Nov 1 2010 15:37 1 : 1/61/2801 15:33 8589216158 PAGE 16/43 sr =e STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, Case Nos. 2010009023 2010009024 LARGO INVESTMENTS & ASSOCIATES, LLC, d/b/a OAK MANOR HEALTHCARE & REHABILITATION CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Largo Investments & Associates, LLC, d/b/a Oak Manor Healthcare & Rehabilitation Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing July 30, 2010 and ending September 7, 2010, impose an administrative fine in the amount of twelve thousand five hundred dollars (612,500.00) and a survey fee of six thousand dollars ($6,000.00) for a total assessment of eighteen thousand five hundred dollars ($18,500.00); based upon Respondent being cited for one Pattemed State Class I deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2010). 2. ‘Venue lies pursuant to Florida Administrative Code R. 28-106.207. Nov 1 2010 15:47 11l/al/28le 16:33 8589218158 PAGE 11/43 PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title TV, Subtitle C (as amended), Chapters 400, Part IL, and 408, Part IJ, Florida Statutes, and Chapter 59A-4, Florida Administrative Cade. 4, Respondent operates a 180-bed nursing home, located at 3500 Oak Manor Lane, Largo, FL 33774, and is licensed as a skilled nursing facility license number 1376096. 5. 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 T 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Florida law, all licensees of nursing homes facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. § 400.022(1)U1), Fla. Stat. (2010). 8. That from July 26, 2010 through July 30, 2010, the Agency completed an annual Health and Life Safety Survey of Respondent’s facility. 9. That based upon the review of records, observation, and interview, Respondent failed to 2 Nov 1 2010 15:48 11l/al/28le 16:33 8589218158 PAGE 12/43 ensure resident's received adequate protective services consistent with the resident care plan, failed to objectively assess ten (10) residents for safe smoking, failed to individualize the care plan based on a smoking assessment, failed to implement the care plan for ten (10) of ten (10) smoking residents related to supervision, and failed to maintain the call bell system to ensure both the audio and visual portions of the system were functioning appropriately. 10, That this failure in the system, to accurately recognize residents who were unsafe smokers and to provide supervision while smoking caused a situation potentially putting smoking residents at risk from burns caused from cigarettes or lighters’ and potentially put all residents and staff at risk from residents who were allowed to keep their lighters where there were known wandering residents and residents who used oxygen, Respondent also failed to recognize that the call bell system is an emetgency response system for both resident and staff alike, for which all portions of the system, must be functioning at all times. 41. That Petitioner's representative observed resident number three (3) on July 26, 2010 at approximately 9:15 a.m, to be smoking alone outside the west wing of the facility, in the area between the facility and the main kitchen. The resident, a bilateral amputee, who used oxygen continuously, had a lighter and pack of cigarettes in the top pocket of the shirt and made some small talk with the surveyor as to the weather. 12. | That Petitioner’s representative observed resident number twenty-nine (29) on July 26, 2010 at approximately 10:40 a.m. and noted as follows: a. The resident was observed to ask for and receive two cigarettes from the nurse, who had them locked in the medication cart, b. The resident wheeled away without any instruction about smoking from the nurse. 13, That Petitioner’s representative interviewed resident number twenty-nine (29) on July 28, 2016 at approximately 1:45 p.m. during which the following occurred: a. The interview was interrupted by the resident searching all over the bed and the 3 11l/al/28le 16:33 8589218158 Nov 1 2010 15:48 PAGE 13/43 shelf next to the bed for the resident's lighter; b. The resident reported that, "I just had it," but agreed to answer some questions; c. The resident revealed that the resident goes out to smoke alone, once the nurse provides the cigareties; d. The resident confirmed that sometimes staff were out oft the patio smoking, but didn't think it was to supervise the residents, e. The resident reported that the resident did not have to wear a smoking apron. 14. That Petitioner’s representative observed Respondent’s smoking patio on July 27, 2010 beginning at 11:00 a.m. and noted as follows, a, Two (2) residents were both sitting in their wheelchairs smoking, without smoking aprons, and no staff present; b. Resident number one hundred forty-three (143) had a pack of cigarettes and a lighter in the resident's lap, ¢. The resident reported that staff only came out to smoke, not to supervise, and that the resident never saw any residents wear smoking aprons; d. No smoking aprons were observed on the smoking patio. 15, That Petitioner's representative reviewed Respondent’s incident log for March 2010 and noted an entry for resident number one hundred ninety (190) dated March 17, 2010 which read “Burned finger when smoking" which occurred on the smoking patio. 16. That Petitioner’s representative reviewed the nurse’s notes for resident number one hundred ninety (190) and noted an entry of March 17, 2010 documenting that the resident admitted to burning a finger while smoking a cigarette and indicated that it happened a week prior. The nurse deseribed the burn as a nickel size blister on the right middle finger. 17. That Petitioner's representative a reviewed Respondent’s Resident Smoking policy, (no policy number, but reviewed on 11/18/08), and noted the statement, "All residents will be 4 11/61/2016 16:33 Nov 1 2010 15:38 85892148158 PAGE 14/43 assessed for ability to smoke safely to ensure that the tesident's safety and well-being are maintained." 