Certified Mail Receipt 7064141460, 00033239 1RB1G2 arings STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINI STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA Nos.: 2006009134 : 2006009284 vs. Mapenionceanewanonn © LOFT Respondent. es ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Raymond and Yvonne Lewis d/b/a Tender Loving Care Manor (hereinafter “Tender Loving Care Manor”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2006), alleges: NATURE OF THE ACTION 1. This is an action to impose (6) six administrative fines against Tender Loving Care Manor, in the amount of Four Thousand Five Hundred Dollars ($4,500.00), based upon three (3) class II deficiencies, and three (3) class III deficiencies, pursuant to Sections 429.19(2)(b), 429.19(2M(c), and 429.275(4), Fla. Stat. (2006), and Rules 58A- 5.0182(1\c), 58A-5.0185(5)(b), 58A-5.019(1), 58A-5.019(4a)5, and 58A-5.024(2)(a), Fla. Admin. Code (2006). JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 429, Part I and Section 120.569 and 120.57, Fla. Stat. (2006). 3. Venue lies in Marion County, Ocala, Florida, pursuant to Section 120.57 Fla. Stat. (2006); Rule 58A-5, Fla. Admin. Code (2006) and Section 28.106.207, Fla. Stat. (2006). PARTIES 4. AHCA, is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part 1, Fla. Stat. (2006) and Rule 58A-5, Florida Administrative Code (2006). 5. Tender Loving Care Manor is a for-profit corporation, whose 6-bed assisted living facility is located at 34 Lake Court Loop, Ocala, Florida 34472. Tender Loving Care Manor is licensed as an assisted living facility license # AL10226; certificate number #17855, effective February 3, 2005 through November 13, 2006. Tender Loving Care Manor was at all times material hereto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I TENDER LOVING CARE MANOR FAILED TO ENSURE THE FACILITY WAS BEING MANAGED AND OPERATED APPROPRIATELY. THIS IS EVIDENCED BY FAILING TO PROVIDE ADEQUATE SUPERVISION TO 1 OF 6 (#1) RESIDENTS BY A STAFF EMPLOYED BY THE ADMINISTRATOR. STATE TAG A500-STAFFING STANDARDS _ ® @ Section 429.19(2)(b), Fla. Stat. (2006) VIOLATIONS; IMPOSITION OF ADMINISTRATION FINES; GROUNDS Rule 58A-5.0191(1), Fla. Admin. Code (2006) STAFF TRAINING REQUIREMENTS AND COMPETENCY TEST 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about September 25, 2006, AHCA conducted a monitoring visit at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about September 25, 2006, Tender Loving Care Manor failed to ensure the facility was being managed and operated appropriately. This is evidenced by failing to provide adequate supervision to 1 of 6 (#1) residents by a staff employed by the administrator. The findings are: The first attempted entry to the facility occurred at 10:30 AM, on 9/25/2006. There was no one Present at the facility, and the facility vehicle was also not present. The second attempted entry to the facility occurred at 12:15 PM, on 9/25/2006 and again their was no one Present at the facility, nor was the facility vehicle Present. Three attempts were made to reach the facility by telephone on 9/25/2006, at which time an answering machine answered, disconnected and a left on the facility answering machine. The third attempt to enter the facility occurred at 1:10 PM, on 9/25/2006 at which time a resident (#1) was found to be sleeping in a lawn chair on the porch, the facility vehicle was still absent and there was no one present in the facility. Interview with resident #1 conducted at 1:15 PM on 9/25/2006 revealed that he/she was able to give his/her first name before falling back to sleep. The resident's skin was extremely warm to the touch, and was dry. The temperature of the porch was taken utilizing 2 thermometers, the location where the resident was sitting, was documented at 91 degrees Fahrenheit at 1:30 PM on 9/25/2006. Observation of the porch, at this time, revealed there was no water available for the resident to drink. There was also a locked refrigerator on the porch. At 1:30 PM on 9/25/2006, Marion County Emergency Medical Services, Marion County Sheriffs Office, Department of Children and Families, and the Ombudsman Council were notified that a resident of the facility had been found on the porch locked out of the home, and that the resident was unable to give any information other than his/her first name, and that the resident would be transported to a local hospital for evaluation. At 2:45 PM on 9/25/06 resident #1 was transported by the Emergency Medical Service (EMS) to the hospital for evaluation. Cellular telephone interview with the Deputy, who had accompanied resident #1 to the hospital, on 9/25/06 at 3:30 PM, revealed that he needed medical information for this resident, but is unable to locate the facility's Administrator. Further interview with the Deputy revealed he has called the facility, but there is still no answer. The Deputy was given information on resident #1.which was obtained during the facility's Biennial licensure survey conducted on 8/21/06. Cellular