed the residents must
wait until the residents lunch trays are delivered before the
residents can drink their milk.
10. Resident #28 was abserved on the same day at
approximately 12:55 P.M., sticking her thumb in the top of the
milk Cart opening it, and drinking the entire content of the
container from the top of the torn milk carton.
i1
At approximately 12:35 P-M., Resident 29 was observed
sitting at the table with an unopenes carton of milk in front of
her and repeatedly reaching for the milk. A staff person
fore or ore ne
erp ee
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stated, "No, to wait till lunch." And another, a CNA stated, "We
i
are waiting for another cart of trays.”
12. During inferview at approximately 12:55 P.M., @ ONaA
stated, "We bring the residents into the day room at 11:30 for
lunch.” The lunch trays arrived at 1:20 P.M.
13. Resident #33 was observed in the Main Dining Room on
3/702 at 5:45 P.M., sitting with three other residents. The
three residents were served their dinner. Resident #39 sat and
watched the other residents eating- The Resident watened the
other residents eating their food. He looked around the dining
room at other residents eating supper. The Resident called out
to a staff persan asking for some soup and crackers but, the
staf person told the Resident that his dinner would be on
another cart.
14. Intexzview with the stafz at the above date and time,
revealed the Resident's supper tray was on the second food cart
and the others residents’ supper trays had been delivered on the
first food cart.
15. Resident #40 was observed in the Main Dining Room on
3/7/01 at 5:45 P.M., sitting at @ table with arother resident.
The other resident was served her Supper tray but Resident #40
sat and was served her supper 20 minutes later.
16. On 3/5/01, 2, residents, #2 and #31, sharing = room,
were noted. Resident #2 received lunch tray at 12:30 P.M., but
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*
Resident #31 did not receive lunch tray until 1:30 P-M., at
which tame Resident #2 had finished eating lunch.
17. During observation of the lunch meal, on 3/5/01 from
1:03 P.M. until 1:40 P.M., 13 residents and 5 staff were noted
in the South Day Room. Also at this time, the lids from the
residents! plates were observed sitting upside down on top of 2
of the tables filled with trash and paper debris from the trays,
yet, the residents were being fed at these taoles and the staff
failed to remove these lids before feeding the residents.
18. On 3/5/01, in the South Dey Room, at approximately
12:30 P.M., Resident #30 was observed sitting in a PVC Lounge
Chair which had another resident's name on it printed in big
black letters.
19. Based on’ the foregoing, Beverly Health & Rehab
Englewood violated 400.022(1) (n) F.S., herein classified as a
class III violation, which carzies, in this case, en assessed
fine of $700 pursuant to 400.23 (8) (c) Florida Statuves. This
is a repeated deficiency from the Annual Survey of 1/26/00.
204 The Respondent was given written notification of
the cited deficiency and the time frame for correction.
20m TNT Se remem: gem
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ad
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COUNT II
BEVERLY~-ENGLEWOOD FAILED TO PROVIDE SERVICES TO MEET
PROFESSIONAL STANDARDS OF QUALITY.
59A-4.1288 F.A.C. (adopting by reference 42 CYR 683.20 (k) (3) (1))
CLASS TIT
21. AHCA realleges and incorporates (1) through (5) as if
fully set forth herein-
'
:
22. Based on record review, observations and interviews
with nurses, an occupational. Therapist (“OT”), a Physical
Therapist Aide and a Registered Dietitian ("RD"), the facility
did net provide services, as ordered by the physician,
concerning the discontinuance of a medication for Resident #3,
the application of'a brace for Resident #1 and Resident #8 and
the application of ted hose for Residents #4 and #12.
23. Review of Residant #3's physician telephone orders,
dated 03/04/01, revealed chat the physician discenrinued the
Resident's Vitemin C and Zine. The nurse signed that the erder
was received on 3/4/01, and wrote, “noted” on the order. Review
or the current 3/01 physician orders, revealed that the
telephone order ré discontinue the supplements had been
transeribed to the current orders. Review of the 3/01,
Medication Administration Record (MAR), revealed that the
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Vitamin C and Zinc ned been given to the Resident on 3/5/01 at
9:00 A.M.
