om 2D STATE OF FLORIDA Ne i AGENCY FOR HEALTH CARE ADMINISTRATION : AGENCY FOR HEALTH CARE ADMINISTRATION, Say Petitioner, HEAR vs. Case No. 2004003095 2004002555 BENEVA LAKES HEALTH CARE ASSOCIATES, LLC, a/b/a BENEVA LAKES HEALTHCARE & REHABILITATION CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against BENEVA LAKES HEALTH CARE ASSOCIATES, LLC, d/b/a BENEVA LAKES HEALTHCARE & REHABILITATION CENTER, (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine against Respondent, ir the amount of two thousand five hundred dollars ($2,500) pursuant to Sections 400.102(1) (a) and (da), and 400.23(8) (b), Florida Statutes (2003) [AHCA Case No. 2003002555]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (ob), Florida Statutes (2003) [AHCA Case No. 2004003095]. 3. The Respondent was cited for the deficiencies set forth below as a result of a focused appraisal survey conducted on or about March 1-2, 2004. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 4C0, Part II, Florida Statutes (2003). 4, Venue lies in Sarasota County, Division of Administrative Hearings, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 28-106, Florida Administrative Code (2003). PARTIES 5. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for the licensure of nursing homes and enforcement of all 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 II, Florida Statutes (2003), and; Chapter 59A-4, Fla. Admin. Code (2003), respectively. 6. Respondent is a nursing facility located at 741 South Beneva Road, Sarasota, FPL 34232. Respondent is licensed to operate a skilled nursing facility pursuant to license #SNF1049096. At all relevant times, Respondent was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I RESPONDENT FAILED TO ENSURE THAT EACH RESIDENT RECEIVED ADEQUATE SUPERVISION AND ASSISTANCE TO PREVENT ACCIDENTS. 42 CFR 483.25(h) (2) (2003), INCORPORATING BY REFERENCE Fla. Admin. Code R. 59A-4.1288(2003) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about March 1-2, 2004, AHCA conducted a focused appraisal survey at Respondent's facility. 9. Based on observations, staff and resident interviews and one of one resident record review, the facility did not provide Resident #1 with the appropriate supervision and assistance with her breakfast meal that would prevent her from spilling her coffee ard causing an injury to herself. The findings include: 1. During interview with the Risk Manager she stated she was investigating an incident on 2/27/04 with Resident #1 burning herself with coffee at breakfast. The Risk Manager and surveyor went to visit Resident #1. An interview was conducted with Resident #1 with the surveyor and staff. Resident #1 stated she remembered the coffee spilling on her and that her arms hurts. She wanted something to take the pain away. The resident also stated when she spilled her coffee no staff was in the room with her. She continued to say she wanted something for her pain throughout the course of this interview. At that time the surveyor and staff notified the nurse to help Resident #1 with her pain. The staff stated the resident seemed very "reliable" during this interview and at times can be very oriented. The resident is required to ask for pain medication before the nurse can administer it to her. During the interview with the resident she kept her eyes closed. The staff stated she is blind. She also stated the resident eats her breakfast in her room and lunch and dinner are in the dependent dining room. Le The dependent dining room is for residents who require assistance with their meals. A review of Resident #1's medical record showed in the nurse's notes on 2/27/04 at 0820 "CNA (Certified Nurses Aid) reported to nurse that resident had spilled hot coffee on herself. Upon checking it was noted that It (left) arm elbow area and part of forearm was red (with) blister forming. Also splotchy area on It abd (abdomen) and It side red (no) blistering.” She was then sent to the hospital and returned the same day. Interview with staff stated she had second degree burns on her left arm. A review of Resident #1's Minimum Data Set (MDS) dated 11/21/03 and 2/16/04 shows she is total dependence with meals and requires one person physical assistance. Her care plan, dated 2/24/04, identified one of the problems for Resident #1 is: "Resident requires total assist with all ADL's R/T severe cognition impairments and poor vision." The first approach for this problem is: "Staff to provide total assist with feeding at meal times." Interview with the CNA who helped Resident #1 on 2/27/04 was conducted on 3/1/04 at approximately 11:00 A.M. She stated she passed by Resident #1's bedroom