STATE OF FLORIDA : AGENCY FOR HEALTH CARE ADMINISTRATION * O5 MAR -t, AGENCY FOR HEALTH CARE ADMINISTRATION, F po Sage Petitioner, vs. AHCA Case No. 2004006051 EMERITUS CORPORATION, d/b/a THE PARK CLUB OF a CS) K ;2 FORT MYERS, .) O 4 > Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”) by and through the undersigned counsel, and files this Administrative Complaint against EMERITUS CORPORATION d/b/a THE PARK CLUB OF FORT MYERS (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $2,500 against the Respondent, pursuant to Sections 400.419(1)(c) and 400.419(1)(b), Florida Statutes (2004); and Rules 58A-5.0181(1)(m)1-3, 58A-5.0182, 58A-5.0182(1)(b), Florida Administrative Code (2004). 2. Respondent was cited for a Class Tl violation during a complaint investigation AHCA conducted on or about March 23, 2004. The aforementioned med a repeat Class IJJ at the Limited Nursing Survey and an appraisal violation was dee! visit AHCA completed on June 8, 2004. Respondent was also cited for two Class Il Page 1 of 13 violations at the Limited Nursing Survey and an appraisal visit AHCA completed on June 8, 2004. JURISDICTION AND VENUE 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). 4. Venue shall be determined pursuant to Chapter 28-106.207, Florida Administrative Code (2004). PARTIES 5. Pursuant to Chapter 400, Part Hl, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules. 6. Respondent is an assisted living facility located at 1896 Park Meadows Drive, Ft. Myers, Florida 33907. Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part II, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), having been issued license number 5096. COUNT 1 Respondent failed to ensure that each resident was appropriate for admission and continued residency. § 400.419(1)(c), Fla. Stat. (2004) Fla. Admin. Code R. 58A-5.0181(1)(m)1-3 (2004) 7. AHCA re-alleges paragraphs 1-6 above. 8. On or about March 23, 2004, AHCA conducted a complaint investigation at Respondent’s facility. AHCA cited Respondent for a deficiency, based on the findings below, to wit: ew with the complainant on 3/23/04 he/she stated the a) During an intervi in the facility to evacuate the residents in facility does not have enough staff i a safe and timely manner. Page 2 of 13 admission and continued residency, Administrati During an interview with the local fire marshal on 3/23/04 he/she stated the facility has a history of unsatisfactory fire safety reports and that he/she is concemed the facility does not have enough staff to safely evacuate the residents in the proper amount of time. He/she stated he/she has heard there is one staff in the facility during the 11:00 PM to 7:00 AM shift. He/she stated this would not allow the residents to evacuate safely and timely. During a tour of the facility on 3/23/04 at approximately 10:00 AM it was revealed that there were four residents in the facility who were in wheelchairs. Three of the residents were able to get out of the wheelchair and walk by themselves. One resident, who resides in the memory Lane (secured unit), was in a wheelchair and required one person assist to get out of the wheelchair. A review of the facility's Evacuation Capability worksheet on 3/23/04 revealed the memory lane unit was done on 2/12/04. There were two staff and 22 residents involved. The level of evacuation capability was rated at "Impractical" (5.9). During an interview on 3/23/04 the administrator stated she has been employed at the facility since January 2004. She stated she was not aware of this evaluation and rating. The facility staffing schedule showed there were two staff scheduled each day on the 11 PM-7 AM shift for each unit (memory lane and assisted living). The census for the facility on the day of the survey showed the memory lane has 21 residents and the assisted living has 61 residents. However, the staff at the facility did not know what time and at what shift this evacuation assessment occurred. 9. Respondent failed to ensure that each resident was appropriate for ve Code (2004), which provides, in pertinent part, as follows: “ggA-5.0181 Residency Criteria and Admission Procedures...(1) ADMISSION CRITERIA. An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license...(m) Have been determined to be appropriate for admission to the facility by the facility administrator. The administrator shall base his/her decision on: 1. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 400.426, F.S., and subsection (2) of this rule; 2. The facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and 3. The ability of the facility to meet the uniform fire safety standards for assisted living facilities established under Section 400.441, F.S., and Chapter 4A-40, F.A.C.” Page 3 of 13 as required by Rule 58A-5.0181(1)(m)1-3, Florida 10. The foregoing violation constitutes a Class III violation due to the nature of the violation and the gravity of its probable effect on the residents of the facility, to wit: “(c) Class III violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class II violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation...” (§ 400.419(1)(c), Fla. Stat. (2004)) 11. On or about June 8, 2004, AHCA completed a Limited Nursing Survey and an appraisal visit at Respondent’s facility. AHCA cited Respondent for a repeat deficiency, based on the findings below, to wit: a) Resident #3 was admitted to the facility on 5/22/04 with the family present from a sister facility out of the area. The nurse’s admission note of 5/22/04 indicated that he "resists toileting...wears attends. ....alert, disoriented to time and place. Incontinent of B & B." There