CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, OD O11 Petitioner, AHCA NO: 2001 051071 He) o a vs. =e ; FOUNTAINS SENIOR PROPERTIES OF FLORIDA, INC., ~ oT d/b/a SPRINGS AT LAKE POINTE WOODS, = ae) “ oa Respondent. o = / oy ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against FOUNTAINS SENIOR PROPERTIES OF FLORIDA, INC. d/b/a SPRINGS AT LAKE POINTE WOODS, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION J) This is an action to impose administrative fines in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2500) pursuant to §§ 400.141(15)(d), 400.102(1) (d), 400.121(2), and 400.23(8), Florida Statutes. 2) The Respondent was cited for the deficiencies set forth below as a result of survey conducted on or about August 8, 2001. JURISDICTION AND VENUE 3) AHCA has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4) Venue lies in County Name County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 Fla. Admin. Code. Page 1 of 10 5) 6) 7) 8) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 PARTIES 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. Respondent is a skilled nursing facility located at 78348 BENEVA ROAD, SARASOTA, FLORIDA, 34238. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. Its license number is 1468096 effective through 06/30/2003 and the certificate number is 9124. COUNTI RESPONDENT FAILED TO ENSURE THAT EACH RESIDENT RECEIVED AND 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, INCLUDING THE PROVISION OF ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS.. FLA ADMIN CODE R 59A-4.1288 (ADPOTING BY REFERENCE 42 CFR §483.25), §§ 400.022(1)(1), 400.022(3), 400.102(1)(d), 400.121(2), and 400.23(8)(b), FLA STAT CLASS II DEFICIENCY AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. On or about August 8, 2001, AHCA conducted a survey of the Respondent. Findings included: a) Based on observations, record reviews and staff interviews, the facility failed to provide adequate supervision and/or assistive devices to prevent incident and/or accident for 5 (Residents #1, #3, #7, #10 and #11) of 8, from a sample of 13 active sampled residents reviewed for falls/fracture/abrasions/bruise. This is evidenced by: b) The facility's failure to develop a plan of care to address the risk for falls on Resident #11 and their failure to provide adequate supervision and/or assistive device to prevent an incident/accident which resulted in a right hip fracture. i) The facility failed to develop a Care Plan to address the risk for incident/accident for Resident #10. Page 2 of 10 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 ii) Resident #7 did not have an adequate Care Plan to prevent skin tears during ADL (Activities of Daily Living) care. ili) Residents #1 and #3 did not have assistive devices, as stated in their Care Plan and as ordered by their physicians, to prevent an accident/incident. 9) Resident #11 was admitted to the facility on 4/17/01 with diagnoses that include, but not limited to, Dementia - Alzheimer's Type with Agitation. a) b) ¢) d) An Interim Plan of Care was developed on 4/17/01, the day of the resident's admission to the facility. Under "Problem/Issue" it stated, "Impaired safety awareness R/T (related to) decreased cognitive function." The goal was for the resident not to have injuries. The following approaches were listed: i) PT, OT eval (evaluation) & tx (treatment)." ii) Monitor freq. (frequently for) safety issues.” iii) Redirect PRN (as needed)." Review of the Physical Therapy (PT) evaluation dated 4/18/01 stated, "Pt. (Patient) able to ambulate independently inside her room & around the hallways without assistive device. Pt. noted with good balance. Pt not a candidate for PT at this time." Review of the Occupational Therapy (OT) evaluation dated 4/18/01 stated, "Present with decreased cognition easily irritable/agitated; Pt ambulates I ly (independently) all over the facility PRN. No OT services warranted at this time." Interview with the rehab. (rehabilitation staff) on 8/8/01 at approximately 11:00 A.M., confirmed that the resident had good balance, however, due to her cognitive impairment "she has poor safety awareness.” The clinical record did not have documentation on how the resident was going to be monitored. There was no documentation in the resident's Plan of Care to indicate what interventions will be put in place to prevent the resident from an incident/accident. Page 3 of 10 f) g) h) i) dD k) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 Review of the resident's MDS (Minimum Data Set) completed on 4/30/01, revealed she was ambulatory. She required extensive assistance to bathe. She was frequently incontinent of bladder. She required supervision/cuing during meals. She also had the following behaviors: wandering, verbally abusive and physically abusive. Review of the RAP (Resident Assessment Protocol) revealed she is triggered for falls. The RAP key stated, "Potential for additional