STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2004000166 CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter ‘“Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine against Respondent, in the amount of five thousand dollars ($5,000) pursuant to Sections 400.102(1) (a) and (d), and 400.23(8) (b), Florida Statutes (2003). 2. The Respondent was cited for the deficiencies set forth below as a result of a complaint survey conducted on or about December 18, 2003. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2003). 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 28-106, Florida Administrative Code (2003). PARTIES 5. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for the licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle Cc (as amended); Chapter 400, Part II, Florida Statutes (2003), and; Chapter 59A-4, Fla. Admin. Code (2003), respectively. 6. Respondent is a nursing facility located at 7173 Cypress Drive Southwest, Fort Myers, FL 33907. Respondent is licensed to operate a skilled nursing facility pursuant to license #SNF11160961. At all relevant times, Respondent was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I RESPONDENT FAILED TO ENSURE THAT A RESIDENT, WHO DISPLAYS MENTAL OR PSYCHOSOCIAL ADJUSTMENT DIFFICULTY, RECEIVES APPROPRIATE TREATMENT AND SERVICES TO CORRECT THE ASSESSES PROBLEM. 42 CFR 483.25(£) (1) (2003), INCORPORATING BY REFERENCE Fla. Admin. Code R. 59A-4.1288 (2003) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about December 18, 2003, AHCA conducted a survey at Respondent’s facility. 9. Based on interview with facility staff and record review, Respondent failed to ensure that one (Resident #5) of four sampled residents received psychiatric evaluation, treatment and services for sexually inappropriate behavior. Findings: Resident #5 was admitted to the facility on July 3, 2001 and re-admitted on May 22, 2003 with diagnoses including, but not limited to Multiple Sclerosis, Glaucoma, COPD and Urinary Calcitus. The resident was discharged to another facility on November 26, 2003. The resident's Minimum Data Set (MDS) completed as an annual and quarterly on July 7, 2003 and October 10, 2003 revealed that the resident is independent in cognition and is capable of making his own decisions. During investigation of the complaint on December 18, 2003, it was revealed that Resident #5 had an adverse incident for sexually inappropriate behavior on June 6, 2003 where a staff member observed, "the resident in a female resident's room touching her genital area." The facility sent a letter to AHCA on June 10, 2003 stating, "Investigation will be completed following the resident's Psychiatric evaluation." Review of Resident #5's record revealed a consent form, dated June 20, 2003, signed by the resident for "a mental health professional and/or their supportive staff for an initial consultation and follow-up services as recommended, including medications." Review of physician's telephone orders, dated June 20, 2003, revealed an unsigned order for "Psych consult." There was no documentation that the resident had the consult. Review of the annual Assessment by the Social Worker, dated July 9, 2003, states, "Although no behavior indicators are present, resident had a recent relationship with another female resident. After the female resident was unable to consent to relationship, resident was informed that he no longer can be in a female resident's room without staff present. Resident agreed." A review of the resident's treatment record for June 2003 and July 2003 revealed that the facility monitored "frequent checks - may not enter other resident's room per facility policy" from June 14, 2003 to July 12, 2003. There was no further monitoring by the facility. A care plan dated July 9, 2003, and reviewed on October 6, 2003, indicated that the facility was aware that the "resident has exhibited sexually inappropriate behavior.” The approach was that the resident understands that he is not to go in other residents' rooms without permission from the nurse. Interview with nursing staff, on December 18, 2003 at 4:00 P.M., who were in the facility in June and July stated they did not understand how he did not have the psychological consult in June. Staff stated that the resident was independent in cognition and aware of his restriction in the facility. Review of the resident's record revealed that the resident did have a psychological evaluation for "adjustment to change in condition and functional status." There was no mention of the sexually inappropriate behavior in the evaluation done on October 31, 2003. There was another incident on November 17, 2003 of sexually inappropriate behavior between Resident #5 and Resident #4. At that time, the police investigated the incident. Both residents were seen by the psychiatrist on November 22, 2003. The psychiatrist’s note states that the resident denies, "fondling another resident. | think this is disinhibition symptom of his MS. Probably not the best environment for him." On November 26, 2003, the resident consented to a discharge to another nursing home out of the area. Interview with the Administrator and the Director of Nursing had no explanation of why the facility did not monitor the resident closely, or why a psychological evaluation was not done until October 31, 2003, and then it did not include a notation regarding inappropriate sexual behavior and a plan for treatment. 10. Respondent was provided a mandated correction date of January 18, 2004. 11. The above actions or inactions are a violation of Title 42, Code of Federal Regulations 483.25(f) (1) (2003), incorporating by reference Rule 59A-4.1288, Florida Administrative Code (2003), which requires the facility to ensure, based on a comprehensive assessment, that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem. 12. Pursuant to Section 400.23(8) (b), Florida Statutes (2003), the foregoing is an “isolated” class II deficiency and as such, has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 13. During the annual survey of May 19-22, 2003, Respondent was cited for Tags F324 and F490, Class I deficiencies. Therefore, pursuant to Section 400.23(8) (b), Florida Statutes (2003), the fine amount is doubled to $5,000. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: a. Enter actual and legal findings in favor of AHCA ; b. Impose a $5,000 civil penalty against Respondent ; c. Assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes (2003); and d. Grant any other general and equitable relief as deemed appropriate. NOTICE The Respondent is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Plorida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page) . All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Katrina D. Lacy, maghixe 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 No. 7003 1010 0002 4667 0227 to CT Corporation System, Registered Agent for Cypress Community Care Center, 1200 South Pine Island Road, Plantation, FL 33324, dated on February é¢ 2004. Katrina D. Lacy, Egftire AHCA, Senior Attorney Fla. Bar. No. 0277200 Counsel for Petitioner 525-Mirror Lake Dr. N., #330G St. Petersburg, FL 33701 (727) 552-1525 (office) (727) 552-1440 (fax) Copies furnished to: CT Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Bill Maggard, Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Mail) Katrina D. Lacy AHCA ~- Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, FL 33701

Docket for Case No: 04-001191