STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION An AGENCY FOR HEALTH CARE in ADMINISTRATION, Petitioner, AHCA No.: 2002045447 Return Receipt Requested: Vv. 7000 1670 0011 4845 8141 7000 1670 0011 4845 8158 ARBOR LIVING CENTERS OF FLORIDA, 7000 1670 0011 4845 8165 INC. d/b/a INTEGRATED HEALTH - SERVICES OF FLORIDA AT LAKE WORTH, Od- D5GR 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 Arbor Living Centers of Florida, Inc. d/b/a Integrated Health Services of Florida at Lake Worth (hereinafter “Integrated Health Services of Florida at Lake Worth”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $8,000.00 pursuant to Section 400.23(8), Florida Statutes (2001), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2, AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2001). 3. Venue lies in Palm Beach County, pursuant to Section Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities, pursuant to Chapter 400, Part II, Florida Statutes (2001), and Chapter 59A-4 Florida Administrative Code. 5. Integrated Health Services of Florida at Lake Worth operates a 120-bed skilled nursing facility located at 1201 12 Avenue South, Lake Worth, Florida 33460. Integrated Health Services of Florida at Lake Worth is licensed as a skilled nursing facility under license number SNF13010961. Integrated Health Services of Florida at Léke Worth was at all times material hereto a licensed facility “under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I INTEGRATED HEALTH SERVICES OF FLORIDA AT LAKE WORTH FAILED TO THOROUGHLY INVESTIGATE SUSPECTED ABUSE OF A RESIDENT WHO HAD A PURPLE BRUISE TO CHEEK. TITLE 42 CHAPTER 483.25(h) (2), CODE OF FEDERAL REGULATION 59A-4.1288 FLORIDA ADMINISTRATIVE CODE (STAFF TREATMENT) CLASS III 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Integrated Health Services of Florida at Léke Worth participated in Title XVIII or Title XIX and therefore must follow certification rules and regulations found in Chapter 42 Code of Federal Regulation 482. 8. Integrated Health Services of Florida at Léke Worth was cited with four (4) Class III deficiencies pursuant to survey conducted on June 4, 2002. 9. Based on the survey conducted on May 1, 2002 énd based upon staff interview and documentation review the facility did not develop and implement policies and procedures for abuse. Findings include the following. 10. On 4-29-02, 2 housekeepers and 1 certified nursing assistant were asked about the abuse protocol. None of the three were able to name the abuse coordinator or what to do if abuse was witnessed. On 4-29-02 the policies and procedures for the abuse program were requested from administration. The policies and procedures were reviewed, and revealed that the first paragraph states, "To further enhance our commitment to excellence, IHS has developed and implemented a training program that educates our staff on how to protect and prevent abuse from: Staff - Visitors - Other Residents" Under # 2, the third bullet states, "In-servicing, training and reinforcement for all new and present employees” that identifies all aspects of abuse prohibition." Throughout the rest of the survey, 8 staff members (1 licensed practical nurse, 2 registered nurses, 1 maintenance person, 2 dietary staff and 2 certified nursing assistants) were interviewed to reveal that 4 were not able to identify the abuse coordinator and/or what to do if abuse is witnessed. The seven individuals, who were not aware of the abuse protocol, were not able to discuss what constitutes abuse, neglect or misappropriation of resident property. The correction date was designated as May 31, 2002. 11. During the follow-up survey conducted on June 4, 2002 based on observation, interview, and clinical record review, it was determined that the facility did not ensure that suspected abuse was thoroughly investigated for one resident in the survey sample. Findings include che following. 12. Clinical record review was conducted during the revisit to the annual survey on June 06, 2002. Resident # 6 was observed on June 06, 2002, with a purple bruise to the left cheek. The resident was sitting in his/her bed. The resident was asked what had happened, but appeared confused and was unable to tell the surveyor how he/she got the bruise. Clinical record review revealed this resident was admitted into the facility on April 14, 2002. Documentation in the record, in the form of a pressure ulcer report/other skin condition report documented a bruise on the residents left cheek, and bruises on both arms. The date listed for when the bruises were first noticed by staff was May 21, 2002. The nursing notes, physician notes, and social service notes were reviewed, but no documentation could be found about the bruises, how the resident received them, or whether an investigation of the occurrence had taken place. The nursing admission assessment does not list the resident as having bruises to the face or arms. The Director of Nursing was asked for an incident report and investigation of the bruises, but none could be provided to the surveyor. The social worker stated that the resident had the bruises on admission, but no documentation cculd be found to wn support the statement. The facility did not investigate an incident possibly related to abuse. 