falls or risk of initial fall suggested based on the following: Wandering; Behavior occurred 4 to 6 days in the last 7 days." The assessment stated that the resident was at risk for fails secondary to her "cognitive losses, need for supervision of ADL's (Activities of Daily Living), psychotropic med (medication) use and incontinence of bladder. She is at times delusional which complicates things. Will address fall-risk and prevention interventions (Resident with companion care during the day).” Review of the physician's order revealed the resident is on Risperdal (psychotropic drug) 0.5 mg twice a day. During the review of the Comprehensive Care Plan developed on 5/8/01, it did not have documentation to indicate that the resident's risk for fall had been addressed. There was no documentation in the resident's clinical record to indicate what "fall-risk and prevention interventions" will be put in place to prevent an incident or accident. During an interview with the MDS/Care Plan Coordinator on 8/8/01 at approximately 10:00 A.M., she disagreed that the resident had good balance. She stated that the resident's gait was unsteady. She confirmed that there was no Care Plan developed on 5/8/01 for the resident to address her risk for falls. She also stated, "I guess we were complacent because she has a sitter." During the review of the nurse’s notes dated 4/20/01, it stated that due to the resident's problem with adjustment secondary to her admission to the facility, her family has provided sitters to whom she is acquainted. The nurse's notes dated 4/26/01, stated that the resident was verbally abusive and hitting a CNA (Certified Nursing Assistant), She is wandering and hallucinating. Page 4 of 10 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 The nurse's notes further stated, all these behaviors occur early in the morning. It also stated, "Our department was “unaware” that "no" sitters were attending her (resident) from 10 PM to 8 AM." Further investigation confirmed that the resident has a private sitter from 8:00 A.M. to 10:00 P.M. 1) The nurse's notes dated 5/8/01, revealed the resident was admitted to the hospital for abdominal pain. She was readmitted to the facility in the evening of 5/10/01. On 5/11/01, the nurse's notes stated, "2 PM - Resident fell in her room while walking toward her husband's bed; X-ray has now shown a fx (fractured) hip..." Further review of the clinical record confirmed a Right Femoral Neck Fracture. The resident was admitted to the hospital on 5/11/01 for hip surgery. m) A review of an incident report completed on 5/27/01, several days after her re-admission to the facility, revealed the resident was calling for help and was found face down on the floor at the foot of the bed at 1:45 A.M. There is no documentation in the resident's clinical record, nor in her Comprehensive Care Plan to address further incidents/accidents. A Care Plan to address falls was not developed for the resident until 8/1/01, two months after her incident on 5/27/01. n) Review of the resident's most current MDS completed on 7/13/01, revealed she continues to be verbally abusive, but this behavior is easily altered. The MDS also showed decline in the following functional status: extensive assistance of 1 to transfer, ambulate, and hygiene. The resident is also now frequently incontinent of bowel. She requires continues supervision and some assistance during meals. 10) During the review of Resident #7's RAI (Resident Assessment Instrument) and significant change MDS (Minimum Data Set) completed on 5/21/2001, indicates that the resident cognitively impaired and requires extensive assistance to transfer. a) During the review of the resident's Comprehensive Care Plan developed on 5/1/01 it revealed the following problems were included, "fragile skin, prone to tear.". There was no documentation to indicate what interventions were to be implemented to prevent her from skin tears. Page 5 of 10 b) c) d) €) 8) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 Review of an incident report dated 6/30/2001, revealed Resident #7 sustained two skin tears while being transferred from the bed to the wheelchair by facility staff. There was no documentation in the resident's clinical record to indicate that measures to prevent this incident from happening again had been put in place. Review of an incident report dated 7/31/01, revealed the resident sustained another skin tear while being transferred from the bed to the chair by facility staff. Further review of the clinical record revealed no documentation to indicate what measures will be put in place to prevent these incidents from recurring. The Care Plan developed on 5/22/01, stated that the resident was resistive to care. However, during the review of the incident reports on 6/30/01 and 7/31/01, it did not indicate that the resident was resistive to care. Resident #10 was admitted with multiple diagnoses including but not