STATE OF FLORIDA Op ¥e STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2002045371 vs. 0D - Divo CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER 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 CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Five Thousand dollars ($5,000) pursuant to Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes. This amount of sanction represents a doubled fine because the facility was previously cited for a Class II violation (F324) on the annual survey of 4/22-25/02. 2. The Respondent was cited for a Class II deficiency during the complaint survey conducted on or about June 28, 2002. Jurisdiction 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 F.A.C. Parties 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida 33907. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PROVIDE THE CARE AND SERVICES NECESSARY TO MAINTAIN RESIDENT #1 AT THE HIGHEST PRACTICABLE PHYSICAL AND MENTAL WELL-BEING, FAILED TO PROMPTLY NOTIFY RESIDENT #1'S RESPONSIBLE PARTY AND PHYSICIAN OF THE CHANGE IN HER CONDITION WHEN SHE STOPPED EATING FOR ONE WEEK PRIOR TO BEING ADMITTED TO THE HOSPITAL. VIOLATING 59A-4.106(4) (q) AND 59A-4.1288 FL. ADMIN. CODE INCORPORATING BY REFERENCE 42 CFR 483.25 CLASS II DEFICIENCY 7. AHCA re~alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about 6/28/02 a complaint investigation was conducted at the respondent’s facility. 9. On that date, based on staff interviews, one of one resident records reviewed, facility and hospital records reviewed, the facility did not provide the care and services necessary to maintain Resident #1 at the highest practicable physical and mental well-being, failed to promptly notify Resident #1's responsible party and physician of the change in her condition when she stopped eating for one week prior to being admitted to the hospital. 10. The findings regarding this violation include: a./ A review of Resident #1's medical record from the facility revealed she was admitted to the facility on 7/12/01. She was discharged to an Assisted Living Facility on 6/10/02, however, did not seem to meet the criteria for an Assisted Living Facility (ALF) and was sent back to the nursing home the same day. In an interview the Social Worker stated she was very weak. b./ The medical records show prior to 6/10/02, a data sheet showing the amount of food she ate for each meal revealed as approximately 25% to 75% of her meals. After 6/10/02, the data sheet revealed she either refused to eat her meals, the amount of food eaten was zero or the box was left blank. Of the 42 meals offered from 6/10 to 24/02, at only two meals documentation showed a meal consumption of 25%, 14 meals were marked with a "R" for refused, 5 meals were marked "0", and 21 meals lacked any documentation. The PM snack documentation from 6/10 to 24/02 showed only 1 documented refusal, and 13 opportunities lacked documentation. Fluid documentation for 6/10 to 24/02 revealed 28 shifts with 16 of 28 showing fluids offered. No fluid consumption is noted. c./ Interview with staff stated she was refusing to eat and stopped eating. Interview with Resident #1 family member revealed the family member and a staff nurse had conversed about the refusal to eat and felt the residents was displaying manipulative attention seeking behavior. d./ A review of her weights showed on 5/18/02 she weighed 172.2 pounds. On 6/13/02, she refused to be weighed and on 6/17/02 she weighed 147.8 pounds. A nutrition note on 6/26/02 revealed there was a 14% weight loss since readmission (6/10/02). According to the nurse's notes on 6/10/02 the resident returned to the facility from the ALF. On 6/11/02, there were family concerns and these issues would be brought up to the Social Worker. The next nurse's note was 6/18/02. It revealed the resident refuses to get out of bed, won't speak to the staff, refuses food and possible depression. e./ Interview with the DON revealed no documentation was found to show the physician was notified of the change in the resident from 6/10 to 6/18 until asking for an order for a Psychological Consult. On 6/21/02, the Psychologist ordered Effexor and Zyprexa. These medications were documented as given 1 time from 6/21 to 6/24, and refused all other times. On 6/21/02, Resident #1 continues to refuse to get out of bed, is incontinent of bowel and bladder, "primarily dependent in care tasks," she does not assist with her activities of daily living skills and "often refused to be toileted." She is lethargic and catatonic at times. She had a decline in overall function in the past 10 days. The nurse's notes on 6/22/02 revealed she refused her medications. A review of her Medication Administration Record revealed she refused her medications on 6/21, 6/22 and 6/23/02. Attempts were made to seat an IV on 6/23/02, without success. She was then sent to the emergency room in the early hours on 6/24/02. £./ Blood was collected on 6/23/02 and the results were printed on 6/24/02. The following are the result: - Sodium level was 152 (high) - normal range 137 - 145. - Potassium was 8.4 (critical factor) - normal range 3.6 - 5.0. - Chloride 116 (high) - normal range 98 - 107. - CO2 below 5.0 - normal range 22 - 30. - BUN 388 (high) - normal range 7 - 17. ~ Creatinine 17.7 (high) - normal range .7 - 1.2. serum glucose - 141 (high) - normal range 70 - 105. calculated serum osmolality - 470 (high) normal range 285 - 295. g./ Interview with facility staff stated they did not notify the family of this change in the resident's condition until she went to the hospital. Interview with another facility staff stated she was not able to find any type of documentation in Resident #1's chart or anywhere else that the family was notified of this change between 6/11/02 and 6/18/02. Interview with the DON revealed no documentation was found to show the physician was notified of the change in the resident from 6/10 to 6/18 until asking for an order for the psychiatric consult. Family stated they were notified Resident #1 was at the hospital on 6/24/02. 11. The above actions or inactions constitute a violation of Fl. Admin Code R. 59A-4.106(4) (q) which require that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 12. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under Sections 400.022 (3), 400.102(1) (a,d), 400.121(1), and 400.23(8) (b), Florida Statutes. WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a fine of Five Thousand dollars ($5,000) for the violation cited in Count I, against the respondent under Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121 Fl. Stat. (2001) D. All other general and equitable relief allowed by law. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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. Respectfully submitted, Hiheaa tO. heey te Eileen O’Hara Gatc¥a, Esquire AHCA - Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 I HEREBY CERTIFY that a copy hereof has been furnished to CT Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 Return Receipt No. 7002 0510 0005 5504 4871 and to Administrator, Cypress Community Care Center, 7173 Cypress Drive S.W., Fort Myers, FL 33907, U.S. Mail, on December /X , 2002. hrkinw? Secu Mh Fileen O'Hara Gar€ig, Esquire Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Bileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330D St. Petersburg, Florida 33701

Docket for Case No: 03-000160