ra 09, “b p. STATE OF FLORIDA hg *~ & Py AGENCY FOR HEALTH CARE ADMINISTRATION 79 by a STATE OF FLORIDA, AGENCY FOR HEALTH CARE ij 4 ; ( 4 ry 7 ADMINISTRATION, Petitioner, vs. Case No. 2007011115 FOUNTAINS OF LIVING, INC. d/b/a LILLIES HOUSE, 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, FOUNTAINS OF LIVING, INC. d/b/a LILLIES HOUSE (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and states: NATURE OF THE ACTION This is an action to impose an administrative fine against an assisted living facility in the sum of TWELVE THOUSAND DOLLARS ($12,000.00) and to assess a survey fee in the amount of FOUR HUNDRED SIX DOLLARS ($406.00) based upon twelve (12) Class II deficiencies. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2007). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2007). PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable federal and state regulations, statutes and rules governing such facilities. Chapters 408, Part II, and 429, Part I, Florida Statutes (2007); Chapter 58A-5, Florida Administrative Code (2007). The Agency may deny, revoke, or suspend any license issued to an assisted living facility, or impose an administrative fine in the manner provided in Chapter 120, Florida Statutes (2007). Sections 408.815 and 429.14, Florida Statutes (2007). 5. The Respondent was issued a license by the Agency (License Number 10409) to operate a 6-bed assisted living facility located at 119 Harbor View Drive, Tavernier, Florida 33070, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules governing assisted living facilities. COUNTI The Respondent Failed To Ensure That Residents Had Physician’s Orders For The Medications They Were Receiving In Violation Of Rule 58A-5.024(3)(c), Florida Administrative Code (2007), and Section 429.26(4), Florida Statutes (2007) 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, resident records shall be maintained on the premises and include any health care provider’s orders for medications, nursing services, therapeutic diets, do not resuscitate order, or other services to be provided, supervised, or implemented by the facility that require a health care provider’s order. Rule S8A-5.024(3)(c), Florida Administrative Code (2007). 8. Pursuant to Florida law, if possible, each resident shall have been examined by a licensed physician, a licensed physician assistant, or a licensed nurse practitioner within sixty (60) days before admission to the facility. The signed and completed medical examination report shall be submitted to the owner or administrator of the facility who shall use the information contained therein to assist in the determination of the appropriateness of the resident's admission and continued stay in the facility. The medical examination report shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection or upon request. An assessment that has been completed through the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program fulfills the requirements for a medical examination under this subsection and s.429.07(3)(b)6. Section 429.26(4), Florida Statutes (2007). 9. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 10. Based on observation, record review, and interview, the facility failed to ensure three (3) of three (3) sampled residents, Resident number one (1), Resident number two (2) and Resident number three (3), had physician's orders for the medications they were receiving. 11. Staff failed to ensure they had orders for medications they were providing to Resident number three (3). Staff were assisting Resident number three (3) with medications for which they had no orders from a health care provider. The medications require close monitoring and supervision, and the facility failed to demonstrate they were aware of the adverse effects of the medications. 12. Staff failed to obtain orders for Xanax for Resident number one (1) and failed to _obtain orders for Calcium chews for Resident number two (2). 13. An observation on September 10, 2007 at 9:30 a.m., revealed Resident number three (3) in the resident’s room and in bed. Two Certified Nursing Assistants walked into his room to assist him with his shower. 14. At 10:30 am., Certified Nursing Assistant number one (1) was asked to provide the resident's record for review. She stated the resident did not have a record; she would have to call the Assistant Administrator. 15. At 11:30 am., the Assistant Administrator arrived to the facility without the record. He thought the record was at the facility and proceeded to look for it. 16. At 12:15 p.m.,, the Certified Nursing Assistant was observed assisting Resident number three (3) with self-administration of medication which included Potassium, Lasix and Neurontin. 17. A review of the Medication Observation Record for Resident number three (3) included the following medications at 9:00 am.: Prilosec 20 mg., Dilantin 100 mg., and Neurontin 600 mg. At 12:00 p.m., the resident was to receive the Potassium, Lasix and Neurontin. At 4:00 p.m., the Medication Observation Record revealed the resident is taking the following medications: Coumadin 4 mg. on Monday and Tuesdays, and Coumadin 6 mg. on Saturdays and Sundays. At 8:00 p.m., the Medication Observation Record revealed the resident is taking Dilantin, 2-200 mg. tablets (400 mgs.), Neurontin 600 mgs., Tenormin 25 mgs., and Lanoxin .25 mg. 18. Per the Medication Observation Record, Resident number three (3) is supposed to take Hydrocodone/Apap 5/500 mg. every six (6) hours for pain; however, the Medication Observation Record does not reveal the resident is taking it as ordered. 19. According to Lexi-Comp's drug reference handbook for nursing, 8th edition, 2007, Coumadin is an anticoagulant medication which requires close monitoring; bleeding is the major adverse effect of Coumadin and blood levels of the medication should be monitored. Lanoxin is an antiarrythmic which also requires monitoring and the resident's pulse should be taken the same time each day; following prescribers instructions for holding medication if pulse is less than fifty (50). 20. There-was no evidence the Coumadin was being monitored through lab work or a level of awareness by the facility of the effect of the medication on Resident number three (3) by evaluating the resident’s physical signs or symptoms. There was no evidence the resident's pulse was being taken while receiving the Lanoxin at the facility. 21. The Certified Nursing Assistant was asked to provide the physician's orders for these medications. She provided a "typed" listing of the medications the resident was taking; however, they were not signed by the physician. The Certified Nursing Assistant was providing medications to the resident that she had no orders from a health care provider. 22. The Administrator was out of the country and not available for interview. An interview with the Assistant Administrator on September 10, 2007 at 4:30 p.m., confirmed he could not locate Resident number three’s (3) record to include physician's orders. 23. While reconciling medications on September 10, 2007 with the physician's orders, it was noted Resident number one (1) was receiving Xanax 0.5 mg.'s as needed. The label on the medication vial stated Xanax 0.5 mg. every eight (8) hours as needed; however, there were no orders by the physician clarifying its use. 24. While reconciling medications on September 10, 2007 with the physician's orders, it was noted Resident number two (2) was receiving Viactiv (Calcium) chews daily. There were no orders for the chews. 25. An interview with the Certified Nursing Assistant on September 10, 2007 at 1:00 p.m., confirmed the missing orders. 26. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 27. | The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 28. | The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT IL The Respondent Failed To Ensure That Residents Were Able To Perform Activities Of Daily Living As Necessary In Order To Meet Residency Criteria In Violation Of Rule 58A-5.0181(1)(c), Florida Administrative Code (2007) 29. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 30. Pursuant to Florida law, 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: Be able to perform the activities of daily living, with supervision or assistance if necessary. Rule 58A-5.0181(1)(c), Florida Administrative Code (2007). 31. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 32. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2), was able to perform Activities of Daily Living as necessary in order to meet residency criteria. 