limited to Cerebral Vascular Accident, Hypertension, Hemiplegia, Hypothyroidism, Dementia and Diabetes Mellitus. The resident initial skin assessment on 7/16/01, revealed multiple skin tears, an abrasions and an ecchymotic area on the resident's left and right arm and hand. The resident's Minimum Data Set revealed the resident to be occasional incontinent of bowel and has a Foley catheter. The Interdisciplinary Resident Care Plan dated 4/17/01 revealed, "Decline in Activities of Daily Living. Patient with decrease in functional mobility - extensive assist in bed mobility and transfer." Interdisciplinary Resident Care Plan approaches revealed, "PT/OT (Physical Therapy and Occupational Therapy) per MD order." The resident was assessed at risk for falls on 4/26/01 and the RAPS (Resident Assessment Protocol Summary) was completed on 4/27/01. The RAPS stated to proceed to Care Plan the resident on 5/01/01 for the risk for falls. The resident RAPS key on 4/27/01 revealed, "Resident is at risk for falls secondary to his complaint of dizziness, unsteady gait, ADL (Activities of Daily Living) dependencies, Cognitive losses, etc. See ADL RAP as well. Will address Fall-Risk and Page 6 of 10 h) i) aD) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 prevention interventions as well as OT/PT (Occupational Therapy and Physical Therapy) Treatment.” On interview with the Care Plan Coordinator on 8/6/01, she provided the surveyor with a written Interdisciplinary Resident Care Plan dated 4/17/01 and up dated on 6/20/01. She also provided printed Care Plans dated 5/1/01 with up dated of 6/20/01. There was no Care Plan to address the resident's risk for falls 5/1/01 through 6/20/01. On 7/10/01, the resident's nurses notes revealed skin tears from old ecchymotic areas on right hand and elbow. Probable cause was resident hitting right arm on bedside rails, behavior related. An Interim Plan of Care was completed on 7/10/01 for skin tears. The approaches included but not limited to monitor for safety awareness. There was no documentation to indicate how the resident will be monitored for safety. The resident was Care Planned on 8/5/01 for, "At Risk for Falls related to decline in mobility, AEB (as evidenced by) statements made and increased need for assistance." The resident was also Care Planned on 8/5/01, "At Risk for impaired skin integrity related to occasional bowel incontinence and decreased mobility.". This Care Plan does not have documentation to indicate what interventions will be implemented to prevent the resident from further skin tears. 11) Clinical record review for Resident #3 revealed a Significant Change in Status Assessment MDS (Minimum Data Set). Assessment reference dates of 4/4/01 and 4/9/01, indicated that the resident had fallen within the last 31-180 days. Nurses notes dated 4/21/01, "12:10 A.M. Res. (resident) found on the floor by her bed, stated that she was restless in bed and rolled out. Denies and discomfort no apparent injuries noted..." Nurses notes dated 4/21/01, "4:15 P.M. CNA (Certified Nursing Assistant) found (resident's name) on her knees between w/c & her bed. States, "I tried to go to bed." Tabs alarm off & had not used call bell..." Nurse's notes dated 7/10/01, "11 A (A.M.) Res. found on floor in front of bathroom stated that she was attempting to grab door handle and fell on her bottom. No injuries. Family and (doctor's name) notified." Page 7 of 10 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 a) Review of the resident's Interdisciplinary Resident Care Plan dated 4/12/00, under need states, "decline in function due to L (left) hemiparesis related to CVA (Cerebral Vascular Accident) + places resident at risk for falls + injury.” Further review of the Care Plan revealed that the resident had a fall on 10/6/00, 11/8/00 and 12/1/00. Under goals, "#3 Res. (resident) will have no falls within the facility through 7/25/00, 10/23/00, 1/10/01 and 4/17/01." Under approaches lists, "Tabs alarm on while in w/c." Review of the resident's treatment sheets revealed an order dated 1/3 1/01, that the resident is to have the Tabs alarm while in bed. b) Observation on 8/6/01 at approximately 10:30 A.M., in the main dining room sitting up in her wheelchair. There was no Tabs alarm on her. Observation on 8/6/01, in front of the main dining room at approximately 11:00 A.M., revealed that the resident was again in a wheelchair without her Tabs alarm. Observation on 8/6/01 at 2:55 P.M., revealed that the resident was lying in a supine position without a Tabs alarm in place. At 3:00 P.M., this was verified with nursing staff. Upon further investigation revealed that the resident's Tab alarm was located in the bottom portion of her bedside table. c) Clinical record review for Resident #1 had a Fall Risk Assessment completed upon admission and revealed a score of 10, which is indicative of the resident being at high risk. Physician telephone orders dated 7/17/01 