pe, EXHIBIT a STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA ey o AGENCY FOR HEALTH CARE "Oo, 08 ADMINISTRATION, . ya Xe vet PS a, Patitioner, on “ay “ao vs, Case No. 2004002185 “s 2004005421 ed 2004008508 C & M HEALTHCARE CORPORATION, d/b/a COUNTRYSIDE HAVEN, | Gy Respondent. CY zeks | ey ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency” or “AHCA”), by and through the undersigned counsel, and filea this Administrative Complaint against c & M HEALTHCARE CORPORATION, d/b/a COUNTRYSIDE HAVEN (hereinafter ‘Respondent”), pursuant to Section 120.569 ang 120.57, Fla, Stat, (2003), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the - amount of $3,100.00, based upon the Respondent being cited with one State Class ITI deficiency, two repeat State Class IIr deficiencies, two uncorrected State Class IIT deficiencies, and one uncorrected State Class IV deficiency, pursuant to $§ 400,419(2) (b), 400.419(2) (c), and 400.419(2) (d), Fla. Stat. (2003), and a survey fee in the amount of $500.00 pursuant to § 400.419(10) Fla. Stat,, (2003), JURISDICTION AND VENUE 1, The Agency has jurisdiction Pursuant to §§ 20.42, 120.60 and 400.407, 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 assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities Pursuant to the Chapter 400, Part III, Pla. Stat, and Fla. Admin. code 58A-5, Yreapectively. 4. Respondent operates a 30-bed assisted living facility located at 6960 CR 95, Palm Harbor, Pinellas County, Florida 34684, and is licensed as an assisted living facility under license number 5305. 5. Respondent is, and was at all times material hereto, a licensed facility under Chapter 400, Part III, Fla. Stat. and Chapter 58A-5, Fla. Admin. Code. COUNT IT €. AHCA re-alleges and incorporates paragraphs (1) throug Pro" (5) as if fully set forth herein. 7, Pursuant to § 400.428(1), Fla. Stat. (2003), the Respondent ia required to comply with the Resident Bill of Rights, including providing residents with a safe and decent living environment, free from abuse and neglect, and treating residents with consideration and respect and with due recognition of personal dignity. 8. On February 5, 2004, the Agency conducted a complaint investigation at Raspondent’s facility. 9. Based on review of the Facility Employee Manual, documentation by the Administrator, and staff interviews, conducted on February 5, 2004, the Agency determined that Respondent failed to comply with the Resident Bill of Rights, including ensuring that residents live in a safe environment, free from abuge and neglect, and ensuring that residents are treated with consideration and respect, for two of three residents (Resident #1 and Resident #2) reviewed by failing to report allegations of resident abuse to the abuse hotline, in violation of § 400.428(1), Fla. Stat, 10. Based upon a confidential staff interview conducted during the investigation, the Agency determined that Resident #1 had a confrontation with an employee (Employee #1) “last week”, when the employee put a pillow over Resident #1’s face to quite him/her, Soro ree 1228 A378 NSAVH 3ACISASLNNAD Wd @f28sa +eaz—raG—AON ’ 11. The employee denied any problems with Resident #1, and stated that he/she just wanted the “residents taken care of like family”, 12. The employee was questioned about whether a pillow had been thrown at the resident, however, the employeedenied this and, instead, demonstrated that a Pillow was purposefully pushed against the resident’s face to make him/her quiet, 13. The Administrator stated in an interview on February 5, 2004, that he/she had been told about the incidents, but believed they had occurred “23 months ago”. 14, The Administrator was questioned as to the reason he/she did not call the abuse hotline, and he/she stated that the reason was “because we don’t know it’s true”. 15. The Administrator also stated that he/she “waned to be fair to my employees” and wanted to fully investigate the allegations before deciding to call. 16. Based upon the Administrator’s statements, the Agency determined that the facility’s focus was not on the residents and their protection, but onthe impact on its employees. 17. Although the Administrator stated after the Meeting on February 5, 2004, that he/she had told the employees to always ave another employee with them when giving care, the Agency observed staff entering and leaving resiant rooms alone during the survey, 18, According to a confidential staff interview and review of documentation from the Administrator's notebook concerning his/her meeting with two staff members on the prior Sunday, the Agency determined that Employee #1 also had a confrontation during the week of 1/26-1/30/04 with Resident #2, in which the employee “put a pillow on the (Resident’s) face to stop (named Resident) him/her from yelling” as the resident was being changed. 19. The Administrator’s also stated in his/her notebook, “This happened two times already”. 