33. An observation on September 10, 2007 at 9:15 am., revealed Resident number two (2) in a room in a bed pushed next to a wall with two 1/2 rails up. A Certified Nursing Assistant was observed feeding the resident. The Certified Nursing Assistant stated the resident was totally dependent on staff for care. 34. Further observation revealed a Hoyer lift in a different room next to Resident “number two’s (2) room. A second Certified Nursing Assistant indicated the Hoyer lift is "sometimes" used for transferring Resident number two (2) out of bed. 35. An observation on September 10, 2007 at 10:30 a.m., revealed the two Certified Nursing Assistants lifting the Resident number two (2) out of bed and transferring into a recliner chair. Certified Nursing Assistant number one (1) confirmed Resident number two (2) could not stand or assist to stand. Certified Nursing Assistant number two (2) confirmed Resident number two (2) is totally dependent on staff for all Activities of Daily Living and had been admitted this way. 36. | Aninterview with Certified Nursing Assistant number two (2) on September 10, 2007 at 10:45 a.m., confirmed Resident number two (2) was not admitted under Hospice services and is receiving Home Health Care for sores to her "butt and feet.” 37. A review of the Pressure Risk Score by the Home Health Agency revealed Resident number two (2) is chair fast and cannot bear own weight and/or must be assisted into chair or wheelchair. Their initial assessment dated July 31, 2007 revealed Resident number two (2) is bed/chair bound and has no weight bearing capabilities. _ 38. An interview with the Home Health Nurse on September 10, 2007 at 12:30 p.m., confirmed Resident number two (2) had been admitted to the assisted living facility needing total care from staff. 39. An interview with the Assistant Administrator on September 10, 2007 at 1:00 p-m. revealed he was unaware the resident required total care. ’ 40. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 41. | The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 42. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against. the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT Il The Respondent Failed To Ensure That A Resident Was Able To Transfer With Assistance As Necessary In Order To Meet Residency Criteria In Violation Of Rule §8A- 5.0181(1)(d), Florida Administrative Code (2007) 43. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 44. Pursuant to Florida law, 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: Be able to transfer, with assistance if necessary. The assistance of more than one person is permitted. Rule 58A-5.0181(1)(d), Florida Administrative Code (2007). 45. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 46. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2), was able to transfer with assistance as necessary in order to meet residency criteria. 47. An observation on September 10, 2007 at 9:15 a.m., revealed Resident number two (2) in a room in a bed pushed next to a wall with two (2) 1/2 rails up. A Certified Nursing Assistant was observed feeding the resident. The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. 48. Further observation revealed a Hoyer lift in a different room next to Resident number two’s (2) room. A second Certified Nursing Assistant indicated the Hoyer lift is "sometimes" used for transferring Resident number two (2) out of bed. 49. An observation on September 10, 2007 at 10:30 a.m., revealed the two Certified Nursing Assistants lifting Resident number two (2) out of bed and transferring the resident into a recliner chair. Certified Nursing Assistant number one (1) confirmed Resident number two (2) could not stand, hold on to the arms of the Certified Nursing Assistants, or assist to stand. Certified Nursing Assistant number two (2) confirmed Resident number two (2) is totally dependent on staff for all Activities of Daily Living and had been admitted this way. 50. A review of the Pressure Risk Score by the Home Health Agency revealed Resident number two (2) is chair fast and cannot bear own weight and/or must be assisted into chair or wheelchair. Their initial assessment dated July 31, 2007 reveals Resident number two (2) is bed/chair bound and has no weight bearing capabilities. 51. Aninterview with the Home Health Nurse on September 10, 2007 at 12:30 p.m. confirmed Resident number two (2) had been admitted to the Assisted Living Facility needing total care from staff. 52. An interview with the Assistant Administrator on September 10, 2007 at 1:00 p.m., revealed he was unaware the resident required total care. 53. | The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 54. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 55. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT IV The Respondent Failed To Ensure That A Resident Was Admitted Without Evidence Of A Stage III Or IV Pressure Sore In Violation Of Rule 58A- §.0181(1)(j)1-3, Florida Administrative Code (2007) 56. | The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 57. Pursuant to Florida law, 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: Not have any stage 3 or 4 pressure sores. A resident requiring care of a stage 2 pressure sore may be admitted provided that the facility has a LNS (limited nursing services) license and services are provided pursuant to a plan of care issued by a physician, or the resident contracts directly with a licensed home health agency or a nurse to provide care; the condition is documented in the resident’s record; and if the resident’s condition fails to improve within thirty (30) days, as documented by a licensed nurse or physician, the resident shall be discharged from the facility. Rule 58A-5.0181(1)G)1-3, Florida Administrative Code (2007). 58. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 59. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2) was admitted without evidence of a Stage III or IV pressure sore. This failure led to the worsening of the current pressure sores as well as the development of additional pressure sores which resulted in the resident's transfer to the emergency room. 60. An observation on September 10, 2007 at 9:15 a.m. revealed Resident number two (2) in a room in a bed pushed next to a wall with two 1/2 rails up. A Certified Nursing Assistant was observed feeding the resident. The Certified Nursing Assistant stated Resident 11 number two (2) was totally dependent on staff for care. 61. Anobservation at 11:50 p.m. revealed the Home Health Nurse (HHN) removing a duoderm patch off of Resident number two’s (2) upper right buttock area. An irregular shaped pressure sore measuring approximately 2 in. (width) x 2 in. (length) was exposed. The center of the wound presented with yellowish brown slough material and in the center was hardened brown crust. A full layer of the skin was lost exposing subcutaneous tissue around the center of the wound. This area was deep red and moist. The wound was foul smelling. An observation revealed a purplish black leathery necrotic area the size of a half dollar on the posterior portion of Resident number two’s (2) right heel. The wound was foul smelling and Resident number two (2) flinched each time the Home Health Nurse touched the foot. A deep purplish red area surrounded the periphery of the wound and bloody drainage was on the sheets. An observation also revealed a scabbed pressure sore the size of a nickel on the inner aspect of Resident number two’s (2) left heel. Subcutaneous tissue (Stage IIT) was exposed surrounding the scabbed area. An observation revealed a soft area of blackish brown necrotic tissue surrounded by full thickness of skin loss on top of Resident number two’s (2) right ankle bone (Stage IV). This too was the size of a nickel. A small amount of yellowish-brown drainage was present on the sheets. An observation revealed a small necrotic area the size of a dime to the outer aspect of the resident's left ankle. Small scabs were also observed on top of the 2nd through 5th digits of Resident number two’s (2) right foot. 62. A review of the 1823 Health Assessment revealed Resident number two (2) was admitted to the facility on July 20, 2007 with a "sore on the buttocks." The physician did not stage or size the sore. The date of the examination was July 23, 2007. 63. A review of the transfer form (3008) dated July 31, 2007 (8 days later) revealed 12 Resident number two’s (2) skin condition presented with a decubitus on the right buttock and right heel. The size or stage of the wound was not assessed. 64. Physician's orders dated July 23, 2007 revealed an evaluation/diagnoses of Hypertension and Peripheral Vascular disease. This physician indicates Resident number two (2) has a sacral and bilateral heel decubiti. No staging or sizing of the wounds was noted. 65. All three assessments lacked accuracy in the exact location of all of the wounds. 66. A review of the Home Health Nurse assessment dated July 26, 2007 revealed Resident number two (2) was admitted with a sacral pressure ulcer and a necrotic heel decubitus. Neither wound was staged. 67. There was no documentation or evidence by the facility itself demonstrating they were monitoring whether the wounds were improving or worsening. 68. A review of the Home Health Nurse's documentation dated August 17, 2007 revealed Resident number two (2) had four (4) wounds, two (2) to the sacral area and two (2) on Resident number two’s (2) right foot. The wounds were assessed as Stage II's with minimal drainage. On September 5, 2007 (47 days after the resident's admission), the Home Health Nurse's documentation revealed the wounds have worsened. The assessment indicates the surface area of the wounds have eschar and in addition to the wounds on the buttocks and right heel, a new area on the left inner ankle has developed. 