revealed, "Tab's alarm at all times D/T (due to) poor safety awareness." d) Observation on 8/6/01 at approximately 2:55 P.M., revealed the resident was lying in bed with his head elevated 45 degrees. The Tabs alarm was not attached to the resident. The clip was attached to the string coming out of the alarm. These same observations were made at 3:25 P.M. and again at 3:30 P.M. This was confirmed in the presence of nursing staff at 3:30 P.M. 12) Based upon the forgoing, the Respondent violated 42 CFR §483.25, which requires the Respondent to 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. The Page 8 of 10 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 care that this regulation requires includes the provision to each resident of adequate supervision and assistance devices to prevent accidents. Fla. Admin Code R. 59A-4.1288 implements §§ 400.102, 400.121(2), and 400.23 Fla. Stat. and incorporates by reference 42 CFR 483.25. The Respondent also violated § 400.022(1)(1) and 400.022(3) Florida Statutes, which require the Respondent to ensure the resident’s right to receive adequate and appropriate health care and protective and support services, and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. 13) The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2500) is authorized under §§ 400.102(1)(d), 400.121(2), and 400.23(8), Fla. Stat. CLAIM FOR RELIEF FOR COUNT II WHEREFORE, AHCA requests this Court to order the following relief: a) Make factual and legal findings in favor of AHCA on Count II, b) Impose a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2500) for the violation cited in Count II against the Respondent under Fla. Admin. Code R. 59A-4.1288, §§ 400.022(1)(), 400.022(3), 400.102(d), 400.102(1)(d), 400.121(2), and 400.23(8)(b), Fla. Stat., Page 9 of 10 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0910 NOTICE 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 Joanna Daniels, Assistant General Counsel, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, FL 32308. 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, Fonacd enol. Joanna Daniels FL Bar #0118321 Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, FL 32308 (850) 922-5873 Fax (850) 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Administrator, SPRINGS AT LAKE POINTE WOODS, 7848 BENEVA ROAD, SARASOTA, FLORIDA, 34238, Return Receipt No. 7106 4575 1294 2050 0910 by U.S. Certified Mail, on December /O_, 2002. JOANNA DANIELS Assistant General Counsel Copies furnished to: Wendy Adams Joanna Daniels Agency for Health Care Administration Agency for Health Care Administration 2727 Mahan Drive, MS #3 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 Tallahassee, FL 32308 (Interoffice Mail) JD/ghm Page 10 of 10 . AUG-29-2881 15:52 THE FOUNTAINS LAKE PT 3419235694 P.12/35 ‘HEALTH CARE FINANCING ADMINIS”™~ ATION 2567-L eee STATEMENT OF DEFICIENCIES X1) PROV ue R/SUPPLIERICLIA (%2) MULTIPLE CONSTR STION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING B. WING 105567 STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD SARASOTA, FL 34238 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEI SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECBEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8. On interview with a fumily member (not identified due to confidentiality) stated, "I know my © mother/father don't get baths like they should. They don't get a bath all ofthe time. I know she/he only gets a bath once a week. J have complained.” 9, On interview with the Unit Manager on 8/7/01, she was unable to provide any other documentation that { Resident #6 and #8 had other baths/showers during the month of July and August. 10. On interview with the Social Worker on 8/7/01 at 1 2:10 P.M, he stated, "The mmber one grievance of residents and families are complaiits of not getting enough showers." 59A-4.1288 Class IT Correction Date: 9/8/01 F 324] 483.25(h)(2)QUALITY OF CARE $55G The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. ; This Requirement is not met as evidenced by: Based on observations, record reviews and staff _ interviews, the facility failed to provide adequate supervision and/or assistive devices to prevent incident and/or accident for 5 (Residents #1, #3, #7, #10 and #11) of 8, from a sample of 13 active sampled residents __ | reviewed for falls/fracture/abrasions/bruise. This is | evidenced by: 1) The facility's failure to develop a plan of care to address the risk for falls on Resident #1 HCFA-2567L “aTGo21199 IX9B11 Ifcontinuation sheet 9 of 32 9419235694 P.13/35 226/-L 3) DATE SURVEY COMPLETED AUG-29-2001 15:52 THE FOUNTAINS LAKE PT ‘HEALTH CARE FINANCING ADMINIS RATION STATEMENT OF DEFICIENCIES (Xi) PROV. ER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONS1.. -CTION A BUILDING 105567 B. WING 8/8/01 STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS HCFA-2567L SARASOTA, FL. 34238 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) and their failure to provide adequate supervision and/or assistive device to prevent an incident/accident which resulted in a right hip fracture. 