STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 0s x) AGENCY FOR HEALTH CARE ADMINISTRATION, A Petitioner, vS. AHCA Case No. 2004009588 EMERITUS CORPORATION, _ ve CS -OSY% d/b/a THE PARK CLUB OF FORT MYERS, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (*“AHCA”) by and through the undersigned counsel, and files this Administrative Complaint against EMERITUS CORPORATION d/b/a THE PARK CLUB OF FORT MYERS (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and alleges: NATURE OF THE ACTION YO ee 1. This is an action to impose two administrative fines, each in the amount of $5,000, and a survey fee of $500, for a total of $10,500, against Respondent, pursuant to Sections 400.419(1)(c) and 400.419(2){a), 400.428(1), Florida Statutes (2004); and Rule58A-5.019(1), Florida Administrative Code (2004). 2. Respondent was cited for two Class I violations during a complaint investigation AHCA conducted on or about September 17, 2004. Page 1 of 13 JURISDICTION AND VENUE JURISDICTION AND VEN*= 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). 4. Venue shall be determined pursuant to Chapter 28-106.207, Florida Administrative Code (2004). PARTIES 5. Pursuant to Chapter 400, Part Il, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules. 6. Respondent is an assisted living facility located at 1896 Park Meadows Drive, Ft. Myers, Florida 33907. Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), having been issued license number 5096. COUNT I Respondent failed to operate and maintain the facility in a condition that insured the 87 residents in facility remained free of any imminent danger with a substantial probability that serious physical harm or death might result. § 400.419(2)(a), Fla. Stat. (2004) Fla. Admin. Code R. 58A-5.019(1) (2004) 7. AHCA te-alleges paragraphs 1-6 above. 8. On or about Septernber 17, 2004, AHCA conducted a complaint investigation survey at Respondent's facility. AHCA cited Respondent for a deficiency, based on the findings below, to wit: a) The facility had experienced a fire in the laundry room's commercial clothes dryer on the evening of 9/14/04 at about 11:15 p.m. The facility acknowledged their awareness of a problem with this dryer. The Executive Director stated that "Southeastern Laundry Equipment" had worked on the equipment on 9/14/04. Page 2 of 13 The South Trail Fire Department responded and upon their arrival found the laundry room door propped open with a wood wedge allowing the smoke and water from the sprinklers, which activated, to expel water and smoke into the hallways and throughout the dinning room and lobby area. Evacuation was in progress into the lobby area from the four hallways and out the front doors. The fire personnel assisted to complete the evacuation in a safe and orderly manner. All residents had been accounted for. The fire was contained to the laundry room and extinguished. , was issued to the Executive Director for having a fire door propped open. If the fire door was closed, as intended to contain water and smoke in the laundry room, it would not have been allowed to permeate the entire building creating the possibility of adverse side effects to the residents due to possible smoke inhalation. A citation, in the amount of $100.00 The facility has four residents who require the assistance of oxygen for various respiratory diseases. The Residents involved were #3, #4, #5 and #6 (4 of 13 sampled residents). Interviews with the residents did not reveal any adverse effects at this time. A tour of the facility on 9/16/04 at about 8:25 a.m., which began on the "D" Wing, revealed the laundry room door, which is a fire door, was blocked open using a wooden wedge. A three-tier cart was also in front of the door as well as a large blue fan. The laundry room had two other large blue fans in use placed around the room. The room contained a large commercial type clothes dryer, with its door open, glass front missing and it had obvious appearances of a fire. There was a commercial washer in use at that time. Next to the commercial washer, there was a small home type dryer, which was operating. On top of the dryer was a large piece of plastic that appeared to be an old shower curtain. On top of that plastic was a load of laundry apparently waiting to be washed. Next to the small dryer was an older small home type washing machine. This washing machine was not in use. The top of this washer contained a load of wet laundry that appeared to be towels possibly waiting to go into the dryer. In the hallway outside the laundry room were several other large blue fans placed facing various directions. These fans had cords spread across the carpeting and plugged into various outlets around the hall. In a hallway across from the laundry room, there were additional fans in operation and a dehumidifier. The area had an odor of wet carpeting and