Jul 22 2009 3:14 a7/22/2889 @a:a9 8589218158 PAGE 14/28 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No. 2009005745 Vv. AMERICAN SENICR LIVING OF, DADE CITY, FL, LLC, d/b/a EDWINOLA RETIREMENT .COMMUNITY , Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (the ‘Agency”) and files this Administrative Complaint against American Senior Living of Dade City, FL, LLC, a/b/a Edwinola Retirement Community (*“Respondent” or “Respondent Facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of one thousand dollars ($1,000.00), and a survey fee of Eive hundred dollars ($500.00), for a total assessment of one thousand five hundred dollars ($1,500.00), or such other relief as this tribunal may determine, based upon one cited State Class II deficiency, pursuant to Section 429.19, Florida Statutes. JURISDICTION AND. VENUE Jul 22 2009 3:14 a7/22/2889 @a:a9 8589218158 PAGE 15/28 1. The Agency has jurisdiction pursuant to Sections 20.42, 120,60, and 429.07, and Chapter 408, Part II, Florida Statutes. 2. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. ' PARTIES 3. The Agency is the regulatory authority responsible for licensing assisted living facilities and enforcing all applicable state statutes and rules governing assisted living facilities pursuant to Chapter 408, Part YI, and Chapter 429, . Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a one hundred and seventy (170) bed assisted living facility located at 14235 Edwinola Way, Dade City, Florida 33525, and is licensed ag an assisted living facility, license number 7295, with an extended congregate care (“ECC”) designation. | 5. At all times material to the allegations of this complaint, Respondent was a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates above paragraphs one (1) through five (5}, as if fully set forth in Jul 22 2009 3:14 a7/22/2889 @a:a9 8589218158 PAGE 16/28 this count. 7. Rule 58A-5.0182, Florida Administrative Code, provides: Resident Care Standards: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (b) 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. (c} General awareness of the resident’s whereabouts. The resident may travel independently in the community. (d} Contacting the resident's health care provider and other appropriate party such as the resident‘s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or cage manager if the reaident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. a. Rule 58A-5.0131(33), Florida Administrative Code, defines: (33) “Significant change” means a sudden or major shift in behavior or mood, or a deterioration in health status such as unplanned weight change, stroke, heart condition, or stage 2, 3, OF 4 pressure sore. Ordinary day-to-day fluctuations in functioning and behavior, a short-term illness such as a cold, or the Jul 22 2009 3:15 a7/22/2889 @a:a9 8589218158 PAGE 17/28 qradual deterioration in the ability to carry out the activities of daily living that accompanies the aging process are not considered significant changes. go. Rule 58A-5.024(4}) (a), Florida Administrative Code, requires: (4) RECORD INSPECTION. (a) All records required by this rule chapter shall be available for inspection at all times by staff of the agency, the department, the district long-term care ombudsman council, and the advocacy center for persons with disabilities. 10. Section 429.255, Florida statutes, requires: (1) (a) 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 s. 464.022(1), and others as defined by rule, may administer medications to residents, take residents! vital signs, manage individual weekly pill erganizers 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 s. 429.26. Nursing assistants certified pursuant to part IL of chapter 464 may take residents' vital signs as directed by a licensed nurse or physician, (b) All staff in facilities licerised under this part shall exercise their professional responsibility to observe residents, to document observations on the appropriate resident's record, and to report the observations to the resident's physician. However, the owner or administrator of the facility shall be responsible for determining that the resident receiving services is appropriate for residence in the facility. , (2) In facilities licensed to provide extended congregate care, persons under contract to the Jul 22 2009 3:15 a7/22/2889 @a:a9 8589218158 