Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: EDENGARDENS-GAINESVILLE, L.P.
Judges: BARBARA J. STAROS
Agency: Agency for Health Care Administration
Locations: Gainesville, Florida
Filed: Aug. 19, 2002
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Wednesday, December 4, 2002.
Latest Update: Jan. 03, 2025
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
AGENCY FOR HEALTH CARE
ADMINISTRATION,
Petitioner,
v. AHCA CASE NO. 2001076511
EDENGARDENS -GAINESVILLE, L.P.,
Respondent.
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ADMINISTRATIVE COMPLAINT
COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION
(hereinafter “Agency”), by and through its undersigned counsel,
and files this Administrative Complaint against EDENGARDENS -
GAINESVILLE, L.P. (hereinafter “Edengardens”), pursuant to
Sections 120.569 and 120.57, Florida Statutes (2001), and
alleges the following:
Nature of the Action
1. This is an action to impose a $3,500.00 administrative
fine against Edengardens pursuant to Sections 400.414(1) (e),
400.419(1) (b), and 400.419(3), Florida Statutes, based on three
(3) class II deficiencies and to impose a $500.00 survey fee
against Edengardens pursuant to Section 400.419(9), Florida
Statutes.
Jurisdiction And Venue
2. This Court has jurisdiction pursuant to Sections
120.569 and 120.57, Florida Statutes.
3. The Agency has jurisdiction over Edengardens pursuant
to Chapter 400, Part III, Florida Statutes.
4. Venue shall be determined pursuant to Rule 28-106.207,
Florida Administrative Code.
Parties
5. Pursuant to Chapter 400, Part III, Florida Statutes,
and Chapter 58A-5, Florida Administrative Code, the Agency is
the licensing and enforcing authority with regard to assisted
living facility laws and rules.
6. Edengardens-Gainesville, L.P., is a foreign limited
partnership with a principal address of 10 Roswell Street, Suite
200, Alpharetta, Georgia 30004.
7. Edengardens is an assisted living facility located at
1415 Fort Clarke Boulevard, Gainesville, Florida 32606.
Edengardens 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, having been issued
license number AL9815 by the Agency (certificate number # 12300)
with an effective date of April 5, 2002, and an expiration date
of March 29, 2004 and an extended congregate care designation.
COUNT I
EDENGARDENS FAILED TO ENSURE
THE PROVISION OF ADEQUATE CARE
TO RESIDENTS IN ITS FACILITY.
Section 400.428(1)(b), Fla. Stat. (2001)
Rule 58A-5.019(1), Fla. Admin. Code (2001)
CLASS II DEFICIENCY
8. The Agency re-alleges and incorporates by reference
paragraphs one (1) through seven (7) above as if fully set forth
herein.
9. On or about August 31-September 3, 2001, the Agency
performed a survey at Edengardens. Based on surveyor
observations, staff interviews and record reviews, the Agency
cited Edengardens for a class II deficiency based on the
findings below.
10. Resident #1, a male resident, climbed into bed with
other female residents. Resident #1 also became violent on one
known occasion and kicked another resident in the pelvic area.
Other residents in the facility were afraid of resident #1.
li. A nurse’s note dated on or about July 6, 2001, at
approximately 10:00 p.m. provided "resident constantly wandering
into female residents' rooms climbing into their beds with them.
Female residents are afraid of this male resident."
12. On or about August 31-September 3, 2001 an Agency
surveyor reviewed resident #3’s medical record. The record
contained a statement made on or about July 6, 2001 by this
female resident that she was afraid of resident #1 and could not
relax.
13. According to Resident #1’s nurse’s note dated on or
about July 15, 2001, at approximately 12:20 p.m. "resident #1
had an incident this morning where he for no apparent reason
kicked resident #2 in the pelvic area." According to Resident
#2’s nurses’ notes dated July 15, 2001, the resident complained
of low stomach pain during the 3:00 p.m. to 11:00 p.m. shift.
14. Resident #1's physician was notified of the July 15,
2001 incident. The physician recommended that resident #1's
hearing aides be placed in his ears and ordered a medication
dosage change.