and heard her screaming, "My arm is on fire." She went into the room and found brown on her sheets. She then noticed the coffee was spilled and saw her left arm. She then contacted a nurse for help. She stated when she went into her room to help her there was no other staff in the room. She stated she did not set up her breakfast tray. She stated the staff that set up her breakfast tray was in the hallway setting up other residents’ trays. She also stated you doesn't give Resident #1 coffee and walk away. Observation at 12:00 P.M., during lunch, showed Resident #1 in the dependent dining room. All the residents in this dining room were receiving assistance with their meals from staff. Resident #1 was receiving 1:1 assistance from a staff. She was feeding her meal and giving her liquids by handing her the glass, and then the resident would take the glass with both hands. The staff continued with assistance when Resident #1 required it throughout her meal. Interview with the staff stated she puts 1/2 the coffee in her cup and gives it to her so she doesn't spill it. She needs assistance with her meals and sometimes she uses cuing also, depending on her mood. However, she mostly needs assistance. Interview with the staff who set her breakfast tray up (on 2/27/04) on 3/2/04 at approximately 8:30 A.M., revealed she set up Resident #1's breakfast tray. She gave her a 1/2 cup of coffee and put her set-up breakfast tray on the bedside table. The resident was sitting up in bed. She then left the room and help set up other residents. When asked what type of assistance the resident requires for meals identified in the care plan she stated she does not know where the care plan is. Therefore, the resident was assessed by the staff to require total assistance from the staff to eat her meals. A problem was identified in the care plan where she requires total care with her ADLs (activities of daily living). The approach was to provide total assist with Resident #1 during her meals. The staff set-up Resident #1's breakfast meal and left the bedroom. The resident then spilled her coffee on her causing second degree burns. The resident was complaining of being in pain and needed help to take the pain away. The facility did not provide Resident #1 with the appropriate supervision and assistance with her breakfast meal on 2/27/04 allowing this accident to occur. 10. Respondent was provided a mandated correction date of April 3, 2004. 11. The above aczions or inactions are a violation of Title 42, Code of Federal Regulations 483.25 (h) (2) (2003), incorporating by reference Rule 59A-4.1288, Florida Administrative Code (2303), which requires the facility to ensure that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being, in accordance with the comprehensive assessment and plan of care. Additionally, the facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 12. Pursuant to Section 400.23(8) (b), Florida Statutes (2003), the foregoing is a class II deficiency and as such, has 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. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an “isolated” Class II deficiency. 14. Pursuant to Section 400.23(7) (b), Florida Statutes (2003), the Agency is authorized to assign a conditional licensure status to Respondent’s facility. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: a. Enter actual and legal findings in favor of AHCA; b. Impose a $2,500 civil penalty against Respondent ; c. Assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes (2003); d. Uphold the conditional licensure status pursuant to Section 400.23(7) (b) (2003); and e. Grant any other general and equitable relief as deemed appropriate. NOTICE The Respondent is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2003). 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. KittucwD. Shee Katrina D. Lacy, Esquire, AHCA, Senior Attorney Fla. Bar. No. 0277200 Counsel for Petitioner 525-Mirror Lake Dr. N., #3306 St. Petersburg, FL 33701 (727) 552-1525 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail Return Receipt No. 7003 1010 0002 4667 0333, to C.T. Corporation System, Registered Agent for Beneva Lakes Health Care Asso., 1200 South Pine Island Road, Plantation, FL 33324, dated on sDudhey ay th. April ap 2004. datrina ‘D. Lacy, Wequire Copies furnished to: c.T. Corporation System Registered Agent for Beneva Lakes Health Care Asso. 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) David F. Staup, Administrator Beneva Lakes Healthcare & Rehab 741 South Beneva Road Sarasota, FL 34232 (U.S. Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, FL 33701

Docket for Case No: 04-002040