A ENT RE USL? 14 STATE OF FLORIDA ACENCY FOR HEALTH CARE RDMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Fan he Patitioner, AHCA No: 200201268168 Return Receipt Requested vs. F000 1670 OO11 4847 9900 7000 1670 0011 4847 ga94 7000 1670 0011 4847 9887 BROOKWOOD-EXTENDED CARE CENTER OF HIALEAH GARDENS, LLP, d/b/a WATERFORD CONVALESCENT CENTER, Respondent / a ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Brookwood Extended Care Center of Hialeah Gardens, LLP, d/b/a Waterford Convalescent Center (hereinafter “waterford”) pursuant to 28- 106,111, Florida Administrative Code (2001) (F.A.C.), and Chapter 120, Florida Statutes (Fla. Stat.) hereinafter alleges: NATURE OF ACTION l. This is an action to impose a conditional licensure rating, effective November 15, 2001, pursuant to Section 400.23(7) (b), Fla. Stat. << AAS Pe JURISDICTION AND VENUE 2, This court has jurisdiction pursuant to Section 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C, 3. venue lies in Dade County, pursuant to 120.57, Fla. Stat., and Chapter 28-106.207, F.A.C. PARTIES 4, AHCR is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Fla. Stat., and Rules 59A-4, F.A.C. 5, Waterford Convalescent Center is a nursing home located at 9333 West Okeechobee Road, Hialeah Gardens, Florida 33016, and is licensed under Chapter 400, Part II, Fla. Stat., and Chapter 59A-4, F.A.C. COUNT I WATERFORD FAILED TO ENSURE THAT RESIDENTS HAVE AUTONOMY AND CHOICE IN EXERCISING THEIR RIGHTS AND TO BE FREE FROM STAFF MEMBERS DELIBERATE ACTIONS TO PROMOTE OR LIMIT THE RESIDENTS’ AUTONOMY 483.15(b), C.F.R., 59A-4,.106(4) (x), F.A.C. (QUALITY OF LIFE) CLASS II 6. AHCA xe-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the annual survey conducted during 11/13- 15/01 and based on observation, interview and record review, the facility failed to ensure that residents have autonomy and choice in exercising their rights and to be free from staff members deliberate actions to promote or limit the resident's autonomy or choice which prevents independent functioning for two (#23 and R33) of thirty sampled residents. 8. Curing observation of the activity that was given on 11/14/01 at approximately 11:30 a.m. in the activity room on the third floor, two staff members were observed being actively involved with a small number of residents leaving the majority of the twenty-six residents in the room inactive. After about 10 minutes of observation, sampled resident #23 was observed not receiving any interaction from staff and appeared to be anxious evidenced by the resident moving back and forth in his/her wheel chair and attempting to roll the wheelchair out of the room. One of the staff was observed standing in front of the resident, without speaking to him/her, and preventing the resident from moving. This action appeared to make the resident more anxious to the point where he/she started to speak in a loud voice. 9. An interview, with the staff that was blocking the resident's way, revealed that the resident was not allowed to leave to activity room because whenever the resident is allowed to leave he/she is immediately brought back by one of the certified nursing assistance (CNAs). The activity staff stated that she did not see the benefit of allowing the resident to leave if the CNAs were just going to return the resident. The staff was questioned as to the reason for net speaking to the resident. The staff stated that she does not speak Spanish. Upon further investigation, the activity staff stated that the resident is able to roll his/her wheelchair without supervision from staff. Upon surveyor intervention, the resident was allowed to leave the room. 10. nterview with the unit supervisor at approximately 11:50 a.m. revealed that the staff member should have allowed the resident to leave the room as desired and that the facility's policy is for the resident, regardless of the cognitive status, be allowed to exercise their rights. The unit supervisor then spoke with the staff. The staff stated the reason for not allowing the resident to leave was because he/she would be immediately returned to the activities rocm by the CNAs. The unit supervisor informed the staff of the resident's right to choose. The unit supervisor then informed the surveyor that the resident propels his/her wheel chair all the time down the halls without staff assistance and supervision. 11. Observation later that day at approximately 3:50 p.m. revealed a CNA sitting in front of the entrance to the activity room on the same floor (3rd Floor), blocking the residents from exiting the room. Sampled resident #23 was observed at this time asking the CNA to be allowed to leave the room, however, the CNA was observed telling the resident "no", The unit supervisor, sitting at the nursing station, was asked to follow the surveyor to the activity room. The CNR had moved from the chair by this time, put the chair remained in the middle of the doorway preventing anyone from entering or leaving the room, The unit supervisor informed the CNA to move the chair to the wall and that the door way should be accessible to residents. Upon moving the chair to the wall, a resident entered the activity room. 12. Review of sampled resident's (#23) medical record on 11/15/01 at approximately 10:30 a.m., revealed that the resident was assessed in the Minimum Data Set (MDS) annual assessment dated 9/24/01, as having severe cognitive impairment, as usually making self understood, and sometimes understands others. An improvement in behavior symptoms was assessed and the resident was described as being at ease interacting with others. Review of the social services, assessment dated 3/19/01, provided by the facility on 11/16/01 following the survey, revealed that the resident's behavior was assessed as having socially inappropriate behavior, however, these behaviors did not include wandering, verbally or physically abusive behaviors, or resisting care. 13. During a routine tour of the facility on 11/15/01 at about 9:00 am, a staff member was observed preparing to transport a resident via wheelchair into dining/activities/ TV room. The staff member asked resident R33, if she wanted to be transported in to dining/activities/TV room. Resident R33 answered "NO" three (3) times. Staff member still proceeded to transport resident R33 into the dining/ activities/TV room against her verbal consent. 14. Based on the foregoing, Waterford Convalescent Center violated 483.15(b), C.F.R., and 59A-4.106(4) (x), F.A.C., herein classified as a Class II violation, which gives rise to a conditional licensure status pursuant to §400.23(7) (b), Fla. Stat. (2001) PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Enter a recommended rder in favor of the Agency for Health Care Administration against Waterford Convalescent Center. B. Assess against Waterford Convalescent Center 4 Conditional License, in accordance with §400,23(7} (b), Fla. Stat. Cc. Award the Agency for Health Care Administration costs related to the investigation and prosecution of the case pursuant to §400.12:(19), Fla. Stat. D. Grant such other relief as the court deems is just and proper. Respondent 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 and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 Nw 53°* Street, Miami, Florida 33166; Nelson Rodney, Assistant General Counsel. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted. Assistant General Counsel Agency for Health Care Administration 8355 NW 53°¢ Street Miami, Florida 33166 Copy to: Nelson Rodney, Assistant General Counsel Agency for Health Care Administration Manchester Building 8355 NW 53% Street Miami, Florida 33166 Elizabeth Dudek, Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive, MS#9 Tallahassee, Florida CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregeing has been furnished by U.S. Certified Return Receipt Requested to Roberto OD. Vital, Administrator, Waterford Convalescent Center, 8333 West Okeechobee Road, Hialeah Gardens, Florida 33016, Brookwood-Extended Care Center of Hialeah Gardens, LLP, 545 Wahoo Road, Panama City, Florida 32408, and to Theodore E£. Mack, Esquire, 803 North Calhoun ¢ Street, Tallahassee, Florida 32303, on fda J ' 2002. el5n (Rodney

Docket for Case No: 04-001598