2) The facility failed ta develop a Care Plan to address the risk for incident/accident for Resident #10. 3) Resident #7 did not have an adequate Care Plan to prevent skin tears during ADL (Activities of Daily Living) care. 4) Residents #1 and #3 did not have assistive devices, as stated in their Care Plan and as ordered by their physicians, to prevent.an accident/incident. The findings inchide: 1. Resident #11 was admitted to the facility on 4/17/0]] with diagnoses that include, but not limited to, Dementia - Alzheimer's Type with Agitation. An Interim Plan of Care was developed on 4/17/01, th day of the resident's admission to the facility. Under "Problem/Issue" it stated, “Lmpaired safety awareness R/T (related to) decreased cognitive finction.” The goal was for the resident not to have injuries. The following approaches were listed: -"t. PT, OT eval (evaluation) & tx (treatment)," -"2. Monitor freq. (frequently for) safety issues." -"3. Redirect PRN (as needed)." Review of the Physical Therapy (PT) evaluation dated 4/18/01 stated, "Pr. (Patient) able to ambulate independently inside her room & around the haliways without assistive device. Pt. noted with good balance. Pinot a candidate for PT at this time.” Review of the Occupational Therapy (OT) cassie dated 4/18/01 stated, "Present with decreased cognitio easily irritable/agitated; Pt ambulates I ly (independently) all over the facility PRN. No OT * aran23199 TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) : Resident #11, Plan of Care reviewed to address fulls, skin tears, accident/incidents with appropriate interventions as needed. All Residents were reassessed for risk for falls, and need of assistive devices to prevent accidents/incideuts with updated Care Plans, New Assessments tools for falls implemented for all residents, Staff inservice 8/29/01 on prevention of falls, skin tears, incidents/accidents adaptive devices, documentation, and care Planning. Unit manager to do Compliance Rounds daily to include adaptive devices, Director of Nursing to Monitor Tfcontinuation sheet 10 of 32 IX9B11 __AUG-23-2081 15:52 THE FOUNTAINS LAKE PT 9419235694 P.14/35 HEALTH CARE FINANCING ADMINIS” ~ ATION 20/-L STATEMENT OF DEFICIENCIES (Xi) PROViveR/SUPPLIER/CLIA (X2) MULTIPLE CONSTRYTION AND PLAN OF CORRECTION IDENTIFICATION NU MBER: A BUILDING 105567 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD SARASOTA, FL 34238 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS "(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION i PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTIONSHOULD BE =| COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 324 F324 services warranted at this time." Interview with the rehab. (rehabilitation staff) on. 8/8/01 at approximately 11:00 A.M., confirmed that the resident had good balancé, however, due to her cognitive impairment “she has poor safety awareness." The clinical record did not have documentation on how the resident was going to be monitored. There was no documentation in the resident's Plan of Care to indicate what interventions will be put in place to prevent the — resident from an incident/accident. Review of the resident's MDS (Minimum Data Sct) completed on 4/30/01, revealed she was ambulatory. She required extensive assistance to bathe. She was frequently incontinent of bladder. She required supervision/cuing during meals. She also had the following behaviors: wandering, verbally abusive and physically abusive. Review of the RAP (Resident Assessment Protocol) revealed she is riggered for falls. The RAP key stated] “Potential for additional falls or risk of initial fall | suggested based on the following: Wandering; Behavior occurred 4 to 6 days in the last 7 days.” The assessment stated that the resident was at risk for falls secondary to her "cogiiitive losses, need for supervisior of ADL's (Activities of Daily Living), psychotropic med (medication) use and incontinence of bladder. She is at times delusional which complicates things, Will address fall-risk and prevention interventions (Resident with companion care during the day)." Review of the physician's order revealed the resident is on Risperdal (psychotropic drug) 0.5 mg twice a day. HCFA-2567L , : " ATGOZII99 IX9B1I Ifcontinuation sheet 11 of 32 AUG-29-2881 15:53 THE FOUNTAINS LAKE PT 9419235694 P.15/35 HEALTH CARE FINANCING ADMINIST™ ATION Zeb STATEMENT OF DEFICIENCIES {X1) PROV1L.