24. At 3:45 PM, the surveyor showed the erder to 2 nurses |
who were working on the evening shift on 3/5/01. They stated,
that che day snift nurse "must have missed it" and stated that
the nurse whe noted the order shculd have corrected the MAR.
They confirmed that the Vitamin C and Zine should not have been
given today to the Resident. a
25. Review of the MAR on 3/6/01 at 10:25 A.M., revealed
that the evening shift nurse had given the Resident the Vitamin
C at 5:00 P.M. on 3/5/01 and the dey shift nurse had given the
Resident the Vitamin ¢ and Zinc at 9:00 A.M. on 3/6/01.
26- Interview with the day shift nurse on 3/6/01 at 10:30
A.M., contizmmed that she gave the Vitamin C and Zinc to the
Resident that morning, and she stated, that the nurse who took
the order off the chart didn't change the MAR so She waS unaware
that they had been discontinued.
27. Review of Resident #3's Nutritional Assessment dated
1/8/01, revealed chat the RD had recommended one sccop of Promod
{protein powder) twice a day for a pressure sore that had
developed. Review of the physician telephone orders, revealed
that the Promod was ordered to be given twice a day on 1/17/01.
Review of the January 2001 MAR, revealed that the Promed was not
documented on the MAR. Further review of the physician
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telephone orcers in the Resident's record, revealec that there
was no order to aisgontinue the Promod. )
‘og. Interview with the RD on 3/6/01 at 10:35 A.M. revealed |
that she had recommended that the Pramod be discontinued on
L/1S/0L. She confirmed that the nursing staff should have been
giving the Resident the Promod from 1/17/01 until the
discontinue order was received from the physician. Interview
with the nurse on 3/7/01 at 9:60 A-M., revealed that she had
never given the Resident Promod. She stated, that she was not
aware of an order for Promod and would check the computer to see
if it had been dascontinued.
29. At 11:10 A.M. on 3/7/01, the RD provided the survey
team with a list of D/C (discontinue) Orders for Resident #3
that documented the D/C date for the Promod as 1/20/01.
30. Resident #1 was admitted on 12/14/00, with multiple
diagnoses and his/her physician orders of 12/14/00, called for a
Cash Brace to se applied when up.
31. The Resident was observed on 3/5/01, 3/6/01 and
3/7/01, up in his wheelchair not wearing his Cash Brace-
32. The Resident's treatment record revealed no
documentation that the brace was applied during the month of
January, February and March.
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33. On interview the nurse stared that the resident hed
been admitted from the hospital with the brace because of lumbar
pain.
34. The PT Aide and the nurse added that they had found
the Resident’s prace in his closet and the PT Aide added thet
she had not peen aware that the resident had a Cash brace.
35, Resident #8 was admitted with multiple diagnoses,
which included Cerebral Vascular Accident. ;
36. The Resident's medical record revealed that she had a
right hand contracture and her Plan of Care called for, “Soft
hand splint to right hand, apply every AM and remove at night"
yet the Resident was observed on 3/5/01 and 3/6/01, during the
day, without a sight hand splint.
37. On 3/6/01, during an interview, the OT, referring to
Resident$8, stated, "Yes the resident is to have a right hand
splint on during waking hours.”
38. Resident #12 was admitted with muitiple diagncses, and
his physician's order of 11/7/00, called for “Ted Hose every
Shift”, yet the resident was observed, on 3/5/01 and 3/06/01,
~
witheut ted hose.
33. On 3/6/01, @uring interview, the nurse, stated, "Yes
he has an order for Ted Hose.” But she could not find them in
his room.
