STATE OF FLORIDA ip fie AGENCY FOR HEALTH CARE ADMINISTRATION, || “Y foamy ei stp yy ' STATE OF FLORIDA, : °7 py 4: hg: AGENCY FOR HEALTH CARE AD fIVisig OW a a ADMINISTRATION, Nig pat OF . OT Yu Kl : EAR AT Ve Petitioner, ; vs. ) ABCA No.: 2007008068 KIVA Cl vALATKA, LLC, Respondent. : / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency For Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Kiva of Palatka, LLC (hereinafter “the Respondent”), pursuant to Sections 120,569 and 120.57, Florida Statutes (2006), and alleges as follows: NATURE OF THE ACTION | 1. This is an action to impose an administrative fine against an assisted living facility in the amount of one thousand dollars ($1,000), pursuant to Rule 58A- 5.0182(1)(b), Fla. Admin. Code, based upon one (1) Class II deficiency. JURISDICTION AND VENUE 2. This Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2006). 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 429, Part I . Florida Statutes (2006), Chapter 58A-5, Florida Administrative Code (2006) and Ch. 408, Part I, Florida Statutes (2006). Venue lies in Putnam County pursuant to Rule 28-106.207, Florida Administrative Code (2006). PARTIES The Agency is the regulatory authority responsible for the licensure of assisted living facilities and the enforcement of all applicable federal and state regulations, statutes and rules, governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code (2006). . The Respondent is a Florida licensed assisted living facility (License Number 827), operates a thirty-five (35) bed assisted living facility located at 201 Zaegler Drive, Palatka, Florida 32177, and was at all times material required to comply with all applicable state regulations, statutes and rules for assisted living facilities. COUNTI THE RESPONDENT FACILITY FAILED TO MAINTAIN OBSERVATION AND AWARENESS OF RESIDENT’S WELL BEING FOR ONE OF THREE RESIDENTS’ RECORD REVIEWED, IN VIOLATION OF RULE 58A-5.0182(1)(b), Fla. Admin. Code 7. 8. The Agency re-alleges paragraphs 1 through 6. On or about June 15, 2007, the Agency made an unannounced complaint investigation of the Respondent. The facility was found not.to be in compliance with Chapter 429 Part I, Florida Statutes and 58A-5, Florida Administrative Code. Based on record review and interview, the facility failed tomaintain observation =——™*” and awareness of residents’ well being, for 1 (#1) of 3 residents' records reviewed. A failure to be aware of residents’ physical well being has the potential for health decline or death of the resident. The findings include: . An interview with staff #2 at 1:30 PM, 6/15/2007 revealed that this staff member found resident #1 at approximately 7:00 AM on 6/12/2007. The resident was discovered laying face down without clothing, between the bedroom and bathroom area of his/her room. According to staff #2, the resident reportedly had no pulse, was not breathing, the skin was cold and the Tesident had what appeared to be dried vomit around his/her face area, The resident's bed was made and appeared to not have been slept in. . An interview conducted with staff member #1 at 2:15 PM revealed that she had worked the 3 PM-11 PM shift on 6/11/2007, She reportedly saw resident #1, she thinks, at around 10:00 PM in his room when she offered him a snack, She reports that she was positive that she saw him at 6:00 PM. When asked about the time the facility usually serves snacks, she replied that it is usually 8:00 PM. ; . A telephone interview was conducted with staff member #4 at 2:25 PM, on 6/15/2007. The staff member stated that she had only checked on resident #1 at 5:30 AM because she had been busy with another resident, and had only checked on him/her the one time on her shift, She stated that resident #1 was in his/her chair at 5:30 AM and had his/her things out getting ready to take a’ shower. As the interview continued, the staff member (#4) changed her report and stated that she had checked on the resident every one to one and a half hours throughout the night. . A review of the facility's policy and procedures failed to reveal a policy or procedure for checking on the well being of the residents. An interview was conducted with the administrator 6/15/2007 at 1:00 PM revealed that the facility had no policy and procedure in place for how often the residents are to be checked on throughout the day and night, . Areview of the job description for the resident aides on the 11 PM to 7AM shift revealed that rounds of the entire facility was to be done every 30 minutes and to report any change in a resident's condition to the administrator or assistant administrator. A review of the facility's report log from 6/11/2007, 11 PM-7 AM shift revealed that resident #1 was "in chair," but there was no time documenting when this was observed. . Areview of resident #1's record revealed the last entry made into the resident's individual chart observation log was dated 4/29/2007 on the 3 PM- 11 PM shift. . Areview of the facility's One Day Adverse Incident report, which was submitted to the state agency on 6/12/2007, revealed the administrator wrote that resident #1's body was cold. An interview