20. The Administrator stated that, according to Employee #1, he/she “was joking”, and the Administrator did not believe three (other) employees concerning what was occurring, 21. Based upon a confidential staff interview, the Agency determined that the Administrator was told by staff about this incident “about 3 weeks ago”, and staff stated, “ft didn’t call the abuse number and 1 thought they (the Administrator or Spouse) would call”; however, this did not ogcur. 22. Both confidential interviewees denied a personality conflict with Employee #1, but wanted only “to protect the residents”. 23, Resident #2 was observed in the facility; however, he/she was unable to give any information due to a diagnosis of Dementia. 24. The resident was observed in his/her room, and was noted to be frail and thin, seated in a wheelchair, and required assistance with all Activities of Daily Living (ADL’s). 25, Resident #2 would have been unable to catch a pillow or protect him/herself. 26. According to a confidential staff interview, another altercation occurred with Resident #2 and Employee #1 about three months prior, but staff did not report it to the Administrator. 27. Staff stated that they did not report the incident to the administrator because “we worried he/she wouldn’t do anything, and that’s what has happened.” 28. During a staff interview, Employee #1 described disrespectful and abusive treatment that had occurred when changing Resident #2, however, Employee #1 did not recognize any concerns with anything he or she had done. 29. Employee #1 stated during the interview, “(the Resident) yells and wants to kick you; I picked up a pillow and threw it at him/her and he/she caught the pillow.” 30. Employee #1 denied putting a pillow over the resident’s face to make the resident be quiet. 31. Purther questioning revealed that Employee #2 “was surprised with complaints” relating to his/her behavior with residents. 32. Employee #1 denied any problems with Resident #1 and stated that he/she was not aware of “anything with named resident (Resident #1)”. 33. Upon review of the Employee Manual, which was dated July 1998 and was still in use, the Agency noted the statement “the safety of residents and employees is very important” under the Safety section. 34. The Employee Manual also stated that all incidents were to be reported to the supervisor “immediately”, however, this did not occur. 35. The Resident Rights poster and the Abuse Hotline telephone number were observed in the facility. 36. Based upon review of facility documentation related to the altercations, the Agency determined that none of the prior incidents had been reported. 37. The facilities last available document related to altercations was dated January 11, 2003, and was unrelated. 38. Employee #1 waa terminated from employment at the facility on February 5, 2004, the date of the investigation. 39, Based upon the aforementioned findings, the Agency found the Respondent to be in violation of § 400.428(1), Fla. Stat. 40, The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the residents which the Agency determined directly threatened the physical or emotional health, safety, ox security of the facility residents and cited Respondent for a State Clasa II deficiency. 41, The Agency provided Respondent with a mandatory correction date February 7, 2004, WHEREFORE, the Agency intende to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400,419(2) (b), Fla. Stat. COUNT IL 42, The Agency re-alleges and incorporated paragraphs (1) through (5) and paragraphs (7) through (41) aa if fully set forth herein. 43, Pursuant to § 400.419(10), Fla. Stat. (2003), the S2ro PBL 222 a1y NSAvH AGISAyLNNOS Wd £tiee PUBSS—bB-AON Agency may assess a survey fee, in addition to any administrative fines imposed, equal to the lesser of one-half of the facility’s biennial license and bed fee or $500.00. 44, The Respondent has been the subject of complaint investigation CCR# 2004000994, and is therefore subject to the additional fee. WHEREFORE, the Agency intends to impose an additional administrative fee in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla, Stat. COUNT IIT 45. The Agency re-alleges and incorporates paragrapha (1) through (5) as is fully set forth herein. 46, Pursuant to § 400.441(1) (a)l.m., Fla, Stat. (2002), and Fla. Admin. Code R. 58A-5.015(1) (a) (3), the Respondent is required to have an annual fire inspection conducted by the lecal fire marshal or authority having jurisdiction and shall provide documentation of a satisfactory fire safety inspection at the time of the Agency’s biennial survey. 47. On May 20, 2002, the Agency conducted a biennial state licensure survey at Respondent’s facility. 48. Based upon record review and interview, the Agency determined that the facility did not have a current satisfactory fire inspection available for review. 49. The Administrator stated in an interview that documentation was not available for review, as the fire department had not conducted a re-inspection of the annual inspection. 50. The Agency determined that the aforementioned finding was a violation of § 400.441(1) (a)l.m., Fla. Stat., and Fla. Admin. Code R. 58A-5.015(1) (a) (3). 51. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the facility residents and cited Respondent for a State Class III deficiency. 