STATE OF FLORIDA obey AGENCY FOR HEALTH CARE ADMINISTRATION, 2 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2003008738 2003009196 FI-WALDEMERE, LLC, d/b/a WALDEMERE PLACE, 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 FI-Waldemere, LLC, d/b/a Waldemere Place, (hereinafter Waldemere), pursuant to §§ 120.569, and 120.57, Fla. Stat., (2003), and alleges NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $10,000.00 and assign a conditional licensure status commencing 11/05/03, based upon two cited State Class II deficiencies for Waldemere’s failure to ensure the residents’ rights as a resident of the facility, a citizen and resident of the United States were not restricted, and Waldemere’s failure to ensure policy and procedures regarding investigation of resident abuse were implemented. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2003). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. 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 IV, Subtitle C (as amended), Chapter 400, Part Il, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Waldemere operates a 169-bed nursing home located at 2071 Waldemere Street, Sarasota, Florida 34239, and is licensed as a skilled nursing facility, license number 1 1350961. 5. Waldemere was at all times material hereto, 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 paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.10(a)(1)&(2) and § 400.022(1)(a) Fla. Stat., Waldemere must ensure the resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States and be free of interference, coercion, discrimination, and reprisal from the facility in exercising his/her rights. 8. On, or about, 11/05/03, the Agency conducted a complaint investigation of Waldemere. 9. Based on clinical record review, interview with a resident, interview with the facility's Administrator, Director of Nursing (DON), Risk Manager (RM), Social Worker/Abuse Liaison, facility’s Nurse Consultant and staff nurse, the facility failed to ensure the rights of Resident # 2 as a citizen and self determined adult, were not restricted by: denying the resident the night to leave the facility with her significant other; denying the resident’s right to be alone with visitors; removing the resident’s clothes for a body inspection on return from outings with the significant other, and; asking the resident about personal sexual encounters when out on pass resulting in embarrassment and anger to Resident # 2. 10. Resident #2 was admitted to the facility on 05/13/03 with a readmission date of 06/19/03 following a fall with a resultant fractured hip sustained at the facility. Additional diagnosis include Past Head Injury, Osteoarthritis, Seizures, Delirium with Delusions and History of Alcohol Abuse. 1]. Current medications include but are not limited to Seroquel 25 mg. BID for seizures and Ativan PRN (as necessary) for agitation. 12. Review of the clinical record revealed, a Health Care Proxy form was signed by the physician on 05/02/03. The health care proxy is the daughter. 13. A letter written to the facility by the daughter dated 04/29/03, indicates the resident has a close male friend with whom the family wishes to have care information shared. 14. The resident has not been deemed incapacitated and is able to make her own decisions. 15. The most recent MDS (Minimum Data Set) is dated 05/26/03 and is a Medicare 30 day assessment. 16. The chart lacks any initial MDS Assessment from admission, RAP (Resident Assessment Protocol) summary, RAP work sheets or Care Plan. 17. The resident did not have a discharge, re-entry or significant change MDS generated after return from the facility post fractured hip. 18. The resident was due for a quarterly assessment and review of Care Plan in August but this assessment was not performed. 19. There is a hand written Care Plan dated 06/23/03, indicating the resident has a history of falls and is to have a clip belt when up in the wheelchair. 20. Interview with DON and Nurse Consultant on 11/04/03 revealed the facility had not generated any MDS assessment for residents since June of 2003. 21. The Administration is new in the facility and is just beginning to re-assess all residents. 22. Review of the MDS dated 05/26/03, revealed the following: a. B4. Cognitive skills for daily decision-making = 2. Moderately - decisions poor, cues/supervision required. b. BS. Indicators of delirium, periodic disordered thinking / awareness, f. Mental function varies over the course of the day - (e.g., sometimes better, sometimes worse; behaviors sometimes present, sometimes not) = 1."1" meaning Behavior present, not of recent onset. c. C4 and C5 indicate the resident has no problem making herself understood or understanding others. d. El. Indicators of depression, anxiety, sad mood, d. Persistent anger with self or others - e.g., easily annoyed, anger at placement in nursing home, anger at care received = 2. "2" meaning indicator of this type exhibited daily or almost daily (6 - 7 days a week). e. E2. Mood persistence. One or more indicators of depressed, sad, or anxious mood were not easily altered by attempts to "cheer up", console, or reassure the resident over the last 7 days = 2. "2" meaning indicators present, not easily altered. 