@ | OT au oF STATE OF FLORIDA 07 JUN | AGENCY FOR HEALTH CARE ADMINISTRATION 3 PM it: 31 OV ispae ap STATE OF FLORIDA, AGENCY FOR Abi pH OF HEALTH CARE ADMINISTRATION, HEARINGS IVE Petitioner, AHCA Nos.: 2007000671, 2007000674 v. EMERALD SHORES HEALTH CARE ASSOCIATES, LLC, Respondent. ADMINISTRATIVE COMPLAINT CoMES NOW the Agency for Health Care. Administration (hereinafter “AHCA”), by and through undersigned counsel, and : files’ this Administrative Complaint against EMERALD SHORES _ HEALTH CARE ASSOCIATES, LLC, (hereinafter “Respondent”), and alleges: NATURE OF THE ACTION 1. This is an action to impose upon Respondent, pursuant to Sections 400.23 (7) and 400.23(8), Florida Statutes (2005) ' and Rule S9A-4.107(5), Florida Administrative Code, an administrative fine in the amount of $4,000.00. The imposition of this fine is based on an uncorrected Class III deficiency. AHCA also intends to impose a conditional rating effective November 19, 2006 through November 30, 2006, pursuant to section 400.23(7), Florida Statutes (2005). JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to: Sections 120.569 and 120.57, Florida Statutes (2005), and Chapter 28-106, Florida Administrative Code (2005) . 3. Venue lies in Bay County, pursuant to Rule 28-106.207, Florida Administrative Code (2005). PARTIES 4. AHCA is the enforcing authority with regard to skilled nursing facility licensure pursuant to Chapter 400, Part II, Florida Statutes (2005), and Chapter S9A-4, ” Plorida Administrative Code (2005). 5. Respondent is a skilled nursing facility located at 626 North Tyndall Parkway, Calloway, FL 32404 having been issued skilled nursing facility license number 1292096. Respondent. was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. , | CouNT I RESPONDENT FAILED TO PROMOTE CARE FOR RESIDENTS IN AN ENVIRONMENT THAT MAINTAINS OR ENHANCES EACH RESIDENT’S DIGNITY SECTION 400-022 FLORIDA STATUTES (2006) UNCORRECTED CLASS III VIOLATION . @ Se 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. An annual Survey was conducted on November 19, 2006. 1 Deficiencies were identified. The facility is not in compliance with Section 400-022, Florida Statutes (2006). On November 19, 2006, based on observation, and — 8. erview, it was determined the facility failed to promote care or residents in an environment that maintains or enhances each ent's dignity by staff pushing resident in the hallway ithout a foot rest on the wheelchair, therefore, dragging their feet by not assisting: resident to the bathroom forcing resident to urinate in her adult depends, and allowing residents to Pemain in soiled clothing for five (5) of nineteen (19) sampled residents. (#10,#12,#16,#18,#19). The findings include as reported by the surveyor: 1. During the lunch time observation on 11/19/06 at approximately 1:00 p.m., a Certified Nursing Assistant (C.N.A. # 1) was observed assisting residents back to the unit after lunch was completed. C.N.A. #1 was observed pushing resident # 16's wheelchair down the hallway with her feet dragging the floor. An open area was observed on resident's 16's right ankle. An interview was conducted with this C.N.A. on 11/19/06 at approximately 1:03 p.m. The C.N.A. stated resident # 16 received a skin tear from the rod on the '. wheelchair and did not know if she had any foot rest for the wheel chair. 2. Another C.N.A. (C.N.A. # 2) was observed pushing a wheelchair with resident # 10 dragging her feet on the floor on 11/19/06 at approximately 1:04 p.m. An interview was conducted with C.N.A. # 2 on 11/19/06 at approximately 1:04 p.m. C.N.A. stated she did know if resident # 10 had any foot rest. An interview was conducted with the Unit Manager on 11/19/06 at approximately. 1:10 p.m. The Unit Manager stated C.N.A #1 and C.N.A. # 2 should have place foot rest on the wheelchair prior to pushing their wheelchairs. The Unit Manager acknowledged the foot rest were taken off the wheel chair in order for the residents to self propelled themselves. _ 3. Resident # 18 was observed on 11/19/06 at approximately 5:30.p.m..being pushed into the dining room by C.N.A. #4 with his feet dragging the floor. Resident # 18's wheelchair was lacking the foot rests. a 4. This surveyor heard someone yelling, "I can't hold it any longer.