STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NOS.2004002484 2004005093 2004005099 2004007256 vs. , APPLE HOUSE, INC. Pe The Appleh II , - d/b/a The Applehouse O¢ a% | | Respondent. / ADMINISTRATIVE COMPLAINT COMES "Now the Agency for Health Care Administration (hereinafter “Agency”), by and through its undersigned counsel, and files this Administrative Complaint against Respondent, Apple House, Inc. (The) (hereinafter . “APPLE HOUSE II” or “Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2003), and as grounds therefore, alleges the following: NATURE OF THE ACTION 1. This is an action: (a) to impose an administrative fine in the amount of twenty thousand and five-hundred dollars ($26,000.00) against Apple House II pursuant to Sections 400.419(2) (a) and 400.419(2) (b), Florida Statutes (2003). This amount includes a survey fee of $500.00 authorized by section 400.419(10), F.S. JURISDICTION AND VENUE , 2. The Agency has jurisdiction pursuant te Sections | 1 120.569 and 120.57, and Chapter, 400, Part III, Florida Statutes (2003). 3. This Complaint is based on the violations arising from a biennial survey on or about February 24, 2004, and follow-up surveys on or about April 6, 2004, again on May 3, 2004, and again on June 28, 2004. 4. venue shall be determined pursuant to Rule 28-106.207, _ Florida Administrative Code (2003). PARTIES 3: The Agency is the regulatory agency responsible for the Ligensure of assisted living facilities and for the enforcement of all applicable state laws and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes, and Chapter 59A-5, Florida Administrative Code. 6. At all times material hereto, Apple House II is an Assisted Living Facility located at 2301 South Highway 17, Crescent City, Florida 32055. 7. At all times material hereto, the Respondent was licensed by the Agency to operate an assisted living facility located at 2301 South Highway 17, Crescent City, Florida 32055 in Putnam County having been issued license number 9265 by the Agency. + . 1 8. At all times relevant hereto, the ‘Respondent is and was ‘a licensed assisted living facility required to comply with all applicable rules and statutes. COUNT I VIOLATION FOR FAILURE TO DISCHARGE RESIDENT NO LONGER APPROPRIATE FOR CONTINUED PLACEMENT AT THE FACILITY Subsections 400.419 (a) and (2) (b), ‘and 400.426(1), Fla. Stat. (2003) Rules 58A-5.0181 (1)(d), (4)(d) and (5), and 58A-5.0131(5), \ Plorida Administrative Code CLASS II DEFICIENCY 9. AHCA re-alleges and incorporates by reference paragraphs (2) through (8) above as if fully set forth herein. ‘ 10. AHCA surveyors conducted a biennial survey at APPLE HOUSE II on or about February 24, 2004, that determined that the Facility maintained two residents who were inappropriate for continued residency at this assisted living facility because these residents wexe physically unable to assist themselves with “transfers” and required a mechanical lift for the transfer procedures. Based upon Rules 58A-5.0181 1) (a) and 58A-5.0131(5), Florida Administrative Code, residents who are not physically able to assist themselves with “transfers” are not candidates for placement in assisted living facilities. 11. Surveyors established the findings below: Based on observation, record review and interviews, two of 24 resident (#2 & #3) were not able to transfer with assistance and required the use of a Hoyer lift. The Facility failed to inform the resident or her/his representative of the resident’s inability to meet the requirements for continue residency and further give 45 days notice of discharge. Failure to transfer a resident whose needs exceed the licensed capabilities of the Assisted Living Facility could compromise the resident's ability to reach his/her highest practicable level of function. Findings: . 1. During initial tour of the facility on 2/23/04 at 10:30 AM it was observed that resident # 3 was sitting in a recliner with a Hoyer lift pad under her/him. ' During the two days of the survey the resident was observed being transferred from the recliner to a wheelchair and back again multiple times (for meals, shower, etc.) with the Hoyer lift. Interview with the Administrator (Owner) during initial tour revealed that the resident was not able to stand, but that the facility was hoping to get the resident to stand again with therapy. 2. On initial tour it was observed that there was a hoyer lift in room #4. At lunch on 2/23/04 at 12:35 PM resident #2 was observed in the dinning room in a wheelchair with a hoyer lift'pad under the resident being fed by staff. Interview on 2/24/04 at 12:56 PM with staff nurse revealed that resident #2 has not stood for 2 years. 12. Rules 58A-5.0181(4) (a) and (5), Florida Administrative Code (2003), read as follows: Rule 58A-5.0181, Florida Administrative Code (2003), Residency Criteria and Admission Procedures. (4) CONTINUED RESIDENCY. Criteria for continued residency in a facility holding a standard, limited nursing services, or limited mental health license shall be the same as the criteria for admission, except as follows: (a) The resident may be bedridden for up to 7 consecutive days. (b) A resident requiring care of a stage 2 pressure sore, may be retained provided that: 1. The facility has a LNS license and services are provided pursuant to a plan of care issued by a physician, or the resident contracts directly with a licensed home health agency or a nurse to provide care; ; 2. The condition is documented in the resident’s record; and 3. If the resident’s condition fails to improve within 30 days, the resident shall be discharged from the facility. (c) A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: 1. The resident qualifies for, is admitted to, and consents to the services of a licensed hospice which coordinates and ensures the provision of any | additional care and services that may be needed; : 2. Continued residency is agreeable to the resident and the facility; 3, An interdisciplinary care plan is developed and implemented by a licensed hospice in consultation with the facility. Facility staff may provide any nursing service permitted under the facility’s license and total help with the activities of daily living; and ; 4. Documentation of the requirements of this paragraph is maintained in the resident’s file. (d) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. (5) DISCHARGE. If the resident no longer meets the criteria for continued residency, or the facility is unable to meet the resident’s needs, the resident shall be discharged in accordance with Sections 400.426(9) and 400.428(1), Florida. 13. The Facility failed to provide adequate care and services to these two residents because their continued placement represented a violation of, Section 400.426 (1), F. S., and Rules 5@A-5.0181 (4) and (5), Florida Administrative Code (2003). This law and rule requires that the ALF administrator continuously evaluate the needs of residents and determine whether the ALF Facility is capable of ‘addressing their needs. This continuous or periodic assessment utilizes those same standards appropriate to the needs of residents accepted for admission to the' facility. AHCA surveyors found the placement of two residents inappropriate and detrimental to the affected residents. This condition had existed for some time prior to the survey. Based upon the statute and administrative rule, the Facility administrator is responsible for making these evaluations on a periodic basis and to consider the Yieed for relocation (see section 400.426 (1), F.S.), and further,. upon t ' that decision, to give forty five-days (45) advance notice of relocation to the resident and their custodians or guardians. (see subsection 400.428(1)(k), F. S.). Neither thé “assessment nor the resultant notice was performed by the Administrator. 