STATE OF FLORIDA STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, CASE NO: 2002046613 Petitioner, vs. ALTERRA HEALTHCARE CORPORATION, d/b/a ALTERRA STERLING HOUSE OF PORT CHARLOTTE, 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 ALTERRA HEALTHCARE CORPORATION, d/b/a ALTERRA STERLING HOUSE OF PORT CHARLOTTE (hereinafter “Respondent”) and alleges the following NATURE OF THE ACTION 1. This is an action to impose administrative fines on Respondent pursuant to Sections 400.419(1) (b) and 400.419(9), Florida Statutes. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 3. AHCA, Agency for Health Care Administration, has jurisdiction over Respondent pursuant to Chapter 400 Part III, Florida Statutes. 4. Venue lies in Charlotte County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. PARTIES 5. Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 18440 Toledo Blade Blvd., Port Charlotte, FL 33948. Respondent, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code, having been issued license number 9027. COUNT I RESPONDENT FAILED TO MONITOR THE QUANTITY AND QUALITY OF RESIDENT DIETS VIOLATING Fla. Admin. Code R. 58A-5.0182(1) (a) (2002); Fla. Admin. Code R.58A-5.020 (2002) CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about July 30, 2002, a survey was conducted at Respondent’s facility. AHCA cited Respondent based on the findings below, to wit: Based on record review, review of the diet roster, interview with facility staff, and observation of foods served at the noon and evening meals, the facility failed to provide health care provider ordered therapeutic diets to meet the needs of 1 (Resident #4 who is on a Renal Diet) of 3 active sampled residents. The findings include: 1. Observation of the menu posted in the kitchen confirmed that only the menu for a Regular Diet (Week At A Glance) was posted in the serving area. When questioned by the surveyor as to how servers knew what to serve those residents with special dietary needs, the Dietary Manager replied, "We basically serve everybody a Regular Diet because that is what they want, and they have a right to eat anything they want.” 2. Resident #4 was admitted to the facility 3/31/01 with diagnoses including End-Stage Renal Disease, Diabetes Mellitus, and Gout. The diet order by the health care provider called for a Renal Diet. This resident received dialysis 3 times weekly. The meal plan for the Renal Diet for this resident was observed posted on the refrigerator in the kitchen. However, the Dietary Manager stated that only high potassium foods such as cantaloupe were limited for this resident and that the resident knew what she should and should not eat. The meal plan specified modifications from the Regular Diet to include protein, carbohydrates, fats, sodium, phosphorus, potassium, and a fluid restriction. The Dietary Manager confirmed that this resident's special dietary needs were not being addressed. The meal plan and instructions from the dialysis RD (Registered Dietitian) for this resident specified that 8 to 10 ounces of protein should be consumed daily because dialysis treatments remove "some of your much needed protein." The Renal Diet of the facility for the day of the survey provided only 5 ounces of protein while the Regular Diet, per menu, provided 6 ounces. Observation made during the meals confirmed that this resident was served a 1 and 1/2 ounce portion (weighed at request of the surveyor) of lemon chicken for lunch and a 2 ounce portion of turkey for dinner, This resident was also served plain rice with no gravy for dinner. When the resident requested some of the gravy from the Stir-Fry Beef that was being served to other residents, this resident was provided a small serving of the gravy that, when tasted by the surveyor, was extremely salty. The Dietary Manager confirmed that the dish was too salty due to the Soy Sauce added. Instructions from the RD specified that salt should be limited. "Too much salt will cause you to retain fluids. This can make your blood pressure too high or extra swelling that the treatments may not be able to remove." Review of lab values from the Dialysis Center for this resident for 4/03/02, revealed an albumin level of 3.9 with a goal level of 4.0 to 5.0. The comment regarding this albumin level is as follows: "Your albumin is too low. This means you body's protein stores are low. This may cause muscle breakdown (which includes your heart) and an increased chance for infection. It is an indication that you must eat more animal protein like meat, poultry, fish, and eggs. You also need adequate calories so that the protein is available for muscle building. You may need a supplement. Please speak to the dietitian." Review of the most current lab values from the Dialysis