STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Ol - O ) O —) vs. Case No. 2006010000 LOVE-N-CARE ASSISTED LIVING FACILITY INC., d/b/a LOVE-N-CARE ASSISTED LIVING, 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 LOVE-N-CARE ASSISTED LIVING FACILITY, INC., d/b/a LOVE-N-CARE ASSISTED LIVING (hereinafter “Respondent”), pursuant to §§ 120.569 and 120.57, Fla. Stat. (2006), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $2,000.00 and a survey fee in the amount of $500.00, based upon Respondent being cited for two State Class II deficiencies pursuant to §§ 429.19(2)(b) and 429.19(10), Fla. Stat. (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 429.407, Fla. Stat. (2006). 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 Chapter 429, Part I, Fla. Stat., and Chapter 58A-5 Fla. Admin. Code, respectively. 4. Respondent operates a 16-bed assisted living facility located at 5426 18" Street West, Bradenton, Florida 34207, and is licensed as an assisted living facility, under license number 10666. 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 one (1) through five (5) as if fully set forth herein. 7. Pursuant to Fla. Admin. Code R. 58A-5.0181(4)(d) and § 429.26(1), Fla. Stat. (2006), the owner or administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. 8. On or about 10/04/06, the Agency conducted a complaint investigation (CCR # 2006008413) of the Respondent's facility. 9. Based on observation, interview and record review, the Respondent failed to monitor the appropriateness of placement of one of three sampled residents. 10. A review of Resident # 1's record revealed a health assessment, dated 09/18/06, indicating that the resident suffered from Alzheimer's Disease, Dementia, Anxiety, and was "pleasantly confused," and was noted to require supervision in ambulation and to need total help for self-care tasks. 11. Observations during the tour on 10/04/06, at approximately 7:28 a.m., revealed the laundry room door to be held open with a doorstop. The door knob was one which could not be locked, even if closed, with the aide present on tour, stating that "at night it's open." 12. Present in this room, easily accessible, was a two gallon container, unlabeled, made of clear plastic, similar in construction to large containers of ice cream. This container was filled with a white powdery substance, identified by the aide as laundry detergent. 13. Also present in an unlocked cabinet, at waist level, was a one gallon container of carpet extraction cleaner, clearly marked “keep out of reach of children”, a bottle of “power house bowl cleaner”, and a 1/4 full container of Shineline floor prep, labeled “danger, corrosive, keep out of reach of children.” 14. Observation of the kitchen revealed an unlocked waist high cabinet at the left side of the entrance to the kitchen. Inside this unlocked cabinet was a one-gallon container of "Mint Too” cleaner, labeled as a "hazard to human and domestic animals." Next to this was a one gallon container of Prostrip cleaner labeled, "Danger Corrosive." 15. | During observation of the kitchen, Resident # 1 wandered in and was redirected by staff. 16. The doorway to the kitchen was observed to be wide, adjacent to the living area, and to have no door, lock, or any form of deterrence for demented wandering residents. 17. Observation on 10/04/06 revealed that while staff was occupied with other residents, Resident # 1 wandered into the kitchen, walked to the back of the kitchen, passing the easily accessible cleaner and Prostrip, and began touching items in the kitchen, approaching a clear plastic bucket and opening it. This container was virtually identical to the container holding laundry detergent in the laundry room, located only a few feet from the kitchen. The resident began to get the powdery substance out of the container in the kitchen. At this time, the Agency brought the resident's actions to the attention of staff, whereupon the resident was redirected. 18. Further observation by the Agency, at approximately 7:50 a.m., revealed that the aide monitoring Resident # 1 had left the resident to answer a telephone. The resident immediately wandered into a bathroom, where s/he began touching objects. Returning, the aide redirected the resident back to the area outside the nurse's station. 19. Observation on 10/04/06, at approximately 7:53 a.m., revealed Resident # 1 exiting the facility via the front door. A staff member ran outside to retrieve the resident. 20. A review of resident records revealed a lack of documentation regarding assessment or reporting of Resident # 1's wandering behavior beyond a facility document, dated 09/24/06, indicating that the resident “went outside at 0700 AM - brought back by staff no adverse effect to resident. Administrator notified” with the facility's response to be “listen for alarm on doors. Watch resident at all times. Move resident closer to Nurse's station.” 21. During an interview conducted on 10/04/06, the Administrator, repeatedly denied that Resident # 1 had left the facility without permission prior to 09/16/06, had been hospitalized, or had police involvement in the month of August, or at any time prior, since admission on 05/21/06. 