14. Based on the foregoing, APPLE HOUSE II violated the t above-referenced provisions of Rule 58A-5.0181 Florida Administrative Code (2003), by the administrator failing to _ monitor the continued appropriateness of placement of a resident in the facility, as required by Rule 58A-5.0181(4) (d), Florida Administrative Code (2003), : which : is similar to ‘that determination at the time of admission whether the resident is appropriate for residency in an assisted living facility. The failure to discharge is at issue, in this Count I. 15. Pursuant to subsection 419.419(2) (b), Florida Statutes, the foregoing rule violation is a class II violation in that it directly threatened the physical or emotional health, safety, or security of the two residents. Pursuant to'Section 400.419(1) and (2)(b), Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE II in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional * health, safety, or security of the facility residents, other than class I violations.” CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in ‘the allegations of this count. . b. Impose ‘a fine in the amount of $1,000.00 for the referenced violation. COUNT II VIOLATION FOR FAILURE TO DISOHARGE RESIDENT , WHO IS NO LONGER APPROPRIATE FOR ' CONTINUED PLACEMENT AT THE FACILITY ‘ Subsections 400.419 (a) and (2)(b), Fla. Stat. (2003) Rule 58A-5.0181(1)(m)and (5), Florida Administrative Code CLASS II DEFICIENCY REPEAT 16. AHCA re-alleges and incorporates by reference paragraphs (1) through (15) above as if fully set forth herein. 17. On or about May 3, 2004, a second follow-up survey was conducted at Respondent’ s facility. At that survey, AHCA surveyors again discovered the continuing inappropriate resident placement issues cited in Count I above and that the Facility had not reacted to ACHA’s notification to the Respondent on or about February 24, 2004, and the Respondent took no action as required by rule and statute to resolve this placement issue. Those findings are: Based on observation, interview and record review, the facility failed to ensure that ofie (1) (Resident #2 who is the same resident involved in Count I above) of 26 residents reviewed was transferred from the facility after providing ‘the family with the required 45-day notice that the resident's care needs exceeded the facility's licensed capabilities. Failure to transfer — inappropriate residents increases the potential for neglect of those residents whose needs are medically complex and require more skilled nursing care. Findings: on. Observations at the facility on 5/03/04 from 2:55 PM to 3:12 PM revealed residents #2, (who had previously been documented in the 2/24/04 Biennial Licensure Survey as being inappropriate due to the inability to transfer) was still present in the facility. The resident was observed asleep in his/her bed, with the half side rails up on both sides. Record review revealed that the family of resident #2 was notified in writing by the facility, on 3/08/04, that the resident was no longer appropriate for placement in the Assisted Living Facility. Interview with the facility Assistant Administrator on 5/03/04 at 3:15 PM confirmed that the family of resident #2 had been notified by letter on 3/08/04 to relocate him/her to a more ' appropriate facility within 45 days. The Assistant Administrator stated she called the family following the 4/06/04 monitoring visit to remind them of the requirement for the resident to be moved. The Assistant Administrator stated she thought the facility would be cited "everyday the resident (#2) remained in the facility". ' ' 18. Based on the foregoing, APPLE HOUSE II violated the above-referenced provisions of Rule 58A-5.0181 Florida Administrative Code (2003), by the administrator failing to react to the AHCA’s notification and for not notifying and resolving the issue that a resident was inappropriate for residency in Respondent’s assisted living facility. 19. Pursuant to subsection 419.419(2) (b), Florida Statutes, the foregoing rule violation is a class [I violation in that it directly threatened the physical or emotional health, safety, or security of the two residents. Pursuant to Section 400.419(1) and (2) (b), Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE tI in the amount of FIVE THOUSAND AND No/100 DOLLARS ($5,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” | CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in the allegations of this count. b. Impose a fine in the amount of $5,000.00 for the referenced violation. COUNT IIL ‘ ' VIOLATION FOR FAILURE TO DETERMINE THE APPROPRIATENESS OF ADMISSION AND PLACE RESIDENTS IN EXTENDED CONGREGATE CARE SERVICES ‘Subsections 400.419 (a) and (2) (ce), 400.4255, Fla. Stat. (2003) Rule 58A-5.0182(5)(a) and (b), Florida Administrative Code UNCORRECTED CLASS IIT DEFICIENCY 20.AHCA re-alleges and incorporates by reference paragraphs (1) through (8) above as if fully set forth. herein. 21. AHCA surveyors conducted a biennial survey visit at APPLE HOUSE II on or about February 24, 2004, that resulted in a class III deficiency cited against APPLE HOUSE II on findings below: oz Based on record review and interview the facility failed to place 2 residents (#6 and'#10) on Extended Congregate Care (ECC) Services when their care needs were more thar the care ; permitted under the standard Assisted Living Facility license. oe { ; ‘ Findings: \ Observations during the two days of survey revealed that resident #6 and # 10 had dressings changed by the medication nurse. The nurse was noted on both days to leave residents #10 room with a utility caddy filled with dressing supplies. Resident #6 was noted tohave a dressing on her/his hand that was also changed. Interview with the medicine nurse on 2/24/04 at 9:00 AM revealed that resident #10 had a daily dressing change. ' 22. On or about February 24, 2004, AHCA provided Respondent with a mandated correction date of March 25, 2004, ' within which to correct the above-referenced deficient practices. (23. On or about April 6; 2004, a first follow-up survey was conducted at Respondent’s facility. At that survey, AHCA surveyors again discovered inappropriate ‘resident placement issue violations. Based on ‘observation, record review and interview by the surveyors, the facility failed to place four (4) residents (#2, #3, #10 and #14) on Extended Congregate Care (ECC) Services when their care needs exceeded the limits of care permitted under the standard Assisted Living Facility license. Failure to transfer residents to an appropriate level of care may endanger the quality of the care they receive. Findings: 1. Medical record review revealed that resident #2 had a skin tear on right arm and wound care was done and a dressing was applied. Also noted on record review was that the resident 10 . ‘received a PRN (as necessary) breathing treatment at 11:00 PM on 03/02/04. Review of the ‘Medication Observation Record (MOR) revealed that the resident is ordered to receive breathing treatments three times a day and PRN starting 03/04/04. This resident is a total assist with care and could not do the treatment his/herself after the medication was mixed into the nebulizer by the nurse. 2. Review of the MOR revealed that resident #3 had received a DuoDerm dressing to the resident's coccyx every 3 to 4 days since 02/14/04 for two dime size red and painful sores, one on each side of crack of buttocks. 3. Medical record review revealed that resident #10 had a blister that broke on 03/29/04 and was draining on his/her right lower leg. The area was cleaned and a adsorbent dressing was applied. 4. Observation on 04/06/04 at 8:30 AM of the Administrator labeling blood tubes that she had drawn from resident #14. ‘ 5. Interview with the Administrator on 04/06/04 at 12:30,PM stated that she believed that the facility had 30 days to clear skin tears and that she had standing orders for care of skin tears and the use of DuoDerm. 24. The assisted living facility is limited by law as to the type of services it may offer to 'the public. As,a facility, it caters to independent living, offering: housing, meals, supervision, assistance with activities‘ of daily living, housekeeping, social and recreation activities, and transportation. Furthermore, the ALF (with a standard license) is not designed to deliver the type of nursing services being ; delivered by the Respondent to its residents as noted in the surveyor findings, who are not designated as ECC residents. Subsection 400.4255, Florida Statutes, authorizes the Respondent _ to deliver simple but limited nursing services, and other more complex nursing services only in emergency situations. For example, Rule 58A-5.0182(5), Florida Administrative Code (2003), authorizes the Respondent to offer limited nursing. . 