15. On or about July 15, 2001 the physician changed
Resident #1’s prescription for Risperdal from one (1) milligram
tablet every day to one (1) milligram tablet twice a day. The
directions on resident #1’s medication observation record,
however, erroneously provided that the medication was to be
administered once a day rather than twice a day as per the
physician’s order. Therefore, Resident #1 received only one (1)
milligram tablet of Risperdal a day. The active ingredient in
Risperdal is Risperidone, which is used to treat psychotic
disorders and symptoms such as hallucinations, delusions, and
hostility.
16. On or about August 31-September 3, 2001 an Agency
surveyor interviewed Edengardens’ Administrator. The interview
revealed that the Administrator was unaware of resident #1’s
behavior.
17. On or about August 31-September 3, 2001 an Agency
surveyor interviewed Edengardens’ direct care staff. The
interviews revealed that Edengardens had failed to take actions
to control resident #1’s behavior.
18. On or about August 31-September 3, 2001 the Agency
surveyor observed resident #1 at various times. The surveyor
observed that resident #1 was not wearing his hearing aides as
recommended by the resident’s physician. The Agency surveyor
interviewed a nurse caring for resident #1. The nurse was
unaware that resident #1 wore hearing aids.
19. Based on all of the foregoing, Edengardens has
violated: (a) Rule 58A-5.019(1), Florida Administrative Code,
by failing to ensure the provision of adequate care to its
residents; and (b) Section 400.428(b), Florida Statutes, by
failing to ensure that each resident is treated with
consideration and respect and with due recognition of personal
dignity, individuality, and the need for privacy.
20. The foregoing violation is a class II violation in
that it directly threatened the physical or emotional health,
safety, or security of Edengardens’ residents. Pursuant to
Section 400.419(1) (b), Florida Statutes, the Agency is
authorized to impose a fine against Edengardens in the amount of
$1,000.00.
21. The facility was given a mandated correction date of
September 30, 2001, in accordance with Section 400.419(1) (b),
Florida Statutes.
22. In addition to any administrative fines imposed, the
Agency may assess a survey fee, equal to the lesser of one-half
(1/2) of the facility’s biennial license and bed fee or $500.00,
to cover the cost of conducting initial complaint investigations
that result in the finding of a violation that was the subject
of the complaint or monitoring visits conducted under Section
400.428 (3) (c) to verify the correction of the violation.
23. Edengardens’ biennial license and bed fee for the
2002-2004 biennium is equal to $6,723.00.
24. Based on the foregoing, Edengardens may assess a
$500.00 survey fee against Edengardens pursuant to Section
400.419(9), Florida Statutes.
COUNT II
ENDENGARDENS FAILED TO MAINTAIN AN ACCURATE DAILY UP-TO-DATE
MEDICATION OBSERVATION RECORD FOR EACH RESIDENT. ADDITIONALLY,
EDENGARDENS FAILED TO ENSURE THAT EACH RESIDENT’ S MEDICATION
OBSERVATION RECORD WAS IMMEDIATELY UPDATED EACH TIME THE
MEDICATION WAS OFFERED OR ADMINISTERED TO THE RESIDENT.
Rule 58a-5.0185(5) (b), Fla. Admin. Code (2001)
CLASS II DEFICIENCY
25. The Agency re-alleges and incorporates by reference
paragraphs one (1) through seven (7) above as if fully set forth
herein.
26. On or about August 31-September 3, 2001, the Agency
performed a survey at Edengardens. Based on surveyor
observations, staff interviews and record reviews, the Agency
cited Edengardens for a class II deficiency based on the
findings below.
27. Edengardens had no system in place to assure that
residents received their medications accurately and timely.
28. On or about September 1, 2001 at approximately 3:00
p.m. an Agency surveyor observed the medication observation
records for the month of September 2001 for the twenty-two (22)
“keepsake” residents in a pile on a table. No morning or
afternoon medications had been documented as being given to any
of these residents.
29. On or about September 1, 2001 an Agency surveyor
interviewed an Edengardens’ nurse. The nurse stated, "the night
nurse didn't do the MORs last night." The nurse further stated
that she gave each resident his or her day shift medications but
she did not update each resident’s medication observation record
at the time the medication was offered or administered to the
resident.
30. Edengardens’ failure to immediately update each
resident’s medication observation record at the time the
medication is administered to the resident has caused and/or has
the potential to cause future medication errors and omissions.