telephone interview with the investigator from Adult Protection Services (APS) on 9/25/06 at 4:30 PM revealed he was with resident #1, at the hospital. Further interview revealed that he also needed some medical information for resident #1, but is unable to locate the facility's Administrator, as no one is answering the telephone at the facility. Interview with the facility co-owner, 9/26/2006 at 4:00 PM revealed that he had left. the facility on 9/25/2006 at approximately 10:00 AM to take all of other residents to the "Drop In" area at local Mental Health Center. The co-owner also stated that the resident found on the porch had refused to go with the group to the "Drop In" area and had left the facility property at the time the other residents left which was at 10:00 AM. The co-owner also stated that he/she returned to the facility and left again at 1:10 PM on 9/25/2006 to take his/her adult child to a doctor's appointment, and that the resident was not seen at the facility when they left. Further interview revealed that no provisions had been made to have an employee remain at the facility, in case resident #1 returned. Continued interview with the administrator and the co-owner at 4:00 PM on 9/25/2006 revealed that the resident has been non compliant with regard to house rules, medication, wandering and transportation for the last "few months" and is becoming increasingly non compliant. Further interview with the administrator on 9/25/2006 at 4:30 PM revealed the resident was given a discharge notice on 8/15/2006. Class II Correction Date: 10/25/2006 8. The regulatory provisions of the Fla. Stat. (2006), that is pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds. ~ (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. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation: * ok 58A-5.019 Staffing Standard ~ (1) The facility shall be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required by Part I of Chapter 429, F.S., and this rule chapter. ee OK 9. The violation alleged herein constitutes a class II deficiency, and warrants a fine of $1,000.00. ~WHEREFORE, AHCA. demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000.00. COUNT I TENDER LOVING CARE MANOR FAILED TO KNOW THE WHEREABOUTS OF 1 OF 6 (#1) RESIDENTS. FAILURE TO APPROPRIATELY SUPERVISE RESIDENTS HAS THE POTENTIAL FOR INJURY TO THE RESIDENT WHILE WANDERING AWAY FROM THE FACILITY UNSUPERVISED. IT ALSO HAS THE POTENTIAL FOR THE RESIDENT BECOMING LOST WHILE WALKING THROUGH THE COMMUNITY. STATE TAG A705-RESIDENT CARE STANDARDS Section 429.19(2)(b), Fla. Stat. (2006) VIOLATIONS; IMPOSITION OF ADMINISTRATION FINES; GROUNDS Rule 58A-5.0182(1)(c), Fla. Admin. Code (2006) RESIDENT CARE STANDARDS 10. | AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 11. On or about September 25, 2006, AHCA conducted a monitoring visit at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about September 25, 2006, Tender Loving Care Manor failed to know the whereabouts of 1 of 6 (#1) residents. Failure to appropriately supervise residents has the potential for injury to the resident while wandering away from the facility unsupervised. It also has the potential for the resident becoming lost while walking through the community. The Findings AT: en eae On 9/25/2006 at 1:10 PM, an unattended resident was found on the porch of the facility. There was no one present inside of the facility and the facility vehicle was not present. Interview with the co-owner and the administrator conducted 9/26/2006 at 4:00 PM revealed that the co-owner, who was also the scheduled staff member on duty, had taken their adult child to a doctor's appointment at 1:10 PM, on 9/25/2006, and that no other staff members were present at the time of his departure. Further interview also revealed that there was no staff member assigned to wait for resident commenced at 10:00 AM. According to this interview, resident #1 left the facility at 10:00 AM, when the co-owner transported the other residents to the stoup outing. At the completion of this Teport, the co-owner and the administrator were unable to account for the resident's whereabouts from the time he/she left the facility, at 10:00 AM, to the time he/she was observed asleep on the Porch, at 1:10 PM. Class II Correction Date: 10/25/2006 12. The regulatory provisions of the Fla. Stat. (2006), that is Pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds, ~ than $1,000 and not exceeding $5,000 for each violation, A fine shall be levied notwithstanding the Correction of the violation. ee 58A-5.0182 Medication Standards, ~ 13. The violation alleged herein constitutes a class [I deficiency, and warrants a fine of $1,000.00, WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. Oe IE Oe 2. Impose a fine in the amount of $1,000.00, COUNT III STATE TAG A508-STAFFING ST, ANDARDS Section 429.19(2)(c), Fla. Stat. (2005) VIOLATIONS; IMPOSITION OF ADMINISTRATION FINES; GROUNDS : Rule 58A-5.019(4)(a)5, Fla. Admin. Code (2006) STAFFING STANDARDS 