13. Based on the foregoing facts, Integrated Health Services of Florida at Lake Worth violated Chapter 59A- 4.1288 Florida Administrative Code and 483.25(h) (2), Code of Federal Regulation herein classified as a Class III deficiency, which warrants a fine of $2,000.00. COUNT II INTEGRATED HEALTH SERVICES OF FLORIDA AT LAKE WORTH FAILED TO PROVIDE APPROPRIATE POST MORTEM CARE FOR ONE (1) RESIDENT AND DID NOT PROVIDE PRIVACY DURING TREATMENT FOR ANOTHER RESIDENT. TITLE 42 CHAPTER 483.25(h) (2), CODE OF FEDERAL REGULATION AS INCORPORATED BY RULE 59A-4.1288 FLA. ADMIN. CODE SECTIONS 400.022(1) (a)& 400.022(1) (m), FLORIDA STATUTES (QUALITY OF LIFE) CLASS III 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. Integrated Health Services of Florida at Lake Worth participated in Title XVIII or Title xXIx and therefore must follow certification rules and regulations found in Chapter 42 Code of Federal Regulation 482. 16. Based on survey conducted on May 1, 2002 and based upon observation, interviews witn the resident's group, individual resident interviews, and family interviews, it was determined the facility did not promote care for residents that maintains or enhances dignity and respect for all of the residents in the facility. Findings include the following. 17. During the group interview on 4-30-02 at approximately 10:30 AM, 10 of 11 residents reported they are emotionally upset that the members of the staff speak a foreign language in their presence. It must be noted that all units of the nursing home were represented at the group meeting. The following are examples of incidents which have happened in the last two or more months. 18. One resident reported that two or three certified nursing assistants come into his/her room and speak a language other than English. He/she said that" they laugh and look at him". He/she said," it is very degrading and that he/she feels "lousy" when this is done". He/she stated," this happens often". 19. Two residents reported that the certified nursing assistants speak in their native foreign language and point at them as if the certified nursing assistants are talking about them. The residents said," on many occasions the certified nursing assistants laugh while they are pointing at the residents". One of these residents said to the surveyor, "how would you feel about that happening to you?" These two residents reported that speaking in the foreign language goes on daily. 20. Three residents reported that two or three certified nursing assistants go into a room of a bed bound resident and talk in their native foreign language and laugh while in there. The residents reported that the certified nursing assistants could be heard from the hall. 21. A resident in the group meeting stated, "It is hard enough for us to listen to the foreign language, but what about the people who can't speak for themselves. How can we protect them?" 22. Several residents, who have been at the facility for six months or more, reported that this has been going on as long as they have been at the facility. 23. Resident group minutes were reviewed with the permission of the president of the resicent council. For the month of March, the residents addressed the issue of staff speaking in a foreign language so it could be addressed by administration. The residents reported that this has been brought up many times in the past. 24. An interview with a resident who was oriented times three revealed that he/she has personally asked the certified nursing assistants to speak English. He/she said," the request didn't do any good; they still speak their own language". 25. On 4-29-02 during the noon meal, resident #8 was brought into the dining room complaining that her foot was cold. One foot had a sock on it and the other did not. She reported that she wanted socks on both feet. 26. The family of resident # 9 was interviewed and revealed that they requested, many times, to have their loved one's finger nails cleaned. Every time when they come to visit (2 times per week) the nails are always dirty. 27. The family of resident # 9 reported that when they come in to the facility to visit their loved one, they always have to request the he/she be bathed because of the body odor. 28. Based on observation on 4/29/02 at 12:45 PM in room 251, it was determined that resident #2 had no clothing hanging in the closet and was dressed in bed in a hospital gown. Additionally, it was observed that this resident was aphasic, cognitively impaired, contracted and received nutrition via PEG tube. A subsequent record review revealed resident #2 had no family other than a son residing in Arizona. The following mornirg it was observed that the resident was dressed in bed in a hospital gown. An interview with the social worker at 10 AM revealed the resident had no clothing in the room nor in the facility laundry. At 10:15 AM the social worker found some unmarked clothing with no name marked on the garments, and hung them in the room 251 closet for resident #2. On the third cay of the survey (05/1/02), it was observed by the surveyor that this resident was still in bed dressed in a hospital gown. 29. While touring the facility at 10:34 am on April 29, 2002 a surveyor noted that a C.N.A. on the second flcor entered a resident room without knocking on the door or waiting for the resident to respond. The L.P.N. who was touring with the surveyor and the C.N.A. were informed of this finding at the time of its occurrence. 