52. The Agency provided Respondent with a mandatory correction date of June 30, 2002. 53. On or about July 23, 2002, the Agency conducted a follow-up survey of Respondent's facility and determined that the above-cited violation had been corrected, 54. On April 26, 2004, the Agency conducted a biennial survey of Respondent’s facility. 55. Based on record review and interview, it wag determined the facility did not have a satisfactory annual fire inspection conducted by the local fire marshal or authority having jurisdiction. 10 56. During the survey, the Agency determined from a review of facility records that the last inspection report completed by the local fire jurisdiction was dated March 18, 2003, anda re-~- visit had been scheduled for March 30, 2003 to ascertain if cited violations had been corrected. 57, The Administrator stated in an interview during the survey that the re-visit had not been completed, and that the’ facility did not have a current annual fire inspection that indicated a satisfactory review. 58, The Agency determined that the aforementioned finding was in violation of § 400.441(1) (a)l.m., Pla. Stat., and Fla. Admin. Code R. 58A-5.015(1) (a) (3). 59. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the facility residents and cited Respondent for a repeat State Class III deficiency. 60. The Agency provided Respondent with a mandatory correction date of May 26, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. 1i COUNT IV 61. The Agency re-allegés and incorporates paragraphs (1) through (5) as ig fully set forth herein. 62, Pursuant to § 400.441, Fla. Stat., and Fla. Admin. Code R. 58A-5.0182(6) (h), the Respondent is required to ensure that the use of physical restraints ig 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. 63. On May 20, 2002, the Agency conducted a biennial state licensure survey at Respondent’s facility. 64. Based upon observation and record review, the Agency determined that the facility was utilizing half and full bedrails without written physician’s orders. 65. During a tour of the facility, Resident #2 was observed with a half-bed rail on her bed, and Resident #4 hada full-bed rail on her bed, 66. Review of Resident #2’s file revealed that there wag no physician’s order for the use of the half-bed rail, 67, The Agency determined that the aforementioned findings were violations of § 400.441, Fla. Stat., and Fla. Admin. Code R. 58A-~5.0182(6) (h). 12 68. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the pergonal care of the residents that indirectly or potentially threatened the health, safety, or security of the facility residents and cited Respondent for a State Class IfT deficiency, 69. The Agency provided Respondent with a mandatory correction date of June 30, 2002. 70. On or about July 23, 2002, the Agency conducted a follow-up survey of Respondent’s facility and determined that the above-cited violation had been corrected. 71. On April 26, 2004, the Agency conducted a. biennial survey of Respondent’s facility. 72. Based on record review, observation, and staff interview, the Agency determined that the facility failed to ensure that written orders for the use of half-hed rails were obtained for 3 of 7 residents (Resident #1, Resident #3, and Resident #4). 73. During the initial tour of the facility on April 26, 2004, the Agency noted that Residents #1, #3, and #4 all had half-bed rails on their beds. 74. Based upon review of the Resident’s medical charts, the Agency determined that none of the three Residents had physician’s orders for use of half-bed rails. 13 75, The Administrator indicated in an interview that the medical supply company would not deliver (bedrails) without duch an oxder, but she was unable to find an order in any of the said medical charts. 76. The Agency determined that the aforementioned findings were violations of § 400.441, Fla. Stat., and Fla, Admin. Code R. 58A-5.0182(6) (h). 77, The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the facility residents and cited Respondent for a repeat State Class III deficiency. 78. The Agency provided Respondent with a mandatory correction date of May 26, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Pla. Stat. COUNT V 79. The Agency re-alleges and incorporates paragraphs (1) through (5), paragraph (62), and paragraphs (71) through (78) as is fully set forth herein. 14 80. On June 8, 2004, the Agency conducted a re-visit survey at Respondent's facility. Bl, Based on record review, observation, and staff interview, the Agency determined that the facility failed to ensure that written orders for the use ef half-bed rails were obtained for 2 of 6 (Resident #2 and Resident #3) residents. 82. During the initial tour of the facility on June 8, 2004, the Agency observed that Residents #2 and #3 had half-bed yails on their beds. 83, Neither Resident #2 or Resident #3 had a physician’s order in their records, which allowed the use of half-bed raila. 84, Review of Resident # 3's record revealed an order for “bed rails”, but the order did not specify half-bed rails. 