18. That the Policy Interpretation and Implementation of Respondent’s Resident Smoking policy listed eight points including as follows: a. Point 1- “To ensure the safety and well being of our residents, a resident will be assessed for safe smoking" (emphasis added); Absent from the policy was a description of the assessment tool or the criteria that would be used; The assessment referenced in point 1 would be necessary to apply point 3 - "Based upon the assessment all smoking materials will be kept in the appropriate locations" and point 4 "Based upon assessment residents will be provided smoking aprons and/or supervision during smoking." Point 5 indicated, "Residents will be prohibited from smoking during the administration of oxygen.” Respondent’s Resident Data Set assessment form did not have a place where resident use of oxygen would be documented; Point 8 provided “The staff will secure all smoking materials for the resident, if necessary.” There were no criteria indicated for determining what would make the application of point 8 necessary; Points 2 and 6 referred to the designated smoking area: “The residents will be oriented to the appropriate smoking areas and the smoking policy will be explained to all residents/responsible party upon admission." And “Residents will be shown the designated smoking areas and will be instructed that smoking is prohibited outside of these areas,” 5 Nov 1 2010 15:39 11l/al/28le 16:33 8589218158 PAGE 15/43 19. That Petitioner’s representative twice observed resident number three @) smoking in a non-designated smoking area, on July 26, 2010 at approximately 9:15 am. and on July 29, 2010 at approximately 11:00 a.m. . 20, That Petitioner’s representative interviewed Respondent’s administrator on. July 28, 2010 who indicated that the facility was aware of the resident's noncompliance of resident number three (3) with the policy of only smoking in the designated area. 21, That the facility did not follow their policy on smoking related to smoking areas as it relates to this noncompliant resident, resident number three (3). 22. That Petitioner’s representative interviewed Respondent's administrator and director of nurses on July 28, 2010 who indicated as follows: a, On a monthly basis, the unit managers completed an assessment (the Resident Data Set) on every resident, which included a section on smoking; b. The director of nurses reported that, at that time, there were ten (10) residents currently living in the facility who smoked, none of which had been assessed as needing supervision by staff or needing to wear a smoking apron; c. The director of nurses confirmed that this monthly Resident Data Set was separate from the Minimum Data Set (MDS) assessments and did not rely on the MDS assessment for cognitive status; d. The director of nurses confirmed that a few of the residents had their own lighters, but the nurses locked up the resident's cigarettes in the medication carts and residents needed to ask for cigarettes; ¢. The director of nurses did not address how residents without lighters would have their cigarettes lit as staff was not scheduled to be on the patio to supervise residents, and residents had been instructed, per the policy, not to share their smoking supplies with other residents. 6 11/61/2818 16:33 Nov 1 2010 15:49 8589218158 23. PAGE 16/43 That Petitioncr’s representative reviewed Respondent’s Resident Data Set assessments and noted as follows: 24. a. h, The assessment was completed for all residents on admission to the facility, and on a monthly, quarterly, annually, or with a significant change basis; The assessment required identifying the resident's cognitive status, whether the resident had a memory problem and if the resident was confused, lethargic, or oriented; A section of the assessment, entitled “Lifestyle,” was to be completed if the resident was a current smoker; Five questions required a yes or no answer, which resulted in staff determining whether the resident was a safe or unsafe smoker; The five questions asked whether the resident was able to light and smoke a cigarette while demonstrating safe technique; whether the resident was able to physically hold the smoking device, whether the resident remained alert during the course of smoking; whether the resident was able to understand that smoking materials should not be shared; and whether the resident was able to understand that smoking should be only in designated areas; That the degree of supervision needed while smoking required a decision to be made as to whether the resident needed occasional, frequent, or constant supervision; There was no further instruction or criteria to guide the decision maker as to whether the smoker was safe or unsafe and the degree of supervision needed; There was no definition of what “occasional”, “frequent” or "constant" supervision entailed. That Petitioner’s representative reviewed Respondent’s records related to the ten (10) 7 l1l/al/28le 16:33 Nov 1 2010 15:49 8589218158 PAGE 17/43 residents who were identified 4s smoking residents and noted the following facility evaluation of the residents’ capabilities and deficits related to safe smoking along with, where appropriate, resident interviews: a. Resident Number one hundred ninety (190): a The resident had been identified on the quarterly MDS assessment, completed on May 5, 2010, as having short and long term memory problems with moderately impaired cognitive status; The Resident Data Set, completed on July 7, 2010, documented all ‘yes’ answers to the five questions, and assessed the resident as needing occasional supervision, The resident's care plan, written on May 18, 2010, indicated there was the potential for smoking related injury related to Alzheimer's disease; Nurses notes and