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40. Resident #4 was readmitted on 1/29/01, with multiple
diagnoses, including a Left Hip Fracture and her physician
orders of 1/29/01 called for "Thigh High Teds", yet the
Resident was observed on 3/5/01 and 3/4/01, during the day,
without Thigh High Teds.
4l. The Resident's treatment records revealed, that during
two days in February, the Resident refused to wear the Thigh
High Teds, but. there was no other documentation for the
remaining days noting whether the ted hose was applied.
42. During the month of March the Resident's treatment
records revealed no documentation that the Thigh High Teds were
applied and on 3/6/01 the nurse stated, "The reason why she does
not wear the Thigh High Teds is because of left hip drainage."
Yet observations on 3/5/01 and 3/6/01, noted the Resident with a
dry dressing on her left hip.
43. Based on the foregoing, Beverly — Englewood violated
59A-4.1288 F.A.C., adopting by reference 42 CFR 483.20(k) (3) (id,
herein clessified as a class III violation, which carries, in
this case, an assessed Zine of $700 pursuant to 400.23 (8) (c}
Florida Statutes. This is a repeated deficiency from the Annual
Survey of 1/26/00.
44. The Respondent was given written notification of
the cited deficiency and the time frame for correcticn.
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count Tit
BEVERLY - ENGLEWOOD FAILED TO PROVIDE SUFFICIENT NURSING STAFF
layp SERVICES TO RESIDENTS. |
S9A-4.108(4) F.A.C.
CLASS IIT
45, ARCA reelleges and incorporates (1) through (S}) as if
fully set forth herein.
46. Based on observation, % residents at the graup
interview, 1 individual interview and Certified Nursing
Assistant aunterview, the facility failed to provide sufficient
nursing staff to provide for prompt assistance/supervision at
meals and prompt response to residents’ call izghts for 8 of 18
active residents sampled and 24 random sampled residents.
€7. During the group interview, conducted on 3/5/01, 3 of
12 residents in attendance complained that the facility does not
have enough staff especially during meal times, evenings and on
weekendS and also complained that it takes staff up to 15
minutes te answer call lights.
48. During an individual interview on 3/6/01, a resident
stated, "They are short of help, especially on the weekends end
when the students are here nothing gets done. They run in and
out and sometimes they don't even Say hello or speak. There is
one nurse wno is real abrupt. She runs in and says here are
your pills and leaves. There are lots of changes in staff."
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49. Observation on the South Hall, at approximately 9:15
A.M., on 3/6/01, revealed that a call light was on. Ne staff
was observed in the hall or at the nurse's station. At 3:58
A.M., @ resident came out of the room and stated, “My roommate
needs help. That's why the light is on. It has been sn for
quite some time.” At this time a staff person was observed to
enter the room. The resident who had come out to the hell also
stated, ¥Somerimes it takes a while” and shook his head.
50. Observation, on 3/7/01, at 12:58 P.M., at the South
Hall nurses station, revealed a call light ringing for room 203.
A nurs® was sitting at the desk, yet as of 1:10 P.M., the call
light still remained unanswered.
Si. Observation on 3/6/01 at 3:25 P.M-, on the North Wing,
revealed an emergency bathroom call bell/light tinging. There
were no staff in the hall er at the nurses station. This call
bell/light continued to ring for 5 minutes. During this time, a
staff person was obsezved in the hallway talking to 4 resident
and this staff person walked down the hall and ignored the
emergency call bell/light. Subsequently, a second staff person
was observed going down the hall and this staff person looked up
at the call light and was noted to also ignore the ringing
emergency call light/bsll-
52. Observation on 3/7/01 in the South Dining Room at
12:50 P.M., revealed Residents #9, #6, and #33 sitting at their
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tables with theiz covered lunch in front of them while staff
were observed sitting at the tables feeding othez residents.
The nurse’s aides stated all the nurses’ aides were feeding
other residents and that the aides would get to the residents
when they were finished feeding residents. The aides added that
the nurses will nelp feed after passing residents’ medications.