23. A nurse's note dated 09/06/03 and times 1930 (7:30 P.M.) reads, "Received call from Pt. (patient) male companion that Pt. stay over night in his care." The note continues, the DON and she instructed the staff to tell the companion to bring the resident back before midnight. 24. The resident was returned to the facility and a nurse's note dated 09/06/03 and timed 2358 (11:58 P.M.) reads, "Pt is returned to her room via wheelchair by her male companion. Upon his departure, Pt was assessed from head to toe. No changes in mental status, nor skin integrity.” 25 _ The surveyor attempted to reach the nurse per telephone two times to have the above note explained. The nurse did not call back. The facility was requested to call the nurse. Again the nurse did not call back. 26. A weekly nurse's summary note, dated 09/20/03, revealed the resident still leaves the facility at times and is returned. 27. A nursc's note dated 10/03/03 and timed 9:10 P.M. reads, "Resident return from out on pass with boyfriend via w/c (wheelchair) resident asst (assisted) to rm. (room) undress by me and staff, head to toe assessment (body) completed. No s/s (signs or symptoms of any abnormalities noted gown put on resident..." 28. Interview with the nurse on 10/04/03 revealed the former Administrator instructed her to do so but did not specify the reason. 29. A social worker note dated 06/19/03 reads resident was readmitted to the facility from a hospital secondary to a fall. 30. The next social service note dated 10/03/03, no time indicated, reads, "SSD (Social Service Director) was notified that res (resident) complained of "man fondly her in her room." 31. Resident has made such statements before which prove unfounded. 32. This too has had an evidence of truth. 33. Resident's boyfriend ---- has been approved by family to visit and take resident out. 34. Res family feels resident --- unable to decipher--- confused boyfriend with other males, besides family is aware of boyfriend. 35. Res family feels that boyfriend has good intentions for resident and approves of boyfriend interactions. 36. On 10/20/03, the Social Worker writes, "SSD informed by acting DON that the boyfriend was again in Res (Resident's) room performing "sexual acts." 37. SSD spoke with the acting DON and Adm (Administrator). 38. SSD contacted protective services for inappropriate liaisons. 39, SSD went to a protective meeting re Res significant other. 40. It has been requested that the dtrs (daughters) obtain guardianship... since they have been approving of his (boyfriend) continuation of taking the resident out. 41. On 10/21/03, "SSD spoke with res significant other - explained that he should not take the resident outside the facility at this time, sig (significant) other stated that - daughter - did call and explain this today. 42. _ Sig other was also asked not to be alone in rm (room) with resident. ___ (sig other) stated he would comply. 43. A letter written to the resident's daughter on 10/22/03 reads, "Within the last two months, you have been notified of two incidents regarding your mother (our resident) and her boyfriend - ----, The first incident in which your mother's roommate was wheeled out into the hallway so that the two could lay in bed together alone. ... The agreement was that ---- would continue to visit your mother, and take her out of the building on outings, but any incidents of this nature would not occur. Both of you (daughters) have acknowledged ---- continued presence in your mother's life as important to her. The second incident occurred Saturday, October 18th, where three staff members witnessed some sort of sexual behavior between your mother and ---. Because your mother has been deemed incapable of making safe decisions by our medical director..., and that although your mother can be very lucid of her surroundings, at times she becomes quite confused. There is a concern of her giving her consent to such actions, and the possibility of her confusing male caregivers to her boyfriend, the facility is requesting that you become not just you mothers Health Care Proxy, but to obtain court appointed guardianship of your mother." 44. The letter continues, a psychologist re-evaluated the resident who concurred the resident was unable to make her own decisions. 45. On 10/23/03, "Res dtrs in to discuss issues with mother and boyfriend - contract refuses now to sign. Made an appointment with Lutheran services for guardianship Mon. (Monday) Oct 27, 03. SSD and Administrator discussed with dtrs sexual activities that have occurred. ---dtr feels res boyfriend has the best interest and loves her. She does not feel that her mother should be w/held from sexual pleasures. Was asked not to do here (exact wording) secondary her mother's incapacity and confused status. ..." 46. Review of the clinical record lacks any documentation that physicians conducted an examination or the resident is incapable of making any decisions. 47. On 11/04/03 at approximately 2:00 P.M., the surveyor interviewed Resident #2. 48. The resident was sitting in bed. 49. She was alert and oriented to person and place but not day or month. 