an entry on an incident tog on March 17, 2010 noted the resident had burned a finger while smoking; There was no revision of the care plan to address the resident's injury or to the degree of supervision needed to prevent further smoking related injury; During an interview with this resident, on July 28, 2010 beginning at 3:53 p.m, the resident's shirt was noted with two stall holes, similar to a bole from a dropped ash from a cigarette, The resident was not able to state when the shirt had been burned, or the circumstances, but did confirm that it happened while smoking. This resident received one pack of cigarettes at a time from the nurse and maintained his/her own lighter. b. Resident Number three (3): a. The resident had been identified on the quarterly MDS assessment, completed on May 10, 2010, as having short term memory deficit, and moderately impaired cognitive status, b, The Resident Data Set, completed on July 6, 2010, revealed no identification of the memory problem; The resident was assessed as being a safe smoker and needing occasional supervision While smoking; This assessment did not refer to the resident's use of continuous oxygen and how it impacted the resident's ability to smoke independently; 8 Nov 1 2010 15:49 11/81/2818 16:33 85892148158 PAGE 18/43 & This resident was the resident who had been observed smoking on July 26, 2010 at 9:15 am. in the non designated smoking area; £ The Resident Data Set indicated that the resident was able to understand that smoking should be only in designated areas, but chose to smoke where s/he wanted to smoke; , g. Respondent's administrator had confirmed on J uly 28, 2010, at approximately 5:00 p.m., that he was aware of the resident wanting to smoke im a non designated area and frequently saw the resident in that area and reminded the resident that the resident needed to go to the designated area, h. The resident's care plan did not reflect this noncompliance with smoking only in the designated area, atd did not reflect a reevaluation based on the noncompliance, as directed in approach number six (6) noted on the form care plan, "If not compliant, reevaluate immediately.” j. The resident was oxygen dependent, using an E cylinder and nasa) cannula in the wheelchair, while away from the room and an oxygen concentrator and nasal cannula when in the resident’s room; j. The resident indicated during an interview of July 28, 2010.at 1:30 p.m., while in the resident’s room, that the resident smokes anywhere and anytime the resident wants to as the resident has the resident’s own smoking supplies; ki. The resident reported, when asked about smoking with oxygen, that the resident knew how to light a cigarette; |, The resident also reported that the resident never would wear a smoking apton, and has never had to have supervision when smoking; m. The resident confirmed that the resident maintained the resident’s own lighter and received one pack of cigarettes from the nurse at a time. c, Resident Number one hundred fifty-one (151): a. The resident had been identified on the quarterly Minimum Data Set (MDS) assessment, completed on June 25, 2010, as having short and long term memory problems with moderately impaired cognitive status; b, ‘the Resident Data Set, completed on June 20, 2010, assessed the resident as having no memory problems, being a safe smoker and needing occasional supervision, ce. All five of the smoking assessment questions had been answered “yes” 9 11/41/2818 16:33 Nov 1 2010 15:40 8589218158 PAGE d, 8 The care plan, written on July 6, 2010, revealed that the resident "Requires supervision while smoking," Interview with resident on July 29, 2010 at 4:40 p.m., revealed that the resident always went to smoke by self without supervision; The resident indicated that sometimes there were others on the patio; The resident received one pack of cigarettes at a time from the nurse, and reported that the resident did not have a lighter; Two of Respondent’s nurses, staff members seven (7) and eight (8), reported on July 28, 2010 that the resident did in fact own and possess a lighter. d. Resident Number twenty-nine (29): a The resident had been identified on the initial MDS, completed on May 9, 2010 as having short and long term memory problems and having moderately impaired cognitive status; . The Resident Data Set dated July.9, 2010, did not include the resident's cognitive status, contained ‘yes’ to all five smoking questions, indicated the resident was a safe smoker, but did not include the degree of supervision needed while smoking; The resident's care plan, dated May, 16, 2010, contained the concern of potential for smoking related injury related to Paranoid Schizophrenia; The resident reported having had her/his own lighter, but received a few cigarettes at a time from the nurse; A. nursing note dated July 18, 2010, documented, “Resident has created several complaints from other halls because [the resident] is entering other patient's rooms looking for cigarettes and lighters. Patient lit a cigarette in the building, near the central nurse's station." e, Resident Number seventy-cight (78): a c. The resident had been identified on the quarterly MDS assessment, completed on July 2, 2010, as having short term memory problems but intact long term memoty atid modified independence in decision making; The Resident Data Set, completed on July 14, 2010, identified the resident as having no memory problems, ‘yes! answers to all five smoking questions, being a safe smoker, and needing constant supervision; The resident's care plan identified the concern as potential for smoking related 10 1a/4a 11/41/2818 16:33 Nov 1 2010 15:40 8589218158 PAGE 28/43 injury related to impaired safety awareness; The resident indicated on July 28, 2010 at 1:03 p.m., that the resident keeps the resident's own cigarettes and lighter; The resident reported that the