85, Review of Resident # 2's record revealed no order for half-bed rails. a6. During an interview with the Administrator, she revealed that she was unable to locate a physician’s order for Resident # 2's half-bed rails. 87. The Agency determined that the aforementioned findings were violations of § 400.44], Fla. Stat., and Fla. Admin. Code R. 58A-5.0182(6) (h). 88. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the residents that indirectly or 15 potentially threatened the health, Safety, or security of the facility residents and cited Respondent for an uncorrected State Class III deficiency. 89. The Agency provided Respondent with a mandatory correction date of July 8, 2004, WHEREFORE, the Agency intends to impose an administrative fine in the amount o£ $500.00 againat Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2) (a), Pla, Stat, 90, The Agency re-alleges and incorporates paragraphs (1) through (5) as is fully set forth herein. 91. Pursuant to § 400.4256(1) (a) and (b), Fla. Stat. (2003), Fla. admin. Cade R. 58A-5. 904 (3) (g) and R, S8a- 5.0181 (1) (e)1, facilities which have unlicensed staff assisting with the self-administration of medicationg must include a copy of the written informed consent in the resident’ s record, if and Resident #5) of seven sampled residents in the residents’ records acknowledging that unlicensed staff supervised their medications. 94, The Agency determined that the aforementioned findings were violations of § 400.4256(1) (a) and (b), Fla. Stat., and Fla. Admin. Code R. 58A-5.024(3)(g) and R. 58A-5.0181(1) (e)1. 95, The Agency determined that this deficient practice wae related to required reports, forms, or documents that do not have the potential of negatively affecting residents and cited Respondent for a State Class Iv deficiency. ‘96. The Agency provided Respondent with a mandatory correction date of May 26, 2004. 97. On June 8, 2004, the Agency conducted a re-visit survey. 98, Based on record review and interview, tha Agency determined that the facility, which used unlicensed staff to assist residents with self-administration of medications, did not have a copy of written informed consent for one (Resident #2) of six residents sampled. 99. During review of Resident # 2's record, a blank copy of a written informed consent form, which acknowledged that unlicensed staff supervises self-administration of medications, was found in the record. 17 100. The Administrator confirmed during an jnterview that neither Resident #2 nor Resident #2’s representative had signed the informed consent form, although unlicensed staff supervised Resident #2’s self-administration of medication. 101. The Agency determined that the aforementioned findings were violations of § 400,4256(1) (a) and (b), Fla. Stat., and Fla. Admin. Code R. 58A-5,024(3) (g) and R. 58A-5.0181 (1) (e)2.— 102. The Agency determined that this deficient practice was related to required reports, forms, or documents that do not have the potential of negatively affecting residents and cited Respondent for an uncorrected State Class IV deficiency. 103. The Agency provided Respondent with a mandatory correction date of July 8, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $100.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2) (d), Fla. Stat. COUNT VII 104, The Agency re-alleges and incorporates paragraphs (1) through (5) as is fully set forth herein, 105. Pursuant to Fla. Admin. Code R. 58A-5.0181(2) (a) and § 400,426(4) and (5), Fla. Stat. (2003), within 60 days prior to a residents admission to a facility but no later than 30 days after admission, the individual shall be examined by a physician 18 or advanced registered nurse practitioner who shall provide the administrator with a medical examination report, or a copy of the report, which addresses the following: a, 106. the physical and mental status of the resident, including the identification of any health-related problems and functional limitations; whether the individual requires supervision or asgistance with activities of daily living; any nursing or therapy services required; any special diet; a list of current prescribed medications, and whether the individual will need any assistance with the administration of medication; whether the individual has signs or symptoma of a communicable disease, which is likely to he transmitted to other residents or staff; a gtatement as to whether the individuals needs can be met in an assisted living facility; and, the date of the examination, the name, signature, address, phone number, and license number of the examining physician or ARNP. In addition, pursuant to Fla. Admin. Code R. 58A- 5.0181(2) (d), any information required by Fla. Admin. Code R. 58A-0.181(2) (a) that is not contained in the medical examination report conducted prior to the individual’s admission to the facility must be obtained by the administrator within 30 days after admission using DOEA Form 1823. 107. On April 26, 2004, the Agency conducted a biennial state licensure survey at Respondent’s facility. 108. Based on record review and staff interview, the Agency determined that the facility failed to ensure that the medical 13 examination report addressed all required criteria on 3 of 7 (Resident #1, Resident #3, and Resident #4) residents reviewed. 