Center dated 7/10/02, reflected an albumin level unimproved at 3.9. The phosphorus level was also outside the goal range of 2.5 to 5.5 at 2.3. Comments were: "This may mean that you are not eating enough. Speak with your doctor about this. Please review your diet with the dietitian." The creatine level was low at 9.2 with a goal of greater than 10. Comments were: "This refers to your protein intake (inadequate)." The Glycohemoglobin A1C was too low at 5.8 with a goal range of 6.0 to 7.5. Comments included: "It may mean that you are not eating enough. Please review your diet with the dietitian." The fluid gains reported was 3.0 kg. which is at the upper end of the goal range of 1 to 3 kg between treatments. Due to the lab values of this resident being outside of goal range, the facility was not meeting the special dietary needs of this End-Stage Renal Disease resident. 9. The above actions or inactions are a violation of Rule 58A-5.0182(1) (a), Florida Administrative Code, which requires that an assisted living facility shall offer personal supervision, as appropriate for each resident, including the following: monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, Florida Administrative Code. 10. The above referenced violation constitutes the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (b), Florida Statutes, the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 11. Pursuant to Section 400.419(9), Florida Statutes, AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint or for monitoring visits conducted under 400.428 (3) (c) to verify the correction of the violations. COUNT II RESPONDENT FAILED TO PROVIDE REGULAR MEALS WHICH MEET THE NUTRITIONAL NEEDS OF RESIDENTS, AND THERAPEUTIC DIETS AS ORDERED BY THE RESIDENT’S HEALTH CARE PROVIDER FOR RESIDENTS WHO REQUIRE SPECIAL DIETS IN VIOLATION OF Fla. Admin. Code R. 58A-5.020(1) (c) CLASS II DEFICIENCY 12. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 13. On or about July 30, 2002, a survey was conducted at the facility. AHCA cited Respondent based on the findings below, to wit: Based on review of current approved menus in use by the facility, meal observations, review of the Diet Roster and clinical records, as well as interviews, the facility failed to serve meals adequate in nutrients to meet the dietary needs of all residents and failed to serve therapeutic diets ordered by the health care provider to 1 (Resident #4 who is on a Renal Diet) of 3 active sampled Residents, and failed to serve meals adequate in caloric content to 2 (Residents #1 and #3) of 3 active sampled residents as evidenced by undesirable weight loss of 9% from usual weight in 2 months by Resident #1 and 17.6% weight loss in Jess than 2 months by Resident #3. The findings include: 1. Observation of the noon meal at approximately 12 noon on the day of the survey revealed a small portion of boneless, skinless chicken breast. Multiple complaints were voiced by residents dining at that time that the meat portions served by the facility were inadequate and, at times, non-existent with pasta dishes being served several times weekly without meat sauce. The surveyor requested that the portion of chicken be weighed to determine if the 4 0z. portion specified on the facility's menu was being served to the residents. The Dietary Manager weighed the chicken in the presence of the surveyor. The portion weighed approximately 1 and 1/2 ounces instead of the menu-specified 4 ounce serving. 2. Review of the menu for the evening meal confirmed that the main dish item was to be 4 ounces of Stir Fried Beef served over 1/2 cup of rice. Preparation of the beef was observed in the afternoon to consist of boiling rather than stir-frying 10 pounds of beef and vegetables. The item was prepared without benefit of a standardized recipe. The Dietary Manager was observed to use 10 pounds of cubed beef in the dish. The surveyor searched for and found the recipe that should have been used. The recipe specified that 12 pounds of beef should be used to yield 48 servings of the product. Therefore, the facility served only 105 ounces of beef instead of the required 127 ounces (calculated considering losses during cooking). This is 2.2 ounces per resident. The total protein serving for these two meals equaled 3.7 ounces instead of the 6.6 ounces specified on the menu for these two meals. (One ounce of protein was listed on the menu to be served at breakfast bringing the total for the day to 7.6 ounces.) 