30. While observing medication pass between 9:40 AM and 9:45 AM on April 30, 2002 a surveyor noted that Resident #4 was wearing a white sweater, which had a fist- sized hole in the right arm. This finding was reviewed with and substantiated by the Director of Social Services at 9:53 AM on April 30, 2002, and the Director of Nursing at 10:25 AM on April 30, 2002. 31. On 04/29/2002, during the initial tour of the c Wing, Resident ID # 5 was heard calling for" help”. As the initial tour continued, resident #5 was heard, continually, 10 calling for "help". Upon entering the resident's room with the door ajar, the resident was observed lying on the floor in front of the wheel chair, clad in an incontinent brief and as blouse. When the facility staff (2) was questioned as to why the resident was not wearing clothing on lower part of the body, the 2 staff persons replied, "I dor't know". The correction date was designated as May 31, 2002. 32. Based on follow-up survey conducted on June 4, 2002 and based upon observation and interviews with staff, the facility did not maintain dignity and respect for 1 ‘Resident #11) of 12 sampled residents and 2 (Residents #3 and #14) of 3 random residents. Findings include the following. 33. During the tour on 6-4-02 at approximately 10:00 am the door to room 125 was open. A certified nursing assistant was finishing shaving Resident #14 who resides in the window bed. He was sitting in his wheel chair approximately 4 feet out side of the bathroom. His head was turned to the left facing the resident in the door bed. When the surveyor knocked and entered the open door, she passed Resident #14 and went to the bedside of resident # ll whose privacy curtain was open to the bottom of the bed on the side facing to door. The resident in the door bed (resident # 11) had expired at approximately 6:00 am. The ll expired resident had not been transferred to a funeral home during this time, as the spouse had not decided which funeral home to use. A review of the facility's policy for cost-mortem care was reviewed and _ the following was determined. 34. The facility's policy for "The Care of the Body After Death" states the following: "Have body placed in a private room or have roommate moved to another area as body is being prepared." "Close room door or draw bedside curtain." "Tf the person wore dentures, reinsert them. If mouth fails to close, place a rolled-up towel urder the chin." "Place small pillow or folded towel on the head or elevate head of bed 10 to 15 degrees." "Maintains dignity and respect for the client and significant others." None the above was executed in regards to Resident #11, which allowed anyone entering the room to observe the expired resident. 35. The expired resident and his roommate did not have their dignity and respect maintained in death (Resident #11) as well as in life (Resident #14). 36. During tour at approximately 10:15 am the door to room 104 was closed. The surveyor knocked and was told to enter. Resident #13 was sitting on the bed by the door in his incontinent brief with his G-tubing exposed receiving am care without the benefit of his cubicle curtain closed 12 for privacy and dignity. The roommate was in his wheel chair on the side of his window bed observing the care given to Resident #13. 37. Based on the foregoing facts, Integrated Health Services of Florida at bake Worth violated Section 400.022(1) (a), Florida Statutes, herein classified as a Class III deficiency, which warrants a fine of $2,000.00. COUNT III INTEGRATED HEALTH SERVICES OF FLORIDA AT LAKE WORTH FAILED TO PROVIDE SOCIAL SERVICES TO TWO (2) RESIDENTS - ONE WITH A ROOMMATE ISSUE AND ONE WITH FINANCIAL ISSUES. TITLE 42 CHAPTER 483.25(h) (2), CODE OF FEDERAL REGULATION 59A-4.1288 FLORIDA ADMINISTRATIVE CODE SECTION 400.022(1) (n),(2), FLORIDA STATUTES (QUALITY OF LIFE) CLASS III 38. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 39. Integrated Health Services of Florida at Lake Worth participated in Title XVIII or Title XIX and therefore must follow certification rules and regulations found in Chapter 42 Code of Federal Regulation 482. 40. Based on survey conducted on May 1, 2002 and based upon on observations, record reviews and interviews, it was determined the facility did not provide medically- related social services for 2 of 21 sampled residents (#15, #18), and 2 of 14 random residents (#25, #26), to meet the psychosocial well-being of each resident. The findings include the following. 