with the Funeral Director of the Funeral Home where resident #1 was taken, was conducted 6/16/2007 at 9:00 AM. The interview revealed that he arrived at the facility at around 10:00 AM, on 6/12/2007. The director - reported that the resident appeared to have been deceased for at least 10-12 hours, but most likely had been deceased all night prior to being found. He further stated that Rigor Mortis had set in to the resident's body. An Internet search regarding Rigor Mortis revealed an article entitled, "Rigor Mortis and — Other Postmortem Changes," from the Encyclopedia of Death and Dying." According to the article, "Once the heart stops beating, blood collects in the most dependent part of the body (liver mortis), the body stiffens (rigor mortis), and the body begins to cool (algor mortis)." Continue review of this article revealed, "Livor mortis is usually most pronounced eight to twelve hours after death, The skin, no longer under muscular control, succumbs to gravity, forming new shapes and accentuating prominent bones still further. The body then begins to cool." Table one, in this article, is entitled, "Approximate times for algor and rigor mortis in temperate regions.” Review Of this tablé revealed that if the body is cold (as stated in the facility's One Day Adverse Incident report) then, "the time since death" is 8 to 36 hours. . Further review of this table revealed the source as, "Staerkeby, M. ' What Happens after Death?’ In the University of Oslo Forensic Entomology [web site]." 10. AHCA gave a correction date of 7/15/2007. 12. \ The Agency seeks to impose an administrative fine in the amount of one thousand. dollars ($1000.00), against the Respondent pursuant to Rule 58A-5.01 82(1)(b), Fla. Admin. Code. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests that the Court order the following relief against Respondent: - (A) Make findings of fact and conclusions of law in favor of the Agency as set forth above. (B) Recommend an administrative fine in the amount of one thousand dollars ($1,000) pursuant to Section 396.1065(2)(a), Florida Statutes (2006); and (C) Grant all other general and equitable relief allowed by law. 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. 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. Respectfully submitted on this 3 ) day of August, 2007. Bart O. Moore Florida Bar # 0768715 Agency for Health Care Administration 2727 Mahan Drive, MS #3 - Tallahassee, Florida 32308 © (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the Administrative Complaint and Election of Rights form have been served to: Administrator, Dorothy Cooper, Kiva of Palatka, LLC., 201 Zeagler Drive, Palatka, Florida 32177, by U.S. Certified Mail, Retum Receipt Requested (7004 2890 0000 5527 0049), to Registered Agent Thomas D. Scarborough, 201 Zeagler Drive, Palatka, Florida 32177, by U.S. Certified Mail, Return Receipt Requested (7004 2890 0000 5527 1268), and Owner Kiva of Palatka, LLC, 4717 Stuart Glen Drive, Nashville, Tennessee, 37215, by US. Certified Mail, Return Receipt Requested (7004 2890 0000 5527 0f25) on ite day of August, 2007. Copy furnished to: Kris Mennella, FOM Fietum Recelpt Fee (Endorsement Required) Reatricted Delivery Fae {Endorsement Regittred) as iPS For 3800, \iurie 20 Soren CS SUS Uo ISLS | vray 2D @ 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, 3. Sepite Type Badu ke vw SP iS eon Mall ere = B, Recalved by, Printed Name) - “Tee oe serge | ~OF-06 D, is delivery.address different from item? (J Yes W YES, enter delivery address below: Express Mail Registered ORetum Receipt for Merchandise O insured Mal = C1. Gop. 4. Restricted Delivery? (Extra Fee) 0 Yes 7004 Faq “DODR-55a7..0925 Domestic Retum Receipt 2 [PS Form 3811, February 2004 Postage Canlliad Fas Retum Receipt Fee (Endorsement Required) Restated Dallvery Fea (Endoreamant Required) ‘Total Postage & Feos oe een : cn f SENDER: COMPLETE THIS SECTION ™ Complete Items 1, 2, and 3; Also complete item 4 if Restricted Delivery Is desired, O Agent ™ Print your name and address on the reverse OC Addressee, so that we can return the card to you, A C. Date of Daliv ™ Attach this card to the back’ of the mallplece, " ie ie Divi or on the front if space permits, ‘t D, Is delivery address aiffarent from tami? CJ Yes ‘1. Article Addressed to: = delNary accress ciferent from tiem 17 It YES, enter delivery address below: [No Q Sng ac) “ ice Type Certified Mali 7) Express Mall, C7 Registered C1 Return Receipt for Merchandise O Insured Mal = 0.0.0. ; ; 4: Restricted Delivery? (Extra Fea) D Yes 7004 2890 OD00 5527 12be PS Form 3811, February 2004. " Domestic Return Recalpt . 102595-02-M:1540 Raturn Ri (Endoreomant Hevaiep Fiestrlated Detiy idoreament Rowe 29) Baars Dee FPS iRorm 300; a ae Stites . ee 3 m 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. UZ, L : — : : D, {s delivery address different from item 47 EA Yes 1. Article Addrassed to: if YES, enter delivery address below: O1.No 3. Service Type . oGertified Mail ‘ C1Exprass Mall T Registered (1 Retum Receipt for Merchandise: Dtnsured Mat (1 G.0.D. 4. Restricted Delivery? (Extra Fee) Yes

Docket for Case No: 07-004481