-2/SUPPLIER/CLIA (X2) MULTIPLE CONST, -TION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 105567 B. WING STREET ADDRESS, CITY, STATE, ZIF CODE 7848 BENEVA ROAD SARASOTA, FL 34238 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS (%4)1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION R PREFIX (BACHDEFICIENCY MUST BE PRECEEDED RY FULL. | FREFIX (FACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F324 F 324 During the review of the Comprehensive Care Plan developed on 5/8/01, it did not have documentation to indicate that the resident's risk for fall had been addressed. There was uo documentation in the resident's clinical record to Indicate what "fall-risk and prevention interventions” will bc put in place to prev an incident or accident. ‘| During an interview with the MDS/Care Plan Coordinator on 8/8/01 at approximately 10:00 A.M., she disagreed that the resident had good balance. She stated that the resident's gait was unsteady. She confirmed that there was no Care Plan developed on 5/8/01 for the resident to address her risk for falls. She| also stated, "I guess we were complacent because she has a sitter.” During the review of the nurse's notes dated 4/20/01, it stated that due to the resident's problem with adjustment secondary to her admission to the facility, her family has provided sitters to whom she is acquainted. The nurse's notes dated 4/26/01, stated tha} the resident was verbally abusive and hitting a CNA (Certified Nursing Assistant). She is wandcring and hallucinating. The nurse’s notes further stated, all thesq bebaviors occur early in the morning. It also stated, "Our department was “unaware” that "no" sitters were attending her (resident) from 10 PM to 8 AM." Furthe investigation confirmed that the resident has a private sitter from 8:00 A.M. to 10:00 P.M. The nurse's notes dated 5/8/01, revealed the resident was admitted to the hospital for abdominal pain. She was readmitted to the facility m the evening of 5/10/01 On 5/11/01, the nurse's notes stated, "2 PM - Resident fell in her room while walking toward her husband's bed; X-ray has now shown a fx (fractured) hip...” HCFA-2567L. “ATOLLS IX9B11 Tfeontinustion sheet 12 of 32 AUG~23-2061 15:53 HEALTH CARE FINANCING ADMINIST™ ATION STATEMENT OF DEFICIENCIES {X1) PROVILeR/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 108567 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS THE FOUNTAINS LAKE PT (X2) MULTIPLE CONSTR. -TION A. BUILDING COMPLETED 9419235694 P.16/35 296 /-L. X3) DATE SURVEY 8/8/01 STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD SARASOTA, FL 34238 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} Further review of the clinical record confirmed a Right Femoral Neck Fracture. The resident was admitted to the hospital on 5/11/01 for hip surgery. A review of an iacideni report completed on 5/27/01, several days after her re-admission to the facility, tevealed the resident was calling for help and was found face down on the floor at the foot of the bed at 1:45 A.M. There is no documentation in the resident's clinical record, nor in her Comprehensive Care Plan to | address further incidents/accidents. A Care Plan to address falls was not developed for the resident until 8/1/01, two months after her incident on 5/27/01. Review of the resident's most current MDS completed on 7/13/01, revealed she continues to be verbally abusive, but this behavior is easily altered. The MDS also showed decline in the following finctional status: extensive assistance of | tc transfer, ambulate, and hygiene. The resident is also now frequently incontinent of bowel. She requires continues supervision and some assistance during meals. 2, Duning the review of Resident #7's RAJ (Resident Assessment Instrament) and significant change MDS (Minimum Data Set) completed on 5/21/2001, indicat that the resident cognitively impaired and requires 1 extensive assistance to transfer. Care Plan developed on 5/1/01 it revealed the followin problems were included, “fragile skin, prone to tear.” | There was no documentation to indicate what interventions were to be implemented to prevent her from skin tears. During the review of the resident's Comprehensive { Review of an incident report dated 6/30/2001, revealed HCFA-2567L “ATGOZII99 PROVIDER'S FLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATB DEFICIENCY) Resident #7, Plan of Care reviewed to address falls, skin tears, accidenv/incidents with appropriate interventions as needed. All Residents were reassessed for risk for falls, and need of assistive devices to prevent accidents/incidents with updated Care Plans, New Assessments tools for falls implemented for all residents. Staff . inservice 8/29/01 on prevention of falls, skin tears, incidents/accidents adaptive devices, documentation, and care planning. Dnit manager to do Compliance Rounds daily to include adaptive devices. Director of Nursing to Monitor IX9B11 Ifcontinuation sheet 13 of 32 __AUG-29-2881 15:53 THE FOUNTAINS LAKE PT 9419235694 P.17¢35 HEALTH CARE FINANCING ADMINIS™~ ATION 2567-L STATEMENT OF DEFICIENCIES (Xt) PROVIDel/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION 3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; COMPLETED 105567 8/8/01 STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD SARASOTA, FL 34238 