22. Review of hospital records, dated 08/01/06 at 1:00 p.m., indicated that Resident # 1 had been found several blocks from the facility. The resident's status when EMS arrived was “profuse sweating, hot and dry skin, fatigue.” 23. Further review of hospital documentation revealed that Resident # 1 was seen in the Emergency Department on 08/01/06 at 1430. The patient was documented as a resident of the Respondent's facility, and presented “following an episode where patient wandered outside and was outside for approximately two hours before being located by (the local sheriff's office). Patient noted to be confused (dementia).” The patient complained of bilateral foot pain. The patient was brought in via EMS. 24. Review of the hospital record revealed that the resident's time of exposure had been 61- 120 minutes. The facility had reported the resident missing at approximately 1200 hours and found at approximately 1340 hours. 25. Further, the resident had been transported “for Eval for being outside in the sun for 2 hours/patient has hx of dementia and RN states that his/her mental status is normal for him/her,” indicating that the Registered Nurse (RN), the Administrator of the facility, was fully aware of the situation and present. 26. Further interview conducted on 10/04/06, revealed that: a. On 09/16/06, Resident # 1 left the Respondent's facility without permission, but police were contacted. However, the resident was found several blocks away and taken to the hospital for evaluation. b. On 09/28/06 the resident attempted to depart the facility, but was redirected into the living area, and; c. On 10/01/06 the resident departed out of the.door and was returned. 27. Review of the Respondent's most recent work schedule available, revealed that the Respondent maintained only one staff member on duty from 11:00 p.m. until 7:00 a.m., thus preventing simultaneous care and supervision for those residents requiring supervisory services. 28. An interview conducted on 10/04/06, revealed that the Respondent was “embarking on getting locks,” but had no evidence, estimate or contract, of such an improved egress or ingress system. 29. Further interview revealed that the facility previously had locks which did not meet fire code. Rather than replace the noncompliant locks with an acceptable delayed-egress system, the facility did not replace them at all. 30. Observation revealed that the only system in place to detect entrance or exit to, or from, the facility, was a chime on the front door and alarms on the side doors, but these were unable to detect whether a resident was entering or leaving. 31. During interview, the Agency discovered that the Respondent did not provide 1:1 staff supervision, or any other safety measure, for those residents requiring supervision. 32. During the period of more than two months from the first major incident, negligible measures have been put into place to ensure the safety of the resident, despite the facility's full knowledge of the resident's ongoing wandering, albeit undocumented and non-assessed, behavior. 33. The Respondent presented numerous chemical hazards to demented residents, demonstrating that the facility has not put into place adequate safeguards or arranged to meet the needs of demented residents that wander. 34. Resident # 1 has demonstrated a potential for leaving the Respondent's facility without accompaniment, and has successfully left the facility on multiple occasions, necessitating multiple police searches and at least one helicopter search. 35. | The Administrator chose to retain Resident # 1 for a period of at least two months after the first incident involving a search by law enforcement and helicopters, rather than reassessing the needs of the resident and the appropriateness of his/her continued residency. 36. | The Agency determined that this deficient practice was related to the operation or maintenance of the facility or to the personal care of the resident, which the Agency determined directly threatened the physical or emotional health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 37. The Agency provided Respondent with a mandatory correction date of 10/07/06. WHEREFORE, the Agency intends 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 § 429.19(2)(b) Fla. Stat., (2006). COUNT II 38. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 39. Pursuant to Fla. Admin. Code R. 58A-5.0182(1)(c), facilities shall offer personal supervision, as appropriate for each resident, including general awareness of the resident’s whereabouts. The resident may travel independently in the community. 40. | Onor about 10/04/06, the Agency conducted a complaint investigation (CCR # 2006008413) of the Respondent's facility. 41. Based on observation, interview and record review, the facility failed to provide adequate supervision or general awareness of resident's whereabouts. 