53. On 3/5/01, during observation in the South Dey Room,
from approximately 12:10 P.M. until 12:25 P.M., Resident #29 was
observed drinking and sticking her fingers in another residents
orange juice and staff was noted to do nothing concerning
Resident £28’s actions-
54. Observaticn on 3/7/01 on the South Hall at
approaimately 5:32 P.M., revealed that a meal tray for Resident
£34 was still left om the cart after all other trays hed been
passed to the residents who ate in their reoms. During
interview at approximately 3:50 P.M. a staff person stated,
"Everyone is feeding in the rooms. We have to wait till there
is someone who can feed her. She probably won't eat anyway."
55. During observation of the lunch meal in the South Day
Room on 3/6/01 at 11:55 A-M., 7 residents were observed seated
in the dining room waiting for lunch and no staff were observed
in the dining room with the residents. Resident 729 wes
ohserved pulling apart the centerpiece on the table and dropping
the pieces on the floor. RS Resident #38 was seated next to her
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and yelling out "hurcy up" over and over. Resident #29 became
agitated from the yelling and started swearing at Resident #38.
Ne staff were observed in the hall near the day room or &t the
nurses station. After approximately 10 minutes, 2 nurse's aide
was observed pushing a resident into the dining room. She left
immediately and walked back down the hall away from the day
room. Residents #29 and #38 continued to argue and the aide did
not intervene.
56. At another table, Resident #33 was observed feeding
herself with 4 spoon and an aide was seated next to her
providing verbal cueing. When the aide left the dining room at
1:35 P.M., Resident #33 had finished eating her meat, and could
not reach the remainder of the food on her plete. The Resident
Sat with the spoon in her hand for the next 10 minutes and
received no verbal cueing or assistance from the aides at the
other tables.
S?. Surveyors also observed Rasident #33 yelling at the
table and reaching out for Resident #29's food and Resident #29
became agitated and told Resident 738 to leave her alone. The
staff discussed removing Resident #38 from the room, but since
all staf? were observed to be feeding residents, there was no
one available to remove the resident from the dining room. The
aide whe had been monitoring this table was nov noted to returm
to the dining room.
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58. During the lunch meal in the Seuth Day Room on 3/5/01,
the trays were delivered at 1:00 P.M. Random sampled Resident
#35 was observed sedted in her geri chair with her food placed
on the table in front of her and two nurses' aides were seated
at the table feeding two other residents. Resident #35 was not
fed until 1:30 P.M., when an aide from another table came over
to feed her.
59. Resident #36 was also seated at this table and was
observed sitting in front of her food and not eating from 1:03
P.M. until 1:30 P.M. The staff did not provide the Resident
with verbal cueing during this time or assist the Resident ta
eat. At 1:30 P.M., one of the nurse's aides opened the
Resident's carton of milk and the Resident drank a few sips and
put the milk Garton down on the table. After another 5 minutes,
an aide came over from another table told the Resident to take a
bite of food and want back to the other table. She then called
across the reom to the 2 aides feeding at the table where
Resident #36 was eating and told them to cue her. One of the
aides then gave the Resident a bite of food and handed her the
fork and went back to feeding Resident #11. Residant #36 ate
one bite and received no further verbal cueing or assistance.
60. Ac approximately 1:30 P.M., in the South Day Room on
3/5/01, Resident #33 was observed sitting at a table spilling
food onto her clothing as she Drought food from her plate to her
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mouth. No staff offered any assistance or cueing. The Residenr
Was also observed te spill fruit juice on her clothing protector
which was not removdd by the staff.
61. The Respondent was given written notification of
the cited deficiency and the time frame for correction.
62. Based on the foregoing, Beverly —Englewood violated
5SA-4.108(4) F.A.C., herein classified as a class ITI violation,
Which carries, in this case, an assessed fine of 5700.00
pursuant- to 400.23 (8) (c) Floride Statutes. This is a repeated
deficiency from the annual survey of 1/26/00.