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS SUMMARY STATEMENT OF DEFICTENCTES (FACH DEFICIENCY MUST BE PRECEFDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (FACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Resident #7 sustained two skin tears while being transferred from the bed to the wheelchair by facility staff. There was no documentation in the resident's clinical record to indicate that measures to prevent this incident from happening again had been put in place. Review of an incident report dated 7/3/01, revealed the resident sustained another skin tear while being transferred from the bed to the chair by facility staff. Farther review of the clinical record revealed no documentation to indicate what measures will be put in| place to prevent these incidents from recurring. | The Care Plan developed on 5/22/01, stated that the iF resident was resistive to care. However, during the review of the incident reports on 6/30/01 and 7/31/01, did not indicate that the resident was resistive to care. Resident #10, Plan of Care reviewed to 3. Resident #10 was admitted with multiple diagnoses address falls, skin tears, accident/incidents including but not limited to Cerebral Vascular with appropriate interventions as needed. Accident, Hypertension, Hemiplegia, Hypothyroidism, Dementia and Diabetes Mellitus. The resident mitial All Residents were reassessed for risk for skin assessment on 7/16/01, revealed multiple skin falls, and need of assistive devices to tears, an abrasions and an ecchymotic area on the prevent accidents/incidems with updated tesident's left and right arm and hand. The resident's Care Plans. Minimum Data Sct revealed the resident to be occasional incontinent of bowel and has a Foley New Assessments tools for falls catheter. implemented for all residents, Staff inservice 8/29/01 on prevention of falls, skin The Interdisciplinary Resident Care Plan dated 4/17/01 tears, incidents/accidents adaptive devices, revealed, "Decline in Activities of Daily Living. documentation, and care planning. Patient with decrease in functional mobility — extensivd . assist in bed mobility and transfer." Interdisciplinary Unit manager to do Compliance Rounds Resident Care Plan approaches revealed, "PT/OT daily to include adaptive devices, ensical Therapy and Occupational Therapy) per MD Director of Nursing to Monitor HCFA-2567L. “ATGOII99 IX9B11 Tf continvation sheet 14 0f32 AUG-29-2881 15:54 THE FOUNTAINS LAKE PT 9419235694 P.18-35 * HEALTH CARE FINANCING ADMINISTRATION 2567-L STATEMENT OF DEFICIENCIES {X1) PROV. 28/SUPPLIER/CLIA (X2) MULTIPLE CONST..-CTION X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED 105567 8/8/01 STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD SARASOTA, FL 34238 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING NFORMATION) PROVIDER'S PLAN OF CORRECTION (PACH CORRECTIVE ACTION SHOULD BE CROSS-REPERENCED TO THE APPROPRIATE DEFICIENCY) The resident was assessed at risk for falls on 4/26/01 and the RAPS (Resident Assessment Protocol Summary) was completed on 4/27/01. The RAPS stated to proceed to Care Flan the resident on 5/01/01 for the risk for falls. The resident RAPS key on 4/27/01 revealed, "Resident is at risk for falls secondary to his complaint of dizziness, unsteady gait, ADL (Activities of Daily Living) dependencies, Cognitive losses, etc. See ADL RAP as well. Will address Fall-Risk und prevention interventions as well as OT/PT (Occupational Therapy and Physical Therapy) Treatment." On interview with the Care Plan Coordinator on 8/6/01 she provided the surveyor with a written Interdisciplinary Resident Care Plan dated 4/17/01 and. up dated on 6/20/01. She also provided ptinted Care Plans dated 5/1/01 with up dated of 6/20/01. There “ no Care Plan to address the resident's risk for falls 5/1/01 through 6/20/01. On 7/10/Q1, the resident's nurses notes revealed skin tears from old ecchymotic areas on tight hand and elbow. Probable canseé was resident hitting nght arm on bedside rails, behavior related. An interim Plan of Care was completed on 7/10/01 for skin tears, The approaches included but not limited to monitor for safety awareness. There was no documentation to indicate how the resident will be monitored for safety. The resident was Care Planned on 8/5/01 for, "At Risk for Falls related to decline in mobility, AEB (as evidenced by) statements made and increased need for assistance.” The resident was also Care Planned on 8/5/01, "At Risk for impaired skin integrity related to occasion! bowel incontinence and decreased mobility. HCFA-2567L “ atro021 199 IX9B11 Tfcontinuation sheet 15 of 32 _ AUG~29-2001 15:54 THE FOUNTAINS LAKE PT » HEALTH CARE FINANCING ADMINIS7~?.ATION STATEMENT OF DEFICIENCIES Xi) PROVi vER/SUPPLIER/CLIA (X2) MULTIPLE CONSTis UCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 105567 B. WING (X4) ID PREFIX Taa F324] HCFA-2567L. NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS | function due to L (left) hemiparesis related to CVA SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) This Care Plan does not have documentation to indica! what interventions will be implemented to prevent the resident from further skin tears. 