1 services as follows: ; t t 58A-5.0182 Resident Care Standards. | An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. mes (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: ' ' ; (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general ' health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the’ resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care : surrogate, or case manager if the resident is discharged or moves out. ' '(e) A written record, updated as needed, of any’ significant changes in the resident’s normal appearance or state of health, any illnesses which resulted in medical attention, major incidents, -chdnges in the method of medication administration, or other changes which resulted in the provision of additional services. : ", (2) SOCIAL AND LEISURE ACTIVITIES. Residents shall be encouraged to participate in social, recreational, educational and other activities within the facility and the community. (a) The facility shall provide an ongoing activities program. The program shall provide diversified individual and group activities in keeping with each resident’s needs, abilities, and interests. (b) The facility shall consult with the residents in selecting, planning, and scheduling activities. The facility shall demonstrate residents’ participation through one or more of the following methods: resident meetings, committees, a resident council, suggestion box, group discussions, questionnaires, or any other form of communication appropriate to the size of the facility. (c) Scheduled activities shall be available at least 5 days a week for a total of not less than 10 hours per week. Watching television shall not be considered an activity for the purpose of meeting the 10 hours per week of scheduled activities unless the television program is a special one-time event of special interest to residents of the facility. An activities calendar shall be posted in common areas where residents normally congregate. (d) If residents assist in planning a special activity such as an outing, seasonal festivity, or an excursion, this may be counted toward the activity time. (3) ARRANGEMENT FOR HEALTH CARE. In order to facilitate resident access to needed health care, the facility shall, as needed by each resident: (a) Assist residents in making appointments and remind residents about scheduled appointments for medical, dental, nursing, or mental health services. (b) Provide transportation to needed medical, dental, nursing or mental health services, or arrange for transportation through family and friends, volunteers, taxicabs, public buses, and agencies providing transportation for persons with disabilities. (c) The facility may not require residents to see a particular health care provider. (4) ACTIVITIES OF DAILY LIVING. Facilities shall offer supervision of or assistance with activities of daily living as needed by each resident. Residents shall be encouraged to be as independent as possible in performing ADLs. (5) NURSING SERVICES. (a) Pursuant to Section 400.4255, ¥.S., the facility may employ or contract with a nurse to: 1. Take or supervise the taking of vital signs; 2. Manage weekly pill-organizers and administer medications as described under Rule 58A-5.0185, FA.C.5 3. Give prepackaged enemas pursuant to a physician’s order; and 4. Maintain nursing progress notes. (b) Pursuant to Section 464.022, F.S., the nursing services listed in paragraph (a) may also be delivered in the facility by family ; members or friends of the resident provided the family member or friend does not receive compensation for such services. ‘ 25. The above findings establish that the Respondent delivered care to these two residents that was beyond the scope of a standard ALF license. The violation of Rule 5.0182(5) (a) , and (b), Florida Administrative Code (2003), relating to delivery of a ‘level of care (services) to the resident appropriate to ‘the needs of residents accepted for admission to the facility, is consider to be uncorrected. 26. This finding constitutes a repeat Class III deficiency because the inaction indirectly or potentially threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Sections 400.419(1), and (2) (c), Plorida Statutes, the Agency is authorized to impose a 13 fine in the amount of not less than five hundred dollars’ ($500), put! not exceeding one thousand ($1,000) for this violation, \ j ~ CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in. the allegations of this count. b. Impose a fine in the amount of $500.00 for the referenced 1 violation. COUNT IV VIOLATION FOR FAILURE TO MONITOR THE APPROPRIATENESS OF CONTINUED PLACEMENT AT THE FACILITY FOR EACH RESIDENT Subsections 400.419 (a) and (2) (b), and 400.426(1), Fla. Stat. (2003) \ Rule 58A-5.0181(4)(d), Florida Administrative Code CLASS II DEFICIENCY 27. AHCA re-alleges and incorporates by reference paragraphs (1) through (20) above as if fully set forth herein. 28. AHCA surveyors conducted a biennial visit at APPLE HOUSE II on or about February 24, 2004, that determined that the Facility maintained two residents who were inappropriate for continued residency at this assisted living facility, and that the situation resulted from the Administrator’s failure to do a periodic evaluation of these two residents’ continued residency at the facility. 29. Surveyors established the findings below: 14 erview two of 24 resident (#2 & #3) were not Based on observation, record review and int able to transfer with assistance and required the use of a Hoyer lift. The Facility Administrator failed to periodically determine the appropriateness of these two residents for continued residency at this facility. Failure to make this evaluation and then transfer a resident whose needs exceed the licensed capabilities of the Assisted Living Facility could compromise the resident's ability to reach his/her highest practicable level of function. ‘ Findings: 1. During initial tour of the facility on 2/23/04 at 10:30 AM it was observed that resident #3 was sitting in a recliner with a Hoyer lift pad under her/him. During the two days of the survey the resident was observed being transferred from the recliner to a wheelchair and back again multiple times (for meals, shower, etc.) with the Hoyer lift. Interview with the Administrator (Owner) during initial tour revealed that the resident was not able to stand, but that the facility was hoping to get the resident to stand again with therapy. 2. On initial tour it was observed that there was a hoyer lift in room #4, At lunch on 2/23/04 at 12:35 PM resident #2 was, observed in the dinning room in a wheelchair with a hoyer lift pad under the resident being fed by staff. Interview on 2/24/04 at 12:56 PM with staff nurse revealed that resident #2 has not stood for 2 years. 30. Rules 58A-5.0181(4) (d) and (5), Florida Administrative 4 . Code (2003), read as follows: Rule 58A-5.0181, Florida Administrative Code (2003), Residency Criteria and Admission Procedures. , : \, (4) CONTINUED RESIDENCY. Criteria for continued residency in a facility holding a standard, limited nursing services, or limited mental health license shall be the same as the criteria for admission, except as follows: (a) The resident may be bedridden for up to 7 consecutive days. (b) A resident requiring care of a stage 2 pressure sore, may be retained provided that: 1. The facility has a LNS license and services are provided pursuant to a plan of care issued by a physician, or the resident ‘contracts directly with a licensed home health agency or a nurse to provide care; _ 2. The condition is documented in the resident’s record; and 3. If the resident’s condition fails to improve within 30 days, the resident shall be discharged from the facility. (c) A terminally i] resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: 1. The resident qualifies for, is admitted to, and consents to the services of a licensed hospice which coordinates and ensures - the provision of any additional care and services that may be needed; | 2. Continued residency is agreeable to the resident and the facility; 3. An interdisciplinary care plan is developed and implemented by a ‘ licensed hospice in consultation with the facility. Facility staff may provide any nursing service permitted under the facility’s license and total help with the activities of daily living; and ees 4. Documentation of the requirements of this paragraph is maintained in the resident’s file. (d) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. (5) DISCHARGE. If the resident no longer meets the criteria for ' continued residency, or the facility is unable to meet the resident’s needs, the resident shall be discharged in accordance with Sections 400.426(9) and 400.428(1), Florida. 