PAGE 18/28 facility, facility staff, or volunteers, who are licensed adcording to part I of chapter 464, or those persons exempt under s. 464.022(1), or those persons certified as nursing assistants pursuant to part II of chapter 464, may also perform all duties within the scope of their license or certification, as approved by the facility administrator and pursuant to this part. 11. Section 429.26(3), Florida Statutes, requires; (3) Persons licensed under part I of chapter 464 who are employed by or under contract with a facility shall, on a routine basis or at least monthly, perform a nursing assessment of the residents for whom they are providing nursing services ordered by a physician, except administration of medication, and shall document such assessment, including any substantial changes in a resident's status which may necessitate relocation to a nursing home, hospital, or specialized health care facility. Such records shall be maintained in the facility for inspection by the agency and shall be forwarded to the resident's case manager, if applicable. 22. Rule 58A-5.030(3), Florida Administrative Code, requires; (4) STAFFING REQUIREMENTS. Fach extended congregate care program shall: (>) Provide, as staff or by contract, the services of @ nurse who shall be available to provide nursing services as needed by ECC residents, participate in the development. of resident service plans, and perform monthly nursing assessments. (5) ADMISSION AND CONTINUED RESIDENCY, (a) An individual must meet the following minimum criteria in order to be admitted to an extended congregate care program. 6. Not have any stage 3 or 4 pressure sores, (6) Criteria for continued residency in an ECC program shall be the same as the criteria for admission, Jul 22 2009 3:15 a7/22/2889 @a:a9 8589218158 PAGE 19/28 (9) RECORDS. {a) In addition to the records required under Rule 58A-5,024, F.A.C., an extended congregate care program shall waintain the following: 1, The service plans for each resident receiving extended congregate care services; 2. The nursing progress notes for each resident receiving nursing services; 3. Nursing assessments; and 4, The facility’s ECC policies and procedures. (b) Upon request, a facility shall report to the department such information as necessary to meet the requirements of Section 429.07(3) (b)9., F.S. (10) DISCHARGE. If the facility and the resident are unable to agree on a service plan, or if the facility is unable to meet the resident's needs as identified in the service plan, or if the resident ne longer meets the criteria for continued residency, the resident. shall be discharged in accordance with Sections 429.26(8) and 429,28(1), F.S. 13. Rule 58A-5.0181, Florida Administrative Code, requires: (1) ADMISSION CRITERIA. An individual must meet the following minimum e¢riteria in order to be admitted to ‘a facility holding a standard, limited nursing or limited mental health license: (j) Not have any stage 3 or 4 pressure sores. A resident requiring care of a stage 2 pressure sore may be admitted provided that: i. The facility has.a LNS 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; . 2. The condition is documented in the resident’s record; and 3. If the resident’s condition fails to improve within 30 days, as documented by a licensed nurse or physician, the resident shall be discharged from the facility. (4) CONTINUED RESIDENCY. Criteria for continued Jul 22 2009 3:15 a7/22/2889 @a:a9 8589218158 PAGE 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: {a) The resident May be bedridden for up to 7 consecutive days. (b) A resident requiring care of a stage 2 pressure sore may be retained provided that: 1. The facility has a LNS license and services are provided pursuant to a plan of care issued by a physician, or the resident contracts dixectly with a licensed home health agency or a nurse to provide care; 2, The condition is documented in the resident’s record; and 3. If the resident’s condition fails to improve within 30 days, as documented by a licensed nurse or physician, the resident shall be discharged from the facility. (d) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. (e) Continued residency criteria for facilities holding an extended congregate care license are described in Rule S8A-5.030, F.A.c. (5) DISCHARGE. 