STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINT. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. CASSELBERRY ALF, INC., d/b/a EASTBROOK GARDENS Ol- Yessy Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care ‘Administration (hereinafter “HCA” ), by and through the undersigned counsel, and files this Administrative Complaint against Casselberry ALF, Inc., d/b/a Eastbrook Gardens (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Eastbrook Gardens in the amount of five thousand dollars ($5,000) pursuant to Sections 400.414(1)(a) and 400.419(a) Florida Statutes. E sprees orion oe Jurisdiction And Venue 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 3. Venue lies in Seminole County, Division of Administrative Hearings, pursuant: to 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. Parties 4. AHCA, Agency for Health Care Administration, State of Florida, is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 5. Respondent, Eastbrook Gardens, is an assisted living facility located at 201 N. Sunset Drive, Casselberry, Florida. Eastbrook Gardens, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PROVIDE CARE AND SERVICES APPROPRIATE TO THE NEEDS OF THE RESIDENTS, VIOLATING 58A-5.0182, F.A.C. and 400.428(1) (a) Fla. Stat. CLASS I DEFICIENCY eon Pempengco tyre rer ee meee peer une cemee eemeee wepmueame sheer rye a 6. AHCA re-alleges and incorporates Paragraphs (1) through (5) as if fully set forth herein. 7. On or about June 1, 2001 a survey was conducted of Respondent’s facility. As the result of a deficiency being cited during the June survey, a re-visit survey was conducted of the same facility on or about July 16, 2001. 8. Based upon observations made by the surveyor, resident record reviews, incident report reviews and interviews conducted at the facility, it was determined that the deficiency cited during the June survey remained uncorrected in that the facility continued in its failure to provide the care and services appropriate to meet the needs of the residents. A new deficiency was cited and was again based upon the facilities failure to take sufficient measures to prevent resident-to-resident abuse and to minimize the potential for falls resulting in injuries, to wit: a. Review of the record of Resident _ 6B on July 16, 2001, revealed that she was diagnosed with dementia and confusion. | A note dated June 30, 2001 indicated that She had poured coffee on a resident who touched he xr purse and physically - attacked staff _by kicking “and hitting when they tried to redirect her. Staff explained to her that the other resident had RR rege re OCR ERE RRR peers © Alzheimer’s and wasn’t aware he was invading her space and gave her a table on the patio to use, which she refused. Resident 6B’s sister reported this incident on June 30, 2001. The sister stated that Resident 6B was very strong when upset. Neither the Administrator nor the Director of Nursing could say who the other resident was or whether or not the staff sustained injuries. An incident report for this incident was not available. No additional measures were instituted after the facility became aware of the June 30, 2001 incident to protect other residents from Resident 6B, and the assaults continued, with incidents with additional injuries to other residents occurring on July 11 and July 14, 2001. b. On July 16, 2001, the surveyor was told by facility staff that Resident 1B was in a nursing home being rehabilitated after hospitalization for a broken hip which resulted from a July 11, 2001 incident when Resident 6B knocked him down on the patio, kicked him and set his hat on fire. An incident report revealed that initially it was noted that this resident had sustained a skin tear and denied pain. Half an hour later an entry reflected that 911 was called when he was unable to stand, complained of pain and bone was ee epee penne oem ow eter re omer weer observed protruding from his right hip. The corrective measure documented was “Keep clients separate, lighter taken from other client.” No notations concerning the incident appeared in Resident 1B’s record. c. Also on July 16, 2001 the surveyor observed Resident 3B with gauze wrapping on her left arm and was told by staff that she had been injured by Resident 6B. Record review disclosed that on July 14, 2001, Resident 3B went into Resident 6B’s room and was pulled by her arm to the nurse’s station, resulting in a 4 inch skin tear to her left forearm and a 1 inch skin tear to her left arm. The corrective measure documented was that Resident 3B was instructed back to bed and told not to wander into other resident’s rooms, although she had been told twice previously about going into other resident’s rooms. d. During the July 16, 2001 survey the surveyor observed two residents sleeping or napping in rooms or beds other than their own. These were residents who wander and like to sleep in each other’s beds. Even though the facility state had previous problems with residents wandering into other resident’s rooms with CORR Sere Ccerccceremeremsr ere resulting altercations, no preventions were instituted by the facility to prevent this from occurring. 8. The above referenced actions and or inactions, are violations of Rule 58.5-0182 F.A.C.; requiring that an assisted living facility shall provide care and services appropriate to the needs of its residents, and Section 400.428 (1) (a) Florida Statutes; requiring that every resident of a facility have the right to live in a safe and decent living environment, free from abuse and neglect. 9. The above referenced violations constitute the grounds for the imposed Class II deficiency for which a fine of five thousand dollars ($5,000) is authorized under Sections 400.414(1) (a) and 400.419(1) (b) Florida Statutes. WHEREFORE, AHCA intends to impose a fine against the Respondent under Section s 400.414(1) (a) and 400.419(1) (a) Florida Statutes in the amount of five thousand dollars ($5,000). The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Michael P. Sasso, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, uchad f toooe Michael P. Sasso, Esquire AHCA - Senior Attorney 525 Mirror Lake Drive North, : * St. Petersburg, Florida 33701 a (727) 552-1435 I HEREBY CERTIFY that a true copy and correct copy has been furnished by U.S. Certified Mail Return Receipt No. Z 170 444 501, to Casselberry ALF, Inc., d/b/a Eastbrook Gardens, through its Registered Agent, Rex A. Paggeot, 750 Starkey — Road, Largo, FL 34641, on the /¢ , day of Oct ho, , 2001. Michael P. Sasso, Esquire perpen, cuetn tou voy Copies furnished to: ALF Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 7 Office Agency for Health Care Administration Hurston Tower South 400 W. Robinson Street, $309 Orlando, Florida 33701 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams ; Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Administrator Eastbrook Gardens 201 N. Sunset Dr., Casselberry, Florida 32707 ee ! | : : ! : I

Docket for Case No: 01-004658

Orders for Case No: 01-004658