STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2005008014 SENIOR LIVING/LAKE MARY, LLC, ad d/b/a THE GABLES OF LAKE MARY, Oo -OA7T9 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against SENIOR LIVING LAKE MARY, LLC, d/b/a GABLES OF LAKE MARY, THE, (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Fla. Stat., (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $2,500.00 based upon Respondent being cited with one State Class II deficiency, pursuant to §400.419(2)(b) Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 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 IU, Florida Statutes, and Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 102-bed assisted living facility located at 3655 W. Lake Mary Blvd., Lake Mary, Florida 32746, and is licensed as an assisted living facility, license number 10007. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility including a general awareness of the resident’s whereabouts. The resident may travel independently in the community. R. 58A-0182(1)(c) Fla. Admin. Code (2005). 8. That on August 9, 2005, the Agency conducted a Complaint Survey of the Respondent. 9. That based upon observation, review of records and interview, the Respondent facility failed to provide personal supervision as appropriate for two (2) of six (6) sampled residents, which resulted in physical altercation with serious injuries. 10. That the Respondent maintains a locked memory care unit physically arranged with the main area consisting of the dining room, activity area, bathrooms and nursing station. Resident ha rooms are located away from the main area and are not in plain view from the main centralized area, 11. That the Petitioner’s reviewed the Respondent’s records regarding resident number two (2) which reflected the following: a. That the resident’s health assessment form indicated a diagnosis of Alzheimer's disease; db. That a record entry dated June 29, 2005 written by the Advanced Registered Nurse practitioner (ARNP) documented: "staff states the resident has been agitated lately and hitting during the day"; c. That the ARNP increased Risperdal 0.25 mg in the moming to an additional dosage at bedtime; d. That a nurse's note of July 3, 2005 at 7:45 p.m. memorialized: i, That a RA (resident assistant) found resident sitting in a chair with bleeding knuckles and another resident on the floor of the room with a bleeding lip, swollen/bruised eye (L), and swollen and painful leg; ii. That upon questioning, resident was alert and oriented to person and place; that resident was confused about what happened to the other resident and stated that he/she did not know what happened or why he/she was bleeding; iii. That the resident had three (3) cuts on [left] (L) hand which were cleaned with NS (normal saline) and bandaged; iv. That a Lake Mary police officer arrived and questioned the resident about what happened with no response; 12, That the resident’s records contained no indication that the Respondent facility had implemented any measures to supervise or other interventions to monitor the activities and behaviors of resident number three despite exhibited hostile behavior other than the increased medication prescription. 13. That the resident’s records contained no indication that the Respondent facility had implemented any measures to supervise and monitor the interactions of resident number three with other residents on the dementia wing. 14. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number five (5) which reflected the following: a. That the resident’s health assessment form dated January 25, 2005 reflected diagnoses of seizures and dementia; b. That a nurse’s note dated July 3, 2005 at 7:30 p.m. memorialized that “Resident Assistant found resident in another resident’s room on the floor. Resident’s lip was bleeding, left eye was swollen and the resident was complaining of extreme pain the left mid-thigh. When being helped up, resident was unable to bear any weight on the left leg. When questioned about what happened resident stated that the other resident had hit [him/her.] The other resident was bleeding from 3 places on the knuckles and hand. Cleaned resident’s face, mouth and hands. Applied pressure to stop bleeding on lips. Bleeding cessation occurred. Resident alert and oriented to person. Range of Motion good in all extremities but resident complained of extreme pain whenever weight/pressure was applied to left leg. Resident was transferred to own room for further evaluation. There was swelling and pain to the Left mid-leg, swelling and hematoma to left eye and (2) 2 mm lacerations to bottom lip. Emergency Medical Services arrived and evaluated for possible head injury and fractured femur. Resident was transported to the hospital"; c. That a nurse’s note dated July 5, 2005 documented: "received call from social worker at hospital stating fracture and had surgery will be going to rehabilitation.” 