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), F.S. 14. Under commonly accepted standards of nursing practice, pressure sores are characterized by stage: Stage 1: Pressure ulcer is an observable pressure-related alteration of intact skin whose indicators ag comparéd to an adjacent or Opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer 28/28 Jul 22 2009 3:16 a7/22/2889 @a:a9 8589218158 PAGE 21/28 may appear with persistent red, blue, or purple hues. Stage 2: Partial thickness skin loss invelving epidermis, dermis, or both. The ulcer is superficial and presents clini¢ally as an abrasion, blister, or shallow crater. Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep cxater with or without undermining of adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. 15. On April 13, 2009, the Agency conducted a complaint investigation of Respondent Facility, i5.a. Based upon observation, record review and interview the facility failed to provide care and services appropriate to the needs of one (1) of four (4) residents, Resident #2. 15.b. During record review for Resident #2, it was determined that she/he was admitted te the facility on November 10, 2008, with diagnoses of atrial fib, dementia, and hypertension. There was no documentation of pressure sores on the health assessment dated November 4, 2008, 15.¢. The resident was admitted to the local hospital on March 6, 2009, with diagnoses of hypotension and decreased level of consciousness, after being seen by the Jul 22 2009 3:16 a7/22/2889 @a:89 8589218158 PAGE 22/28 advanced registered nurse at the facility for complaints of cough. Documentation by the home health agency treating the resident noted only a left lower ankle wound being treated, 15.d. Interview on April 13, 2009, at approximately 11:10 a.m. with the facility director of nursing confirmed that there was a note in Resident #2's file dated March 6, 2009, by an unknown author recounting the observation of an area on Resident #2’s buttocks dark in color but not open. 15.e. The initial assessment completed by the hospital on March 6, 2009, indicated a large stage III pressure sore, 6 cm diameter, with necrotic tissue to the coceyx/ sacrum area. The hospital admitting diagnosie was to rule out sepsis, anemia, and pressure sores on buttocks with erythemia. Initial emergency reom treatment consisted of normal saline 500 ml bolus and Rocephine 1 gram TV. The hospital history and physical dated March 6, 2009, completed by the attending physician confirmed an “infection decubitus ulceration’. 15.£. Hospital documentation dated March 7, 2009 at 2:14 p.m. confirmed that the consulting surgeon performed debridement 15 em x 15 cm with wound vac therapy. 15.g. In an interview with complainant on April 13, 2009, at approximately 8:00 a.m., the complainant confirmed Jul 22 2009 3:16 a7/22/2889 @a:a9 8589218158 PAGE 23/28 to the Agency surveyor that the hospital informed Resident #2'’s family that there was nothing more that could be done and a “Do Not Resuscitate” order was initiated. The resident was transported to the local hospice facility where she/he expired 30 minutes after admission. i5.h, Interviews with the chief nursing officer and associate administrator of the hospital on April 13, 2009, at approximately 1:30 p.m. confirmed accuracy of hospital documentation. 15,i. The Respondent's file for Resident #2 contained no monthly nursing assessment, no documentation of Resident #2's significant change, and no documentation that Respondent had notified the family, guardian, health care surrogate or case manager and health care provider of Resident #2's significant change. 15.3. Failure by the facility to document and prevent .a pressure sore from developing or worsening, failure to promptly séek médical care for the Stage III pressure sore, and failure to promptly notify family and Resident #2’s health care provider of the significant change put Resident #2 at risk for unmet needs and a lite threatening situation. 16. The Agency determined that each of these deficient practices of Respondent Facility’s staff -- failing to 10 Jul 22 2009 3:16 a?