3. Observation of the menu posted in the kitchen confirmed that only the menu for a Regular Diet (Week At A Glance) was posted in the serving area. When questioned by the surveyor as to how servers knew what to serve those residents with special dietary needs, the Dietary Manager replied, "We basically serve everybody a Regular Diet because that is what they want, and they have a right to eat anything they want.” 4. Resident #4 was admitted to the facility 3/31/01 with diagnoses including End-Stage Renal Disease, Diabetes Mellitus, and Gout and with a diet order for a Renal Diet. This resident received dialysis 3 times weekly. The meal plan for the Renal Diet for this resident was observed posted on the refrigerator in the kitchen. However, the Dietary Manager stated that only high potassium foods such as cantaloupe were limited for this resident and that the resident knew what she should and should not eat. The meal plan specified modifications from the Regular Diet to include protein, carbohydrates, fats, sodium, phosphorus, potassium, and a fluid restriction. The Dietary Manager confirmed that this resident's special dietary needs were not being addressed. The meal plan of and instructions from the dialysis RD (Registered Dietitian) for this resident specified that 8 to 10 ounces of protein should be consumed daily because dialysis treatments remove "some of your much needed protein." The Renal Diet of the facility for the day of the survey provided only 5 ounces of protein while the Regular Diet per menu provided 6 ounces. Observation made during the meals confirmed that this resident was served a 1 and 1/2 ounce portion (weighed at request of the surveyor) of lemon chicken for lunch and a 2 ounce portion of turkey for dinner. This resident was also served plain rice with no gravy for dinner. When the resident requested some of the gravy from the Stir-Fry Beef that was being served to other residents, this resident was provided a small serving of the gravy that when tasted by the surveyor was extremely salty. The Dietary Manager confirmed that the dish was too salty due to the Soy Sauce added. Instructions from the RD specified that salt should be limited. "Too much salt will cause you to retain fluids. This can make your blood pressure too high or extra swelling that the treatments may not be able to remove." Review of lab values from the dialysis center for this resident for 4/03/02, revealed an albumin level of 3.9 with a goal level of 4.0 to 5.0, The comment regarding this albumin level is as follows: "Your albumin is too low. This means you body's protein stores are low. This may cause muscle breakdown (which includes your heart) and an increased chance for infection, It is an indication that you must eat more animal protein like meat, poultry, fish, and eggs. You also need adequate calories so that the protein is available for muscle building. You may need a supplement. Please speak to the dietitian." Review of the most current lab values from the Dialysis Center dated 7/10/02, reflected an albumin level unimproved at 3.9. The phosphorus level was also outside the goal range of 2.5 to 5.5 at 2.3. Comments were: "This may mean that you are not eating enough. Speak with your doctor about this. Please review your diet with the dietitian." The creatine level was low at 9.2 with a goal of greater than 10. Comments were: "This refers to your protein intake (inadequate).". The Glycohemoglobin A1C was too low at 5.8 with a goal range of 6.0 to 7.5. Comments included: "It may mean that you are not eating enough. Please review your diet with the dietitian.” The fluid gains reported was 3.0 kg. which is at the upper end of the goal range of 1 to 3 kg between treatments. Due to the lab values of this resident being outside of goal range, the facility was not meeting the special dietary needs of this End-Stage Renal Disease resident. 5, Resident #1 was admitted to the facility on 6/01/02. The Health Assessment Form completed on this Resident prior to admission on 5/09/02 listed the weight to be 165 pounds, which the Resident stated in interview to be his usual weight. The weight record of the facility reflected a weight of 150 pounds on 7/04, approximately 1 month after admission. During the evening meal, the resident complained that the meat served to him was tough and that he "would not feed the meal to a dog. A dog would not eat the food served here. The meals here are terrible and getting worse. I have lost a lot of weight. I used to weight 165 pounds. I've only been here a few weeks. The food is getting worse everyday.” 