resident does not use a smoking apron; The resident reported that the resident has seen staff on the smoking patio, but wasn't sure if they were supervising other residents or out to smoke themselves; The resident reported that the only rule the resident was aware of was not to smoke indoors; A second interview with the resident on July 30, 2010, at 9:00 a.m. revealed the resident did not wear an apron because the resident would not drop a cigarette on clothing, and admitted to always smoking independently; The resident confirmed that the resident had his/her own lighter and cigarettes and because of refusing to give up all smoking supplies, on July 28, 2010, was assigned an, aide to maintain visual contact with the resident, after surveyor concern was expressed, until on July 29, 2010 at 12:30 p.m., when the resident agreed to give up all smoking supplies to the facility. f. Resident Number one hundred forty-three (143). a The resident had been identified on the initial MDS assessment, completed on May 14, 2010, as having no memory problems, and no cognitive deficit for decision making; The Resident Data Set, completed on July 6, 2010, had “yes” answers to all five smoking questions, and identified the resident as a safe smoker needing occasional supervision; : This resident's care plan, completed on June 3, 2010, identified the concer as, “Potential for smoking related injury related to general weakness." The resident had been observed. on the smoking patio on several occasions ' with the resident’s own lighter and pack of cigarettes: On July 28, 2010, at approximately 12:30 p.m., a housekeeping staff member was observed to light the resident's cigarette as the resident was having trouble doing it by self; This resident confirmed that the resident maintained own lighter and received one pack of cigarettes at a time from the nurses. il 1l/al/28lea 16:33 8589218158 Nov 1 2010 15:40 PAGE 21/43 g- Resident Number two hundred twenty-nine (229): a. The resident had been identified on the initial MDS assessment, completed on July 5, 2010, as having no memory problems and no cognitive deficit for decision making; b. The Resident Data Set, completed on June 25, 2 010, identified the resident as “forgetful at times", had “yes’ answers to all five smoking questions, and indicated the resident was a safe smoker, needing occasional supervision; c. The resident's care plan, written on July 27, 2010, identified the concern as the potential for smoking related injury related ta traumatic brain injury and decreased cognition, d. The resident confirmed that the resident had own lighter. h. Resident Number five (5): 5. The resident had been identified on the quarterly MDS assessment, completed on June 8,:2010, as having short term. memory problems, but no long term memory problems and moderately impaired cognitive deficit; b. The Resident Data Set, completed on July 9, 2010, revealed the resident was a safe smoker, needing occasional supervision, c. All five smoking questions had “yes” answers; d. The resident's care plan, written on June '9, 2010, revealed the concem as a “potential for smoking related injury related to burns in clothing.” e. The care plan also documented that the resident refused to use a smoking apron. i. Resident Number one hundred twenty-three (123): ' a. The resident had been identified on the quarterly MDS assessment, completed on June 1, 2010, as having short term memory problems, but no long term memory problem, and modified independence in decision making; b. The Resident Data Set identified the resident as a safe smoker, needing occasional supervision; c. All five smoking questions had "yes" answers; d. The resident's care plan, written on June 3, 2010, identified the concern as the “potential for smoking related injury related to cognition.” 25, That Petitioner’s representative interviewed Respondent's licensed practical nurse on the _ 1il/@l/26la 15:33 8589218158 Nov 1 2010 15:41 PAGE 22/43 south side of the 300 hall on July 28, 2010 at 9:37 am. who indicated that “there are a few residents who wander from the south side of the hall, and they get in other resident's rooms. We try to watch them, but we can't always." 26. That Petitioner's representative interviewed Respondent's licensed practical nurse on the north side of the 300 hall on July 28, 2010 at 1:15 p.m. who indicated that two of his residents did not need supervision while smoking and they both held on to their own lighters, and that he did not know of any residents who needed supervision while smoking. 27, That Petitioner’s representative interviewed Respondent's 300 hall unit manager on July 28, 2010 beginning at 1:20 p.m. who indicated that all four of the residents who were smokers on the 300 hall were all assessed as being safe smokers, meaning they did not need supervision, and confirmed that all four residents held onto their own lighters. 28. That Petitioner’s representative review Respondent’s smoking residents and the location of resident's who use oxygen and noted as follows: a. One (1) of the ten (10) smokers was dependent on oxygen and used oxygen when in the wheelchair and in bed and held on to a personal lighter; b. Three (3) other smoking residents lived on the 200 hall, one of which maintained a personal lighter and lived next door to a resident who used oxygen from an oxygen concentrator; c. One (1) resident on the 300 hall, who maintained a personal lighter, did not have oxygen in the room, but the two rooms around the resident’s room had residents who used oxygen from a concentrator, d, One (1) resident on the 100 hall did not use oxygen and no residents on the wing used oxygen; e. The other three (3) smokers lived on the 300 hall in rooms 316, 324, and 328 with one (1) oxygen dependent resident on this unit. 13 Nov 41 2010 15:41 11/61/2818 16:33 8589218158 PAGE 23/43 29, That The Joint Commission on the Accreditation of Healthcare Organizations (ICAHO), at wwjeaho.com, reported in the March 2001 issue of Sentinel Events that Since April 1997, 11 fires occurred in the homes of patients on oxygen therapy. Patients in seven of these fires died, In the remaining four fires, patients were permanently disfigured. All these patients were receiving supplemental oxygen service and were over the age of 65. Cigarette smoking was the contributing factor in all these fires. Investigators found the following tisk factors common to most of the fires: a. The patient lived alone; b. Smoke detectors were absent or non-functional, . Patient had cognitive impairment; 4, Patient had a documented history of smoking while oxygen was running; e. Patient wore flammable clothing. 