/22/2089 88:89 8589218158 PAGE 24/28 prevent Resident #2’s pressure sore from developing or worsening, failure to document the Progress of the pressure sore so that Raspondent’s administrator could make an assessment of Resident #2’s continued suitability for residence at the Respondent facility, failure to promptly document and seek medical care for Resident #2‘s pressure sore, and failure to promptly notify family and Resident #2's health care provider of Resident #2’‘s significant change ~- put the resident at risk for unmet needs and a life threatening situation related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency pursuant to § 429.19 (2) (b), Florida Statutes. | 17. The Agency provided Respondent with a mandatory correction date of May 13, 2009. WHEREFORE, the Agency intends to impose an adminiatrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to &§$§ 429.19(2) (b) and (3), Florida Statutes, or such further relief as this tribunal deems just. COUNT IT 18. The Agency re-alleges and incorporates above paragraphs one (1) through five (5) and Count I, as if fully set forth in this count. 121 Jul 22 2009 3:17 a?/22/2089 88:89 8589218158 PAGE 25/28 19. Pursuant to Section 429.19 (7), Florida Statutes, in addition to any administrative fines imposed, the Agency may agsess a survey fee equal to the lesser of one half of a facility’s biennial licenge and bed fee, or $500, to cover the cost of conducting an initial complaint investigation that results in the finding of a violation that was the subject of the complaint, 20. On or about April 13, 2009, the Agency conducted a complaint investigation of Respondent Pacility which found a violation that was the subject of the complaint. 41. Pursuant to Section 429.19(7), Florida Statutes, such a finding as specified in paragraph 17, above, subjects the Respondent Facility to a survey fee equal to the leaser of one half of the Respondent’s biennial license and bed fee, or $500. WHEREFORE, the Agency intends to additionally impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(7), Florida Statutes. secs of. ns es H. Harris Pla. Bar. No. 817775 Counsel for Petitioner . Agency for Health care Administration 525 Mirror Lake Drive, 330H St. Petersburg, Florida 33701 727.552.1535 (office) 727.552.1440 (fax) 12 Jul 22 2009 3:17 a7/22/2889 @a:a9 8589218158 PAGE 26/28 NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in thig matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahen Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT I$ 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 COMPLAIN? AND THE ENTRY OF A FINAL ORDER BY THE AGENCY, CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 6561 to C.T. Corporation System, Registered Agent for American Senior Living of Dade City, FL, LLC, d/b/a Edwinola Retirement Community, 1200 South Pine tsland Road, Plantation, Florida 33324 and by U.S. Mail to Mark A. Davis, Administrator for American Senior Living of Dade City, PL, LLC, d/b/a Edwinola Retirement Community, 14225 Edwinola Way, Dade City, Florida 33525, on June 2% , 2009. Vf es H. Har¥is, Esquire jistant General Counsel 13 a7/22/2889 @a:a9 8589218158 Copies furnished to: Jul 22 2009 3:17 PAGE 27/28 C.T. Corporation System, Registered Agent for American Senior Living of Dade City, FL, LLC, d/b/a Edwinola Retirement Community, 1200 South Pine Island Road, Plantation, Florida 33324 (0.8. Certified Mail) James H. Harris, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330H St. Petersburg, FL 33701 (Interoffice)} Mark A. Davis, Administrator for American Senior Living of Dade City, FL, LLC d/b/a Edwinola Retirement Community 14235 Edwinola Way Dade City, Florida 33525 (U.S, Mail) Kathleen Varga, Pacility Evaluator Supervisor 525 Mirror Lake Dr., 4° Floor St. Petersburg, Florida 33701 (Interoffice) 14 Jul 22 2009 3:17 a7/22/2889 @a:a9 8589218158 PAGE 28/28 = Completeitems. _ 2, and 3. Also complete item 4 if Restricted Dalivery is deshad. @ Print your name and address on the reverse 80 that we can return the card to you. ® Attach this card to the back of tha mailplece, or on the front if space partnits. 1. Artie Addressed ta: COMPLETE THIS Sim o Ts dofivery address different fam fem 17 CT Yels HFYES, enter delivery address betow: (C1 No Cae + KT a. Sarda Type C1 Cartified Mal =) Express Mail Oi Registered =. Cl Return Recalpt for Merettar O insured Mal CI G.on, vd Stont a. Rakin amt Cs \200 Sach Muncd Dkectotouw, SL. he et, 23324 [Cpeamcted babkog? Baw foo = * ans er b bSLL ~~ ASOGost (Tanster fom 5 7004 2890 000 552 x c ; PS Form 3811, February 2004 Domestic Retum Recalpt 1O25GS-07-M

Docket for Case No: 09-003914