31. The Facility failed to provide adequate care and residents because their continued to ; ; ' violation of Section 400.426(1), F. S., services to these two placement represented a ‘anh Rule 58A-5:0181(4), Florida Administrative Code (2003). This law and rule requires that the . ALF administrator continuously evaluate the needs'of residents and whether the ALF Facility is capable of addressing their needs. This continuous | periodic assessment utilizes those same standards appropriate or to the needs of residents accepted for admission to the facility. AHCA surveyors found the placement of two residents inappropriate and detrimental to the affected residents. This condition had existed for some time prior to the survey. based upon the statute and administrative rule, the Facility administrator is responsible for making these evaluations on a periodic basis and to consider the need for relocation (see 16 section 400.426(1), F.S.), and further, upon that decision, to give forty five-days (45) advance notice of relocation to the resident and their custodians or guardians. (see subsection 400.428 (1) (k), F. §.). Neither the assessment nor the resultant notice was performed by the Administrator. The failure to monitor continued residency is at issue in this particular Count. | 32. Based gn the foregoing, APPLE HOUSE II violated the above-referenced provisions of . Rule 58A-5.0181 Florida Administrative Code (2003), by the ‘administrater failing to monitor the: continued appropriateness of placement of a resident in the facility, as required by Rule 58A-5.0181(4) (da), Florida 4 ‘, Administrative Code (2003). 33. Pursuant to subsection 419.419 (2) (b), Florida Statutes, the foregoing rule violation is a class II violation in that it directly threatened the physical or emotional health, safety, or security of the two residents. Pursuant to Section 400.419(1) and (2) (b), Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE II in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that ‘the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” 17 CLAIM FOR RELIEF i | WHEREFORE, AHCA demands the following relief: oe : a. Enter factual and legal !findings as set forth in the allegations of this count. i b. Impose a fine in the amount of $1,000.00 for the referenced violation. COUNT _V FAILURE TO CONDUCT BACKGROUND SCREENING OF FACILITY EMPLOYEES Subsections 400.4174(2), 400.419 (a) and (2) (b), and 435.03, Fla. Stat. (2003) Rule 58A-5.019(3), Florida Administrative Code CLASS II DEFICIENCY ' 34. AHCA re-alleges and incorporates by reference t paragraphs (1) through (8) above as, if fully.set forth herein. 35. AHCA surveyors conducted a biennial survey at APPLE HOUSE II on or about February 24, 2004, that determined that the Facility did not document, background screening of some of its employees. ; 36. Pursuant to Section 400.4174(2), Florida Statutes, the owner or administrator of an assisted living facility must conduct level 1 background screening, as set forth in chapter 435, on all employees hired on or after October 1, 1998, who perform personal services as defined in section 400.402(17), F.S. Also, pursuant to Rule 58A-5.019(3), Florida 18 i Administrative Code, all staff, hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with section 400.4174, F.S. and meet the screening standards of section 435.03, F.S. This Standard was not met as evidenced by the following observations: Based on record review and interview the facility failed to provide documentation ofa level! background screening on three of five licensed employees. Failure to ensure Level I background ' checks on all employees puts all residents at risk for abuse, neglect or exploitation. n 4 Findings: Review of personnel records revealed that three of the licensed practical nurses, LG date of hire 9/25/02; KP date of hire 1/ 17/02; and CM date of hire 2/21/04; did not have documentation of Level 1 background checks in their records. ' Interview with the Assistant Administrator and Administrator on 2/24/04 revealed that since Level 1 background checks were done when nursing licenses were renewed the facility did not have to do the checks. . 37. Based on the foregoing the Respondent is in violation of Section 400.4174(2), Florida Statutes and Rule 58A-5.019(3), Florida administrative Code (2003), for failing to ensure these employees underwent a “level 1 background screening”. 38. Pursuant to subsection 419.419(2) (b), Florida Statutes, the foregoing rule violation is a class -I violation in that it directly threatened the physical or emotional health, safety, or security of the two residents. Pursuant to Section 400.419(1) and’ (2) (b), Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE II in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) 19 for a class II violation which is defined as one that “the agehcy determines directly threatens the physical or emotional { . —_ health, safety, or security of the facility residents, other ' than class I violations.” CLAIM FOR RELIEF WHEREFORE, AHCA demands 'the following relief: set. forth in the a. Enter factual and legal findings as t allegations of this count. b. Impose a fine in the amount of $1,000.00 for the referenced violation. COUNT .VI FAILURE TO DISPOSE’ OF ; ' ABANDONED AND EXPIRED MEDICATIONS AND OTHER CONTROLLED \ SUBSTANCES 400.4255(1), and 400.4256, and 400.419, Florida Statutes Rule 58A-5.0185(6)(e), Florida Administrative Code CLASS II DEFICIENCY 39. AHCA re-alleges and incorporates by reference paragraphs (1) through (8) above as if fully set forth herein. 40. AHCA surveyors conducted a biennial visit at APPLE HOUSE II on or about February 24, 2004, that determined the following deficiencies: Based on record review and staff interview the facility failed to have a system of documentation in place when partially used packages of resident's medication or controlled substance were expired, discontinued or recalled. The disposal of the control substances by a registered nurse without documentation and witness compromises the validity of the account of disposal. Findings: 20 ‘ 4 A 2/24/2004 review of resident #4's medication records and a 10:45 AM interview with staff nurse revealed a change in medication orders from Duragesic 50 milligram/hour (MCG/HR) to 75MCG/HR. Staff nurse also advised that one batch of resident #4's 75MCG/HR had been recalled. Staff nurse advised that she had placed both aside to be picked up by the pharmacy. Interview with the Administrator on 2/24/2004 at 11:40 AM revealed that upon expiration or discontinuation if it is a non-controlled medication in a full blister pack it would be returned to the pharmacy. If it is a partial blister pack or a controlled substance she takes control of the medication and destroys it with no witness. She does not document this in the resident's record. 41. Rule 58A-5.0185(6) (e), Florida Administrative Code ' (2003) requires ‘the Respondent to have a system of documentation : in place when partially used packages of resident's medication or controlled substance were expired, discontinued or recalled. The disposal of the control substances by a registered nurse without documentation and witness compromises the validity of the account of disposal. ‘ 1 42. Rule 58A-5.0185(6) (e), Florida Administrative Code (2003), establishes that: \ (6) MEDICATION STORAGE AND DISPOSAL. (e) Medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented in the resident’s record. The medication may be taken to a pharmacist for disposal or may be destroyed by the administrator or'designee with one witness. 