STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, a 1. O4 ane AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA Nos. 2009000766 (Fine) 2009000767 (Conditional License) vs. MF LAKE EUSTIS, LLC d/b/a LAKE EUSTIS CARE CENTER Respondent. | ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “Agency”), by and through undersigned counsel, and files this Administrative Complaint, pursuant to Chapter 400, Part Il, and Sections 120.569 and 120.57, Florida: Statutes (2008), against MF LAKE EUSTIS, LLC d/b/a LAKE EUSTIS CARE CENTER, (hereinafter referred to . as “facility” or “Respondent”), and states as follows: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Two Thousand Five Hundred Dollars ($2,500). Additionally, this is an action to impose a conditional licensure based upon a class II deficiency pursuant to Section 400.23 (7)(b) Fla. Stat. (2008) JURISDICTION AND VENUE 2. The Agency has jurisdiction pursuant to Sections 120.569, 120.57, 120.60, and 400.062, Florida Statutes (2008). 3. Venue is within in Lake County, pursuant to Rule 28-106.207, Florida | Administrative Code (2008). | | PARTIES 4. The Agency is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (2008), and Chapter 59A-4, Florida Administrative Code.41, Respondent operates a nursing facility located at West Woodward Avenue, Eustis, Fl. 32726, having been issued license number 12710951. Respondent was at all times material hereto a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I RESPONDENT FAILED TO PROVIDE ADEQUATE AND APPROPRIATE CARE AND SERVICES TO RESIDENTS CHAPTER 400 & SECTION 400.102(1)(a) FLORIDA STATUTES (2008) | CLASS II DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. | . 7. That dn or about January 12, 2009, through date of January 16, 2009, the Agency conducted a licensure survey at Respondent’s facility. 8. Based on interview and record review, the facility failed to have sufficient staff to assist one (#46) of 22 residents in the sample and members of the resident council with their toileting needs in a timely mannet that materially affected the residents' well being. Failure to assist the residents with their toileting needs in a timely manner resulted in the one resident having a bowel incontinent episode in bed and had to lie in the feces for an extended length of time. Review of Resident #46 clinical record revealed that the resident has a history of Colon cancer. Continued review of the clinical record revealed that a physician's order was written on 12/19/08 for a urinalysis and culture for increased temperature. The culture revealed that the resident had Escheria coli (E-Coli). During the interview with Resident #46 on 01/12/09 at 10:00 AM the resident stated that about 3 weeks ago he'she had to wait 1 hour in bed soiled in his/her own bowel movement and was very embarrassed. The resident continued to state that on several other occasions he/she has had to wait 1/2 hour. An interview was vostineted on 1/13/08 at 8:35 AM with the Resident Council President revealed the residents complained that staff was telling the residents that they had to wait to have their activities of daily living(ADL) needs attended to during the passing of resident trays on the nursing units. Continued interview revealed that the resident felt it was not acceptable to be told that they had to wait until the trays were passed out and the administrator had never responded to their concerns. Review of the nurse ' notes dated 12/14/08 revealed that the resident has occasional accidents. During the interview with the Assistant director of nursing (ADON) and the resident's nurse on 01/14/09 at 3:15 PM both stated that Resident #46 is occasionally incontinent of stool. During the interview with the director of nursing (DON) 1/15/09 at 10:15 am she stated that the resident is suppose to wait for help for toileting because he/she has not been cleared by the physical therapy department. During the second interview with Resident #46 on 01/15/09 at 10:00 AM, the resident stated that in the morning after he/she drinks coffee, he/she has a problem with urgent stool. The resident stated that this morning (1/15/09) he/she had to go 3 times and was able to get to the bathroom two times, but on the third occasion did not quite make it and again stated that it is | embarrassing. The ise continued to state that it is always in the morning at breakfast time, when the certified nutsing assistants (C.N.A:s) are passing trays when no help is available. On 1/16/09 at 1:15 pm, the Ombudsman stated during the interview that she visited the facility 2 months ago regarding a complaint about staff not answering the call bells when they were passing meal trays. The ombudsman continued to state that she had informed the administrator of the outcome of the investigation and her concern regarding staff not assisting residents with the ADL needs during meal times. 9. The above delineated allegations constitute a violation of Chapter 400 Florida Statutes and Section 400.102 Florida Statutes (2008) which constitutes a class II deficiency, for which a fine of Two Thousand Five Hundred Dollars ($2500) is authorized pursuant to Section 400.23(8)(b), Florida Statutes (2008). | COUNT IV PURSUANT TO SECTION 400.23 (7)(B) FLORIDA STATUTES (2008) A CLASS Il DEFICIENCY WARRANTS AN IMPOSITION OF A CONDITIONAL LICENSE, SECTIONS 400.19(3) AND 400.23(7)(b), FLORIDA STATUTES (2008) 10. The Agency re-alleges and incorporates paragraphs (1) through (9) as if fully set forth herein. 11. Section 400.23(7)(b) Fla. Stat. (2008) states in pertinent part: “"...(b) A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class J, class II, or class III deficiencies at the time of the followup survey, a standard licensure status may be assigned...” Section 400.23(7)(b) Fla. Stat. (2008)-in pertinent part. 12, Based upon the Respondent’s cited Class II deficiency asserting that Respondent was not in substantial compliance at the time of the survey pursuant to criteria established under Part II of Florida Statute 400, or pursuant to rules adopted by the Agency, assignment of conditional licensure status is warranted pursuant to Section 400.23(7)(b), Florida Statutes (2008). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings as to the allegations relating to a Class II deficiency as delineated by the Agency within Count I of this complaint. (B) Recommend administrative fines against Respondent in the amount of Two Thousand Five Hundred Dollars ($2500);. (C) As to Count II a finding of a Class II deficiency be entered based upon the allegations delineated within Count I thus warranting that conditional licensure status be imposed pursuant to Section 400.23(7)(b) Fla. Stat. (2008). 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, and Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. | RESPONDENT IS| FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A. HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. | Dated Zz Zoot Agency for Health Care Administration by Res _y { Ca Richard Tah aliba, Esquire Senior Attorney Fla. Bar. No. 0240389 Agency for Health Care Administration. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5527 1398 to: Registered Agent National Corporate Research Ltd, Inc., 515 E Park Avenue, Tallahassee, Florida 32301 and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5527 1404 to: Lake Eustis Care Center, Facility Administrator, 411 West Woodward Avenue, Eustis, Fl 32726 1350 S. Nova Road, » 2067: Daytona Beach, FL 32114, on Dibraces 3 Copy furnished to: Ms. Allison Hillhouse, FOM Agency for Health Care Administration ty hy J wae Saliba, Esquire Senior Attorney Fla. Bar. No. 0240389 Agency for Health Care Administration. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax)

Docket for Case No: 09-000928