STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. CYPRESS CREEK ASSISTED LIVING RESIDENCE, INC., d/b/a CYPRESS CREEK ASSISTED LIVING RESIDENCE. Respondent. ADMINISTRATIVE COMPLAINT OE MUST RAT CARH GAM Fy 2005010390 COMES NOW the Agency For Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against CYPRESS CREEK ASSISTED LIVING RESIDENCE, INC., d/b/a CYPRESS CREEK ASSISTED LIVING RESIDENCE (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine and survey fee in the amount of fifteen hundred dollars ($1,500.00) based upon one cited State Class II deficiency ($1,000.00 fine) pursuant to §400.419(2)(b) Fla. Stat. (2005) and a survey fee of five hundred dollars ($500.00) pursuant to §400.419(10) Fla. Stat. (2005). (Ty JURISDICTION AND VENU! 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. él E PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part III, Florida Statutes, and Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 100-bed assisted living facility located at 970 Cypress Creek Blvd., Ruskin, Florida 33573, and is licensed as an assisted living facility, license number 9553. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, no resident shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law... Every resident of a facility shall have the right to, inter alia, live in a safe and decent living environment, free from abuse and neglect, and to be treated with consideration and respect and with due recognition of personal dignity. Fla. Stat. § 400 .428(1) (2005). 8. That further, facilities shall offer personal supervision, as appropriate for each resident, including, inter alia, awareness of the general health, safety, and physical and emotional well- being of the individual; contacting the resident’s health are provider and other appropriate party...if the resident exhibits a significant change; and a written record, updated as needed, of any significant changes in the resident’s normal appearance or state of health, any illnesses which resulted in medical attention, major incidents...or other changes which resulted in the provision of additional services. R. 58A-5.0182(1) Fla. Admin. Code. 9. That on November 3, 2005, the Agency conducted a complaint investigation of the Respondent facility. 10. That based upon the review of records and interview, the facility failed to ensure that one (1) resident lived in an environment free from neglect. . 11. That the Petitioner’s representative interviewed the staff of the Respondent facility on November 3, 2005 who related the following regarding resident number one (1): a. That the resident was found expired at approximately 7:00 AM on October 25, 2005 by the morning shift; b. That the resident’s body was located in the bathroom on the toilet; C. That the resident had experienced episodes of diarrhea on October 24, 2005; d. That on October 24, 2005, the day preceding the resident’s death, the resident was found lying in the resident’s bed at approximately 3:00 PM; e. That the resident’s bed was saturated in feces at that time which necessitated that the resident be showered and all linens removed from the resident’s bed; f. That the resident had not been observed by Respondent’s staff at any time between the resident’s shower at approximately 3:00 PM on October 24, 2005 and the next observation of the resident at approximately 7:00 AM the next day, at which time the resident had expired; g. That the resident did not like to leave the resident’s room. ua 12. That the Petitioner’s representative reviewed the Respondent’s record regarding resident number one (1) on November 3, 2005, and no record existed reflecting that the resident had suffered a significant change in the resident’s bouts with diarrhea, the need to shower the resident and replace linens, or any efforts to contact the resident’s physician or other person regarding this significant change of the resident’s health. 13, That the Petitioner’s representative reviewed the Respondent’s evening work schedule policy which required that staff conduct “...head checks every fifteen to thirty minutes...” 14. That the Petitioner’s representative interviewed the Respondent facility’s staff on November 4, 2005 who indicated that required checks are not conducted due to insufficient staffing. 15. That the Petitioner’s representative interviewed the Respondent’s administrator on November 3, 2005 who indicated that the resident was not experiencing any problems on October 24, 2005 and that the resident was up playing Bingo. 16. That the Petitioner’s representative interviewed the Respondent’s resident care coordinator on November 3, 2005 who indicated a lack of knowledge that the resident was experiencing any change in condition on October 24, 2005. 17. That the above reflects that the Respondent facility neglected the resident in violation of law as follows: a. That the resident experienced a significant change in health evidenced by episodes of diarrhea on October 24, 2005; b. That the resident needed services including, but not timited to, cleansing of both person and bed as a result of the resident’s significant change; c. That the resident’s significant health change was not annotated in the resident’s record as required by law; d. That the resident’s healthcare provider and other person, i.e. family, were not contacted and notified of the resident’s significant health event; e. That the Respondent’s required checks of the resident on a periodic basis was not conducted; f. That the Respondent failed to provide personal supervision of the resident as appropriate in light of the resident’s ongoing significant health issue; g. That the facility failed to maintain a general awareness of the general health, safety, and physical well-being of the resident. 18. That these failures, individually and collectively, reflect the Respondent facility’s failure to provide services required by law and by the Respondent’s internal policies. 19. That these failures, individually and collectively, reflect the Respondent’s neglect of the resident by the Respondent facility 20. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 21. The Agency provided Respondent with a mandatory correction date of December 3, 2005. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2005). COUNT IT 22. The Agency re-alleges and incorporates paragraphs (1) through (19) as if fully set forth herein. 23. That as a result of the Agency’s complaint investigation on or about November 3, 2005, the Respondent was cited for one Class II deficiency which was the subject of the complaint. 24. That pursuant to Section 400.419(10), Florida Statutes (2005), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 400.428(3)(c), Florida Statutes (2005), to verify the correction of the violations. In this case, AHCA is authorized to request a survey fee in the amount of $500.00. WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla. Stat. (2005). Respectfully submitted this ZO day of December, 2005. TI . Walsh, II No. 566365 ounsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 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 Election of Rights (two pages) 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003 1010 0002 4667 1200 on December , 2005 to William Kaklis, Registered Agent for Cypress Creek Assisted Living Residence, 1400 — qh Avenue W., Bradenton, FL 34205 and Maria Green, Administrator, Cypress Creek Assisted Living Residence, 970 Cypress Creek Blvd., Ruskin, FL 33573. . Walsh, If r Attorney Copies furnished to: William Kaklis Maria Green, Administrator Thomas J. Walsh, I | Registered Agent Cypress Creek Assisted Living | Agency for Health Care Admin. Cypress Creek Asst. Liv. Res. Residence 525 Mirror Lake Drive, 330G 1400 4" Avenue W. 970 Cypress Creek Blvd. St. Petersburg, Florida 33701 Bradenton, FL 34205 Ruskin, FL 33573 (Interoffice) (U.S. Certified Mail) (U.S. Mail) PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. Cypress Creek Assisted Living Residence Facility Name 2005010390 AHCA No. agiv|stox MINIS TRATIVE ADHINS RAT VE | COMPLETE THIS-SECTION ON DELIVERY... ~ Pe TOME SL ale ey LF Bee, Lt 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 mailplece, or on the front if space permits. 1. Article Addressed to: Willjoun Kak bis item 17 fi \f YES, enter delivery address below: O Certified Mail > C1 Ex : Ci Registered CO) Return Recelpt for Merchandise C1 Insured Mail -O.L. 4, Restricted Delivery? (Extra Fee) © Yes 2. Article Number ° . Unit 4392) (tanster fom 70035 1010 0002 4b4b7 1lzo0 Ted PS Form 3811, February 2004 Domestic Return Recelpt . 402595-02-M-154C

Docket for Case No: 06-001453