42. A review of Resident # 1's record revealed a health assessment, dated 09/18/06, indicating that the resident suffered from Alzheimer's Disease, Dementia, Anxiety, and was "pleasantly confused." The resident was noted to require supervision in ambulation, and to need total help for self-care tasks. 43. A review of Resident #2's record revealed a health assessment, dated 05/15/06, indicating that the resident suffered from Dementia, memory impairment, and needed supervision. 44. A review of Resident # 3's record revealed a health assessment, dated 12/22/05, that indicated "falls, wandering" under "special precautions" and that the resident's cognitive behavioral status was "globally confused.” 45. Observation on 10/04/06, at approximately 7:03 a.m., upon entering the facility, revealed an extremely soft chime when entering the front door. No other alarm was audible. No aide on duty came to see whether a resident had exited the door. No staff was present within sight of the dgor. 46. At approximately 7:08 a.m., an aide arrived through the front door. She stated that she was coming on duty at that time. Another aide came to the door of a resident's room at that time. She indicated that she did not know whether someone had entered or exited earlier, and had assumed that it was the aide who was to come onto duty. At this time, another aide exited another resident's room. She indicated that she was providing care, and "thought it was (the other aide), I wasn't too sure." 47. Observations during the tour on 10/04/06, at approximately 7:28 a.m., revealed the laundry room door to be held open with a doorstop. The door knob was one which could not be locked, even if closed, with the aide present on tour, stating that "at night it's open.” 48. Present in this room, easily accessible, was a two gallon container, unlabeled, made of clear plastic, similar in construction to large containers of ice cream. This container was filled with a white powdery substance, identified by the aide as laundry detergent. 49. Also present in an unlocked cabinet, at waist level, was a one gallon container of carpet extraction cleaner, clearly marked “keep out of reach of children”, a bottle of “power house bow! cleaner”, and a 1/4 full container of Shineline floor prep, labeled “danger, corrosive, keep out of reach of children.” 50. Observation of the kitchen revealed an unlocked waist high cabinet at the left side of the entrance to the kitchen. Inside this unlocked cabinet was a one-gallon container of "Mint Too" cleaner, labeled as a "hazard to human and domestic animals." Next to this was a one gallon container of Prostrip cleaner labeled, "Danger Corrosive." 51. During observation of the kitchen, Resident # 1 wandered in and was redirected by staff. 52. The doorway to the kitchen was observed to be wide, adjacent to the living area, and to have no door, lock, or any form of deterrence for demented wandering residents. 53. Observation on 10/04/06 revealed that while staff was occupied with other residents, Resident # 1 wandered into the kitchen, walked to the back of the kitchen, passing the easily accessible cleaner and Prostrip, and began touching items in the kitchen, approaching a clear plastic bucket and opening it. This container was virtually identical to the container holding laundry detergent in the laundry room, located only a few feet from the kitchen. The resident began to get the powdery substance out of the container in the kitchen. At this time, the Agency brought the resident's actions to the attention of staff, whereupon the resident was redirected. 54. Further observation by the Agency, at approximately 7:50 a.m., revealed that the aide monitoring Resident # 1 had left the resident to answer a telephone. The resident immediately wandered into a bathroom, where s/he began touching objects. Returning, the aide redirected the resident back to the area outside the nurse's station. 55. | Observation on 10/04/06, at approximately 7:53 a.m., revealed Resident # 1 exiting the facility via the front door. A staff member ran outside to retrieve the resident. 56. During interviews on 10/04/06, at approximately 8:20 a.m., Resident # 3 intruded and began asking the staff members who they were, if they worked there, and why s/he (the resident) was there. This behavior was observed, with varying degrees, on several occasions during the investigation. 57. Observation on 10/04/06, revealed Resident # 2 was exiting the facility via the front door. Staff had to pursue him/her once they saw the resident leave the building. 58. A review of resident records revealed no documentation of the wandering behavior or assessment of Resident # 1, Resident # 2, or Resident # 3 for such behavior. 59. Beyond the initial assessments by physicians, the only documentation provided was a facility document for Resident # 1, dated 09/24/06, indicating that the resident "went outside at 0700 AM - brought back by staff no adverse effect to resident. Administrator notified." The facility's response documented was to "listen for alarm on doors. Watch resident at all times. Move resident closer to Nurse's station.” 