30. That according to 2003-2006 data from the Consumer Product Safety Commission’s National Electronic Injury Surveillance System, home medical oxygen was involved in an average of 1,190 thermal bums seen annually at U.S. emergency rooms. Data from Version 5.0 of the U.S. Fire Administration's National Fire Incident Reporting System indicate that, in 2002- 2005, U.S. fire departments responded to an estimated average of 182 home fires per year in which oxygen administration equipment was involved in ignition. Forty-six people per year died in these fires. Smoking is by far the leading factor in these incidents. Several studies suggest that the number of burn injuries associated with home use of medical oxygen has been increasing over time. Fires burn hotter and faster in oxygen-enriched atmospheres. Things also ignite at lower temperatures. 31. That the above reflects Respondent’s failure to ensure that residents receive adequate and appropriate health care and protective and support services, including social. services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative 14 11/81/2818 16:33 Nov 1 2010 15:41 6569218158 PAGE 24/43 services consistent with the resident care plan, with cstablished and recognized practice standards within the community where Respondent: a. Knowingly allowed a resident to continue to be non-compliant with facility rules related to smoking only in designated areas; Knowingly failed to devise or implement interventions to assure that a resident who was non-compliant with facility rules related to the location of smoking areas complied with smoking area requirements; Knowingly allowed a resident receiving oxygen to smoke while actively receiving oxygen despite facility policy to the contrary; Knowingly failed to consider or implemettt interventions to address known dangerous and injurious smoking activity by residents; Knowingly failed to implement assessed supervision needs for smoking residents, all of which had been assessed to require some level of supervision; The failure to implement safe smoking plans, and policies care service for residents who smoke, endangering all residents, staff, and visitors. 32, That on July 27, 2010 at 10:40 a.m., Petitioner's representative observed the activation of the call system in a bathroom shared by four residents and noted as follows: a. b. ‘The light in the hall indicating the system had been activated did not illuminate; The call system in the bathroom was activated a second time and again the light in the hall did not illuminate; An aide approached the room to answer the call bell and reported that she had been at the nurses' station and heard the call bell ringing for room 321; A faint ringing could be heard while standing in the hall outside room 321; The aide confirmed that the call system did not illuminate in the hall when the call bell in the bathroom was activated, 15 Nov 41 2010 15:41 11/81/2616 16:33 85892148158 PAGE 25/43 f. ) The aide stated she would notify the maintenance man of the broken call light by writing it in the maintenance log at the nurses’ station. 33, That Petitioner's representative: interviewed Respondent’s the nurse for the 300 hall, tooms 315 to 328, on July 27, 2010 at 5:20 p.m. confirmed that from where she was standing with the medication cart, approximately halfway down the hall from the nurses' station, the audible call bell from the nurses! station was difficult to hear. 34, That Petitioner's tepresentative noted that the two (2) residents, who shared a bathroom with a nonfunctional call bell of room 323, were identified as being totally dependent on two staff physically assisting them for toileting per the resident’s Minimum Data Set assessments completed for bed one on June 1, 2010 and for bed two on June 6, 2010. 35. That on July 27, 2010 at 3:30 p.m., Petitioner's representative observed the activation of the call system in the entire building and noted as follows: a Functionality was reviewed at three (3) points - the light above the resident's room in the hall; the light at the call bell system at the nurses’ station; and the sound from the activated call bell at the nurses’ station; b. One surveyor activated the call bells in the resident rooms and the other surveyor stood at the nurses’ station ensuring that both the light and audio portion of the call bell system was functioning; G That Respondent's maintenance technician joined the two surveyors during the check of the call bell system on the 300 hall and reported on July 27, 2010 at 3:30 p-m., that an hour earlier he had been made aware. of the broken call bell in the shared bathroom between rooms 321 and 323, and had had to repair a loose wire. d. The call bell at bed one (1) in room 312, a semi private room, did not illuminate in the hall; e. The surveyor attempted to activate the call bell bedside twice without the light 16 11/e1/2018 15:33 Nov 1 2010 15:42 8589218158 PAGE 26/43 Illuminating in the hall but when an aide pushed the call bell a third time, the light above the door in the hall came on; Residents or staff pushing a call bell would not know that it