smoke. The cords to these pieces of equipment were creating a possible hazard to anyone walking in these hallways as the cords were not secured or taped down. While continuing to tour this hall, the carpeting was stil] wet outside the first four rooms (two on each side of the hallway beginning with the room that Page 3 of 13 shared a common wall with the laundry room). This was verified by actually feeling the carpet. Several fans were aimed down this hall. At the end of this hallway there was an exit door, with a sign that said, “Emergency exit only, alarms will sound." An attempt to open this door found it unlocked (from the inside) and unalarmed. A tour of the other three hallways found those exits also unalarmed and unlocked from the inside. You could go out any of these four doors but doors were locked preventing entrance from the outside. Residents could exit the building by these doors but could not re-enter. A tour of the secured dementia unit at 8:45 a.m. found it unlocked and umalarmed at the entrance from inside the facility. The exit door to the outside was also unlocked and unalarmed. The gates on the wooden fence outside were also unlocked and unalarmed. A re-check at 9:00 a.m., 9:15 a.m., 9:30 a.m. and 9:45 a.m. found them unchanged. At 9:00 a.m., a request was made to the maintenance person to assist the surveyor in testing the fire doors. He was unable to do this. He stated, "The alarm system has been bypassed by the sprinkler company who is in the building replacing sprinkler heads.” A request was made to close the fire doors at this time to attempt to secure the building. At 9:20 a.m., a call was placed to the South Trail Fire Department Fire Marshall and he was informed of the situation at the facility at this time. He arrived at about 9:35 a.m. and found "D" wing to be as stated previously in this document. At this time, it was noted that the small clothes dryer, which was still running, still contained the plastic sheet and a pile of clothing. A member of the fire team placed his hand on the top of the dryer and found it to be extremely hot. The contents were removed from the top of the dryer and several minutes later it remained hot to the touch when the surveyor re- checked it. After the Fire Marshall's arrival, the Executive Director became aware that the building was un-protected from fire as it was determined that the sprinkler head company employees had taken the system off line (by-pass). South Trail Fire Department had not been notified prior to this bypass. ‘An interview with the Executive Director at 9:45 a.m. established that she was unaware that the facility dementia unit was unsecured. She immediately went to this unit and verified the surveyor findings and had staff assemble residents in this unit together in an activity to monitor their safety and wellbeing. At 9:50 a.m., approximately 1-4 hours after first discovery by surveyors, the Executive Director closed the laundry room door, secured the cords to the fans and dehumidifier and secured all the hallways. At about 10:50 a.m. the alarm system had been restored and a test of the system was begun. The fire doors and alarms were functioning at that time. Page 4 of 13 The South Trail Fire Marshall issued a second citation to the Executive Director in the amount of $250.00 for a repeat violation (laundry room fire door propped open). This was the third citation for the same infraction since April 2004. 9. Respondent failed to operate and maintain the facility in a condition that insured the 87 residents in facility remained free of any imminent danger with a substantial probability that serious physical harm or death might result, as required by Rule 58A-5.019(1), Florida Administrative Code (2004), which provides, in pertinent part, as follows: “58A-5.019 Staffing Standards. (1) ADMINISTRATORS. Every facility shall be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required by Part III of Chapter 400, FS., and this rule chapter.” 10. The foregoing violation constitutes a Class I violation, according to the nature of the violation and the gravity of its probable effect on facility residents, and warrants a fine of $5,000, to wit: “(a) Class "I" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines present an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. A fine may be levied notwithstanding the correction of the violation.” (§ 400.419(2)(a), Fla. Stat. (2004)) 11. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; Page 5 of 13 2. Impose a fine in the amount of $5,000 for the referenced violation; and 3. Impose such other appropriate relief as this tribunal may find and deem appropriate. COUNT I failed to (a) provide access to adequate and appropriate health care h established and recognized standards within the community for one de a safe environment for 87 th a strong probability of Respondent consistent wit of its residents, and (b) Respondent failed to provi residents, possibly placing them in imminent danger wi creating physical harm or death. § 400.419(2)(a), Fla. Stat. (2004) § 400.428(1), Fla. Stat. (2004) 12. AHCA re-alleges paragraphs 1-6 above. 