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. On or about September 26, 2006, AHCA conducted a follow-up to the biennial licensure survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about August 21, 2006, Tender Loving Care Manor failed to b.) During a follow-up to the biennial licensure survey on or about September E's e @ the facility and residents in the event of the administrator’s absence has the potential for interruption of care and services to residents, and the daily operation of the facility. The Findings are: administrator was going to be away from the facility for an extended period of time. _ The administrator is employed during day time hours at another facility. Class III Correction Date: 10/26/2006 16. The tegulatory provisions of the Fla. Stat. (2006), that is pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds, ~ health, safety, or Security of facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class III violation in an * Fx @ 17. The violation alleged herein constitutes an uncorrected class Il deficiency, and warrants a fine of $500.00, | WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $500.00. COUNT IV TENDER LOVING CARE MANOR FAILED TO MAINTAIN AN ACCURATE MEDICATION OBSERVATION RECORD (MOR) ON 1 (#1) OF 3 SAMPLED RESIDENTS, FAILURE TO MAINTAIN AN ACCURATE STATE TAG A614-MEDICATION STANDARDS Section 429, 19(2)(b), Fla. Stat. (2006) VIOLATIONS, ADMINISTRATION FINES Rule 58A-5.0185(5)(b), Fla, Admin. Code (2006) MEDICATION STANDARDS 18. = AHCA re-alleges and incorporates Paragraphs (1) through (5) as if fully set forth herein. 19. On or about September 26, 2006, AHCA conducted a follow-up to the - biennial licensure survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: observation record (MOR) on 1 (#1) of 3 sampled residents. Failure to maintain an accurate and current medication observation record has the potential for medication errors resulting in resident health decline, The Findings are: written and not as he/she had transcribed it on the medication observation record (MOR). 2. The medication observation tecord (MOR) on resident #1 is continued as follows: 9/21/2006. No further orders on the medication observation tecord were written ~The physician's orders dated 9/6/ 2006-revealed the following: Clonazepam 0.5 milligrams (mgs.) to be taken twice daily for 7 days, then once daily for seven days, then as needed for agitation or anxiety, Interview with the administrator on 9/26/2006 at 3:30 PM tevealed that he/she was not aware the medication was not being given as the doctor's orders stated, Class II Correction Date: 10/26/2006 11 EEEE'~S Oe e @ 20. The regulatory provisions of the Fla. Stat. (2006), that is Pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds, ~ ee & 58A-5.0185 Medication Standards (5) each resident who Teceives assistance with selfadministration of medications or medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. MOR must be immediately updated each’ time the medication is offered or administered. x ok x 21. The violation alleged herein constitutes an uncorrected class I] deficiency, and warrants a fine of $1,000.00. - -WHEREFORE,-AHCA demands the following relief... 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000.00. 12 NY’ LL e @ COUNT V STATE TAG A1100-STAFF RECORDS STANDARDS Section 429.19(2)(c), Fla. Stat. (2006) VIOLATIONS; ADMINISTRATION FINES Section 429.275(4), Fla. Stat. (2006) BUSINESS PRACTICE; PERSONNEL RECORDS; LIABILITY INSURANCE : 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. On or about September 26, 2006, AHCA conducted a followup to the biennial licensure survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about August 2 1, 2006, Tender Loving Care Manor failed to ensure. that 2 (#2 & #3) of 4 personnel records contained an employment application with references. Failure to have applications with references has the potential for the inability of thoroughly researching an employee’s past work history. b. During a follow-up to the biennial licensure survey on or about September 26, 2006, Tender Loving Care Manor failed to ensure that 1 (#2) of 4 personnel records contained an employment application with references. Failure to have applications with references has the potential for the inability to thoroughly research an employee’s past work history. 13 IEE Sa ad r) The Findings are: Review of facility records revealed employee #2 had no application and references n his/her file. Interview with the administrator on 9/26/2006 at 3:30 PM revealed that he/she was not aware that the co-owner of the facility had to have this documentation. Class IH Correction Date: 10/26/2006 24. The regulatory provisions of the Fla. Stat. (2006), that is pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds, ~ (b) 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. The agency shall impose an administrative fine for a cited class III violation in an x oe & 429.275 Business practice; personnel records; liability insurance.