43. Based on the foregoing, APPLE HOUSE II violated the above-referenced provisions of Rule 58A-5.0185 Florida Administrative Code (2003). 44. Pursuant to subsection 419.419(2) (b), Florida Statutes, the foregoing rule violation is a class II violation in that it directly threatened the physical or emotional health, 21 safety, or security of the two residents. Pursuant to Séétion 400.419(1) and (2) (b), Florida Statutes (2003), the Agenty.is ; : ; ¥~4 authorized to impose an administrative fine against APPLE’ HOUSE ' It in the amount of FIVE THOUSAND AND NO/100 DOLLARS ($5,000.00) ' for a class II violation which is defined as one that *the agency determines directly threatens the'physical or emotional health, safety, or security of the facility residents, other ‘ than class I violations.” CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. ‘Enter factual and legal findings as set forth in the -'allegations of this count. vo : ; ' | .b.t Impose a fine in the amount of $5,000.00 for the referenced ; violation. COUNT VII VIOLATION: ONLY A PHARMACIST MAY TRANSFER MEDICATIONS FROM ONE STORAGE CONTAINER TO ANOTHER 400.4255(1), and 400.4256, 400.419, Florida Statutes Rule 58A-5.0185(7)(b), Florida Administrative Code CLASS II DEFICIENCY 45. AHCA re-alleges and incorporates by reference paragraphs (1) through (8) above as if fully set forth herein. 46. AHCA surveyors conducted a biennial visit at APPLE HOUSE II on or about February 24, 2004, that determined that the 22 Facility failed to treat resident drug prescriptions in a proper and accountable fashion, contrary to the provisions of Rule 58A- 5.0185, Florida administrative Code. The findings of that survey are as follows: | Based on record review, observation and staff interview facility failed to prevent the transfer of one resident's control drug to another resident by someone other than a pharmacist. Findings: | On 2/24/2004 a review of resident #4's chart revealed that in 6/2003, 8/2003, 9/2003 and 12/2003 Lortab, a control.drug, was borrowed numerous times from other resident's containers and administer to resident '#4 by a staff nurse or medication technician. On 2/24/2004 during a random review of the facility's February 2004 Individual Patient's Narcotic Records it was observed that a sticker bearing resident #1's name and the directions for medication use had been affixed to another resident's (#8) Narcotic Record. A 4:34 PM interview with the nurse verified resident #8's information under the sticker. A 5:14 PM interview with the Administrator revealed that resident #8 resided at the Administrator's other facility, Apple House I in Pomona Park. ‘ ' 47. Rule 58A-5.0185(7) (b), | Florida Administrative Code (2003), establishes: 58A-5.0185 Medication Practices. Pursuant to Sections 400.4255 and 400.4256, F.S., and this rule, facilities holding a standard, limited mental health, extended congregate care, or limited nursing services license may assist with the self-administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule. (1) SELF ADMINISTERED MEDICATIONS. (a) Residents who are capable of self-administering their medications without assistance shall be encouraged and allowed to do so. (b) If facility staff note deviations which could reasonably be attributed to the improper self- administration of medication, staff hall consult with the resident concerning any problems the resident may be experiencing with the medications, the need to notify the resident’s health care provider, or to permit the facility to aid the resident through the use of a pill organizer, provide assistance with self-administration, or administer medications if such services are offered by the facility. (2) WEEKLY PILL ORGANIZERS. (a) A nurse may manage a weekly pill organizer for residents who self-administer. A “weekly pill organizer” means a container which is designed to hold solid doses of m edication and is divided according to day and time increments not to exceed 7 days. 1. The nurse shall manage the pill organizer in the following manner: = a. Obtain the labeled medication container from the storage area or the resident; , b. Transfer the medication from the origina! container into a pill organizer, labeled with the resident’s name, according to the day and time ingrements as prescribed; and a c. Return the medication container to the storage area or resident. 2. The nurse is responsible for instructing the resident with respect to the proper use of the pill organizer. (b) If there is a determination that the resident is not taking medications as prescribed’: after the benefits are explained it shall be noted in the resident’s record and the facility shall consult with the resident concerning providing assistance with self-administration, or the administration of medications if such services are offered by the facility. The facility shall contact the resident’s health care provider regarding questions, concerns, or observations relating to the resident’s medications. Such communication shall be documented in the residerit’s record. (3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) For facilities which provide assistance with self:administered medication, either: a nurse; or an unlicensed staff member, who is at least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5.0191, F.A.C., and able to demonstrate to the | . administrator the ability to accurately read and interpret a prescription label, must be available to assist residents with self-administered medications in accordance with procedures described in Section 400.4256, F.S. , (b) In order to facilitate assistance with self-administration staff may prepare and make avajlable such items as water, juice, cups, spoons, etc.,'as needed by résidents. Staff may also return unused doses to the medication container. Medication which appears to have been contaminated, shall not be returned to the container. (c) Staff shall observe the resident take the medication. Any concerns about the resident’s reaction to the medication shall be reported to the resident’s health care provider and documented in the resident’s record. ; (d) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to enable the resident to take medication as prescribed: 1. The health care provider may prescribe a medication schedule which coincides with the resident’s presence in the facility; ‘ 2. The medication container may be given to the resident or a friend or family member upon leaving the facility, with this fact noted in the resident’s medication record; 3. The medication may be transferred to a weekly pill organizer pursuant to the requirements of subsection (2), and given to the resident or a friend or family member upon leaving the facility, with this fact noted in the resident’s medication record; or 4. Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose packaging; , (4) MEDICATION ADMINISTRATION. (a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider’s order or prescription label. (b) Unusual reactions or a significant change in the resident’s health or behavior shall be documented in the resident’s record 24 and reported immediately to the resident’s health care provider. (c) Medication administration includes the conducting of any examination or testing such as blood glucose testing or other procedure necessary for the proper administration of medication that the resident cannot conduct himself and that can be performed by licensed staff. (d) A facility which performs clinical laboratory tests for residents, including blood glucose testing, must be in compliance with the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Part I of Chapter 483, F.S. A copy of the state license or a Certificate of Exemption must be maintained in the facility. A state license or certificate of exemption is not required if the resident performs the test himself/herself or if the test is performed by a third party. Information about laboratory licensing is available from the Clinical Laboratory Licensure Unit, Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, FL 32308; ' telephone (850) 487-3109. (5) MEDICATION RECORDS. (a) For residents who use a weekly pill organizer managed under subsection (2), the facility shall keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider’s name, the resident’s name, the date dispensed, the name and strength of the drug, and the directions for use. (b) For residents who receive assistance with self-administration or medication administration, the facility shall maintain a daily up-to-date, medication observation record (MOR) for each resident. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name of each medication prescribed, its strength, and directions for use; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. ; (c) For medications which serve as chemical restraints, the facility shall, pursuant to Section 400.441, F.S., maintain a record, of the prescribing physician’s annual evaluation, of the use of the medication. " (6) MEDICATION STORAGE AND DISPOSAL. (a) In order to accommodate the needs and preferences of residents and to encourage residents to remain as independent as possible, a resident may keep his/her medication, both prescription and over-the-counter, on his/her person both on or off the facility premises; or in his/her room or apartment which must be kept locked when the resident is absent unless the medication isina secure place within the room or apartment; or in some other secure place which is out of sight of other residents. However, both prescription and over-the-counter medication for a resident shall be centrally stored if: 1. The facility administers the medication; 2. The resident requests central storage; 3. The medication is determined and documented by the health care provider to be hazardous if kept in the personal possession of the person for whom it is prescribed; 4. The resident fails to maintain the medication in a safe manner as described in this paragraph; 5. The facility determines that because of physical arrangements and the conditions or habits of residents, the personal possession of medication by a resident poses a safety hazard to other residents; or 25 6. The facility’s rules and regulations require central storage of medication and that fdlicy has been provided to the resident prior to admission as required under Rule 58A-5 0181, F. AL. (b) Centrally stored medications must be: ! 1. Kept in a locked cabinet, locked cart, or other Jocked storage receptacle, room, or area at all times; 2. Located: in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration shall be refrigerated. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in which refrigerator is located locked; 3. Accessible to staff responsible for filling pill-organizers, assisting with self-administration, or administering medication. Such staff must have ready access to keys to the medication storage areas at all times; and 4. Kept separately from the medications of other residents and properly closed or sealed. (c) Medication which has been discontinued but which has not expiréd shall be returned to the resident or the resident’s representative, as appropriate, or may be centrally stored by the facility for future resident use by the resident at the resident’s request. If centrally stored by the facility, it shall be stored separately from medication in current use, and the area in which it is stored shall be marked “discontinued medication.” Such medication may be reused if re-prescribed by ' the resident’s health care provider. (d) When a resident’s stay in the facility has ended, ‘the administrator shall return all medications to the resident, the resident’s family, or the resident’s guardian unless otherwise prohibited by law. If, after notification and waiting at least 15 days, the resident’s medications are still at, the ' ‘facility, the medications shall be considered abandoned and may disposed of in accordance with ‘paragraph (e). .(e) Medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented in the resident’s record. The medication may be taken to a pharmacist for disposal or may be destroyed by the administrator or designee with one witness. (f) Facilities that hold a Special-ALF permit issued by the Board of Pharmacy may return dispensed medicinal drugs to the dispensing pharmacy pursuant to Rule 64B16-28.870, F.A.C. (7) MEDICATION LABELING AND ORDERS. (a) No prescription drug shall be kept by the facility unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, F.S. (b) Except with respect to the use of weekly pill organizers as described in subsection (2), no person other than a pharmacist may transfer medications from one storage container to another. (c) If the directions for use are “as needed” or “as directed,” the health care provider shall be contacted and requested to provide revised instructions. For an “as needed” prescription, the circumstances under which it would be appropriate for the resident to request the medication and any limitations shall be specified; for example, “as needed for pain, not to exceed 4 tablets per day.” The revised instructions, including the date they were obtained from the health care provider and the signature of the staff who obtained them, shall be noted in the medication record, or a revised label shall be obtained from the pharmacist. (d) Any change in directions for use of a medication for which the facility is providing assistance with self-administration or administering medication must be accompanied by a written medication order issued and signed by the resident’s health care provider, or a faxed copy of such order. The new directions shall promptly be recorded in the resident’s medication 26 dbservation record. The facility may then place an “alert” label on the medication container which directs staff to examine the revised directions for use in the MOR, or obtain a revised label from the pharmacist. (e) A nurse may take a medication order by telephone. Such order must be promptly documented in the resident’s medication observation record. The facility must obtain a written medication order from the health care provider within 10 working days. A faxed copy of a signed order is acceptable. (f) The facility shall make every reasonable effort to ensure that prescriptions for residents who - receive assistance with self-administration or medication administration are refilled in a timely manner. , (8) OVER THE COUNTER (OTC) MEDICATIONS. (a) A stock supply of OTC medications for multiple resident use is not permitted in any facility. (b) Non-prescription over-the-counter drugs, when centrally stored, shall be labeled with the resident’s name, and the manufacturer’s label with directions for use shall be kept with the medication. i (c) When an over-the-counter medication is prescribed by a health care provider, the medication becomes a prescription medication and shall be managed in accordance with prescription medication under this rule. 48. Based on the foregoing, APPLE HOUSE II violated the ‘ ‘ above-referenced provisions of Rule 58A-5.0185(7), Florida Administrative Code (2003), because the findings represent violations of section 499.005, Florida Statutes, entitled “Prohibited acts.” : 1 49. Pursuant to subsection 419.419(2) (b), Florida Statutes, the foregoing rule violation is a class II violation in that it directly threatened the physical or emotional health, safety, or security of the affected residents. Pursuant to Section 400.419(1) and (2) (b), Florida Statutes (2002), the Agency is authorized to impose an administrative fine against APPLE HOUSE IL in the amount of FIVE THOUSAND AND NO/100 DOLLARS ($5,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or 27 emotional health, safety, or security of the facility residents, law othér than class I violations. ' , \ ~ CLAIM , FOR RELIEF 1 WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in the allegations of this count. b. Impose a fine in the amount of $5,000.00 for the referenced i violation. 