109, Review of Resident #1’s medical chart revealed a medical examination in which the date had been crossed out and inked over (the “3” in 2003 was changed to “4”), therefore, the examination was dated either February 17, 2003 or February 17, 2004. 110. Resident #1 was admitted to the facility on April 21, 2003, therefore, the medical examination report was not completed within 60 days prior to the resident’s admission nor within 30 days after the resident’s admission to the facility. 111. The medical examination form was annotated that. the resident had no pressure sores. 112. The form was also annotated that the Resident required only supervision in all areas of activities of daily living. 113. Based upon observation of the resident and interview with staff on April 26, 2004, the Agency determined that the resident was being treated by home health care for a pressure sore and had been admitted to the facility from the hospital with this pressure sore. 114. Review of Resident #1’s medical chart revealed a physician’s order dated December 31, 2003, for home health care to provide wound care and for a low-pressure mattress. 20 115. Observation of the Resident revealed that the Resident required the assistance of 2 people to transfer the Resident from a wheelchair to the bed. 116. Staff interview confirmed the need for 2 staff members to transfer the Resident. 117. Observation revealed that 2 nurses from the home health agency were needed to care for the Resident. 118, One nurse turned, positioned, and held the Resident while the other performed care and treatment. 119. Based upon review of the medical record, the Agency determined that Resident #3 had been admitted into the facility on October 8, 1999. 120. Resident #3’s health assessment did not contain a date, which documented when the physical examination had been completed. 121. The assessment documented that the resident required total care in ambulation, bathing, dressing, and transferring. 122. The Administrator stated in an interview during the survey that the assessment was not accurate, and that the Resident did not require total assistance with transferring or dressing, 123. Observation of the resident during the survey confirmed that Resident #3 did not require total assistance, 21 124. A review of Resident #4’s records revealed that the resident had been admitted into the facility on January 5, 2001. 125, A review of Resident 44's health assessment, dated January 14, 2004, identified that the resident required total assistance with ambulation, bathing, dressing, and transferring. 126. During an interview, the Administrator stated that the health assessment was not accurate, in that Resident #4 did not require total assistance in those areas. 127. Observation of Resident #4 during the survey on April 26, 2004, confirmed that Resident #4 did not require total assistance in the identified areas. 128. The Agency determined that the aforementioned findings were violations of Fla. Admin. Code R, 58A-5,0181(2) and § 400.426(4) and (5), Fla. Stat. 129. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the facility residents and cited Respondent for a State Clasa III deficiency. 130. The Agency provided Respondent with a mandatory correction date of May 26, 2004. 131. On June 8, 2004, the Agency conducted a re-visit survey of Respondent’s facility. 22 132. Based on record review and staff interview, the Agency determined that the facility failed to ensure that the medical examination report properly addressed al] required criteria on 1 of 6 (Resident #2) residents reviewed. 133. Review of the resident record for Resident #2 revealed that the resident had been admitted to the facility on January 26, 2004. 134. Resident #2’s health assessment was dated March 15, 2004, therefore, it had not been completed within 30 days of the Resident’s admission to the facility. 135, Review of the resident’s health assessment indicated under the medications section that the resident’s medications were to be pre-poured and administered, 136, The Administrator atated during an interview that the health assessment was not accurate, as the resident did not need to have medications administered. 137. The Administrator revealed that the resident was supervised in self-administration of medications by unlicensed staff. 138. The Agency determined that the aforementioned findings were violationsof Fla. Admin. Code R. 58A-5.0181(2) and § 400.426(4) and (5), Fla. Stat. 139. The Agency determined that this deficient practice was related to the operation and maintenance of the facility or to 23 the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the facility residents and cited Respondent for an uncorrected State Class III deficiency. 140. The Agency provided Respondent with a mandatory correction date of July 8, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an asgisted jiving facility in the State of Florida, pursuant to § 400.419(2) (c), Fla. Stat. Respectfully submitted this Qed day of November 2004.