31. Resident #1 was prescribed Atarax 25mg three (3) times
a day as needed for itching on August 30, 2001. The directions
had been erroneously transcribed and given as three (3) times a
day routinely on the August 2001 medication observation record.
Therefore, Edengardens failed to assess resident #1’s need for
Atarax prior to each medication administration.
32. Finally, according to Resident #1’s medical record,
his order for Risperdal was changed on or about July 15, 2001
from one (1) milligram every day to one (1) milligram twice a
day. The directions on resident #1’s medication observation
record, however, erroneously provided that the medication was to
be administered once a day rather than twice a day as per the
physician’s order.
33. Based on all of the foregoing, Edengardens has
violated Rule 58A-5.0185(5) (b), Florida Administrative Code, by
failing to ensure that each resident’s medication observation
record is immediately updated each time the medication is
offered or administered and by failing to ensure that each
resident’s medication observation record was accurate and up-to-
date.
34. The foregoing violation is a class II violation in
that it directly threatened the physical or emotional health,
safety, or security of Edengardens’ residents. Pursuant to
Section 400.419(1) (b), Florida Statutes, the Agency is
authorized to impose a fine against Edengardens in the amount of
$1,000.00.
35. The facility was given a mandated correction date of
September 30, 2001, in accordance with Section 400.419(1) (b),
Florida Statutes.
36. In addition to any administrative fines imposed, the
Agency may assess a survey fee, equal to the lesser of one-half
(1/2) of the facility’s biennial license and bed fee or $500.00,
to cover the cost of conducting initial complaint investigations
that result in the finding of a violation that was the subject
of the complaint or monitoring visits conducted under Section
400.428(3) (c) to verify the correction of the violation.
37. Edengardens’ biennial license and bed fee for the
2002-2004 biennium is equal to $6,723.00.
38. Based on the foregoing, Edengardens May assess a
$500.00 survey fee against Edengardens pursuant to Section
400.419(9), Florida Statutes.
COUNT III
EDENGARDENS FAILED TO PROVIDE CARE AND SERVICES APPROPRIATE TO
THE NEEDS OF RESIDENTS ACCEPTED FOR ADMISSION TO THE FACILITY.
Section 400.428(1) (a), Fla. Stat. (2001)
Rule 58a-5.0182, Fla. Admin. Code (2001)
CLASS II DEFICIENCY
39. The Agency re-alleges and incorporates by reference
paragraphs one (1) through seven (7) above as if fully set forth
herein.
40. On or about August 31-September 3, 2001, the Agency
performed a survey at Edengardens. Based on surveyor
observations, record reviews and staff interviews, the Agency
cited Edengardens for a class II deficiency based on the
findings below.
41. Resident #3 and resident #1 each sustained numerous
ant bites at Edengardens on two (2) separate occasions. On or
July 9, 2001 Resident #3 was bitten by numerous ants while in
her bed at Edengardens. On or about August 30, 2001 resident #1
sustained about one hundred (100) ant bites while in his bed at
Edengardens.
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Resident #3
42. On or about July 9, 2001 at approximately 10:00 a.m.
Resident #3’s caregiver discovered Resident #3 soaked in urine
with multiple ant bites. According to the nurses’ notes, a
nurse observed ants on resident #3's sheets and bedspread.
43. Although Edengardens sprayed resident #3’s room,
Edengardens failed to immediately contact a professional pest
control company to address the severe fire ant problem in the
facility. Edengardens failed to address the fire ant problem
after the incident on or about July 9, 2001. This failure
resulted in another fire ant incident on or about August 30,
2001 involving resident #1.
Resident #1
44. On or about August 30, 2001 at approximately 2:50
p-m., Edengardens’ direct care staff found resident #1 with
approximately one hundred (100) ant bites on his body.
According to the nurses’ notes, the resident had "long, brownish
red ants all over his bed" and "multiple lesions red, swollen,
pus filled (white pus) on neck, right arm, front and back,
waist, right back, chest and both hips."
45. On or about August 31-September 3, 2001 an Agency
surveyor observed Resident #1. Resident #1 gave the Agency
surveyor permission to inspect his body. His upper torso
remained covered with red marks and white pustules. Forty-six
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(46) pustules remained on his right arm and right side of neck.