41. During the initial tour of the facility on 4/29/02 at 10:45 am, the nursing staff touring with tae surveyor reported that resident #18 was a "racist" and was only 62 years old. In addition, the surveyor was informed that resident #18 refused to get out of bed and complained "all the time." Observations in room 249 during the tour revealed the resident appeared to be alert, oriented and was watching TV while in bed. Based on record review on 5/1/02 on the second floor, it was determined resident #18 was admitted 3/5/01, and readmitted on 12/22/01, and has diagnoses of depressive disorder, anxiety, muscular dystrophy, stroke and hypertension. A review of the most recent quarterly Minimum Data Set (MDS) assessment revealed the resident exhibited a sad, pained, worried expression, resisted care, and could be abusive. Continued record review revealed the resident received a psychiatric consult on 2/2/02. At the time of this consult a diagnosis of psychotic disorder was determined by the physician, and the medication Risperdal was ordered. Review of this consult also indicated resident #18 was "very paranoid and accused staff of plotting to intentionally harm him/her." Nursing progress notes on 3/14/02 document that resident #18 had an incident with a nursing assistant at 8:45 pm, in which he/she accused the staff of throwing water at him/her. A review of the social services notes revealed there was no counseling nor attempts at psychosocial intervention provided to resident #18 after this incident. In fact, 15 there was no social work notes on resident #18 from 6/5/01 through 4/10/02 (ten months). A subsequent inquiry was made to medical records to see if the resident's chart had been thinned of social services notes. The surveyor was informed by medical records staff that the "social services notes were not thinned from the record." An interview with the social worker revealed this employee had only worked at the facility for approximately one week. Therefore, no explanation could be offered why social services had rot been intervening with resident #18's psychosocial needs during this ten-month time span. 42. During the resident group meeting on 4-30-02, three (3) residents reported that there have been so many social service staff in the last several months that they don't know who to talk to. The remaining eight (8) residents agreed that this has been a problem. 43. Resident #26 asked to speak to the surveyor. He/she complained that he/she cannot hear and that no one is helping him/her. Additionally, the resident reported that his/her eyeglasses do not fit right and that he/she cannot wear them. As a result, the resident said, he/she could not hear well nor see well. Review of the medical record for resident #26 revealed that this resident had an audiology appointment on 04-11-02 with no follow-up or 16 intervention. With regard to the eyeglasses, there has been no intervention. This resident stated," he/she believes he/she spoke with someone in the social service department. 44. Resident # 15, who is oriented times three, reported that he/she was abused. There was an in-house investigation, which could not definitively substantiate the abuse. However, the two alleged perpetrators were removed from this resident's unit so as not to care for him/her again. The resident reported that there has been no intervention such as counseling or follow-up. 45. Resident #25, who is under 65 years of age, was admitted in December of 2001 from a hospital following surgery. During the resident group meeting, the resident complained that he/she does not have any spending money. The resident receives Medicaid and is entitled to $35.00 per month for spending money. During interview with the social service designee, she admitted that she never informed the resident that he/she was entitled to the $35.00 per month. Further review revealed the resident, at this time, does not meet the criteria for nursing hone placement. According to the resident, who is oriented times three, the social service designee told him/her that te will have to leave the facility due to not meeting the 7 criteria for nursing home. He/she does not have a home and does not have resources to help/her him live. The resident further reported that Social Services has not helped him/her find a place to live. He/she further reported that he/she has not been able to sleep for the last two weeks due to the worry that he/she will be homeless and "have to live under a bridge somewhere." Review of the resident's medical record revealed that there is no documentation that Social Services has been intervening to help place this resident in an appropriate setting. The correction date was designated as May 31, 2002. 46. Based on the follow-up survey conducted on June 4, 2002, and based upon interviews and medical record review, the facility did not provide medically-related social services for 2 (residents # 10 and 12) of 12 sampled residents. Findings include the following. 47. Interview with the family of Resident # 12 revealed that there were problems with a roommate situation. Resident # 12 who is aphasic was extremely upset because his roommate continually went though his belongings. The roommate was moved but there was no follow up with Resident #12. There were no notes indicating that the roommate had been moved or that Resident #12 was even having emotional issues. Interview with the administrator 18 revealed that she was aware of the situation and so was che social service person who in fact arranged for the room change. The wife of the resident and the administrator reported that this resident was extremely upset. They both reported that the resident was crying and the wife reported that the resident was frustrated. 