69. An interview on September 10, 2007 at 1:30 p.m. with the Home Health Nurse, who is a Licensed Practical Nurse, revealed Resident number two’s (2) wounds had worsened. She stated she was unable to stage the center of the wounds because of the necrotic tissue and she staged the surrounding tissues of the necrotic areas and felt they were Stage II. 70. An interview on September 10, 2007 at 1:40 p.m. with the case manager of the 13 Home Health Agency, who is a Registered Nurse and oversees the Licensed Practical Nurse, revealed Resident number two (2) acquired additional wounds since admission. She stated she was wondering why a resident in this condition who required this much care was admitted to an Assisted Living Facility. She stated the right heel was unstageable because of the necrotic area but felt it was most likely a Stage IV. She confirmed the heel appeared this way on admission. She confirmed the sacral area was a Stage III-IV because of the surrounding tissue and the necrotic area in the center of the wound. She could not explain why the Licensed Practical Nurse inaccurately assessed the wounds. 71. An interview with the Administrator Assistant on September 10, 2007 at 1:40 p.m., revealed the Administrator had taken pictures of Resident number two’s (2) wounds prior to admission and stated, "They were a lot worse than what they are now.” He was not aware the resident could not remain in the facility despite the resident developing additional Stage III-IV wounds while remaining with the same wounds at the same severity. 72. A physician was called to assess Resident number two’s (2) condition. The physician arrived to the facility at 4:45 p.m. and at 5:00 p.m., assessed Resident number two (2) and Resident number two’s (2) wounds. He stated the sacral wound was "definitely infected" and was degrading and needed debridement. He observed the wound to the right heel and stated he was very concerned about the condition of the wound. The physician acknowledged the other pressure sores to Resident number two’s (2) left heel and bilateral ankles and stated he was going to immediately transfer the resident to the emergency room for surgical wound care evaluation and treatment. . 73. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 74. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 75. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT V The Respondent Failed To Ensure That A Resident Was Appropriate For Admission In Violation Of Rule 58A-5.0181(1)(n)1-3, Florida Administrative Code (2007) 76. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 77. Pursuant to Florida law, 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: Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator shall base the decision on an assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429.26, Florida Statutes, and Subsection (2) of Rule 58A-5.0181, Florida Administrative Code; the facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and the ability of the facility to meet the uniform fire safety standards for 15 assisted living facilities established under Section 429.41, Florida Statutes, and Rule 69A-40, Florida Administrative Code. Rule 58A-5.0181(1)(n)1-3, Florida Administrative Code (2007). 78. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 79. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2), was appropriate for admission and continued residency. This is evidenced by admitting a resident who required twenty-four (24) hour supervision and was totally dependent on staff for Activities of Daily Living and was admitted with Stage III-IV pressure sores. The Administrator failed to monitor for appropriateness for continued residency which resulted in Resident number two’s (2) current wounds failing to heal within the required time frame. Resident number two’s (2) worsening pressure sores in conjunction with the development of new pressure sores led to the immediate transfer of the resident to the emergency room. 80. An observation on September 10, 2007 at 9:15 a.m., revealed Resident number two (2) in a room in a bed pushed next to a wall with two half rails up. A Certified Nursing Assistant was observed feeding the resident. The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. 81. _ A further observation revealed a Hoyer lift in a different room next to Resident number two’s (2) room. A second Certified Nursing Assistant indicated the Hoyer lift is "sometimes" used for transferring Resident number two (2) out of bed. 82. An observation on September 10, 2007 at 10:30 a.m., revealed the two Certified Nursing Assistants manually lifting Resident number two (2) out of bed and transferring into a recliner chair. Certified Nursing Assistant number one (1) confirmed Resident number two (2) could not stand or assist to stand or transfer. Certified Nursing Assistant number two (2) confirmed Resident number two (2) is totally dependent on staff for all Activities of Daily Living and had been admitted this way. 83. A review of the Pressure Risk Score by the Home Health Agency revealed Resident number two (2) is chair fast and cannot bear own weight and/or must be assisted into chair or wheelchair. Their initial assessment dated July 31, 2007 revealed Resident number two (2) is bed/chair bound and has no weight bearing capabilities. . 84. A review of the 3008 transfer form dated July 31, 2007 revealed Resident number two (2) needed total care. 85. Aninterview with the Home Health Nurse on September 10, 2007 at 12:30 p.m., confirmed Resident number two (2) had been admitted to the Assisted Living Facility needing total care from staff. 86. An interview with Certified Nursing Assistant number two (2) on September 10, 2007 at 10:45 a.m., confirmed Resident number two (2) was not admitted under Hospice services and is receiving Home Health Care for sores to her "butt and feet.” 87. An observation at 11:50 p.m., revealed the Home Health Nurse (HHN) removing a DuoDerm patch off of Resident number two’s (2) upper right buttock area. An irregular shaped pressure sore measuring approximately 2 in. (width) x 2 in. (length) was exposed. The center of the wound presented with yellowish brown sloughy material and in the center was hardened brown crust. A full layer of the skin was lost exposing subcutaneous tissue around the center of the wound. This area was deep red and moist and the wound was foul smelling. 88. An observation revealed a purplish black leathery necrotic area the size of a half dollar on the posterior portion of Resident number two’s (2) right heel. The wound was foul smelling and Resident number two (2) flinched each time the Home Health Nurse touched the foot. A deep purplish red area surrounded the periphery of the wound and bloody drainage was on the sheets. An observation also revealed an unstageable scabbed pressure sore, the size of a nickel, on the inner aspect of Resident number two’s (2) left heel. Subcutaneous tissue was exposed surrounding the scabbed area. An observation revealed a soft area of blackish brown necrotic tissue surrounded by full thickness skin loss on top of Resident number two’s (2) right ankle bone. This too was the size of a nickel. A small amount of yellowish-brown drainage was present on the sheets. An observation revealed a small necrotic area the size of a dime to the outer aspect of Resident number two’s (2) left ankle. Small scabs were also observed on top of the second through fifth digits of Resident number two’s (2) right foot. 89. A review of the 1823 Health Assessment form revealed Resident number two (2) was admitted to the facility on July 20, 2007 with a "sore on the buttocks." The physician did not stage or size the sore. The date of the examination was July 23, 2007. 90. A review of the transfer form (3008) dated July 31, 2007 (eight days later), revealed Resident number two’s (2) skin condition presented with a decubitus on the right buttock and right heel. The size or stage of the wound was not assessed. 91. Physician's orders dated July 23, 2007, revealed evaluation/diagnoses of Hypertension, Peripheral Vascular disease. The physician indicates Resident number two (2) has a sacral and bilateral heel decubiti. No staging or sizing of the wounds was noted. 92. All three assessments lacked accuracy in the exact location of all of the wounds. 93. A review of the Home Health Nurse assessment dated July 26, 2007 revealed Resident number two (2) was admitted with a sacral pressure ulcer and a necrotic heel decubitus. Neither wound was staged. 94. There was no documentation or evidence by the facility itself demonstrating they were monitoring whether the wounds were improving or worsening. 95. A review of the Home Health Nurse's documentation dated August 17, 2007 revealed Resident number two (2) now has four (4) wounds. Two (2) to the sacral area and two (2) on Resident number two’s (2) right foot. The wounds were assessed as Stage II's with minimal drainage. On September 5, 2007, 47 days after Resident number two’s (2) admission, the Home Health Nurse's documentation revealed the wounds have worsened. The assessment indicates the surface areas of the wounds have eschar and in addition to the wounds on the buttocks and right heel, a new area on the left inner ankle has developed. 