wasn't activated and wouldn't continue to attempt to call for assistance; An emergency call bell system must work every time it is activated for it to be a true emergency call system; That a review of the cognitive status as recorded in the quarterly Mininmum Data Set (MDS) assessment for the resident in this room, completed on May 25, 20100, revealed that the resident had a short and Jong term memory problem with moderately impaired decision making abilities. This resident was totally dependent on one person physically assisting for bed mobility, transferring, and toileting; This resident's nurse, on July 29, 2010 at 5:20 p.m, indicated that the resident did not use the call bell, but the resident had a sensor pad on the bed and wheelchair to alert staff to the resident attempting to get up; An intervention such as a sensor pad may reduce the risk of the resident attempting to self transfer, but it does not take the place of a functioning call bell system, especially in the case of a resident transferring out and another using the bed; . The call bell in the bathroom of room 313, a private room, did not illuminate in the hall when activated; ) The resident of this room’s cognitive status as recorded in the resident’s quarterly MDS, completed on June 12, 201 0, reflected that the resident had a short and long term memory problem with moderately impaired decision making abilities. This resident required extensive physical assist by one person for bed mobility and was IT Nov 1 2010 15:42 11l/al/28le 16:33 8589218158 PAGE 27/43 totally dependent with the need of one person physically assisting for transferring and toileting; m. If this resident needed assistance to toilet, an emergency call system is required should something happen to either the resident or the staff member assisting the resident; n. Respondent’s maintenance technician, on July 27, 2010 at approximately 3:45 p-m., reported that he had had to fix a loose wire at the call bell in the bathroom; 0. The call bell at bed one in room 317, a semi private room, did not illuminate in the hall when activated; p. With the surveyor still in the room, on July 27, 20100 at approximately 3:35 p.m, the Director of Nurses was able to get the light to illuminate in the hall by pushing the plug into the wall firmly; q. A resident or staff member would not know that the call bell was not activating and would be waiting for assistance if they attempted to utilize the call bell. A call bell that is not fully functioning, such as this call bell that was not fully engaged and making the connection is not part of an emergency call system; r The resident in bed one (1) is identified in the resident’s initial MDS assessment completed on June 24, 2010 as having short and long term memory problems and had moderately impaired decision making skills. The resident was identified as needing extensive assistance by two staff members physically assisting with bed mobility, transferring, and toileting, 8. The call bell in the shared bathroom between rooms 306 and 308, affecting four residents, when activated did not illuminate in the hall or at the nurses! station; t. Two (2) of the four (4) residents sharing one of the rooms had been identified on MDS assessments, completed for bed one on an annual assessment on July 8, 18 11/@l/281e 16:33 Nov 1 2010 15:42 8589218158 PAGE 28/43 2010 and for bed two on a quarterly assessment on Jume 3, 2010, as being totally dependent with needing one person physically assisting with bed mobility, transferring, and toileting; The resident in bed one (1) in 308 had been assessed on the resident's initial MDS, completed on June 5, 2010 as needing extensive assistance with two staff members physically assisting for bed mobility, transferring, and toileting; The resident in bed two in 308 had been assessed on the resident’s annual MDS assessment, completed on June 1, 2010, as being totally dependent on two staff members physically assisting the resident for bed mobility and transferring, but needing extensive assist with one person for toileting; Three (3) of the four (4) residents sharing the bathroom were identified as not using the toilet. 36. That Petitioner’s representative reviewed Respondent’s maintenance log and noted as follows: c. For the 300 West hall for July 2010, an entry was made ori July 27, 2010 for "323 bath call light out." The time that it was fixed was documented as "205." There had been no time logged with the entry that the call light was out, and the maintenance technician explained. that "205" was the time the repair was made (ie., 2:05 p.m.); The nonfunctioning call bell located in the shared bathroom, light did not illuminate in the hall, had been identified at 10:40 aim, The entry in the maintenance log did not include a time when the entry was made, but the repair was entered as occurring at "205", or three hours and twenty five minutes later. 11/41/2814 16:33 8589218158 Nov 1 2010 15:42 PAGE 29/43 37. That Petitioner’s representative reviewed Respondent's policy for Call Bells (no policy mumber, but review date of 11/18/08), which provided "Ensure that any call lights found not to be functioning properly will be repaired immediately.” As the call bells of that room had been identified as not working, the maintenance technician had since addressed the issue. 38. That Respondent’s maintenance technician, on July 27, 2010 at 4:10 p.m., reported, when told of the nonfunctioning bathroom call bell in the shared bathroom between rooms 306 and 308, that he would add it to his 'to do’ list for the “next day.” . 39. That waiting until the next day to repair a portion of the call system is not indicative of the urgency of an emergency call system and is contrary to Respondent’s written policy on call lights ( no policy number, but dated reviewed’ 11/18/08) which provides, inter alia, “In an effort to reduce /prevent the possibilities of a malfunctioning call hght system...” point 1b "Ensure that any call light system found not to be functioning properly will be repaired immediately"; and point le "Ensure that all bathroom call lights found not to be functioning properly will be repaired immediately." 