60.‘ During an interview, conducted on 10/04/06, the Administrator repeatedly denied that Resident # 1 had left the facility without permission prior to 09/16/06, or that the resident had been hospitalized, or had police involvement in the month of August, or at any time prior, since admission on 05/21/06. 61. Review of hospital records from 08/01/06, at 1:00 p.m., indicate that the resident was found several blocks from the facility. The resident's status when EMS arrived was "profuse sweating, hot and dry skin, fatigue." The resident's time of exposure was 61-120 minutes. The facility reported the resident missing at approximately 1200 hours and was found at approximately 1340 hours. 62. Further review of the hospital documentation revealed that Resident # 1 was seen in the Emergency Department on 08/01/06 at 1430. The patient was documented as a resident of the Respondent, and presented "following an episode where patient wandered outside and was outside for approximately two hours before being located by (the local sheriff's office). Patient noted to be confused (dementia)." The patient complained of bilateral foot pain. The patient 10 was brought in via EMS. The resident was transported "for Eval for being outside in the sun for 2 hours/patient has hx of dementia and RN states that his/her mental status is normal for him/her." 63. Further interview conducted on 10/04/06, revealed that: a. On 09/16/06, Resident # 1 left the Respondent's facility without permission, but police were contacted. However, the resident was found several blocks away and taken to the hospital for evaluation; and : b. On 09/28/06 the resident attempted to depart the facility, but was redirected into the living area, and; c. On 10/01/06 the resident departed out of the door and was returned. 64. — Review of the most recent work schedule available, revealed that there was only one staff member on duty from 11:00 p.m. until 7:00 a.m. 65. An interview conducted on 10/04/06, at approximately 7:51 a.m., revealed that aides monitored Resident # 1 when there was only one on duty, by taking the resident with them while providing care to the other residents. The aide was unable to explain how it was possible to do so while providing personal care to one of the other ten residents, some of whom were prone to wander. 66. The Agency determined that this deficient practice was related to the operation or maintenance of the facility or to the personal care of the resident, which the Agency determined directly threatened the physical or emotional health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 67. The Agency provided Respondent with a mandatory correction date of 10/07/06. WHEREFORE, the Agency intends to impose an administrative fine in the amount of 11 $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b) Fla. Stat., (2006). COUNT III 68. The Agency re-alleges and incorporates paragraphs one (1) through five (5), seven (7) through thirty-six (36), and thirty-nine (39) through sixty-six (66), as if fully set forth herein. 69. The Agency conducted a complaint investigation (CCR # 2006008413) on 10/04/06 that resulted in the finding of violations that were the subject of the complaint. 70. Pursuant to § 429.19(10), Fla. Stat. (2006), these violations subject Respondent to a survey fee of $500.00. WHEREFORE, the Agency intends to impose a survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Fla. Stat. Respectfully submitted this 4-74 day of oo) Gerald L. Pickett, Esquire Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330K. St. Petersburg, Florida 33701 (727) 552-1526 (office) (727) 552-1440 (fax) (2006). Respondent is notified that it 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. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bidg #3, MS #3, Tallahassee, Florida 32308. Telephone (850) 922-5873 RESPONDENT IS FURTHER NOTIFIED 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 THEREBY CERTIFY, that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8443 on January & , 2007 to: Sandra E. Campbell, Administrator/Registered Agent, Love-N-Care Assisted Living, 5426 18" Street West, Bradenton, Florida 34207. Ash efi ‘Gerald L. Pickett, Esq ife Copies furnished to: Sandra E. Campbell Gerald L. Pickett, Esquire Administrator/Registered Agent Agency for Health Care Administration Love-N-Care Assisted Living 525 Mirror Lake Drive N., 330K 5426 18" Street West St. Petersburg, Florida 33701 Bradenton, Florida 34207 (Interoffice Mail) (U.S. Certified Mail) THIS SECTION COMPLETE THIS SECTION ON DELIVERY ™ Complete items 1; ., 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: pn 4 . Sondra, £. Compe etl e wad y ry ole: Shector Eeg Og , i 1 Om “€ at i Lave NL ware Aes sie hy win! Lod Che ot Le ST Beale [YU Street ues Graserten , Rlowda. SNOY D. Is delivery address different from item 1? (I Yes 'f YES, enter delivery address below: 1 No SNC. SRT ae ' = a, a ed ee 2. Article Numbi 4g (Transtar fron ce 7005 1160 0002 2254 34 PS Form 3811, February 2004 Domestic Return Receipt

Docket for Case No: 07-000602