96. An interview on September 10, 2007 at 1:30 p.m., with the Home Health Nurse, who is an Licensed Practical Nurse, revealed Resident number two’s (2) wounds had worsened. She stated she was unable to stage the center of the wounds because of the necrotic tissue and she staged the surrounding tissues of the necrotic areas and felt they were Stage II's. She stated she educated the staff at the facility regarding Resident number two (2) requiring repositioning at least every two hours. 97. An interview on September 10, 2007 at 1:40 p.m., with the case manager of the Home Health Agency, who is a Registered Nurse and oversees the Licensed Practical Nurse, revealed Resident number two (2) acquired additional wounds since admission. She stated she was wondering why a resident in this condition who required this much care was admitted to an assisted living facility. She stated the right heel was unstageable because of the necrotic area but felt it was most likely a Stage [V. She confirmed the heel appeared this way on admission. She confirmed the sacral area was a Stage III-IV because of the surrounding tissue and the necrotic area in the center of the wound. She could not explain why the Licensed Practical Nurse inaccurately assessed the wounds. 98. An interview with the Administrator Assistant on September 10, 2007 at 1:40 p.m., revealed the Administrator had taken pictures of Resident number two’s (2) wounds prior to admission and stated, "They were a lot worse than what they are now." He was not aware Resident number two (2) could not remain in the facility despite developing additional Stage II- IV wounds while remaining with the same wounds at the same severity. 99. A physician was called to assess Resident number two’s (2) condition. The physician arrived to the facility at 4:45 p.m. and at 5:00 p.m. assessed Resident number two’s (2) wounds. He stated the sacral wound was "definitely infected" and was degrading and needed debridement. He observed the wound to the right heel and stated he was very concerned about the condition of the wound. The physician acknowledged the other pressure sores to Resident number two’s (2) left heel and bilateral ankles and stated he was going to immediately transfer Resident number two (2) to the emergency room for surgical wound care evaluation and treatment. 100. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 101. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 20 102. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT VI ; The Respondent Failed To Discharge A Resident Who Was Not Appropriate For Admission And Continued Residency In Violation Of Rule 58A-5.0181(5), Florida Administrative Code (2007) 103. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). . 104. Pursuant to Florida law, if the.resident no longer meets the criteria for continued residency, or the facility is unable to meet the resident’s needs, as determined by the facility administrator or health care provider, the resident shall be discharged in accordance with Section 429.28(1), Florida Statutes. Rule 58A-5.0181(5), Florida Administrative Code (2007). 105. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 106. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2) was appropriate for admission and continued residency. This is evidenced by admitting a resident who required twenty-four (24) hour supervision and was totally dependent on staff for Activities of Daily Living and was admitted with Stage III-IV pressure sores. The Administrator failed to monitor Resident number two (2) for appropriateness for continued residency which resulted in the resident's pressure sores failing to heal within the required time frame. While Resident number two (2) remained at the facility, his/ her condition deteriorated as evidenced by the development of additional Stage II-IV pressure sores. Because of inadequate monitoring, the facility failed to determine 21 Resident number two’s (2) needs could not be met at the facility and failed to initiate discharge. 107. An observation on September 10, 2007 at 9:15 a.m., revealed Resident number two (2) in a room in a bed pushed next to a wall with two half rails up. A Certified Nursing Assistant was observed feeding the resident. The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. 108. An observation at 11:50 p.m., revealed the Home Health Nurse removing a duoderm patch off of Resident number two’s (2) upper right buttock area. An irregular shaped pressure sore measuring approximately 2 in. (width) x 2 in. (length) was exposed. The center of the wound presented with yellowish brown slough material and in the center was hardened brown crust. A full layer of the skin was lost exposing subcutaneous tissue around the center of the wound. This area was deep red and moist. The wound was foul smelling. An observation revealed a purplish black leathery necrotic area the size of a half dollar on the posterior portion of Resident number two’s (2) right heel. The wound was foul smelling and Resident number two (2) flinched each time the Home Health Nurse touched the foot. A deep purplish red area surrounded the periphery of the wound and bloody drainage was on the sheets. An observation also revealed a scabbed pressure sore the size of a nickel on the inner aspect of Resident number two’s (2) left heel. Subcutaneous tissue (Stage III) was exposed surrounding the scabbed area. An observation revealed a soft area of blackish brown necrotic tissue surrounded by full thickness skin loss on top of Resident number two’s (2) right ankle bone (Stage IV). This too was the size of anickel. A small amount of yellowish-brown drainage was present on the sheets. An observation revealed a small necrotic area the size of a dime to the outer aspect of Resident number two’s (2) left ankle. Small scabs were also observed on top of the second through fifth digits of Resident number two’s (2) right foot. 22 109. A review of the 1823 Health Assessment form revealed Resident number two (2) was admitted to the facility on July 20, 2007 with a "sore on the buttocks." The physician did not stage or size the sore. The date of the examination was July 23, 2007. 110. A review of the transfer form (3008) dated July 31, 2007 (eight days later) revealed Resident number two’s (2) skin condition presented with a decubitus on the right buttock and right heel. The size or stage of the wound was not assessed. 111. Physician's orders dated July 23, 2007 revealed an evaluation/diagnoses of Hypertension and Peripheral Vascular disease. The physician indicates Resident number two (2) has a sacral and bilateral heel decubiti. No staging or sizing of the wounds was noted. 112. All three assessments lacked accuracy in the exact location of all of the wounds. 113. A review of the Home Health Nurse’s assessment dated July 26, 2007, revealed Resident number two (2) was admitted with a sacral pressure ulcer and a necrotic heel decubitus. Neither wound was staged. 114. There was no documentation or evidence by the facility itself demonstrating they were monitoring whether the wounds were improving or worsening. 115. A review of the Home Health Nurse's documentation dated August 17, 2007 revealed Resident number two (2) now has four (4) wounds. Two (2) to the sacral area and two (2) on Resident number two’s (2) right foot. The wounds were assessed as Stage II's with minimal drainage. On September 5, 2007, forty-seven days after Resident number two’s (2) admission, the Home Health Nurse's documentation revealed the wounds have worsened. The assessment indicates the surface area of the wounds have eschar and in addition to the wounds on the buttocks and right heel, a new area on the left inner ankle had developed. 116. An interview on September 10, 2007 at 1:30 p.m. with the Home Health Nurse, 23 who is a Licensed Practical Nurse, revealed Resident number two’s (2) wounds had worsened. She stated she was unable to stage the center of the wounds because of the necrotic tissue and she staged the surrounding tissues of the necrotic areas and felt they were Stage Ils. 117. An interview on September 10, 2007 at 1:40 p.m. with the case manager of the Home Health Agency, who is-a Registered Nurse and oversees the Licensed Practical Nurse, revealed Resident number two (2) acquired additional wounds since admission. She stated she was wondering why a resident in this condition and required this much care was admitted to an Assisted Living Facility. She stated the right heel was unstageable because of the necrotic area but felt it was most likely a Stage IV. She confirmed the heel appeared this way on admission. She confirmed the sacral area was a Stage III-IV because of the surrounding tissue and the necrotic area in the center of the wound. She could not explain why the Licensed Practical Nurse inaccurately assessed the wounds. 