50. The resident agreed to speak to the surveyor regarding her relationship with her boyfriend. 51. The resident stated she had worked for her boyfriend in the past and also had helped take care of his mother. 52. She stated, "He has so much to give. He is so tender." 53. The resident acknowledged she does have sexual intercourse with the boyfriend. 54. At this time the resident needed personal care and the surveyor asked staff to accommodate the resident. 55. The surveyor asked the resident if it would be all right to come back tomorrow to continue the conversation. The resident agreed. 56. On 11/05/03 at approximately 10:30 A.M., the surveyor entered the resident's room. 57. The resident smiled and stated she remembered the surveyor from the day before and was happy I was back. 58. Our conversation continues. 59. The resident stated she was upset this morning. 60. Last evening the staff came in and told her, her boyfriend could not even sit on the bed. 61. They were not allowed to close the door to her room. 62. The resident stated, "He doesn't deserve that." 63. She stated their relationship does include sexual intercourse and it is normal to her. 64. She states her boyfriend is a very loving, dear man and is so good to her. 65. She loves him and they have a very loving relationship. 66. The resident did not recall being undressed after outings with the boyfriend. 67. However, the resident does remember explicit sexual questions being asked. 68. The resident stated, "That was out of line. It's none of their business. I'm old enough to have a man in my life." 69. The resident then stated, "I can take care of myself. I know how to say "No" if I have to." 70. Reviews of the nurse's notes, physician notes and social service notes lack any documentation the resident herself was involved in any of the meetings with her daughters or the boyfriend. 71. The chart lacks any documentation of the resident's personal comments or expressed wishes, or that the resident was even interviewed. 72. On 11/5/03 at approximately 9:30 A.M., the surveyor interviewed the DON, Nurse Consultant, Regional Consultant and Administrator. The facility administrative staff was unaware the staff had been disrobing the resident after outside visits with the boyfriend. 73. The administrative staff was unaware the resident was angry over the fact the door to her room could not be closed when her boyfriend is in the facility or that he is not allowed to sit on the bed and she was not allowed to go on outings with him. 74. The Agency provided Waldemere with the mandatory correction date for this deficient practice of 12/05/03. 75. The Agency determined that these conditions or occurrences compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 76. The Agency cited this deficient practice as an isolated State Class II deficiency, a violation subjecting Waldermere to the imposition of an administrative fine. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Waldemere, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT II 77. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (74) as if fully set forth herein. 2. Pursuant to 42 CFR § 483.13(c) and Fla. Admin. Code R. 59A-4.1288, the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 79 .On, or about, 11/05/03, the Agency conducted a complaint investigation of Waldemere. 80. Based on clinical record review, interview with a resident, interview with the facility's Administrator, Director of Nursing (DON), Risk Manager (RM), Social Worker/Abuse Liaison, facility's Nurse Consultant, staff nurse, and local law enforcement, review of the facility's policy and procedures and employee training to prevent abuse, job descriptions of the Social Worker and Risk Manager, review of the accident and incident reports and Adverse Incidents submitted to the Agency for Health Care Administration, the facility failed to ensure policy and procedures regarding investigation of resident abuse were implemented for 3 (Residents # 1, # 2 and # 4) of 4 residents in that it: a. failed to investigate Resident # 2 allegations of sexual abuse by a facility staff member; b. failed to accurately identify and investigate allegations of sexual abuse by a facility staff member for Resident # 4; c. failed to identify and investigate possible sexual abuse of Resident # 4; d. failed to assess and care plan Residents # 2, whose needs and choices may make her vulnerable to abuse; e. failed to obtain guardianship for a Resident # 2, whom the facility feels is incapable of self determination; f. failed to assess and care plan Resident #1 whose psychological history and present cognition makes her vulnerable for abuse; g. failed to investigate possible sexual abuse for Resident #1; h. failed to report all alleged violations to the Agency for Health Care 10 Administration and local law enforcement; 1. failed to follow facility's policy and procedures for investigation of abuse; j. failed to educate staff in identifying and reporting allegations of abuse, 81. Due to the facility's systemic breakdown in conducting investigations of abuse allegations, and the fact allegations remain uninvestigated, the residents' physical and mental well-being have been compromised and all residents remain at risk. 82. A compliant was received during the first day of the annual recertification and licensure survey at this skilled nursing facility. 