40. That by 4:30 p.m. on July 27, 2010, the call bell system review on the 100 and 200 halls had been completed and found ali call bells to be functioning fully. 41. That by 7:00 p.m. on July 27, 2010, Respondent's administrator reported that all cal! bells had been repaired and all points of the call bell system were functioning. 42. That on July 28, 2010, at approximately 9:00 a.m., Respondent’s administrator reported that the call bell system would be evaluated by an outside company for functionality and on July 29, 2010, the administrator ‘provided an informational letter to the survey team which noted that on July 29, 2010 at 1:30 p.m. the outside company evaluating the ca!l system had identified four new call bells that were not in working order, rooms 214, 230, 315, and 316, and described the system malfunction as non-i!luminating at the nurses’ station, 43, That Petitioner’s representative interviewed Respondent’s maintenance technician on. 20 11/61/2818 16:33 8589218158 Nov 1 2010 15:43 PAGE 38/43 July 27, 2010 who indicated as follows: a. Staff are to enter concerns with a nonfunctioning call bell in the maintenance logs which are kept on each nurses’ station; b. He checked the logs twice in the morning and twice in the afternoon during the week and maintenance staff were available after 5:00 p.m. at night and over the weekend by telephone for emergency maintenance repairs, which he did not define; c. He confirmed, when asked who was responsible for ensuting that the resident call system was working, that it was nursing that would report to maintenance any concerns; d. Nursing would write any concerns with the call system in the maintenance log kept on each nursing station. 44. That Petitioner's representative reviewed Respondent's policy for the Maintenance Log (no policy number, effective date 07/30/2007) which indicated that the maintenance tech would review all unit maintenance logs four times daily. 4S. That Petitioner's representative reviewed Respondent's policy for the Call Lights (no policy number, effective date 02/17/2002, reviewed 11/18/2008), which provided inter alia "If at any fire a staff member finds a call light not operating properly, they are to document the call light by room number in the specific unit's maintenance log.” 46. That Petitioner’s representative interviewed two (2) of Respondent's nurse's aides on July 27, 2010 who confirmed that when a call bell was not working, staff had been directed to log the concern into the maintenance log. 47. That Petitioner’s representative interviewed Respondent's administrator on July 28, 2010 who indicated as follows: 21 Nov 1 2010 15:43 11/81/2818 16:33 85892148158 PAGE 31/43 a. Two (2) monitoring systems that were in effect to ensure that call belis were functioning fully; b. One monitoring system was completed by the unit managers on a weekly basis and included a check list that monitored whether call bells in each resident room were within resident's reach and if they were answered in a timely manner, c The call bell system was not monitored specifically for the light illuminating outside of the resident's room, and the light and sound activating at the nurses’ station; d. The weekly review by the unit managers tequited monitoring of the response time | to an activated call bell in six resident rooms; e. The form did not require that the location of the call bell, whether bedside or in the bathroom, be documented. 48. That Petitioner’s representative reviewed Respondent’s July weekly reviews of the 300 hall and noted that in the four (4) weeks reviewed, twelve (12) of the twenty-eight (28) rooms had not been checked, 49, That the second monitoring system was conducted by a Safety Team, whose members included the Administrator, the Director of Housekeeping, the Director of Maintenance, the Quality Assurance Director, the Social Services Director and the unit manager of the unit that was being reviewed. Each unit was monitored once every three weeks. 50. That a review of the items’ that were monitored on each unit included whether the call lights were within reach and whether the call lights were in good working order, 51, That on July 28, 2010, Respondent’s Quality Assurance Director revealed that the functionality of the call system was monitored at all three points — the hall light illuminating and both the light illuminating and sound at the nurses’ station. 22 Nov 1 2010 15:43 11l/al/28le 16:33 8589218158 PAGE 32/43 52. That the 300 hall had been monitored by the Safety Team on July 8, 2010 and notes indicated two call bell concerns - The Safety Team documented that the call bell in room 313D (bedside call bell) was not working and the cord for the bell in room 325 needed to be replaced (location of the call bell was not indicated). 53, That on July 29, 2010, Respondent’s call bell system throughout the facility was evaluated by an outside company for functionality and Respondent’s administrator provided an informational letter on said date that indicated a site visit would occur by an electronic systems company to evaluate the nurse call system and to make recommendations and/or repairs. 54, That this check on the functionality of the call system was after the state agency had conducted a facility wide check on July 27, 2010 from 3:30 p.m. to 4:30 p.m, and found call lights non-functional bedside in two rooms (312 and 317) and in two shared bathrooms (306 and 308, and 321 and 323) and one private bathroom (313). 