Four (4) were on the front of his neck and twenty-two (22) on
his right upper hip. Several more bites were scattered on his
left hip.
46. On or about August 31-September 3, 2001 an Agency
surveyor interviewed Edengardens’ Administrator, Maintenance
Director and a representative of the pest control company under
contract with the facility. The interviews revealed that the
pest control company treated the inside and outside of the
building on or about, respectively, August 30 and 31, 2001.
However, the contract by and between Edengardens and the pest
control company did not include “carpenter ants, fire ants or
Pharaoh ants”. The Maintenance Director stated that Edengardens
had a lawn service company but he was unable to advise as to
whether this company was responsible for the eradication of
outside fire ant nests. In fact, Edengardens failed once again
to eradicate the fire ant problem as evidenced below.
47. On or about August 31, 2001 at approximately 7:30 p.m.
the Agency surveyor observed ants in Edengardens’ laundry room.
On or about September 1, 2001 at approximately 10:00 a.m. an
Agency surveyor observed twelve (12) fire ant nests on the lawn
beneath resident #1's window. The surveyor further observed
three (3) more fire ant nests three (3) feet beyond the twelve
(12) nests located below resident #1’s window. On or about
September 3, 2001 at approximately 1:00 p.m. the Agency surveyor
observed ants in Edengardens’ Wellness Room.
48. Edengardens failed to provide care and services
appropriate to the needs of the residents in the facility by
failing to eradicate the fire ant problem in its facility and by
failing to be aware of the general health, safety, and physical
and emotional well-being of the residents in its facility.
49, Edengardens further failed to provided care and
services appropriate to resident #1’s needs by failing to ensure
that he was receiving his medication accurately and by failing
to assess his needs upon becoming aware of changes in his
behavior or mood.
50. On or about August 31-September 3, 2001 an Agency
surveyor interviewed an Edengardens’ nurse regarding resident
#1. The nurse stated, "after his medication was doubled when he
kicked that woman in July he has been sedated and lethargic and
groggy.” The surveyor interviewed another Edengardens’ nurse
who stated that for the last several days resident #1 walked
much slower, he sat with his head hanging down, he seemed
groggy.
51. On or about August 31-September 3, 2001 an Agency
surveyor reviewed resident #1’s record. On or about August 29,
2001 a nurse documented on his medication record that he was
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"very sedated." A second nurse documented that, "he has been
lethargic the last two days."
52. On or about August 31-September 3, 2001 the Agency
surveyor observed resident #1 sitting in the dining area slumped
forward with his head hanging against the wooded balustrade. He
required an aide to assist him with walking. White pustules
remained visible on the right side of his neck.
53. On or about September 3, 2001 at approximately 11:30
a.m. Edengardens’ direct care staff found Resident #1 lying on
the floor. Resident #1 was transported to a hospital emergency
room for evaluation.
54. After being bitten by fire ants, Resident #1’s
physician prescribed one 25 milligram tablet of Atarax three (3)
times a day as needed for itching. The directions had been
erroneously transcribed onto the August 2001 medication
observation record as three (3) times a day routinely. Due to
this error, Edengardens failed to assess Resident #1’s need for
Atarax prior to each administration of the medication. By
failing to do these assessments, Edengardens failed to provide
services and care appropriate to resident #1’s needs. A side
effect of Atarax is drowsiness.
55. Finally, on or about August 31, 2001 at approximately
12:00 p.m. an Agency surveyor observed a chair on the facility's
lawn with a broken leg. This chair could be dangerous if a
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resident attempted to sit on it. The Agency surveyor brought
this matter to the attention of Edengardens’ administrative
staff. However, a few days later on or about September 3, 2001
at approximately 12:30 p.m. the Agency surveyor observed that
the broken chair was still on the facility’s lawn.
56. Based on all of the foregoing, Edengardens has
violated: (a) Rule 58A-5.0182, Florida Administrative Code, by
failing to provide care and services appropriate to the needs of
residents accepted for admission to its facility; and (b)
Section 400.428(1) (a), Florida Statutes, by failing to ensure
that each resident has the right to live in safe and decent
environment, free from abuse and neglect.