~ (4) The department may by rule clarify terms, establish requirements for financial records, accounting procedures, personnel procedures, insurance coverage, and procedures, and specify documentation as necessary to implement the requirements of this section. *x* *e x 25. The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $500.00, WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 14 ee 2. Impose a fine in the amount of $500.00. COUNT VI TENDER LOVING CARE MANOR FAILED TO ENSURE THAT 3 (#1, #3 AND #4) OF 4 EMPLOYEES WERE FREE OF COMMUNICABLE DISEASE. FAILURE TO DOCUMENT FREEDOM OF COMMUNICABLE DISEASE IN EMPLOYEES HAS THE POTENTIAL FOR EXPOSURE OF RESIDENTS TO A FORM OF COMMUNICABLE DISEASE. STATE TAG A1101-STAFF RECORDS STANDARDS Section 429.19(2)(c), Fla. Stat. (2006) VIOLATIONS; ADMINISTRATION FINES Section 429.275(4), Fla. Stat. (2006) BUSINESS PRACTICE; PERSONNEL RECORDS; LIABILITY INSURANCE Rule 58A-5.024(2)(a), Fla. Admin. Code (2006) STAFF RECORDS 26. | AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 27. On or about September 26, 2006, AHCA conducted a follow-up to the biennial licensure survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about August 21, 2006, Tender Loving Care Manor failure to ensure that 4 of 4 employees were free of communicable disease. Failure to document freedom of communicable disease in employees has the potential for expose of residents to a form of communicable disease. b. During a follow-up to the biennial licensure survey on or about September 26, 2006, Tender Loving Care Manor failed to ensure that 3 #1, #3 and #4) of 4 employees were free of communicable disease. Failure to document freedom of communicable disease in employees has the potential for expose of residents to a form of communicable disease. 15 ad @ The Findings are: Review of employee records on employees #1, #3 & #4 revealed no evidence from a health care provider of being free of communicable disease. Interview with the co-owner and administrator on 9/26/2006 at 3:30 PM revealed that they were aware of the missing documentation for communicable disease. Further interview with the administrator revealed that there are appointments set up for the employees to procure this documentation. Class III Correction Date: 10/26/2006 28. . The regulatory provisions of the Fla. Stat. (2006), that is pertinent to this alleged violation read as follows: 429.19 Violations; imposition of administrative fines; grounds. ~ (b) 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 | or class I violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. ek * 429.275 Business practice; personnel records; liability insurance.~ (4) The department may by rule clarify terms, establish requirements for financial records, accounting procedures, personnel procedures, insurance coverage, and procedures, and specify documentation as necessary to implement the requirements of this section. 58A-5.024 Staff Records ~ (2)(a) Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition as applicable: 1. Documentation of compliance with all staff training required by Rule 58A- 5.0191, F.A.C. ; 2. Copies of all licenses or certifications for all staff providing services which require licensing or certification; 3. Documentation of compliance with level 1 background screening for all staff subject to screening requirements as required pursuant to Rule 58A-5.019, F.A.C.; and 4. For facilities with a licensed capacity of 17 or more residents, a copy of the job description given to each staff member pursuant to Rule 58A-5.0419, F.A.C * * * 29, The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $500.00. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $500.00. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2006). 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, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. d Respectfully Submitted this 22 day of 4 wn 006 Leon County, Tallahassee, Florida. Michael O. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE L HEREBY CERTIFY that a true and correct copy of the foregoing has been served +] Michael O. Mathis, Esq. SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 3. Also comple item 4 if Restricted Delivery is desigaf,2 ™@ Print-your name.and address on. so that we can return the card tq’ gs ™ Attach this card to the back of the or on the front if space permits. \ alegre Beet Eee for Sh Lex Lae | Oeala, FL BUTS. _ | greeted Mat 2 Express Mal RE: “Fendan Loving Gore es _ Di Registered (‘Return Receipt for Merchandi Menor 4 Insured Mait _(1.C.0.D. - 4, Restricted Delivery? (Extra Fee) Ovea 2. Article Number " : (Transtar trom seevice intel) 7004 2160 0003 3739 Wb PS Form. 3811, February 2004 Domestic Return Receipt - ae *102505-08M- 1540 SUOHONASU] 10) BSiaAdY BAS 25M VVid!s Dy | ®uoo'sdsn' MMM 2 SUSGaM INO PISIA UOHeUWO}UT AJaAIap 104 4TOb BEAE ED00 O8TT hOOed (papiaoig abesanog aqueunsuy.on ‘Aug ley. 2seu0g) 4Idld94y “IVAW GsisdiLdsa5 ™QOIAIAS (21SOd ‘S'N

Docket for Case No: 07-000412