4 COUNT VIII UNAUTHORIZED USE OF PHYSICAL RESTRAINT ON RESIDENTS Subsections 400.441(1) (k), 400.419 (a) and (2) (b), Rule 58A-5.0182(6)(h), ' ‘orida Administrative Code 50., AHCA re-alleges and incorporates by reference (8) above as if fully set forth herein. 51. AHCA surveyors conducted a survey tour with a staff paragraphs (1) through member of APPLE HOUSE II on or about February 24, 2004, that cited against APPLE HOUSE It. resulted in a class II deficiency 52. The regulatory provision that is pertinent to this alleged violation is Subsection 400.441 (1) (k), Florida Statutes, and the related administrative rule, which reads as follows: Rule 58A4-5.0182, Florida Administrative Code (2003), Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility... 28 (6) RESIDENT RIGHTS AND FACILITY PROCEDURES.... (h) Pursuant to Section 400.441, F.S., the use of physical restraints shall be limited to half-bed rails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance shall not be considered a physical restraint. 53. The Facility failed to Limit utilization of half-bed y upon the written order of the rails as a bed restraint, and onl resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative, as evidence by the following survey findings: Based on observation and staff interview it was determined that the facility routinely uses half- bed rails for residents without obtaining written physician's order (with the physician's review every 6 months) or'the written consent of the resident or their representative. Findings: During the Initial tour it was determined that all of the resident beds had half-bed rails. Observation on 2/24/04 at 10:20 AM revealed that resident #4 was in bed with the half-bed rails up. At 1:53 PM on 02/24/04 resident #2 was observed in bed with the half-bed rails up. Interview with the administrator on 02/24/04 at 1 1:40 AM tevealed that there were no written orders for the use of half-bed rails. She stated that the facility had a standing verbal order from the medical director for the use of half-bed rails for anyone over 85 years old. She further reported that the order was verbal and that there were no written orders for half-bed rails. 54, On or about February 24, 2004, AHCA provided Respondent with a mandated correction date of March 25, 2004, within which to correct the referenced deficient practices. 55. Based on the foregoing, APPLE HOUSE II violated the above-referenced provisions of Rule 58A-5.0182 (6) (a) Florida Administrative Code (2003), by the failure to limit restraints posed by half-bedrails, and only upon the written order of the 29 on: resident’s physician, who shall review the order biannually, and i i} the consent of the resident or the resident’s representative. 56. The foregoing unauthorized use of restraints is a class II violation in that it directly threatened the physical ote or emotional health, safety, or security of Residents” #4,5,8,20,21 and 22. Pursuant to Section 419.419(2) (b), Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE ‘HOUSE II in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00) for a class II violation which is defined as one that “the agency determines directly threatens the physical or emotional health, safety, or security ' ' of the facility residents, other than class I violations.” i} CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal ' findings as set forth in the allegations of this count. b. Impose a fine in the amount of $1,000.00 for the referenced violation. COUNT IX UNAUTHORIZED USE OF PHYSICAL RESTRAINT ON RESIDENTS Subsections 400.441(1) (k), 400.419 (a) and (2)(c), F.S. Rule 58A-5.0182(6)(h), Florida Administrative Code 30 UNCORRECTED CLASS III DEFICIENCY 57. BHCA re-alleges and incorporates by reference paragraphs (50) through (56) above as if fully set forth herein. 58. On or about April 6, 2004, a first follow-up survey was conducted at Respondent’s facility. At that survey, AHCA surveyors again discovered: Based on record review and interview the facility continued to use half bed rails on all residents. The facility had obtained a written order from the physician, but the facility had failed to obtain consent of the resident or the resident's representative for the use of the restraints. Failure to obtain consent violates the resident's right to participate in their care decisions. Findings: Review of the five sampled residents revealed that all records had orders for half bed rail, but that none of the residents had a signed consent in the record. Interview with the administrator on 04/06/04 at 9:15 AM revealed that the residents had all given verbal consent to the half bed rails and that she had not obtained a written consent. : ‘ " 59. This finding constitutes a repeat Class III deficiency because the inaction indirectly or potentially threatened the > physical or emotional health, safety, or security of the facility’s residents. Pursuant to Sections 409.419(1), and (2) (c), Florida Statutes, the Agency is authorized to impose a fine in the amount of not less than five hundred dollars ($500), but not exceeding one thousand ($1,000) for this violation. CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in the allegations of this count. 31 b. Impose a fine in the amount of $500.00 for the refer@nced violation. t 197 ay, ne COUNT xX FAILURE TO COMPLY WITH PRIVACY RULE AND THE RESIDENT CARE STANDARDS ENUMERATED IN THE RESIDENT BILL OF RIGHTS* ores Sections 400.428(1), 400.419 (a).and (2) (ce), F.S. Rule 58A-5.023(5)(e), Florida Administrative Code (2003) 60. AHCA re-alleges and incorporates by reference paragraphs (1) through (8) above as if fully set forth herein. 61. The statutory guarantee applicable to this alleged violation reads as follows: §400.428, Florida Statutes (2003), Resident bill of rights.— ' '1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or ; privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident ofa facility. Every resident shall have ’ the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal individuality, and need for privacy. 62. AHCA surveyors conducted a monitoring inspection visit at APPLE HOUSE II on or about February 24, 2004, that resulted in the following class III deficiency cited against APPLE HOUSE II on findings below that relate to Rule 58A-5.023 (5) (e), Florida Administrative Code, that establishes that residents, who use portable bedside commodes in semi private rooms, be provided with privacy in their use: 32 Findings: During Initial tour, portable bedside commodes were observed in rooms 12, 13 and 14 but no privacy screens were observed in these rooms. Room #13 door was locked on initial tour. When the door was opened resident #1, who was very short of breath, was sitting in a chair beside the portable bedside commode. A staff caregiver was returning the pot to the portable bedside commode. Interview with staff on 02/24/04 at 2:20 PM revealed that the facility did not have privacy screens available in the facility. During Exit interview on 2/24/04 at 7:00 PM the - Administrator stated that the portable bedside commodes were only used at night and because of the dark it was private. 63. On or about February 24, 2004, AHCA provided Respondent with'a mandated correction date of March 25, 2004, within which to correct the above-referenced deficient practices. 