118. An interview with the Administrator Assistant on September 10, 2007 at 1:40 p.m. revealed the Administrator had taken pictures of Resident number two’s (2) wounds prior to her admission and stated, "They were a lot worse than what they are now.” He was not aware Resident number two (2) could not remain in the facility despite the resident developing additional Stage III-IV wounds while remaining with the same wounds at the same severity. 119. A physician was called to assess Resident number two’s (2) condition. The physician arrived to the facility at 4:45 p.m. and at 5:00 p.m., assessed Resident number two’s (2) wounds. He stated the sacral wound was "definitely infected" and was degrading and needed debridement. He observed the wound to the right heel and stated he was very concerned about the condition of the wound. The physician acknowledged the other pressure sores to Resident number two’s (2) left heel and bilateral ankles and stated he was going to immediately transfer 24 Resident number two (2) to the emergency room for surgical wound care evaluation and treatment. 120. The Respondent’s deficient practice constituted a Class If violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 121. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 122. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT VIT The Respondent Failed To Ensure That A Resident Was Appropriate For Continued Residency In Violation Of Rule 58A-5.0181(4)(d), Florida Administrative Code (2007) and Section 429.26(1) Florida Statutes (2007) 123. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 124. Pursuant to Florida law, criteria for continued residency in a facility holding a standard, limited nursing services, or limited mental health license shall be the same as the criteria for admission, except as follows: The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. Rule 58A-5.0181(4)(d), 25 Florida Administrative Code (2007). The owner or administrator of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident's representative or designee or the resident's family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the Department of Elderly Affairs or the Department of Children and Family Services, the administrator must notify the appropriate contact person in the applicable department. Section 429.26(1), Florida Statutes (2007). 125. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 126. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2) was appropriate for admission and continued residency. This is evidenced by admitting Resident number two (2) who required twenty-four (24) hour supervision and was totally dependent on staff for Activities of Daily Living and was admitted with Stage III-IV pressure sores. The Administrator failed to monitor Resident number two (2) for appropriateness for continued residency which resulted in the resident's pressure sores failing to heal within the required time frame. While Resident number two (2) remained at the facility, his/her condition deteriorated as evidenced by the development of additional Stage III-IV pressure sores. Because of inadequate monitoring, the facility failed to 26 determine that Resident number two’s (2) needs could not be met at the facility and failed to initiate discharge. 127. An observation on Sept 10, 2007 at 9:15 a.m. revealed Resident number two (2) in a room in a bed pushed next to a wall with two half rails up. A Certified Nursing Assistant was observed feeding Resident number two (2). The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. 128. An observation at 11:50 p.m., revealed the Home Health Nurse removing a duoderm patch off of Resident number two’s (2) upper right buttock area. An irregular shaped pressure sore measuring approximately 2 in. (width) x 2 in. (length) was exposed. The center of the wound presented with yellowish brown slough material and in the center was hardened brown crust. A full layer of the skin was lost exposing subcutaneous tissue around the center of the wound. This area was deep red and moist. The wound was foul smelling. An observation revealed a purplish black leathery necrotic area the size of a half dollar on the posterior portion of Resident number two’s (2) right heel. The wound was foul smelling and Resident number two (2) flinched each time the Home Health Nurse touched the foot. A deep purplish red area surrounded the periphery of the wound and bloody drainage was on the sheets. An observation also revealed a scabbed pressure sore, size of a nickel, on the inner aspect of Resident number two’s (2) left heel. Subcutaneous tissue (Stage IIJ) was exposed surrounding the scabbed area. An observation revealed a soft area of blackish brown necrotic tissue surrounded by full thickness skin loss on top of Resident number two’s (2) right ankle bone (Stage IV). This too was the size of a nickel. A small amount of yellowish-brown drainage was present on the sheets. An observation revealed a small necrotic area the size of a dime to the outer aspect of Resident number two’s (2) left ankle. Small scabs were also observed on top of the second through fifth 27 digits of Resident number two’s (2) right foot. 129. A review of the 1823 Health Assessment form revealed Resident number two (2) was admitted to the facility on July 20, 2007 with a "sore on the buttocks." The physician did not stage or size the sore. The date of the examination was July 23, 2007. 130. A review of the transfer form (3008) dated July 31, 2007 (8 days later) revealed Resident number two’s (2) skin condition presented with a decubitus on the right buttock and right heel. The size or stage of the wound was not assessed. 131. Physician's orders dated July 23, 2007 revealed an evaluation/diagnoses of Hypertension, and Peripheral Vascular disease. The physician indicates Resident number two (2) has a sacral and bilateral heel decubiti. No staging or sizing of the wounds was noted. 132. All three assessments lacked accuracy in the exact location of all of the wounds. 133. A review of the Home Health Nurse’s assessment dated July 26, 2007, revealed Resident number two (2) was admitted with a sacral pressure ulcer and a necrotic heel decubitus. Neither wound was staged. 134. There was no documentation or evidence by the facility itself demonstrating they were monitoring whether the wounds were improving or worsening. 135. A review of the Home Health Nurse's documentation dated August 17, 2007 revealed Resident number two (2) now has four (4) wounds. Two (2) to the sacral area and two (2) on Resident number two’s (2) right foot. The wounds were assessed as Stage II's with minimal drainage. On September 5, 2007 (forty-seven days after the resident's admission), the Home Health Nurse's documentation revealed the wounds have worsened. The assessment indicates the surface area of the wounds have eschar and in addition to the wounds on the buttocks and right heel, a new area on the left inner ankle has developed. 28 136. An interview on September 10, 2007 at 1:30 p.m. with the Home Health Nurse, who is an Licensed Practical Nurse, revealed Resident number two’s (2) wounds had worsened. She stated she was unable to stage the center of the wounds because of the necrotic tissue and she staged the surrounding tissues of the necrotic areas and felt they were Stage IIs. 137. An interview on September 10, 2007 at 1:40 p.m. with the case manager of the Home Health Agency, who is a Registered Nurse and oversees the Licensed Practical Nurse, revealed Resident number two (2) acquired additional wounds since admission. She stated she was wondering why a resident in this condition who required this much care was admitted to an Assisted Living Facility. She stated the right heel was unstageable because of the necrotic area but felt it was most likely a Stage IV. She confirmed the heel appeared this way on admission. She confirmed the sacral area was a Stage III-IV because of the surrounding tissue and the necrotic area in the center of the wound. She could not explain why the Licensed Practical Nurse inaccurately assessed the wounds. 138. An interview with the Administrator Assistant on September 10, 2007 at 1:40 p.m. revealed the Administrator had taken pictures of Resident number two’s (2) wounds prior to his/her admission and stated, "They were a lot worse than what they are now." He was not aware Resident number two (2) could not remain in the facility despite the resident developing additional Stage IIJ-TV wounds while remaining with the same wounds at the same severity. . 139. A physician was called to assess Resident number two’s (2) condition. The physician arrived to the facility at 4:45 p.m. and at 5:00 p.m., assessed Resident number two’s (2) wounds. He stated the sacral wound was "definitely infected” and was degrading and needed debridement. He observed the wound to the right heel and stated he was very concerned about the condition of the wound. The physician acknowledged the other pressure sores to resident 29 number two’s (2) left heel and bilateral ankles and stated he was going to immediately transfer Resident number two (2) to the emergency room for surgical wound care evaluation and treatment. 