48. Resident #10 was interviewed and reported that he doesn't know about his financial situation. He said that he spoke with social service but nothing was resolved. -nvestigation with the business office revealed that this resident is “Medicaid pending”. After the resident was informed of this by the surveyor, he reported that he wished that he had known this before as he would have felt much better. 49. Based on the foregoing facts, Integrated Health Services of Florida at Lake Worth violated Section 400.022(1) (n), (2), Florida Statutes, Chapter 59A-4.1238 Florida Administrative Code and 483.25(h) (2), Code of Federal Regulation herein classified as a Class III deficiency which warrants an assessed fine of $2,000.00. 19 COUNT IV INTEGRATED HEALTH SERVICES OF FLORIDA AT LAKE WORTH FAILED TO PROVIDE PODIATRIC SERVICES TO A DIABETIC RESIDENT WHO HAD REQUESTED THESE SERVICES. TITLE 42 CHAPTER 483.25(h) (2), CODE OF FEDERAL REGULATION 59A-4.1288 FLORIDA ADMINISTRATIVE CODE 59A-4.106(4) (u) FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) 50. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. Sl. Integrated Health Services of Florida at Lake Worth participated in Title XVIII or Title XIX and therefore must follow certification rules and regulations found in Chapter 42 Code of Federal Regulation 482. 52. Based on survey conducted on May 1, 2002 and based on direct observation, clinical record review, and interview with facility staff on the c Wing, on 04/30/02, it was determined the facility failed to ensure that residents receive proper treatment and care for special services in foot care, for one (#12) of 21 residents in the sample selection. Findings include the following. 53. Resident #12 was admitted to the facility on 04/14/02 with multiple wounds and cellulites to bilateral extremities. On 04/30/02, during a dressing change ooservation, the toenails on both feet were noted to he long and thick, with a dark color substance under the 20 nails. The toenails, on the 3rd, 4th, and Sth toes of che left foot, were noted to be reddish/ black in color. Interview with the wound care nurse revealed that there were "no orders for any type of treatment, and no podiatrist has seen the resident since admission" ‘The correction date was designated as May 31, 2002. 54, Based on the follow-up survey conducted on June 4, 2002 and based on interview, observation, and clinical record review, it was determined that the facility did not provide podiatry services to one resident in the survey sample. Findings include the following. 55. A dressing change observation was conducted on resident # 10 on June 04, 2002, during a revisit to an annual survey. Observation of the resident's toenails revealed them to be thick, yellow, and long, to the point of curving inward. The resident is a diabetic and at risk for developing infections. The resident is alert and oriented, and able to communicate his/her needs. The nurse doing the dressing change saw the toenails and stated he/she needed them cut by a Podiatrist. The resident expressed a desire to have them cut as well, and stated he/she had been asking to see a Podiatrist. Review of the resident's clinical record revealed no documentation that a Podiatrist had been called. The resident was admitted into 21 the facility on January 10, 2002. The facility failed to provide the services of a Podiatrist, pucting the resident at risk of infection. 56. Based on the foregoing facts, Integrated Health Services of Florida at Lake Worth violated Chapter 59A- 4,106(4) (u), Chapter 59A-4.1288 Florida Administrative Code and 483.25 (h) (2), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class III deficiency which warrants a fine of $2,000.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of AHCA against Integrated Health Services of Florida at Lake Worth on Counts I, II, III and IV. 2. Assess against Integrated Health Services of Florida at Lake Worth an administrative fine of $8,000.90 on Counts I, II, III and IV. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4, Grant such other relief as the court deems is 22 just and proper on Counts I, II, III and Iv. 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, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. tad Ap Badges, ? Assistant General Counsel Agency for Health Care Administration 8355 N. W. 53rd Street Miami, Florida 33166 23 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 24 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 Barbara Yanez-Artiles, Administrator, Integrated Health Services of Florida at Lake Worth, 1201 12 Avenue South, Lake Worth, Florida 33460; Arbor Living Centers of Florida, Inc., 910 Ridgebreoke Road, Sparks Glencoe, MD 21152; National Corporate Research Ltd. Inc., 2406 Hays Street - Suite #2, Tallahassee, Florida 32301 on this 3ed day of May, 2003. toa, Alba M. 2) 4a has git, 2

Docket for Case No: 03-002582