83. Interview with the API (Adult Protection Investigator) on 11/03/03 at approximately 11:00 A.M., revealed the names of the three residents whom she had investigated. 84. Review of the clinical records for the three involved residents revealed that Resident #2 was admitted to the facility on 05-13-03 with a readmission date of 06-19-03 following a fall with a resultant fractured hip sustained at the facility. 85. Additional diagnosis includes Past Head Injury, Osteoarthritis, Seizures, Delirium with Delusions and History of Alcohol Abuse. 86. Current medications include but are not limited to Seroquel 25 mg. BID for seizures and Ativan PRN (as necessary) for agitation. 87. A letter written to the facility by the daughter, dated 04/29/03 indicates the resident has a close male friend whom the family wishes to have care information shared. 88. The resident has not been deemed incapacitated and is able to make her own decisions. 89. The most recent MDS (Minimum Data Set) is dated 05/26/03 and is a Medicare 30 day assessment. ti 90. The chart lacks any initial MDS Assessment from admission, RAP (Resident Assessment Protocol) summary, RAP work sheets or Care Plan. 91. The resident did not have a discharge, re-entry or significant change MDS generated after return from the facility post fractured hip. 92. The resident was due for a quarterly assessment and review of Care Plan in August but this assessment was not performed. 93. There is a hand written Care Plan, dated 06/23/03, indicating the resident has a history of falls and is to have a clip belt when up in the wheelchair. 94. Interview with DON and Nurse Consultant on 1 1/04/03, revealed the facility had not generated any MDS assessment for the resident since June of 2003. 95. The administration is new in the facility and is just beginning to re-assess all residents. 96. Review of the MDS, dated 05/26/03, revealed the following: a. B4. Cognitive skills for daily decision-making = 2. Moderately - decisions poor, cues/supervision required. b. B5. Indicators of delirium-periodic disordered thinking / awareness, f. Mental function varies over the course of the day - (e.g., sometimes better, sometimes worse; behaviors sometimes present, sometimes not) = 1. "1" meaning Behavior present, not of recent onset. c. C4 and CS indicate the resident has no problem making herself understood or understanding others. d. El. Indicators of depression, anxiety, sad mood, d. Persistent anger with self or others - e.g., easily annoyed, anger at placement in nursing home, anger at care received = 2. "2" meaning indicator of this type exhibited daily or almost daily (6 - 7 days a week). e. E2. Mood persistence. One or more indicators of depressed, sad, or anxious mood were not easily altered by attempts to "cheer up", console, or reassure the resident over the last 7 days = 2. "2" meaning indicators present, not easily altered. 97. A nurse's note dated 09/06/03 and timed 1930 (7:30 P.M.) reads, "Received call from Pt. (patient) male companion that Pt. stay over night in his care.” 98. The note continues, the DON and she instructed the staff to tell the companion to bring the resident back before midnight. 99. The resident was returned to the facility and a nurse's note dated 9/6/03 and timed 2358 (11:58 P.M.) reads, "Pt is returned to her room via wheelchair by her male companion. Upon his departure, Pt was assessed from head to toe. No changes in mental status or skin integrity." 100. The surveyor attempted to reach the nurse per telephone two times to have the above note explained. The nurse did not call back. The facility was requested to call the nurse. Again the nurse did not call back. 101. A weekly nurse's summary note, dated 09/20/03, revealed the resident still leaves the facility at times and is returned. 102. A nurse's note dated 10/03/03 and timed 9:10 P.M. reads, "Resident return from out on pass with boyfriend via w/c (wheelchair) resident asst (assisted) to rm. (room) undress by me and staff, head to toe assessment (body) completed. No s/s (signs or symptoms of any abnormalities noted gown put on resident..." 103. Interview with the nurse on 10/04/03, revealed the former Administrator instructed her to do so but did not specify the reason. 13 104. A nurse's note dated 10/26/03 at 5:00 A.M., revealed the resident had been straight catheterized for a urine specimen by a female staff member. 105. The resident tolerated the procedure well. 106. A social service note, dated 10/03/03, no time indicated, reads, "SSD (Social Service Director) was notified that res (resident) complained of "man fondly her in her room." 107. Resident has made such statements before which prove unfounded. 108. This too has had an evidence of truth. 109. Resident's boyfriend ---- has been approved by family to visit and take resident out. Res family feels resident res --- unable to decipher --- confused boyfriend with other males, besides family is aware of boyfriend. Res family feels that boyfriend has good intentions for resident and approves of boyfriend interactions. 