13. On or about September 17, 2004, AHCA conducted a complaint investigation survey at Respondent’s facility. AHCA cited Respondent for a deficiency, based on the findings below, to wit: a) Resident #7 was admitted to the facility on 8/01/03 with diagnoses including but not limited to Left Hip Replacement, Bilateral cataracts, Right Kidney Transplant, Hypertension, Angina, Atrial Fibrillation, Hypercholestremia and Insulin Dependent Diabetes Mellitus. Record review indicated on 5/19/04 at 9:00AM Resident #7 was complaining of not feeling well and stayed in bed. The blood sugar was 123. The resident ate oatmeal and tea. The notes indicated later on when the resident was out of bed to the bathroom, she/he complained of intermittent chest pain for approximately 1 1/2 hours. The resident's blood sugar was documented at 69. Orange juice with 2 packets of sugar was given to the resident. At 12:00PM, Emergency Services was called and the resident was transferred to the hospital. According to Mosby's Diagnostic and Laboratory Test Reference, 6th Edition, the critical blood sugar range for females is identified as less than 40 and greater than 400. On 5/21/04 at 11:30 AM, Resident #7 returned to the facility with an 1823 form that included medications. The medication orders for the resident's diagnosis of Diabetes were Insulin NPH 30 Units in the AM and 36 Units at 4:30PM. There were no orders to include a sliding scale of Insulin for this resident. Page 6 of 13 On 5/22/04 at 11:30 AM, the notes indicated the resident had a blood sugar of 366. It further noted there were or orders for coverage. The physician was called and a message was left. At 2:00 PM, the notes stated there was no call from the physician. At 2:30 PM, a second call was placed to the physician. At 3:00 PM, the family was at the facility to take the resident out of the facility for 3 days. The notes stated there was no call from the physician and the blood sugar was 416. The nurse wrote, "will resume insulin coverage from prior to hospital stay - 18 U (units) Reg. (Regular) insulin given. Left on LOA (leave of absence) and son with instructions for prior use of R + N (Regular and Novolin) insulin and will call them if or when we receive new orders. To return 5/25/04." Review of the Physician Fax Request for Orders dated 5/21/04 indicated a request had been sent to ask the physician to review the medication orders on the 1823 Form. The fax was returned with the physician's signature on 5/23/04. There were no new orders noted. Review of the signed Physician Fax Request for Orders dated 5/26/04 indicated to retum to Insulin orders prior to hospitalization per telephone order. The orders were for 26 Units of Regular Insulin and 30 Units of Novolin in the AM, 11 Units of Regular at noon, 18 Units of Regular at 4:30PM, and 38 Units at hour of sleep. Interview with the Resident Care Coordinator on 9/16/04 at approximately 3:00 PM revealed she was unaware of the incident. She added that the nurse in question had been counseled several times and had resigned as of 9/30/04 per mutual agreement. She also indicated there was no facility policy regarding Hypo/Hyperglycemia Management. b) Please refer to Paragraph 8(a) above for findings pertaining to failure to address an unsafe environment. 14. Respondent failed to (a) provide access to adequate and appropriate health care consistent with established and recognized standards within the community for one of its residents, and (b) Respondent failed to provide a safe environment for 87 residents, possibly placing them in imminent danger with a strong probability of creating physical harm or death by not having a facility with functioning fire alarm systems, by not having locks and alarms on a closed dementia unit that were functioning, and by continuing to prop open a fire door leading to the laundry room where there had been a recent fire. This is all in violation of Section 400.428(1), Florida Statutes (2004), which provides in pertinent part, as follows: Page 7 of 13 400.428 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 of a facility...” 15. nature of the violation and the gravity of its probable e The foregoing violation constitutes a Class I violation, according to the ffect on facility residents, and warrants a fine of $5,000, to wit: “(a) Class "I" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines present an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine for a cited class ] violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. A fine may be levied notwithstanding the correction of the violation.” (§ 400.419(2)(a), Fla. Stat. (2004)) 16. violation, AHCA, in determining the penalty imposed, considered the gravity of the the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. 