6. Resident #3 was admitted to the facility on 4/05/02 with diagnoses including Advanced Alzheimer's Disease. The resident's weight obtained on 4/08/02 was recorded to be 131 pounds. The weight record documents a steady fast weight loss to 108 pounds on 6/05/02, a loss of 17.6% of body weight in 2 months. The weight record nor the clinical record of the resident contained any documentation that the physician had been notified of the weight loss. Nor had the facility intervened to stop the weight loss. A Resident Care Aide who was observed feeding the resident at the evening meal stated that the resident was losing weight because of depression. Review of this resident's record revealed that he had been placed on ECC (Extended Congregate Care) services on 7/23/02 due to an open area on the buttocks. The resident was observed to be dining during the evening meal positioned more than 12 inches from his food, lap buddy in place, and unable to reach any of his meal. He was being fed by a staff member who was also feeding another resident at the same table. Resident #3 was observed to be chewing on his napkin, not eating, and being offered lumpy-consistency pureed foods when his diet order is for Regular Diet. 14. The above actions or inactions are a violation of Section 58A-5.020(1) (c), Florida Administrative Code, which requires Respondent to provide regular meals that meet the nutritional needs of residents, and therapeutic diets as ordered by the resident’s health care provider for residents who require special diets. 15. The above referenced violation constitutes the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (b), Florida Statutes, the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 16. Pursuant to Section 400.419(9), Florida Statutes, AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint or for monitoring visits conducted under 400.428 (3) (c) to verify the correction of the violations. COUNT III RESPONDENT FAILED TO ENSURE THAT THE RECOMMENDED DIETARY ALLOWANCES WERE MET IN VIOLATION OF Fla. Admin. Code R.58A-5.020(2) (b) (2002) CLASS II DEFICIENCY 17. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 18. On or about July 30, 2002, a survey was conducted at the facility. AHCA cited Respondent based on the findings below, to wit: Based on review of current approved menus in use by the facility, meal observations, review of the Diet Roster and clinical records as well as interviews, the facility failed to serve meals adequate in nutrients, specifically protein, to meet the dietary needs of all residents including 1 (Resident #4) of 3 active sampled residents resulting in albumin below goal values and failed to serve meals adequate in caloric content to 2 (Residents #1 and #3) of 3 active sampled residents as evidenced by undesirable weight loss of 9% from usual weight in 2 months by Resident #1 and 17.6% weight loss in less than 2 months by Resident #3. The findings include: 1. Resident #4 was admitted to the facility 3/31/01 with diagnoses including End-Stage Renal Disease, Diabetes Mellitus, and Gout and with a diet order for a Renal Diet. This resident received dialysis 3 times weekly. The meal plan of and instructions from the dialysis RD (Registered Dietitian) for this resident specified that 8 to 10 ounces of protein should be consumed daily because dialysis treatments remove "some of your much needed protein." The Renal Diet of the facility for the day of the survey provided only 5 ounces of protein while the Regular Diet per menu provided 6 ounces. Observation made during the meals confirmed that this resident was served a ] and 1/2 ounce portion (weighed at request of the surveyor) of lemon chicken for lunch and a 2 ounce portion of turkey for dinner. Review of lab values from the Dialysis Center for this resident for 4/03/02, revealed an albumin level of 3.9 with a goal level of 4.0 to 5.0. The comment regarding this albumin level is as follows: "Your albumin is too low. This means you body's protein stores are low. This may cause muscle breakdown (which includes your heart) and an increased chance for infection. It is an indication that you must eat more animal protein like meat, poultry, fish, and eggs. You also need adequate calories so that the protein is available for muscle building. You may need a supplement. Please speak to the dietitian." Review of the most current lab values from the Dialysis Center dated 7/10/02, reflected an albumin level unimproved at 3.9. The phosphorus level was also outside the goal range of 2.5 to 5.5 at 2.3. Comments were: "This may mean that you are not eating enough. Speak with your doctor about this. Please review your diet with the dietitian." The creatinine level was low at 9.2 with a goal of greater than 10. Comments were: "This refers to your protein intake (inadequate)." The Glycohemoglobin A1C was too low at 5.8 with a goal range of 6.0 to 7.5. Comments included: "It may mean that you are not eating enough. Please review your diet with the dietitian.” The fluid gains reported was 3.0 kg. which is at the upper end of the goal range of 1 to 3 kg between treatments. Due to the lab values of this resident being outside of goal range, the facility was not meeting the special dietary needs of this End-Stage Renal Disease resident. 