110. The surveyor could not find documentation prior to 10/03/03 indicating Resident # 2 had complained previously about being sexually abused by the boyfriend or other males. 111. Review of the facility's accident and incident report log for July, August and September of 2003, former owners took any previous reports, lacks any documentation of Resident # 2, or any other resident, had reported inappropriate behavior. 112. Review of the Adverse Incidents submitted to AHCA since the last Recertification Survey conducted in February of 2003, revealed only one resident had triggered an investigation for sexual abuse by a staff member. 113. This is Resident # 4, the date of allegation being 10/01/03. 114. Resident # 4 was admitted to the facility on 06/06/98 with multiple diagnosis including Alzheimer Disease and Diabetes. 115. Review of the clinical record revealed the last MDS available was dated 06/20/03. 116. However, on 10/04/03 the facility found an annual MDS and subsequent Care Plan dated 10/03/03. 117. Review of the MDS revealed the following: a. B4. Cognitive skills for daily living decision-making - 3. Severely impaired - never/rarely made decisions. b. C. Communication / Hearing patterns revealed the resident communicates with only signs, gestures or sounds. The resident is rarely/never understood and her speech is unclear. She is unable to understand others. Cc. E4. Behavioral symptoms - e. Resists care = 1/1. "1/1" meaning, Behavior of this type occurred 1 to 3 days in last 7 days and the behavior is not easily altered. 118. The resident is dependent on all staff for ADLs (Activities of Daily Living). 119, The Care Plan reads the resident can only speak Spanish and is nonsensical. 120. Review of the nurse's notes indicates that per physician order, the resident was straight cathed for a urine specimen on 09/18/03 at 11:30 P.M. by a male LPN (Licensed Practical Nurse). 121. Per surveyor request the facility supplied the Adverse Incident investigation concerning this resident. 122. A local law enforcement personal card was attached to the investigation folder. The date of incident is 10/01/03. 15 123. The incident was actually sent on 10/06/03 to the State agency. 124. The document reads DCF (Department of Children and Families) was notified, "That a male nurse had masturbated in a resident's face." 125. The staff member directly involved was the male LPN who had straight cathed the resident on 09/18/03. 126. This nurse no longer works at the facility. 127. Analysis reads, "Inappropriate. As this never happened." 128. Corrective action included male nurses and male CNAs (Certified Nursing Assistance) should have to have a female staff member present when taking care of a female resident. 129. The surveyor then read the investigation completed on 10/02/03 by the former Administrator. 130. The date the incident happened was either 09/28 or 09/29/03. 131. The resident was interviewed by the Administrator. 132. The resident was verbal and stated she was treated well and she had no complaints. 133. The investigation continues, "This resident has a history of accusing staff, other resident, and her significant other of abuse and sexual acts against her and this is documented in her medical record.” 134. The witness to the allegation stated he was in the linen closet across from the resident's room when he saw the male nurse inappropriately touching the resident. 135. The investigation and subsequent resident interview did not fit the cognition of the resident per the above MDS information. 16 136. Resident # 4 was unable to be interviewed. 137. The surveyor again reviewed the clinical chart. 138. The surveyor was unable to locate any information which would substantiate that Resident # 4 had a history sexual accusations toward anyone as written above. 139. The surveyor then went to the hall where Residents # 1, # 2 and # 4 reside. 140. From inside the linen closet, where the witness to the allegation was standing, Resident # 4's room is not visible. 141. The linen room is directly adjacent to Resident # 4's room. 142. However, both Resident # 1 and # 2's rooms are visible from the linen room as they are across the hall. 143. The surveyor went into talk with the Resident # 4. 144. The resident was non-verbal. 145. Interview with a staff nurse at this time, 10/04/03 at approximately 10:30 P.M., confirmed this finding. 146. At approximately 11:00 A.M., the surveyor called the local law enforcement agency in order to speak with the officer who had done the abuse investigation. 147, The officer returned the call. 148. The officer had been called to the facility, but not to do an adult abuse investigation. 149. The officer came to the facility at noon to speak with the surveyor and the facility's Regional Manager. 17 150. The officer stated the reason he was called to the facility was to investigate a threat made by a staff member to another staff member and at no time was a resident involved. 151. At this time the Regional Manger realized the officer’s card had mistakenly been put into the abuse investigation chart. 152. The law enforcement agency had never been called in to investigate the alleged abuse. 