4, Clinical record review for Resident #3 revealed a Significant Change in Srams Assessment MDS (Minimum Data Set). Assessment reference dates of 4/4/01 and 4/9/01, indicated that the resident had fallen! within the last 31-180 days. Nurses notes dated 4/21/01, "12:10 A.M. Res. (resident) found on the foo} by her bed, stated that she was restless in bed and rolle out Denies and discomfort no apparent injuries noted..." Nurses notes dated 4/21/01, "4:15 P.M. CN, (Certified Nursing Assistant) found (resident's name) on her knees between w/c & her bed. States, "I tried to go to bed.” Tabs alarm off & had not used call bell..." Nurse's notes dated 7/10/01, "11 A (A.M.) Res. found on floor in front of bathroom stated that she was attempting to grab door handle and fell on her bottom. No injuries. Family and (doctor's name) notified." Review of the resident's Interdisciplinary Resident Care Plan dated 4/12/00, under need states, "decline in (Cerebral Vascular Accident) + places resident at tisk for falls + injury." Further review of the Care Plan i revealed that the resident had a fall on 10/6/00, 11/8/0 and 12/1/00, Under goals, "#3 Res. (resident) will hav no falls within the facility through 7/25/00, 10/23/00, 1/10/01 and 4/17/01." Under approaches lists, “Tabs alarm on while in w/c." Review of the resident's treaunent sheets revealed. an order dated 1/31/01, that the resident is to have the Tubs alarm while in bed. Observation on 8/6/01 at approximatcly 10:30 A.M., id the main dining room sitting up in her wheelchair. There was no Tabs alarm on her. Observation on ” aTC021199 STREET ADDRESS, CITY, STATE, ZIP CODE 7848 BENEVA ROAD SARASOTA, FL 34238 PREFIX PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TAG F324 Resident #3, Plan of Care reviewed to with appropriate interventions as needed. All Residents were reassessed for risk for falls, and need of assistive devices to Prevent accidents/incidents with updated Care Plans. New Assessments tools for falls implemented for all residents, Staff inservice 8/29/01on prevention of falls, skin tears, incidents/accidents adaptive devices, documentation, and care planning. Unit manager to do Compliance Rounds daily to include adaptive devices, Director of Nursing to Monitor IX9BU1 Tfcontinuaton sheet 16 of 32 AUG-29-2001 15:54 THE FOUNTAINS LAKE PT 9419235694 P, 20/35 HEALTH CARE FINANCING ADNANT” "ATION ruRM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION TDENTIFICATION NUMBER: 105567 NAME OF PROVIDER OR SUPPLIER SPRINGS AT LAKE POINTE WOODS STREET ADDRESS, CITY, STATE, ZIF CODE 7848 BENEVA ROAD SARASOTA, FL 34238 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 8/6/01, in front of the main dining room at approximately 11:00 A.M., revealed that the resident was again in a wheelchair without her Tabs alarm. Observation on 8/6/01 at 2:55 P.M., revealed that the resident was lying in a supine position without a Tabs alarm in place. At3:00 P.M., this was verified with aursing staff. Upon further investigation revealed that the resident's Tab alarm was located in the bottom portion of her bedside table, 5. Clinical record review for Resident #1 had a Fall Risk Assessment completed upon admission and revealed a score of 10, which is indicative of the tesident being at high risk. Physician telephone orders dated 7/17/01 revealed, "Tab's alarm at all times D/T (due to) poor safety awareness." Observation on 8/6/01 at approximately 2:55 P.M., revealed the resident was lying in bed with his head elevated 45 degrees. The Tabs alarm was not attached to the resident. The clip was anached to the string coming out of the alarm. These same observations were made at 3:25 P.M. and again at 3:30 P.M. This was confirmed in the presence of nursing stalf at 3:30 P.M. S59A~4. 1288 Class If Correction Date: 9/8/01 483.25(i)(2)QUALITY OF CARE Based on a resident's comprehensive assessment, the facility must ensure that a resident receives a therapeutic diet when there is a nutritional problem. ATQ021199 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE / DEFICIENCY) Resident #1, Plan of Care reviewed to address falls, skin tears, accident/incidents with appropriate interventions as needed. All Residents were reassessed for risk for falls, and need of assistive devices to prevent accidents/incidents with updated Care Plans, New Assessments tools for falls implemented for all residents, Staff inservice 8/29/01 on prevention of falls, skin tears, incidents/accidents adaptive devices, documentation, and care planning. Unit manager to da Compliance Rounds daily to include adaptive devices, Director of Nursing to Monitor IX9B11 {fcontinuation sheet 17 of 32

Docket for Case No: 03-000173