PRAYER FOR RELIEF
WHEREFORE, the Plaintiff, State of Florida, Agency for
Health Care Administration requests the Court to erder the
following relief:
A. Enter a judgment in favor of the Agency for
Health Care Administration against Beverly-Englewsod on Counts I
through TII.
“Be Assess against Beverly- Englewood administrative
fines of $2,100.00 for the Class III violations in Counts I
through ITI, in accordance with Section 400.121 FP.s.
Cc. Award the Agency for Health Care Administration
reasonable attorney’s fees, expenses, and costs.
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D. Grant such other relief as the court deems is
just and*proper.
RESPONDENT 18 FURTHER NOTIFIED THAT FAILURE TO REQUEST
A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECPIP? oF THIS
COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL
RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND
THE ENTRY OF A FINAL ORDER BY THE AGENCY.
i
Issued this [Jt N day of December, 2001.
x eA TL.
PENIS L. GODFREY Y
Senior Atrorney
Agency for Health Ca
Administration
FBN: 0158100
525 Mirror Lake Drive Nerth
St. Petersburg, FL 33701
(727) 8352-1525
e
Certificate of Service
I HEREBY CERTIFY that a true and correct copy of the
foregoing complaint and election of rights was sent by U.S.
Mail, postage prepaid, to Michael Allen, Administrator, Beverly
F-406
Sy re cree ont
See or ge
ale a
Fy
a)
Dac-17-2001 02:19pm From T-i18 P.org/o1g
Health & Rehab Englewood, 1111 Drury Lane, Englewood, Florida
34224, Beverly Enterprises-Plorida, inc, One Thousand Beverly
Way, Fort Smith, Arizona 72913, and by U.S. Certified Mail,
Return Receipt No. 2 259 496 230, to Corporation Service
Company, 1201 Hays Street, Tallahassee, Florida 32301-2525 on
this 1 2 bay of December, 2001.
DENNIS L. GODFREY
Copies furnished:
Michael Allen, Administrator
Beverly Health & Rehab. Englewood
1111 Drury Lane
Englewood, Florida 34224
(U. S. Mail)
Beverly Enterprises - Florida, Ine.
One Thousand Beverly Way
Fort Smith, Arizona 72519
(U.S. Mail)
Corporation Service Company
Registered Agent
1201 Hays Street
Tallahassee, Florida 32301
(Certified Mail)
Elizabeth Dudek
Deputy Secretary
Agency for Health Care
Administration
{Inter-office mail)
Dennis L. Godfrey, Esquire
AHCA - Senior Attorney
$25 Mirror Lake Drive North,
St. Petersburg, Florida 33701
~
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Docket for Case No: 02-000701
Issue Date |
Proceedings |
Apr. 10, 2002 |
Order Closing File issued. CASE CLOSED.
|
Apr. 10, 2002 |
Joint Motion to Remand (filed via facsimile).
|
Mar. 12, 2002 |
Order Accepting Qualified Representative issued.
|
Mar. 11, 2002 |
Affidavit of R. Davis Thomas, Jr. (filed via facsimile).
|
Mar. 11, 2002 |
Motion to Allow R. Davis Thomas, Jr. to Appear as Respondent`s Qualified Representative (filed via facsimile).
|
Mar. 07, 2002 |
Notice of Hearing issued (hearing set for April 25, 2002; 9:30 a.m.; Punta Gorda, FL).
|
Mar. 07, 2002 |
Order of Pre-hearing Instructions issued.
|
Feb. 27, 2002 |
Joint Response to Initial Order (filed via facsimile).
|
Feb. 21, 2002 |
Initial Order issued.
|
Feb. 15, 2002 |
Administrative Complaint filed.
|
Feb. 15, 2002 |
Petition for Formal Administrative Hearing filed.
|
Feb. 15, 2002 |
Notice (of Agency referral) filed.
|