15. That the Petitioner’s representative interviewed Respondent’s morning and evening shift staff members on August 9, 2005 who indicated the following: a. That resident number five (5) had a history of wandering into the room of resident number two (2) and removing items belonging to resident number two (2); b. That staff had told resident number five (5) several times not to remove resident number two's (2) belongings; c. That resident number two (2) had a history of becoming agitated and hitting and striking at staff; d. That staff handled the aggressive behavior exhibited by resident number two (2) by walking away from the resident; e. That of staff who had the first hand knowledge of resident number two's (2) behavior, no documentation was made by them in the resident's chart regarding the resident’s hitting behaviors; f. That the Respondent’s staff were of the opinion that there was not enough staff available to adequately supervise the residents in the memory care unit at the time the incident occurred; g. That there are normally two staff members working on the unit, one who toilets residents while the other staff member assists with meals in the dining area; h. That while staff are assisting residents as above described, no staff are available to monitor the whereabouts of the other residents who are out of full view and away from the common area described herein; 1 That the incident of July 3, 2005 had not been witnessed by any staff member and resident number five (5) had been toileted about ten (10) minutes prior to the altercation; j. That staff stated that when they entered the room to question resident number two (2) as to what had occurred, the resident indicated that he/she had hit resident number five (5) because the resident would not "get out of the room"; k. That after the incident of July 3, 2005, the Respondent implemented a procedure whereby every resident was to be accounted for every ten (10) minutes. 16. That the petitioner’s representative observed the Respondent’s locked memory care unit on August 9, 2005 and noted the following: a. That there is a main dining area, an activity room, bathrooms and a nurse's station; b. That the residents' rooms were located in an area away from the above locations; c. That none of the resident rooms were in full view for staff members to observe the activities of resident who were not in the common areas; d. That the rooms were located toward the back of the unit making it difficult for staff working in the front area to monitor residents who wander around in the back location; e. That staff members were observed working with resident in the activity room, dining area, bathrooms and in the nurse's station. 17. That the Petitioner’s representative interviewed the Respondent’s administrator on August 9, 2005 who indicated that the facility cannot provide one to one supervision for the residents. 18. That in review, there was located no indication that staff had discussed the on going behavior problems exhibited by the residents or that any measures, other then documentation to increase the dose of Risperdal for resident number two (2), had been implemented by the facility to ensure the safety of the residents on the dementia wing, who were not able to make the conscious decision to "walk away" from violent behavior. Further, there was no indication that the ten (10) minute checks had been implemented as no documentation to verify the same was presented and the Petitioner’s representative observed no staff activity that would entail the verification of the whereabouts of the Respondent’s residents on a periodic basis. 19. That the Respondent was aware of resident number two’s (2) propensity to violent and striking out behavior, and failed to implement measures to supervise the resident’s behavior despite this known danger to staff, other residents, or visitors. 20. That the Respondent was aware of resident number five’s (5) propensity to enter the room of resident number two (2) and take or otherwise interfere with resident number two’s (2) belongings, and failed to implement measures to supervise the resident’s wandering behavior despite the Respondent’s knowledge of resident number two’s (2) violent propensities. 21, That the failure to provide personal supervision appropriate to their known behavioral propensities is contrary to the requirements of law. 22. That the residents both suffered injuries as a result, one resident’s injury of a serious 23. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 24. ‘That the Agency provided the Respondent with a mandatory correction date of August 10, 2005. 25. That the same constitutes a Class II offense as defined in Florida Statute 400.419(2)(b). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2005). Respectfully submitted this day of December, 2005. J. Walsh II . No. 566365 Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2004). 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). FILED All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to The Agen CNS Aedldyyod Prealth Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Ti allahassee, Rete BT elephone (850) 922-5873. Uiviauuey Ul RESPONDENT IS F ur tether IO THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE IHEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7003-1010-0002 4667 1132 on December f_, 2005 to: NRAI Services, Inc. Registered Agent, 2731 Executive Park Dr., #4, Weston, FL 33331 and by U.S. Mail to Julie S. Fernandez, Administrator, The Gables of Lake Mary, 3655 W. Lake Mary Blvd., Lake Mary, FL 32746. yy . Walsh II, Esq. Copies furnished to: NRAI Services, Inc. Julie S. Fernandez Thomas J. Walsh II, Esq. Registered Agent Administrator Agency for Health Care Admin. 2731 Executive Park Dr. #4 The Gable of Lake Mary 525 Mirror Lake Drive, 330G Weston, FL 33331 3655 W. Lake Mary Blvd St. Petersburg, FL 33701 (U.S. Certified Mail) Lake Mary, FL 32746 (Interoffice) (U.S. Mail) PAYMENT FORM BES. Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. The Gables of Lake Mary 2005008014 Facility Name AHCA No.

Docket for Case No: 06-000375