“Iam going to pee on myself. I can't hold it. I need some help". This surveyor € resident # 12's room. Resident # 12 stated, "I just peed on myself. I couldn't hold it any longer. I peed in my diaper". Resident # 12 stated, "C.N.A. #3 pushed me into my room and told me she would be back and help me to my bathroom" This surveyor asked her when did she tell C.N.A. #3 she had to l resident # 12 stated when she was in the dining room. Resident#-12 stated, "she pushed me in my room and said she had to help the others to get back to their rooms and would come back to help me but I couldn't wait any | as This surveyor asked how many times, this occurred, resident # 12 stated 4 or 5 times a day. Resident # 12 stated, "the reason is because they have to get another person to help me get on the toilet. What I really hate is to be in the hallway around other people and I have to pee in my diaper". When asked if this was embarrassing to her, resident # 12 stated, "yes". . . : This surveyor asked how long had she been in her room, resident # 12 stated, "5-6 minutes". This surveyor stood in the haliway for continuous observation to determine the time C.N.A. # 3 would return to assist resident # 12. At approximately 1:45 p.m. (33 minutes later) C.N.A. #3 was observed entering into resident # 12's room to assist her. An interview was conducted with C.N.A. #3 on 11/19/06 at approximately 1:45 p.m. C.N.A. #3 stated she was going to change resident # 12's wet adult depends and stated she was assisting other residents from the dining room to their rooms. ‘Review of the current Minimum Data Set dated 10/2/06 revealed a code of "1" for Cognitive/Decision making, "3/3 for transferring (extensive assistance with 2 persons) and "2" for Bladder meaning occasional incontinence (extensive assistance with 2 persons). Resident # 12 has the capability of telling (cognitive 1) the staff when she needs assistance to go to the toilet but needs the assistance of two people to be placed on the toilet. Resident # 12 did not receive the assistance to the bathroom and was forced urinate on herself, causing embarrassment. This surveyor observed resident # 12 sitting in her urine soaked adult depends for 33 minutes before a C.N.A. came to assist her to the toilet. . i) 5. Resident # 19 was observed sitting across from the nurse's station on 11/19/06 at approximately 5:45 p.m. with the Risk Manager adjusting a blanket placed on her feet. When the Risk Manager walked away from resident # 19, this surveyor observed a large patch of a brown substance and dried substances of food. An interview was conducted with the Risk Manager on 11/19/06 at approximately 5:50 p.m. The Risk Manager acknowledged the brown substance and dried food substance and stated'she had not notice them. 6. Review of the facility's policy, "Dignity" revealed the statement of "6. Respecting resident's private space and property. 3. Make sure clothing is clean". This class III deficiency was originally cited on or about 10/04/06, given a correction date of 11/05/06, and was ‘recitéd on 11/19/06. 10. The above constitutes an uncorrected Class III violation, as defined in Section 400.022, Florida Statutes (2005), which carries an assessed fine of not less than $4000. 00 . COUNT ITI BECAUSE ONE UNCORRECTED CLASS IIT DEFICIENCY EXISTED AT THE TIME OF THE FOLLOW UP SURVEY TO THE ANNUAL RE- -LICENSURE SURVEY, IMPOSITION OF A CONDITIONAL LICENSE IS WARRANTED SECTION 400.23(7) (b), FLORIDA STATUTES (2006) 11. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (9) as if fully set forth herein. 5 12. Based upon Respondent’s one uncorrected cited State Class III deficiency, it was not in substantial compliance at the time of the revisit survey with criteria established under Part. II of Florida Statute 400, or with rules adopted by the Agency, a violation subjecting it to assignment ef conditional licensure status pursuant to Section 400.23(7) (b);:. Florida Statutes (2006). 13. Wherefore, the Agency intends to assign a cond tional licensure status to Respondent with an t November 19, 2006 through November 30, 2006. CLAIM FOR RELIEF WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Respondent an administrative fine of $4000.00 for the violation cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4. Uphold the imposition of a conditional license from November 19, 2006 through November 30, 2006; and @ © ' 5. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2005). Specific options for _administrative faction are set out in the attached Election of Rights form. All equests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for “Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. If you want to hire an attorney, “you have the right to be represented by an attorney in this matter. | RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE OR “REQUEST A HEARING WITHIN TWENTY - ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. .“Moore, Esquire Florida Bar # 0768715 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 , @ , @ Copies furnished to: Barbara Alford Field office Manager Agency for Health Care Administration (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return ‘Receipt. Requested, to: Owner, 10210 Highland Manor Drive, Suite 250," Tampa, FL 33610 (Receipt # 7004 1160 0003 3739 7876) and to Administrator Raymond Charpentier, 1304 Woodcrest Avenue, Safety ; 4 Harbor, FL 34695(Receipt # 7004 1160 0003 3739 7869) on this 24 ‘day of i 2007. a, —— Moore, Esquire

Docket for Case No: 07-002742