55. That Respondent’s administrator reported on July 28, 2010 at approximately 8:30 am. that his staff had made a facility wide check of the call bell system, after the state agency had monitored the system, and found that the system was functional. 56, That two days later, on July 29, 2010, the outside company evaluating the call system reported that they had found four additional call bells, in rooms 315, 316, 214 and 230 that were not functional as the light at the panel at the nurses” station was not illuminating. 57. -That the outside company founds concems with lights two days after two alleged thorough monitoring checks had been made by Respondent. 58. That the above reflects Respondent’s failure to ensure that residents receive adequate and appropriate health care and ptotective and support services, including social services; mental health services, if available; planned recreational activities: and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community where Respondent failed to ensure that call bell systems for 23 Nov 1 2010 15:43 11/1/2816 16:33 8589218158 PAGE 33/43 impaired residents were maintained in a functional manner, including, but not limited to, Respondent’s failure to ensure that its policies and procedures related to call bell system testing and maintenance were implemented, 59. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a Patterned State Class I deficiency. 60. The Agency provided Respondent with the mandatory correction date for this deficient practice of August 30, 2010. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of twelve thousand five hundred dollars ($12,500.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2010). COUNT 61. | The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I as if fully set forth herein. 62. Respondent has been cited for one (1) State Class I deficiency and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of six thousand dollars ($6,000) pursuant to Section 400.19G), Florida Statutes (2010). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two yeats and impose a survey fee in the amount of six thousand dollars ($6,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2010). COUNT I 63, The Agency re-alleges and incorporates paragraphs one (1) through. five (5) and Count 1 of this Complaint as if fully set forth herein. 24 Nov 1 2010 15:44 11/@1/2616 15:33 8589218158 PAGE 34/43 64. Based upon Respiondent’s one cited State Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(a), Florida Statutes (2010). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2010) commencing July 30, 2010 and ending September 7, 2010, Respectfully submitted this iA - day of October, 2010. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2005), Respondent shall post the most current license in a prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. 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 this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873, RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED iN THE COMPLAINT AND THE ENTRY OP A FINAL ORDER BY THE AGENCY. 25 1l/al/28le 16:33 8589218158 Nov 1 2010 15:44 PAGE 35/43 64. Based upon Respondent's one cited State Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional Licensure status under § 400.23(7)(a), Florida Statutes (2010). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400,23(7), Florida Statutes (2010) commencing July 30, 2010 and ending September 7, 2010. Respectfully submitted this i day of October, 2010. J. Walsh TI, Esquire ar, No. 566365 Agency for Health Care Admin. 525 Mirror Lake Drive, 3306 St. Petersburg, FL 33701 727,552,947 (office) DISPLAY OF LICENSE Pursuant to § 400,23(7)(e), Fla. Stat. (2005), Respondent shall post the most current license in a prominent place that is in clear and unobstructed’ public view, at or near, the place where residents are being admitted to the facility. 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 attomey in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Heatth Care Administration, 2727 Makan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT 18 FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 25 11/61/2816 16:33 8589218158 Nov 1 2010 15:44 PAGE 36/43 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No: 7001 0360 0003 3808 3024 on October , 2010 to: Brad Graham, Administrator, Oak Manor Healthcare and Rehabilitation Center, 3500 Oak Manor Lane, Largo, FL 33774, and by U.S. Mail to Patrick M. O’Connor, Esq., 0’ Connor & Associates, Registered Agent, 1250 $. Belcher Road #160, Largo, FL 33771, Thomas J. Walsh, I, Esquire Copy furnished to: Patricia Caufman, FOM 26 Nov 1 2010 15:44 11l/al/28le 16:33 8589218158 PAGE 37/43 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Largo Investments & Associates, LLC CASE NO. 2010009023 d/b/a Oak Manor Healthcare & ; 2010009024 Rehabilitation Center ELECTION OF RIGHTS This Election of Rights form ‘is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose_a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. : If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3.OPTIONS OPTION ONE (1) [ admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. | understand that by giving up my tight to a hearing, a final order will be igsued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2)_ Ladmit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent -to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and J request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before 11/61/2616 15:33 8589218158 Nov 1 2010 15:45 PAGE 38/43 the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must confonn to the requirements of Rule 98-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3, A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: a Name Title Address: . Street and number City Zip Code Telephone No. Fax No. ____Enmmail(optional). [hereby certify that I atm duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC

Docket for Case No: 10-010004