was no documentation that he was evaluated for grooming, bathing, or dressing. b) Observation of the resident in the dining room of the closed unit on 6/08/04 revealed a resident who was eating independently. He had a bruise across his face and nose, that appeared to have been recently bleeding because of dried blood his finger of his left hand and blood drips on his right forearm. c) Record review of the DOEA 1823 Health Assessment completed on 5/26/04 revealed that he needed total help in bathing, dressing, grooming and was incontinent of toileting. d) Interview with the Director of Nursing on 6/08/04 at 3 P.M. revealed that the resident had fallen on 6/05/08. She stated that at that time she had given the family a verbal notice that the resident was not appropriate for the facility. The MOVE OUT form was not signed by the resident or a family member. 12. The foregoing violation constitutes a repeat Class III violation pursuant to Section 400.419(1)(c), Florida Statutes (2004) (quoted above), due to the nature of the violation and the gravity of its effect on the residents of the facility, and warrants a fine of $500. 13. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Page 4 of 13 Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $500 for the referenced violation; and 3. Impose such other appropriate relief as this tribunal may find and deem appropriate. COUNT Respondent failed to provide care and services appropriate to the needs of a resident accepted for admission to the facility for 1 (Resident #2) of 3 active sampled residents. § 400.419(1)(b), Fla. Stat. (2004) Fla. Admin. Code R. 58A-5.0182 (2004) 14. AHCA re-alleges paragraphs 1-6 above. 15. | On or about June 8, 2004, AHCA completed a Limited Nursing Survey and an appraisal visit at Respondent’s facility. AHCA cited Respondent for a deficiency, based on the findings below, to wit: a) Resident #2 was admitted to the facility on 5/27/04 with diagnosis including Cirthosis of the liver and Hospice Care. Interview with the resident in her room on 6/08/04 at 11:45 A.M. revealed that she was aware of her hospice needs. She stated that at night she has a hard time breathing, which causes her anxiety. She stated that she has adjusted to the facility, "Itis like a co-ed soriety.” Review of the census log revealed that this resident was Independent. Interview with the DON at 3 P.M. revealed that the staff nurse's had not told her that the resident needed medication for anxiety due to SOB (shortness of breath). Discussion with the DON revealed that although she is independent in all her ADL's, the facility assists the resident with medication administration. During the interview with staff nurses they said that Hospice is in charge of the resident. Review of the Resident Health Assessment dated 5/26/04 indicated the resident needed help with her medications. It states, "needs meds poured and given to her." Page 5 of 13 Review of the resident's clinical record did not contain a care plan that showed the services that the facility and hospice would provide for care of the resident. There was lack of coordination of services for this resident between Hospice and the facility. 16. Respondent failed to provide care and services appropriate to the needs of a resident accepted for admission to the facility for 1 (Resident #2) of 3 active sampled residents, as required by Rule 58A-5.0182, Florida Administrative Code (2004), which provides in pertinent part, as follows: “g8A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility.” 17. The foregoing violation constitutes a Class II violation, due to the nature of the violation and the gravity of its effect on the residents of the facility, and warrants a fine of $1,000, to wit: “(b) Class “II” violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. A class II violation is subject to an administrative fine in an amount not less than $1,000 and not exceeding $5,000 for each violation...” (§ 400.419(1)(b), Fla. Stat. (2004)) 18. | AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $1,000 for the referenced violation; and 3. Impose such other appropriate relief as this tribunal may find and deem appropriate. Page 6 of 13 COUNT Ill Respondent failed to provide daily observation by staff to ensure awareness of the general health and well being for 1 (Resident #1) of 3 active sampled residents. § 400.419(1)(b), Fla. Stat. (2004) Fla. Admin. Code R. 58A-5.0182(1)(b) (2004) 19. AHCA re-alleges paragraphs 1-6 above. 20. On or about June 8, 2004, AHCA completed a Limited Nursing Survey and an appraisal visit at Respondent's facility. AHCA cited Respondent for a deficiency, based on the findings below, to wit: a) Resident #1 was admitted to the facility on 10/25/03 with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, Hypertension, Diabetic Neuropathy, Leg Ulcers, and Congestive Heart Failure. The resident receives Renal Dialysis treatments three times a week. Review of the Resident Health Assessment dated 3/15/04 indicated the resident needed help with his/her medications. It further stated the resident had very poor vision. On 3/17/04, the resident had a Psychiatric Consult. The consult indicated the resident had poor insight and judgment and the resident was not competent to self-administer medication, and suggested supervision. It further indicated the resident had been making poor food choices, and recommended Risperdal to be started due to Psychosis. Observation and interview with the resident on 6/8/04 in his/her room, at approximately 10:00 A.M. revealed the resident seated in a chair with his/her right leg elevated on a chair. An open