140. An observation on September 10, 2007 at 5:30 p.m., revealed Resident number two (2) had been transported to the emergency room. 141. An interview with the Assistant Administrator on September 11, 2007 at 10:00 am. revealed the Administrator, who is also a Registered Nurse, had left for Columbia two weeks prior to the survey and was not in the country. He indicated the Administrator was not aware of the new pressure sores acquired by Resident number two (2) and he wasn't either. He stated he felt Resident number two (2) was a lot worse when he/she was first admitted due to the pictures the Administrator took when Resident number two (2) was admitted. The Assistant Administrator could not provide the pictures for review as he indicated they were up in another office and could not be retrieved. 142.. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 143. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 144. The Respondent was given a mandatory correction date of October 11, 2007. 30 WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT Vil The Respondent Failed To Ensure The Availability Of The Administrator And In Conjunction With Class II Deficiencies Is Requiring The Administrator To Repeat Core Training In Violation Of Section 429.52, Florida Statutes (2007) 145. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5), Counts I through VI, and Counts VIII through XII. 146. Pursuant to Florida law, if the Department of Elderly Affairs or the agency determines that there are problems in a facility that could be reduced through specific staff training or education beyond that already required under this section, the Department of Elderly Affairs or the agency may require, and provide, or cause to be provided, the training or education of any personal care staff in the facility. Section 429.52(7), Florida Statutes (2007). 147. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 148. Based on resident record review, observation, interview with the Assistant Administrator, and the unavailability of the Administrator during the Biennial Survey, in conjunction with the deficiencies cited during the survey with special attention to Class II deficiencies cited at A 304, A 402, A 403, A 410, A 415, A 428, A 429, A 522, A 523, A631, and A 704, the Agency for Healthcare Administration is requiring the Administrator of The Fountains of Living to repeat core training. 149. | The Respondent’s deficient practice constituted a Class II violation in that it 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 31 the facility residents, other than a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 150. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 151. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT IX The Respondent Failed To Ensure Adequate Resident Supervision And That Resident Services Were Provided Or Arranged In Accordance With Resident Needs In Violation Of Rule 58A-5.019(4)(b), Florida Administrative Code (2007) 152. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 153. Pursuant to Florida law, notwithstanding the minimum staffing requirements specified in Rule 58A-5.019(4)(a), Florida Administrative Code (2007), all facilities, including those composed of apartments, shall have enough qualified staff to provide resident supervision, and to provide or arrange for resident services in accordance with the residents scheduled and unscheduled service needs, resident contracts, and resident care standards as described in Rule 58A-5.0182, Florida Administrative Code. Rule 58A-5.019(4)(b), Florida Administrative Code (2007). 154. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 32 155. Based on observation, record review, and interview, the facility failed to ensure one (1) of three (3) residents, Resident number two (2) received adequate resident supervision and was provided or arranged for services needed as evidenced by admitting a resident who is totally dependent on staff for Activities of Daily Living and was admitted with Stage I-IV pressure sores. The facility has a Standard, Limited Nursing and Limited Mental Health license. The Administrator failed to remain within the scope of the facility's license by admitting Resident number two (2). She left the country without assuring the laboratory tests ordered by the physician were obtained; failed to assure Resident number two (2) received pain medication for worsening pressure sores; and failed to ensure Resident number two (2) received a nutritional consult. This failure led to Resident number two’s (2) deteriorating condition which required the resident’s transfer to the emergency room and admission to the hospital. 156. An observation on September 10, 2007 at 9:15 a.m., revealed Resident number two (2) in a room in a bed pushed next to a wall with two half rails up. A Certified Nursing Assistant was observed feeding Resident number two (2). The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. 157. An observation at 11:50 p.m., revealed the Home Health Nurse removing a duoderm patch off of Resident number two’s (2) upper right buttock area. An irregular shaped pressure sore measuring approximately 2 in. (width) x 2 in. (length) was exposed. The center of the wound presented with yellowish brown slough material and in the center was hardened brown crust. A full layer of the skin was lost exposing subcutaneous tissue around the center of the wound. This area was deep red and moist. The wound was foul smelling. An observation revealed a purplish black leathery necrotic area the size of a half dollar on the posterior portion of Resident number two’s (2) right heel. The wound was foul smelling and Resident number two 33 (2) flinched each time the Home Health Nurse touched the foot. A deep purplish red area surrounded the periphery of the wound and bloody drainage was on the sheets. An observation also revealed a scabbed pressure sore, size of a nickel, on the inner aspect of Resident number two’s (2) left heel. Subcutaneous tissue (Stage III) was exposed surrounding the scabbed area. An observation revealed a soft area of blackish brown necrotic tissue surrounded by full thickness skin loss on top of Resident number two’s (2) right ankle bone (Stage IV). This too was the size of a nickel. A small amount of yellowish-brown drainage was present on the sheets. An observation revealed a small necrotic area the size of a dime to the outer aspect of Resident number two’s (2) left ankle. Small scabs were also observed on top of the second through fifth digits of Resident number two’s (2) right foot. 158. A review of the 1823 Health Assessment form revealed Resident number two (2) was admitted to the facility on July 20, 2007 with a "sore on the buttocks." The physician did not stage or size the sore. The date of the examination was July 23, 2007. 159. A review of the transfer form (3008) dated July 31, 2007 (eight days later) revealed Resident number two’s (2) skin condition presented with a decubitus on the right buttock and right heel. The size or stage of the wound was not assessed. 160. Physician's orders dated July 23, 2007 revealed an evaluation/diagnoses of Hypertension and Peripheral Vascular disease. The physician indicates Resident number two has a sacral and bilateral heel decubiti. No staging or sizing of the wounds was noted. 161. All three assessments lacked accuracy in the exact location of all of the wounds. 162. A review of the Home Health Nurses assessment dated July 26, 2007 revealed Resident number two (2) was admitted with a sacral pressure ulcer and a necrotic heel decubitus. Neither wound was staged. 34 163. There was no documentation or evidence by the facility itself demonstrating they were monitoring whether the wounds were improving or worsening. 164. A review of the Home Health Nurse's documentation dated August 17, 2007 revealed Resident number two (2) now has four (4) wounds. Two (2) to the sacral area and two (2) on Resident number two’s (2) right foot. The wounds were assessed as Stage II with minimal drainage. On September 5, 2007, (forty-seven days after Resident number two’s (2) admission), the Home Health Nurse's documentation revealed the wounds have worsened. The assessment indicates the surface area of the wounds have eschar and in addition to the wounds on the buttocks and right heel, a new area on the left inner ankle had developed. 165. A physician was called to assess Resident number two’s (2) condition. The physician arrived to the facility at 4:45 p.m. and at 5:00 p.m. assessed Resident number two’s wounds. He stated the sacral wound was "definitely infected" and was degrading and needed debridement. He observed the wound to the right heel and stated he was very concerned about the condition of the wound. The physician acknowledged the other pressure sores to Resident number two’s (2) left heel and bilateral ankles and stated he was going to immediately transfer Resident number two (2) to the emergency room for surgical wound care evaluation and treatment. 