153. The surveyor determined the investigation into abuse against Resident # 4 was never truly performed and had actually been performed using either Resident # 1 or Resident # 2 clinical record and interviews. 154. Resident # 1 was admitted to the facility on 05/21/03 with a readmission date of 09/3/03. Diagnosis includes Psychosis, Diabetes and Cardiovascular Disease. 155. Medications include Wellbutrin, Risperdal and Celexa and PRN Ativan and Lorazepam. 156. The last MDS is dated 06/10/03 and is a Medicare 30 day assessment. 157. The resident would have been due for a quarterly evaluation in September of 2003. 158. The clinical record does not contain a RAP summary or RAP worksheet. 159. There is a hand written Care Plan, dated 05/21/03, reflecting the problem of Psychosis. 160. The Care Plan reads the resident exhibits agitation, combativeness and aggressiveness. 161. The MDS dated 06/10/03, revealed: a. the resident has a cognition of - 2, "2" meaning moderately impaired - decisions poor; cues/supervision required. b. BS. Indicators of Delirium-Periodic Disordered thinking/awareness reveals the resident is easily distracted, has episode of disorganized speech, periods of restlessness and periods of lethargy. The resident is able to understand others and is able to be understood. c. Indicators of depression and anxiety - El indicates the resident exhibits unrealistic fears, has repetitive anxious complaints, is withdrawn and reduced social interactions. d. Section E4. - Behavioral symptoms include socially inappropriate/disruptive behavior. 162. The clinical record revealed a psychiatric history and physical dated 05/18/03. 163. The resident had been taken to the local hospital for depression and delusions. 164. The physician writes, "The report by admitting staff was that she said she was having auditory hallucinations and complained of being assaulted." 165. The resident complained of being assaulted by both her brother and her husband. 166. The resident was living at home at this time. 167. On 09/16/03, per physician order, a straight cath for a urine specimen was performed. 168. The nurse performing the procedure was the same male LPN from the original Adverse Incident. 169 The note reads the resident tolerated the procedure well. 170. Review of the nurse's notes revealed the resident becomes combative with staff. 171. A note dated 10/06/03 revealed the resident became combative to staff during toileting. The nurse writes it took 2 CNAs and the nurse to perform the procedure. 172. The resident stated, "The girls were not acting like ladies." 173. The note does not indicate what procedure was actually performed or what the resident felt was inappropriate at the time. 19 174. On 11/04/03 at approximately 2:30 P.M., an interview was held with Resident # 1. 175. The resident was sitting up in a recliner chair next to her bed. 176. The resident is alert and oriented to self and place but not time. 177. The resident feels the staff are "OK" to her. 178. The staff has not treated her inappropriately nor does she recall any time when she was touched inappropriately. 179. The Agency provided Waldemere with the mandatory correction date for this deficient practice of 12/05/03. 180. The Agency determined that these conditions or occurrences compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 181. The Agency cited this deficient practice as a widespread State Class II deficiency, a violation subjecting Waldemere to an administrative fine. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $7,500.00 against Waldemere, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT III 182. The Agency re-alleges and incorporates paragraphs (1) through (5), (7) through (76) and (78) through (179) as if fully set forth herein. 183. Based upon Waldemere’s two cited State Class II deficiencies, it was not in substantial 20 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)(b), Fla. Stat. (2003). WHEREFORE, the Agency intends to assign a conditional licensure status to Waldemere, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(7) commencing 11/05/03. Respectfully submitted this LOY. day of February 2004. ide L. Pickett ; y Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330K St. Petersburg, FL 33701 727.552.1526 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, 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 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 certified mail, return receipt no: 7003 1010 0003 4303 8258 on February @/ _, 2004 to Vicky K. Washington, Administrator, Waldemere Place, 2071 Waldemere Street, Sarasota, Florida, 34239, and by U.S. Mail to Bart Wyatt, Registered “Vitian 100 Second Avenue South, Suite 9015S, St. Petersburg, Florida, 33701. Hatta L. aD acy 7} 21 Copies furnished to: Vicky K. Washington Administrator Waldemere Place 2071 Waldemere Street Sarasota, Florida 34239 (Certified U.S. Mail) Bart Wyatt Registered Agent Waldemere Place 100 Second Avenue S. Suite 901S St. Petersburg, Florida 33701 (U.S. Mail) 22 Gerald L. Pickett, Esq. Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, Suite 330K St. Petersburg, FL 33701

Docket for Case No: 04-001195