2. Resident #1 was admitted to the facility on 6/01/02. The Health Assessment Form completed on this Resident prior to admission on 5/09/02 listed the weight to be 165 pounds which the Resident stated in interview to be his usual weight. The weight record of the facility reflected a weight of 150 pounds on 7/04, approximately | month after admission. During the evening meal, the resident complained that the meat served to him was tough and that he "would not feed the meal to a dog. A dog would not eat the food served here. The meals here are terrible and getting worse. | have lost a lot of weight. I used to weight 165 pounds. I've only been here a few weeks. The food is getting worse everyday.” 3. Resident #3 was admitted to the facility on 4/05/02 with diagnoses including Advanced Alzheimer's Disease. The resident's weight obtained on 4/08/02 was recorded to be 131 pounds. The weight record documents a steady fast weight loss to 108 pounds on 6/05/02, a loss of 17.6% of body weight in 2 months. The weight record nor the clinical record of the resident contained any documentation that the physician had been notified of the weight loss. Nor had the facility intervened to stop the weight loss. A Resident Care Aide who was observed feeding the resident at the evening meal stated that the resident was losing weight because of depression. Review of this resident's record revealed that he had been placed on ECC (Extended Congregate Care) services on 7/23/02 due to an open area on the buttocks. The resident was observed to be dining during the evening meal positioned more than 12 inches from his food, lap buddy in place, and unable to reach any of his meal. He was being fed by a staff member who was also feeding another resident at the same table. Resident #3 was observed to be chewing on his napkin, not eating, and being offered lumpy-consistency pureed foods when his diet order is for Regular Diet. 19. The above actions or inactions are a violation of Rule 58A-5.020(2) (b),1-7, Florida Administrative Code, which provides that the recommended dietary allowances shall be met by offering a variety of foods adapted to the food habits, preferences and physical abilities of the residents and prepared 10 by the use of standard recipes. For facilities with a licensed capacity of sixteen or fewer residents, standardized recipes are not required. Unless a resident chooses to eat less, the recommended dietary allowances to be made available to each resident daily by the facility, are as follows: 1. protein: 6 ounces or 2 or more servings; 2. vegetables: 3-5 servings 3. fruit: 2-4 or more servings 4. bread and starches: 6-11 or more servings 5. milk or milk equivalent: 2 servings 6. fats, oils and sweets: use sparingly; and 7. water 20. The above referenced violation constitutes the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (b), Florida Statutes, the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 21. Pursuant to Section 400.419(9), Florida Statutes, AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint or for monitoring visits conducted under 400.428 (3) (c) to verify the correction of the violations. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following: 1, Make factual and legal findings in favor of the Agency on Count I, Count II and Count III; 2. Impose a fine and survey fee in the amount of three thousand five hundred dollars ($3,500) for the violations cited in Count I, Count ITI and Count III against the Respondent, pursuant to Sections 400.419(1) (b) and 400.419(9), Florida Statutes; and 3. Any other general and equitable relief as deemed appropriate. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Katrina D. Lacy, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS oF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Hits. fo, fuce Katrina D. acy Baquire AHCA — Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7002 2030 0002 7117 5911, to CT Corporation System, 1200 South Pine Island Drive, /$ _, 2002. Copies furnished to: CT Corporation System Registered Agent for Alterra Sterling House of Port Charlotte 1200 South Pine Island Roal Plantation, FL 33324 (Certified U.S. Mail) Joyce Wyman, Administrator Alterra Sterling House of Port Charlotte 18440 Toledo Blade Blvd. Port Charlotte, FL 33948 (U.S. Mail) Wendy Adams Plantation, FL 33324, on November Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 Tallahassee, FL 32308 (Interoffice Mail) Alberta Granger AHCA, Assisted Living Facilities 2727 Mahan Drive, Bldg #3, MS Code #30 Tallahassee, Florida 32308 (Interoffice Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330G St. Petersburg, Fl 33701

Docket for Case No: 03-000167