166. An observation on September 10, 2007 at 1:00 p.m., revealed a Certified Nursing Assistant wheeling Resident number two (2) from his/her room into the common area and placed him/her next to a wall. Resident number two (2) was sitting in a reclined position next to the wall and remained in the same position, without moving or being repositioned, for 2 1/2 hours. At 3:30 p.m., two Certified Nursing Assistants were observed transferring Resident number two (2) back to bed. Resident number two (2) was positioned on his/her left side and remained in the 35 same position until 5:00 p.m. At approximately 5:00 p.m., the physician entered the room to assess Resident number two’s (2) condition. While he lifted the right foot and removed the dressing, Resident number two (2) flinched several times as if in pain. Due to Resident number two’s (2) knees pressing together while lying on his/her left side, a reddened area had developed. 167. The physician indicated the wound looked painful. The Certified Nursing Assistant who was standing nearby and was the Medication Technician did not question whether Resident number two (2) should be medicated for pain. 168. An interview on September 10, 2007 at 1:30 p.m., with the Home Health Nurse, who is an Licensed Practical Nurse, revealed Resident number two’s (2) wounds had worsened. She stated she was unable to stage the center of the wounds because of the necrotic tissue and she staged the surrounding tissues of the necrotic areas and felt they were Stage II's. She stated she had to start educating the staff at the facility with regard to repositioning Resident number two (2) at least every two (2) hours. She was concerned staff were placing Resident number two (2) in a wheelchair without a cushion, which is why she requested a recliner be brought in for Resident number two (2). 169. An interview on September 10, 2007 at 1:40 p.m. with the case manager of the Home Health Agency, who is a Registered Nurse and oversees the Licensed Practical Nurse, revealed Resident number two (2) acquired additional wounds since admission. She stated she was wondering why a resident in this condition and required this much care was admitted to an Assisted Living Facility. She stated the right heel was unstageable because of the necrotic area but felt it was most likely a Stage IV. She confirmed the heel appeared this way on admission. She confirmed the sacral area was a Stage III-IV because of the surrounding tissue and the necrotic area in the center of the wound. She could not explain why the Licensed Practical Nurse 36 inaccurately assessed the wounds. 170. An interview with the Administrator Assistant on Sept 10, 2007 at 1:40 p.m. revealed the Administrator had taken pictures of Resident number two’s (2) wounds prior to admission and stated, "They were a lot worse than what they are now." He was not aware Resident number two (2) could not remain in the facility despite the resident developing additional Stage I-IV wounds while remaining with the same wounds at the same severity. 171. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 172. The Agency shall impose an administrative fine for a cited Class Il violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 173. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT X The Respondent Failed To Ensure That All Staff Document Observations On The Appropriate Resident’s Record And Report The Observations To The Resident’s Healthcare Provider In Violation Of Section 429.255(1)(a), Florida Statutes (2007) And Rule 58A-5.019(2)(b), Florida Administrative Code (2007) 174. The Agency re-alleges and incorporates by reference paragraphs one (1) 37 through five (5). 175. Pursuant to Florida law, persons under contract to the facility, facility staff, or volunteers, who are licensed according to part I of chapter 464, or those persons exempt under Section 464.022(1), Florida Statutes and others as defined by rule, may administer medications to residents, take residents’ vital signs, manage individual weekly pill organizers for residents who self-administer medication, give prepackaged enemas ordered by a physician, observe residents, document observations on the appropriate resident's record, report observations to the resident's physician, and contract or allow residents or a resident's representative, designee, surrogate, guardian, or attorney in fact to contract with a third party, provided residents meet the criteria for appropriate placement as defined in Section 429.26, Florida Statutes. Nursing assistants certified pursuant to part II of chapter 464 may take residents’ vital signs as directed by a licensed nurse or physician. Section 429.255(1)(a), Florida Statutes (2007). 176. Pursuant to Florida law, all staff shall be assigned duties consistent with his/her level of education, training, preparation, and experience. Staff providing services requiring licensing or certification must be appropriately licensed or certified. All staff shall exercise their responsibilities, consistent with their qualifications, to observe residents, to document observations on the appropriate resident’s record, and to report the observations to the resident’s health care provider in accordance with this rule chapter. Rule 58A-5.019(2)(b), Florida Administrative Code (2007). . 177. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 178. Based on observation, record review, and interview, facility staff failed to demonstrate they were aware of the development of pressure areas to Resident number two’s (2) 38 left heel and ankles and failed to report those observations to the healthcare provider. In addition, they failed to document whether they notified the health care provider related to an episode of the resident "passing out" which ultimately led to Resident number two’s (2) transfer to the hospital. 179. An observation on September 10, 2007 at 9:15 a.m. revealed Resident number two (2) in a room in a bed pushed next to a wall with two half rails up. A Certified Nursing Assistant was observed feeding Resident number two (2). The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. A second Certified Nursing Assistant was questioned whether Resident number two (2) had any wounds and she stated she had a sore on her butt and right heel. 180. An observation at 11:50 p.m. revealed reddish purple areas on Resident number two’s (2) arms and legs as well as pressure areas to Resident number two’s (2) right upper buttock area, bilateral heels, right and left ankles. 181. Certified Nursing Assistant number two (2) was not aware of the additional pressure areas to Resident number two’s (2) ankles, thereby failing to report to the health care provider. 182. A review of the 1823 Health Assessment form revealed Resident number two (2) was admitted to the facility on July 20, 2007 with diagnoses of senile dementia and sore on buttocks. There was no documentation by the facility acknowledging Resident number (2) had pressure sores on his/her heels and ankles. 183, A record review revealed a resident observation log with a note dated August 22, 2007. The notes indicate Resident number two (2) "passed out" while the nurse showered the resident. There was no indication the healthcare provider or legal representative was notified. 39 There were no notes related to the condition of Resident number two (2) or how they were monitoring Resident number two (2) after his/her change in condition. There were no other notes related to the incident until three (3) days later when Resident number two (2) "returned from the hospital." 184. The Assistant Administrator was interviewed on September 11, 2007 at 10:00 am. He was not aware of the missing documentation or why the healthcare provider wasn't notified when the ulcers worsened or when Resident number two (2) passed out. 185. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 186. | The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. 187. | The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT XI The Respondent Failed To Ensure A Reasonable Effort To Fill Prescriptions In A Timely Manner In Violation Of Rule 58A-5.0185(7)(f), Florida Administrative Code (2007) 188. The Agency re-alleges and incorporates by reference paragraphs one qd) through five (5). 40 189. Pursuant to Florida law, the facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration of medication or medication administration are filled or refilled in a timely manner. Rule 58A- 5.0185(7)(£), Florida Administrative Code (2007). 190. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 191. Based on observation, record review, and interview, the facility failed to make every reasonable effort to ensure prescriptions are filled in a timely manner for one (1) of three (3) sampled residents, Resident number one (1). The facility failed to ensure Resident number one (1) received the medication Aricept which was ordered to treat his/her behavior symptoms. The staff independently elected to use an anti-anxiety medication as a result to manage resident number one’s (1) behaviors. This resulted in an unnecessary medication being administered to Resident number one (1). 