STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINIST FILED Date 6 fa he3 _ / Gt 2 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003001964 AHCA No.: 2003001507 v. Return Receipt Requested: 7002 2410 0001 4237 3240 SENIOR HEALTH-TREASURE ISLE, 7002 2410 0001 4237 3257 LLC d/b/a TREASURE ISLE CARE 7002 2410 0001 4237 3264 CENTER c4c ‘ OD- [8357 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA or the “Agency””), by and through the undersigned counsel, and files this Administrative Complaint against Senior Health-Treasure Isle, LLC d/b/a Treasure Isle Care Center (hereinafter “Treasure Isle Care Center”) pursuant to 28-106.111, Florida Administrative Code and Chapter 120, Florida Statutes hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose and maintain the Agency’s administrative fine in the amount of $2,500.00 pursuant to Sections 400.121, 400.23(8), Florida Statutes [AHCA No.: 2003001507]. Division of Administrative Hearings 2. This is an action to impose and maintain the Agency’s assignment of a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No.: 2003001964]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Dade County pursuant to Section 120.57 and Section121(1) (e), Florida Statutes and Chapter 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to nursing home licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Treasure Isle Care Center is a_ skilled nursing facility located at 1735 N. Treasure Drive, North Bay Village, Florida 33141 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I TREASURE ISLE CARE CENTER FAILED TO IMPLEMENT POLICIES AND PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT, AND ABUSE OF RESIDENTS, AND/OR TREASURE ISLE CARE CENTER FAILED TO ENSURE THAT ALL RESIDENTS WERE FREE FROM MENTAL ANGUISH OF FEELING UNSAFE IN THE FACILITY. TITLE 42 SECTION 483.13(c), CODE OF FEDERAL REGULATIONS, As incorporated by RULE 59A-4.1288 FLORIDA ADMINISTRATIVE CODE, and/or 400.022(1) (0), and/or 400.022(1)(1) and 400.022(3), FLORIDA STATUTES. (STAFF TREATMENT OF RESIDENTS) CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Treasure Isle Care Center participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. Pursuant to a licensure and re-certification survey conducted by the Agency on February 4-7, 2003, and based on observation, individual and group interview, staff interview and record review, the Agency found that Treasure Isle Care Center failed to implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and/or Treasure Isle Care Center failed to ensure that all residents were free from mental anguish of feeling unsafe in the facility. The facility failed to ensure that one random sampled resident (R28) and four of five residents in the quality of life group interview were free from mental anguish of feeling unsafe in the facility. The findings include the following, to wit: 10. Review of the Minimum Data Set (MDS) assessment for sampled resident #28, dated 12/3/02, revealed that the resident was assessed as being cognitively independent. on 2/7/03 at 10:30 am, during an individual interview with the resident, the resident voiced concerns about his/her safety. The resident reported that other residents wander into the resident's room uninvited at least two (2) times per week. The resident indicated that during the preceding night prior to dinner (2/6/03) another resident wandered into his/her room uninvited. 11. The resident is non-ambulatory and indicated that he/she is frightened when unknown residents enter his/her room without permission. During the interview, the resident voluntarily revealed a long handled metal device (used to grasp items beyond his/her reach) which he/she keeps at bedside to use as protection from these unknown wandering residents who enter his/her room. The resident stated this device is the only way he/she can feel secure in his/her room. The resident reported feeling helpless due to being bed bound. 12. During the quality of life, group interview, conducted on 2/5/03 at approximately 1:45 pm, four (4) out of five (5) residents stated that they would like a feeling of safety while they are in their rooms. The residents stated that there are approximately 5 - 6 residents who wander into their rooms uninvited. The wandering was occurring mostly in units I and IV. One of the residents stated that it was more of a nuisance, while another resident stated that he/she was fearful and helpless. 13. On 2/7/03 at 11:10 am, interview with the Certified Nursing Assistant (CNA), who works on unit IV, confirmed that residents do wander into other resident's rooms at various times of the day. On 2/7/03 at approximately 11:30 am, the charge nurse for unit IV, confirmed seeing residents from other sections wandering in and out of residents rooms uninvited. The charge nurse identified two residents who consistently wander into residents!’ rooms. 14. On 2/7/03 at approximately 11:15 am, subsequent interviews with two residents, who reside in the same room as the random sampled resident R28, also revealed that unknown residents wander into that room uninvited at all hours day and night, creating a frightening situation. Both residents were assessed as being cognitively independent in the facility's 802 report. 15. On 2/7/03 at 11:00 am, interview with an unsampled resident, from the quality of life group interview, revealed that four to five times during the day and night, unknown residents wander into his/her room. He/she revealed that "about 2 months ago an unknown and uninvited individual attempted to get into the bed with him/her during the evening hours while he/she was sleeping. He/she stated that he/she fended off the uninvited resident by pushing that resident out of the bed. He/she said that this was very annoying and at times frightening. 16. Review of the grievance log, on 2/6/03 at 2:30 pm, revealed a grievance filed on 12/4/02 by a resident's family member concerning their relative, who lives in the facility, indicating that a particular resident, who wanders into the relative's room, became combative with both the resident and family member when the wandering resident was asked to leave the room. Per review of the facility grievance response, the facility is aware of the "wandering resident and his/her combativeness". 17. Throughout the days of the survey, this writer observed residents wandering in the hallways and attempting to enter other residents’ rooms in unit IV. Once the staff noticed this writer's presence, the residents were redirected out of the rooms. 18. Treasure Isle Care Center’s failure to implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and/or it’s failure to ensure that all residents were free from mental anguish of feeling unsafe in the facility, compromised the residents’ ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being. 19. Based on the foregoing, Treasure Isle Care Center violated TITLE 42 SECTION 483.13(c), CODE OF FEDERAL REGULATIONS, As incorporated by RULE 59A-4.1288 FLORIDA ADMINISTRATIVE CODE, and/or 400.022(1) (0), and/or 400.022(1) (1) and 400.022(3), FLORIDA STATUTES, herein classified as a Class II deficiency pursuant to Section 400.23(8), Florida Statutes, which carries, in this case, an assessed fine of $2,500.00. This also gives rise to the conditional licensure status assigned by the Agency, pursuant to Section 400.23(7) (b), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Treasure Isle Care Center shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A” EXHIBIT “A” Conditional License License # SNF 1562096; Certificate No.: Effective date: 02/04/2003 Expiration date: 12/31/2003 9968 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess and maintain the Agency’s administrative fine of $2,500.00 against Treasure Isle Care Center, for one (1) Class II deficiency as cited above. Cc. Assess and maintain the Agency’s assignment of a conditional license against Treasure Isle Care Center, in accordance with Section 400.23(7), Florida Statutes. D. Assess costs related to the investigation and prosecution of this matter, if applicable. E. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002) . Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, 10 Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT 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, Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 NW 53™ Street Miami, Florida 33166 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration Manchester Building 8355 NW 53*° Street Miami, Florida 33166 Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 11 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Miriam C. Pastor, Administrator, Treasure Isle Care Center, 1735 N. Treasure Drive, North Bay Village, Florida 33141; Senior Health-Treasure Isle, LLC, 785 Fifty Avenue, Third Floor, Suite 5, Attn: Carol A. Tschop, Chambersburg, Pennsylvania 17201; Bart Wyatt, 100 2™ Avenue South, Suite 901l-south, St. Petersburg, Florida 33701 on this 3 day of , 2003. athryn F. Fenske, Esq. 12

Docket for Case No: 03-001839