57. The foregoing violation is a class II violation in
that it directly threatened the physical or emotional health,
safety, or security of Edengardens’ residents. Pursuant to
Section 400.419(1) (b), Florida Statutes, the Agency is
authorized to impose a fine against Edengardens in the amount of
$1,000.00.
58. The facility was given a mandated correction date of
September 30, 2001, in accordance with Section 400.419(1) (b),
Florida Statutes.
59. In addition to any administrative fines imposed, the
Agency may assess a survey fee, equal to the lesser of one-half
(1/2) of the facility’s biennial license and bed fee or $500.00,
15
to cover the cost of conducting initial complaint investigations
that result in the finding of a violation that was the subject
of the complaint or monitoring visits conducted under Section
400.428(3) (c) to verify the correction of the violation.
60. Edengardens’ biennial license and bed fee for the
2002-2004 biennium is equal to $6,723.00.
61. Based on the foregoing, Edengardens may assess a
$500.00 survey fee against Edengardens pursuant to Section
400.419(9), Florida Statutes.
CLAIM FOR RELIEF
REE
WHEREFORE, the Agency respectfully requests the following
relief:
1) Make factual and legal findings in favor of the
Agency on Counts I, II, and III;
2) Impose a fine against Edengardens in the amount
of $3,000.00 pursuant to Sections 400.414 (1) (e)
and 400.419(1) (b), Florida Statutes;
3) Impose a $500.00 survey fee against Edengardens
pursuant to Section 400.419(9), Florida Statutes;
and
4) Grant any other general and equitable relief as
deemed necessary in the furtherance of justice.
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NOTICE
Edengardens hereby is notified that it has a right to
request an administrative hearing pursuant to Sections 120.569
and 120.57, Florida Statutes (2001). Specific options for
administrative action are set out in the attached Election of
Rights form and explained in the attached Explanation of Rights
form. All requests for a hearing shall be sent to Lori Cc.
Desnick, Senior Attorney, Agency for Health Care Administration,
2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee,
Florida, 32308.
EDENGARDENS IS FURTHER NOTIFIED THAT THRE FAILURE TO REQUEST
A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT oF THIS
ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE
FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A
FINAL ORDER BY THE AGENCY.
Respectfully submitted,
Lori C. Desnick
Senior Attorney
Florida Bar No. 0129542
Agency for Health Care Administration
2727 Mahan Drive, Mail Stop #3
Tallahassee, Florida 32308
(850) 921-0071
(850) 921-0158 (fax)
CERTIFICATE OF SERVICE
SE ERVICE
I HEREBY CERTIFY that a true and correct copy of the
Administrative Complaint has been sent by U.S. Certified Mail,
Return Receipt Requested, (Return Receipt # 7106 4575 1294 2049
9405) to Mark Kane, Administrator, Edengardens-Gainesville,
L.P., 1415 Fort Clarke Boulevard, Gainesville, Florida 32606 and
(Return Receipt # 7106 4575 1294 2049 9399) to c.7. Corporation
System, Registered Agent, Edengardens-Gainesville, L.P., 1200
South Pine Island Road, Plantation, FL 33324 on this 24th day of
June 2002.
LORI C. DESNICK, ESQUIRE
Docket for Case No: 02-003258
Issue Date |
Proceedings |
Mar. 10, 2003 |
Final Order filed.
|
Dec. 04, 2002 |
Order Closing File issued. CASE CLOSED.
|
Dec. 02, 2002 |
Certificate of Service (filed by Respondent via facsimile).
|
Dec. 02, 2002 |
Unopposed Motion for Stay of Proceedings (filed by Respondent via facsimile).
|
Sep. 09, 2002 |
Order of Pre-hearing Instructions issued.
|
Sep. 09, 2002 |
Notice of Hearing issued (hearing set for December 10 through 12, 2002; 10:00 a.m.; Gainesville, FL).
|
Aug. 30, 2002 |
Amended Joint Response to Initial Order (filed by Petitioner via facsimile).
|
Aug. 28, 2002 |
Joint Response to Initial Order (filed via facsimile).
|
Aug. 21, 2002 |
Initial Order issued.
|
Aug. 19, 2002 |
Administrative Complaint filed.
|
Aug. 19, 2002 |
Request for Hearing filed.
|
Aug. 19, 2002 |
Notice (of Agency referral) filed.
|