192. An observation of Resident number one (1) on September 10, 2007 at 9:30 a.m. revealed Resident number one (1) up and pacing around the inside of the facility. He/She was redirected by staff to sit down and watch TV or listen to music. Resident number one (1) was alert and confused. 193. A review of the 1823 Health Assessment form revealed Resident number one (1) was admitted to the facility on September 4, 2006 with diagnosis including Depression, Dementia and Anxiety. 194. A review of the Resident Observation Log revealed the following entries by the staff: April 13, 2007, "(resident) acting crazy in and out the door and went in (resident's) room, for what I don't know"...April 18, 2007, "(resident) was crying this morning when I got 4l confused today keeps taking things and hiding them in his/her room..." 195. A teview of the physician's orders dated April 29, 2007 revealed Resident number one (1) was ordered to receive Aricept 10 mg. by mouth every day. 196. A review of the Medication Observation Record for August and September ’ 2007 did not reveal evidence the Aricept was taken by Resident number one (1). 197. According to Lexi-Comp's drug reference handbook for nursing, 8th Edition, 2007, Aricept is used for attention-deficit/hyperactivity disorder (ADHD) and for behavioral syndromes in dementia. Patient education indicates the medication will not cure the disease, but may help reduce symptoms (behaviors). 198. An interview with the Certified Nursing Assistant on September 10, 2007 revealed Resident number one (1) has never received this medication since its been ordered and because she usually works the evening shift, doesn't know why it's never been filled. 199. The Administrator was out of the country and not available for interview. The Assistant Administrator was interviewed on September 11, 2007 at 10:00 a.m. He was not aware Resident number one (1) had been without the medication for over four (4) months and did not realize staff (who are unlicensed) was giving Resident number one (1) an alternate medication to manage the resident's behaviors. 200. The Respondent’s deficient practice constituted a Class II violation in that it 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 42 the facility residents, other than a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 201. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). ‘A fine shall be levied notwithstanding the correction of the violation. 202. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). COUNT XII The Respondent Failed To Ensure A Daily Awareness Of The General Health, And Physical And Emotional Wellbeing Of A Resident In Violation Of Rule 58A-5.0185(7)(f), Florida Administrative Code (2007) 203. The Agency re-alleges and incorporates by reference paragraphs one a) through five (5). 204. Pursuant to Florida law, facilities shall offer personal supervision, as appropriate for each resident, including the following, 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. Rule 58A-5.0182(1)(b), Florida Administrative Code (2007). 205. On or about September 10, 2007 through September 11, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 206. Based on observation, record review, and interview, the facility failed to ensure they provided a daily awareness of the general health, and physical and emotional well-being for 43 one (1) of three (3) residents, Resident number two (2). 207. The facility's failure to adequately monitor Resident number two (2) resulted in worsening of and the development of additional pressure sores to Resident number two’s (2) _ sacral area, bilateral heels and ankles. The facility failed to demonstrate a level of awareness and respond to Resident number two’s (2) non-verbal signs of pain and need for pain management. The facility failed to demonstrate how they were monitoring Resident number two’s (2) condition after passing out during a shower which resulted in his/her transfer to the hospital. 208. An observation on September 10, 2007 at 9:15 a.m., revealed Resident number two (2) in a room in a bed pushed next to a wall with two half rails up. A Certified Nursing Assistant was observed feeding Resident number two.(2). The Certified Nursing Assistant stated Resident number two (2) was totally dependent on staff for care. A second Certified Nursing Assistant was questioned whether Resident number two (2) had any wounds and she stated the resident had a sore on the butt and right heel. 209. An observation at 11:50 p.m., revealed reddish purple areas on Resident number two’s (2) arms and legs as well as pressure areas to Resident number two’s (2) right upper buttock area, bilateral heels, right and left ankles. 210. Certified Nursing Assistant number two (2) was not aware of the additional pressure areas to Resident number two’s (2) ankles, thereby failing to report to the health care provider. 211. A review of the 1823 Health Assessment form revealed Resident number two (2) was admitted to the facility on July 20, 2007 with diagnoses of senile dementia and sore on buttocks. There was no documentation by the facility acknowledging Resident number two (2) had pressure sores on his/her heels and ankles. 44 212. A record review revealed a resident observation log with a note dated August 22, 2007. The notes indicate Resident number two (2) "passed out" while the nurse showered the resident. There was no indication the healthcare provider or legal representative was notified. There were no notes related to the condition of Resident number two (2) or how they were monitoring the resident after his/her change in condition. There were no other notes related to the incident until three (3) days later when Resident number two (2) "returned from the hospital." 213. The Assistant Administrator was interviewed on September 11, 2007 at 10:00 a.m. He was not aware of the missing documentation or why the healthcare provider wasn't notified when the ulcers worsened or when Resident number two (2) passed out. 214. The Respondent’s deficient practice constituted a Class II violation in that it 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 a Class I violation. Section 429.19(2)(b), Florida Statutes (2007). 215. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2007). A fine shall be levied notwithstanding the correction of the violation. , 216. The Respondent was given a mandatory correction date of October 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2007). 45 COUNT XU (Assessment of Survey Fee) 217. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and the allegations in Counts I through Count XII. 218. The Agency conducted an unannounced Biennial Survey of the Respondent’s facility on September 10, 2007 through September 11, 2007. 219. As a result of the Agency’s Biennial Survey, the Respondent was cited for twelve (12) Class II deficiencies. 220. Pursuant to Section 429.19(7), Florida Statutes (2007), the Agency 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 five hundred dollars ($500.00), to cover the cost of monitoring visits conducted under Section 429.28(3)(c), Florida Statutes (2007), to verify the correction of the violations. 221. In this case, the Agency is authorized to seek a survey fee of FOUR HUNDRED SIX DOLLARS ($406.00). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assess a survey fee against the Respondent in the amount of FOUR HUNDRED SIX DOLLARS ($406.00) pursuant to Section 429.19(7), Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the following relief: 1. Enter findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of TWELVE THOUSAND DOLLARS ($12,000.00). 46 3. Assess a sutvey fee against the Respondent in the amount of FOUR HUNDRED SIX DOLLARS ($406.00). 4. Order any other relief that the Court deems just and appropriate. Respectfully submitted on this dg day of Fabessarss , 2008. Lint eat oon Senior Attorney Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3209 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. : 47 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served to: Elayne Versage, Administrator, Fountains of Living, Inc. d/b/a Lillies House, 119 Harbor View Drive, Tavernier, Florida 33070, by U.S. Certified Mail, Return Receipt No. 7006 2150 0004 5871 1085, and to Elayne Versage, Registered Agent for Fountains of Living, Inc. d/b/a Lillies House, 25611 S. W. 130" Avenue, Homestead, Florida 33032, by U.S. Certified Mail, Return Receipt No. 7006 2760 0003 1536 6503 on this fief say of EslALLalyy , 2008. a ete Senior Attorney Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3209 Copies furnished to: Elayne Versage, Administrator Fountains of Living, Inc. d/b/a Lillies House 119 Harbor View Drive Tavernier, Florida 33070 U.S. Certified Mail) Mary Daley Jacobs, Senior Attorney Office of the General Counsel Agency for Health Care Administration 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice Mail) Elayne Versage, Registered Agent for Fountains of Living, Inc. d/b/a Lillies House 25611 S. W. 130 Avenue Homestead, Florida 33032 (U. S. Certified Mail) Kriste J. Mennella, Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) 48

Docket for Case No: 08-001397