wound was observed on the right lower leg. There was a large partially filled blister area with clear, yellow and pink drainage. The area surrounding the open wound was reddened. The resident stated he/she has had blisters in the past. The resident stated he/she had been waiting for the nurse to come and put the dressing on the area since 5:00 AM. Interview with the facility LPN (Licensed Practical Nurse) on 6/8/04 at approximately 10:30 A.M. revealed the Home Health Agency nurse cared for the wound. The facility LPN further stated she had not seen the wound. Interview with the facility RN at approximately 1:50 P.M. revealed she had seen the wound since it had been noted, but there was no documentation regarding her observation. When the facility RN was asked if there was any communication between the Dialysis Center and the facility, the RN responded there was not. On 6/3/04 record review revealed a Home Health Agency nurse saw the resident and the documentation indicated the resident received a treatment to Page 7 of 13 a Jarge and draining blister on the right lower extremity. The notes further stated the resident had Iplus edema to both lower extremities, and the resident had pain in his/her feet. On 6/5/04 a Home Health Agency nurse saw the resident. The notes indicated there was slight edema to both lower extremities, and a moderate amount of clear drainage. On 6/8/04 a Home Health Agency nurse saw the resident. Interview with the nurse at approximately 11:30 A.M. following the nurse's assessment of the wound, revealed the current treatment was not appropriate. The Home Health Agency nurse contacted the physician and a new order was obtained for a wound culture, and an antibiotic. The documentation indicated the resident had pain in her right lower extremity. The Home Health Agency Nurse was not aware of the resident's visual status, the history of non compliance with dietary recommendations, psychiatric consult recommendations, or what services the resident was receiving at the Assisted Living Facility. 21. Respondent failed to provide daily observation by staff to ensure awareness of the general health and well being for 1 (Resident #1) of 3 active sampled residents, as required by Rule 58A-5.0182(1)(b), Florida Administrative Code (2004), which provides in pertinent part, as follows: “58 A-5,0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following...(b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual.” 22. The foregoing violation constitutes a Class II violation, due to the nature of the violation and the gravity of its effect on the residents of the facility and warrants a fine of $1,000, to wit: “(b) Class “II” violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. A class II violation is subject to an administrative fine in an amount not less than $1,000 and not exceeding $5,000 for each violation...” (§ 400.419(1)(b), Fla. Stat. (2004)) Page 8 of 13 23. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $1,000 for the referenced violation; and 3. Impose such other appropriate relief as this tribunal may find and deem appropriate. THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK Page 9 of 13 NOTICE Respondent, EMERITUS CORPORATION d/b/a THE PARK CLUB OF FORT MYERS is notified that she 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. THE RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, 4A FINAL ORDER WILL BE ENTERED. Submitted on this And_ day of Barrer boen 2004. Tevet lla Timothy B. tt, Senior Attorney Fla. Bar No. 210536 Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MSC #3 Tallahassee, FL 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or (850) 413-9313 Page 10 of 13 CERTIFICATE OF SERVICE és & 1 HEREBY CERTIFY that the original Administrative Complaint, rxplanati GAP “4 S ia Py Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Redo 4: ‘3 *) up 4 j saa; ee Receipt Requested (receipt # 7000 1530 0000 5684 9204) to The Park Club of Ft. Myers. Ah #5) SU, Ve 1896 Park Meadows Drive, Ft. Myers, Florida 33907. Submitted on this nf _ day of __ Verreml-er 2004. Lally 6 _CLbedlf- Timoth liott, Senior Attorney Page 11 of 13 ‘USPS - Track & Confirm Page 1 of 1 Track & Confirm Current Status Track & cont ‘ Enter Jabel number: -P. You entered 7000 1530 0000 5684 9204 Your item was delivered at 12:35 pm on November 04, 2004 in FORT MYERS, FL 33907. ~ 4 Track & Confirm FAQs U.S. Postal Service : CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) | Sent To PARE Ll LEMOS. [HLM halt [Street Apt. No.; or P ME HE MEADONE EME 0. oe City, State, ZiP> 4 EZ FL 33907 i PS Form 3800, May 2000 See Reverse for Instructions COMPLETE THIS SECTION ON DELIVERY | | a> a fu oc ~ r ADMINS TRATIVE . > Postage _ ALIKE, ip contact us government services = a com 02 USPS. All Rights Reserved. Terms of Use Privacy Policy a Certitied Fee ____| 2o0veeGo$s / uw metum R r qo a Postmark ti cipt Fee =! (Endorsement Fecuired) F a ae = 200400 GSES Rest Delivery Fee |. Fy Endorsement Figured) P| MOLD cy Tt Postage & Fees 1s : WV /2 /ov m — ——- in oa Q a Qa é SENDER: COMPLETE THIS SECTION &™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: The PAK CLUB OF ET MYERS ATTENTION ADMINISTRATOR 1296 PARK MEADOWS DRIVE . 3. $8 ET. MYERS, FLOLIDA 244 07 Certified Mail 1 Express Mail OO Registered Return Receipt for Merchandise O Insured Mail = C.0.D. | 4. Restricted Delivery? (Extra Fee) . O1Yes _ eee 2. Article Number (Transfer from service label) i 5 26). 2 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1540 http://trkenfrm1.smi-usps.com/netdata-cgi/db2www/cbd_243.d2w/output 11/16/2004

Docket for Case No: 05-000843