64. On or about April 6, 2004, a first follow-up survey was \ conducted at Respondent’ s facility. At that survey, AHCA syrveyors again discovered the facility continued to failed to provide privacy screens in semi private rooms where portable bedside commodes are used. Failure to provide privacy while ' iy using the toilet facilities violates the residents’ rights and Rule 58A-5.023(5) (e), Florida Administrative Code (2003). Findings: During tour on 04/05/04 at 10:30 AM and on tour on 04/06/04 at 8:30 AM portable bedside commodes were observed in rooms #8, #12, #13 and #14 without privacy screens being present in the rooms. Interview with the Administrator who said that most of the resident are only using the portable bedside commodes at night. She had called about purchasing the privacy screens and the price of one screen was from $150.00 to $300.00. She stated that her husband had made "U" shaped frames out of I inch aluminum pipe which he was going to hinge two together to make a privacy screen. He had hinged one set together but a staff member had taken that set to use to make the material part of the screen. The staff member is going to make the material part of the screen in the style of pillow case covers that would be Velcro closed on one side and the bottom for easy tad tao removal and exchange for cleaning. She had the material and planned to start makirly the screens on her next day off. = 65. The Facility failed to ensure compliance with the ~ above administrative rule and that these Residents were free from neglect and treated with consideration and due recognition of a need. for privacy pursuant to section 400.428, Florida Statutes (2003), as evidenced by the above findings. 66. This finding constitutes a repeat Class III deficiency because the inaction indirectly (or potentially threatened the physical or emotional health, safety, or security. of the facility’s residents. Pursuant: to Sections 400.419(1), and (2) (c), Florida Statutes, the Agency is authorized to impose a ' firie'in the amount of not less than five hundred dollars ($500), ' but not exceeding one thousand ($1,000) for this violation. . CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in the, allegations of this count. b. Impose a fine in the amount of $500.00 for the referenced violation. — c. Assess survey costs in the amount of $500.00, related to the investigation of this case as authorized by Section 400.419(10), Florida Statutes (2003). 34 COUNT XI VIOLATION FOR FAILURE TO DISCHARGE RESIDENT WHO IS NO LONGER APPROPRIATE FOR CONTINUED PLACEMENT AT THE FACILITY Subsections 400.419 (a) and (2) (b), 400.426(8) and 400.428(1) (k), Fla. Stat. (2003) Rule 58A-5.0181(1)(m) and (5), Florida Administrative Code CLASS II DEFICIENCY REPEAT j 67. AHCA re-alleges and incorporates by reference paragraphs (1) through (15) above as if fully set forth herein. i 68. On or about June 28, 2004, a third follow-up survey was conducted at Respondent’s facility. At that survey, AHCA surveyors again discovered the continuing inappropriate resident placement issues cited in Count I above and that the Respondent had not reacted to ACHA’s notification to the Facility on or about February 24, 2004, and the Respondent took no action as required by rule and statute to resolve this placelhent issue. Those findings are; Based on observation, interview and record review, the facility failed to ensure that 1 (Resident previously identified as Resident #2) of 25 residents was transferred from the facility after providing the family with the required 45-day notice that the resident's care needs exceeded the facility's licensed capabilities. Failure to transfer inappropriate residents increases the potential for neglect of those residents whose needs are medically complex and require more skilled nursing care. : Findings: Observations at the facility on 6/28/04 from 10:45 AM until 11:25 AM revealed resident #2, (who had previously been documented in the 2/24/04 Biennial Licensure Survey as being inappropriate due to the inability to transfer) was still present in the facility. On initial tour the resident was observed resting in his/her lounge chair. Further observation at 11:10 AM was made of the transfer of resident #2 from the lounge chair to the wheel chair. Two nursing assistants with the assistance of a gait belt lifted the resident up from the lounge chair and then moved the wheel chair up and under resident #2's legs and then sat him/her down in the wheel chair. At no time did resident #2 place any weight on his/her feet to assist in the transfer. 35 Interview with the Facility Alternate Administrator and the Facility License Practical Nurse (LPN) otk6/28/04 at 11:25AM, revealed that the resident had been placed on Extended Congregate Care (ECC) "last week”. The Alternate Administrator stated that the Administrator has the Resident's new care plan for ECC with her. Further interviews revealed that the resident is on a waiting fist for a skilled nursing facility and that the facility makes daily calls to see if they have aiplace for Resident #2. 1 Record review revealed that the family of resident #2 was notified in writing by the facility, on 3/08/04, that the resident was no longer appropriate for placement in the Assisted Living Facility. Physician orders and nurses notes dated 6/26/04 reveal no new orders for ECC or documentation of any discussions of ECC services. Documentation on The Monthly Resident Summary Observation form dated for 6/4/04 revealed that Resident #2 is disoriented, unable to speak, has to be fed, and is bathed and dressed with total help. Also documented on the form is that the resident needs assistance of 1-2 for transferring. \ ' Review of information faxed to the Agency for Health Care Administration office on 6/30/04 by the facility revealed that a letter dated June 28, 2004 has been sent to the Resident #2 's family. member to advise that the resident is being transferred to ECC Services. Further review of the information faxed revealed a new Resident Service Care Plan dated 6/25/04 that had been signed by the Administrator and the resident's farhily member. Review of this care plan revealed that the resident is non-ambulatory and unable to feed him/herself due to the resident being unable to move hands or arms. 4 69. Based on the foregoing, APPLE HOUSE II violated the above-referenced statutory provisions and Rule 58A-5.0181 Florida Administrative Code (2003), by the administrator failing ' to timely react to the AHCA’s notification and for not notifying ‘representatives of the resident and resolving the issue that ‘ this resident was inappropriate for ALF residency and needed to be discharged to a skilled nursing facility. 70. Pursuant to subsection 419.419(2) (b), Florida Statutes, the foregoing rule violation is a class II violation ‘ in that it directly threatened the physical or emotional health, safety, or security of this particular resident. Pursuant to Section 400.419(1) and (2) (b), Florida Statutes (2003), the Agency is authorized to impose an administrative fine against APPLE HOUSE II in the amount of FIVE THOUSAND AND NO/100 DOLLARS ($5,000.00) for a class II violation which is defined as one 36 1 ‘that “the agency determines directly threatens the physical or emotional health, safety, or security of the facility residents, other than class I violations.” CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: a. Enter factual and legal findings as set forth in the 1 allegations of this count. b. Impose a fine in the amount of $5,000.00 for the referenced violation. ' NOTICE Apple 'House II hereby is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 i) and 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of 1 ' i Rights form and explained in the attached Explanation of Rights form. All requests for a hearing shall.be sent to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida, 32308. APPLE HOUSE II, IS FURTHER NOTIFIED THAT IF THE REQUEST FOR ' HEARING IS NOT RECEIVED BY THE AGENCY WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT BY GENTIVA, A FINAL ORDER WILL BE RENDERED BY THE AGENCY FINDING THE DEFICIENCY AND/OR. VIOLATION CHARGED AND IMPOSING THE PENALTY SOUGHT IN THE ADMINISTRATIVE COMPLAINT. 37 Respectfully submitted on this / 7 day of August 3004. 1 Robert F. Langfo FL Bar No.: 68949 Respondent’s Counsel Assistant General Counse% Agency For Health Care Administration 2727 Mahan Drive, MS. #3 Tallahassee, Florida 32308 (850) 922-8854 (850) 921-0158 (fax) aS abs CERTIFICATE OF SERVICE I HEREBY CERTIFY that one original Administrative Complaint has been sent via certified mail return receipt requested (return - receipt #9004 [DIO DOOD. tl27__) to Beverly A. Pascoe, Esq. 7 Counsel for Apple House, Inc.; Rogers Towers, P.A., 1301 Riverplace Boulevard, Suite 1500, Jacksonville, FL 32207; on this l / day of 2004. 38

Docket for Case No: 04-003371