2. Enter factual and legal findings as set forth in the allegations of this count; Impose a fine in the amount of $5,000 for the referenced violation; and Impose such other appropriate relief as this tribunal may find and deem appropriate. Page 8 of 13 COUNT II] A survey fee in the amount of $500 is imposed upon the Respondent. § 400.419 (9), Fla. Stat. (2004) 17. | AHCA re-alleges paragraphs 1-16. 18. The above cited survey fee is imposed pursuant to § 400.419(9), Fla. Stat. (2004), which states as follows: «(9) In addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 400.428(3)c) to verify the correction of the violations.” WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a survey fee in the amount of $500, for the referenced complaint investigation; and 3. Impose such other appropriate relief as this tribunal may find and deem appropriate. THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEF: T BLANK Page 9 of 13 NOTICE Respondent, EMERITUS CORPORATION d/b/a THE PARK CLUB OF FORT MYERS is notified that she has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. THE RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Submitted on this — SZ tug Day BC f Timothy B>Eifiott, Senior Attomey Fla. Bar No. 210536 Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MSC #3 Tallahassee, FL 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or (850) 413-9313 Page 10 of 13 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Returm Receipt Requested (receipt # 7000 1530 0000 5684 9204) to The Park Club of Ft. Myers, 1896 Park Meadows Drive, Ft. Myers, Florida 33907. Submitted on this and day of VA mem re, 2004. Timothy B. EMiott, Senior Attorney Page 11 of 13 USPS - Track & Confirm Page 1 of 1 Track & Confirm Current Status Track & Confirm Enter label number: You entered 7000 1530 0000 5684 9204 Your item was delivered at 12:35 pm on November 04, 2004 in FORT MYERS, FL 33907. a I U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) | Track & Confirm FAQs ( ar a} ru! r STRATWE 17 7 > Postage _ areal e ip contact us government services oO 02 USPS. All Rights Reserved. Terms of Use Privacy Policy 0 Cert fied Fee }, 200400€ 0S | uw ret Fevaipt Feed Postmark eect b— 20040095 €8 B fendorsement heaured P| MAILED ay Total Postage & Fees is ly /. ‘2 ji oy m a ce a in | Sent To Tie Ake LLB Me LL. MARS ALM: hantlsstt f=) . 8 [Wit AK MALONE DUE. | in ye. Fi 3340 : PS Form 3600, May 2000 tructions 4 SENDER: COMPLETE THIS SECTION @ Complete items 1, 2, and 3, Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: LINo The PACK SLUR OE ET MYERS ATTENTION: ADMIMISTRATOR 1296 PARK MEADOWS DRIVE ET, MYERS, FLORIDA 22907 "YES, entter delivery address below: 3. Seryice Type Ef Certified Mail B Bsrese Mail DO Registered eturn Recelpt for Merchandise O Insured Mai! =. 6.0... 4. Restricted Delivery? (Extra Fee} D Yes 2. Article Number (Transfer from service label) 73 OC i rad PS Form 3811, August 2001 Domestic Return Receipt 4102595-02-M-1540 http://trkenfrm].smi.usps.com/netdata-cgi/db2www/cbd_243.d2w/output 11/16/2004

Docket for Case No: 05-000842

Issue Date	Proceedings
Nov. 18, 2005	Order Closing Files. CASE CLOSED.
Nov. 18, 2005	Motion to Relinquish Jurisdiction filed.
Nov. 09, 2005	Notice of Appearance (filed by E. Bredemeyer).
Sep. 15, 2005	Order Granting Continuance and Re-scheduling Hearing (hearing set for December 1 and 2, 2005; 9:30 a.m.; Fort Myers, FL).
Sep. 14, 2005	Joint Motion for Continuance filed.
Sep. 09, 2005	Notice of Appearance (filed by K. Gieseking).
Jul. 20, 2005	Order Granting Continuance and Re-scheduling Hearing (hearing set for September 22 and 23, 2005; 9:30 a.m.; Fort Myers, FL).
Jul. 18, 2005	Unopposed Motion for Continuance filed.
May 11, 2005	Order Granting Continuance and Re-scheduling Hearing (hearing set for July 22, 2005; 9:30 a.m.; Fort Myers, FL).
May 04, 2005	Unopposed Motion for Continuance filed.
Mar. 23, 2005	Notice of Hearing (hearing set for May 13, 2005; 9:30 a.m.; Fort Myers, FL).
Mar. 23, 2005	Order of Pre-hearing Instructions.
Mar. 17, 2005	Response to Initial Order (filed by Respondent).
Mar. 15, 2005	Order of Consolidation (consolidated cases are: 05-0842 and 05-0843).
Mar. 07, 2005	Initial Order.
Mar. 04, 2005	Order of Dismissal without Prejudice Pursuant to Sections 120.54 and 120.569, Florida Statutes and Rules 28-106.111 and 28- 106.201, Florida Administrative Code to allow for Amendment and Resubmission of Petition filed.
Mar. 04, 2005	Amended Petition for Formal Administrative Hearing filed.
Mar. 04, 2005	Petition for Formal Administrative Hearing filed.
Mar. 04, 2005	Administrative Complaint filed.
Mar. 04, 2005	Notice (of Agency referral) filed.