eee JUL-28-2807 13:25 AHCA 233 338 2372 P.82 STATE OF FLORIDA Oo AGENCY FOR HEALTH CARE ADMINISTRATION G Ge, 6 “Hy STATE OF FLORIDA, Ks, % Oo AGENCY FOR HEALTH CARE a 7 BU b v Gone 74, ADMINISTRATION, . gl On Gayo Petitioner, ‘ < v. . Case No. 2007006758 CYPRESS COVE AT HEALTH PARK FLORIDA, INC., d/b/a THE INN OF CYPRESS COVE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “the Agency”), by and through the undersigned counsel, and files this administrative complaint against the Respondent, CYPRESS COVE AT HEALTH PARK FLORIDA, INC., d/b/a THE INN OF CYPRESS COVE (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative finc in the amount of twenty thousand dollars ($20,000.00) based upon four class J deficiencies, pursuant to Subsections 429.19(2)(a) Florida Statutes (2006), and to assess a survey fee in the amount of five hundred dollars ($500.00) pursuant to Section 429.19(10), Florida Statutes (2006), for a total sum of twenty thousand five hundred dollars ($20,500.00). JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to sections 120.569 and 120.57, Florida Statutes (2006). JiJL-28-2887 13:25 AHCA 233 338 2372 P.@3 2. The Agency has jurisdiction over the Respondent pursuant to sections 20.42, 120.60 and Chapter 429, Part I, Florida Statutes (2006). 3. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 4, The Agency is the regulatory authority responsible for the licensure of assisted living facilities and the enforcement of all applicable federal and state regulations, statutes and rules, governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code (2006). 5. The Respondent is a Florida licensed assisted living facility (License Number 9630), that operates a fifty-five (55) bed assisted living facility located at 10300 Cypress Cove Drive, Fort Myers, Florida 33908, and was at all times material required to comply with all applicable federal and state regulations, statutes and rules for assisted living facilities. COUNT I The Respondent Failed To Provide Supervision Of An Administrator Who Is Responsible For The Operation And Maintenance Of The Facility In Violation Of Florida Administrative Code 58A-5.019(1) (2006) 6. The Agency re-alleges and incorporates paragraphs 1 through 5. 7. Pursuant to Rule 58A-5.019(1), Florida Administrative Code (2006), an assisted living facility is required to 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 Chapter 429, Part I, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code (2006). 8. Based on observation, interview, and record review the facility failed to provide effective administrative supervision to ensure the provision of adequate care of all residents for 1 (Resident #5) of 1 closed record as evidenced by the death of the resident by drowning. JUL-28-2087 13:25 AHCA 233 338 2372 9. On or about June 20th and 21st, 2007, the Agency conducted a biennial survey of the Respondent’s facility. 10. Observation of the facility and its premises during the survey on June 20, 2007 and June 21, 2007 revealed the facility is located on a parcel of land that contains numerous lakes and/or retention ponds that are not fenced. The facility is connected to an independent living section and a skilled nursing section via a series of hallways. 11. A review of the resident record for Resident #5 on June 20, 2007 revealed that the resident was re-admitted to the facility on February 15, 2005 with a diagnosis of, but not limited to, Alzheimer's disease. The resident had a durable power of attorney (DPOA) and a health care surrogate dated September 10, 2002. The DPOA was the person who had made decisions regarding business and medical treatment decisions. 12. A review of a nurse's note located in the resident record that was’not timed, but was dated March 17, 2007 revealed Resident #5 was seen on the outside of the building, walking in the driveway and disappeared in the dark. Law enforcement was called to assist in locating Resident #5. Law enforcement found Resident #5 and handed Resident #5 over to facility staff. 13. During an interview on June 21, 2007 at 12:00 p.m. the Facility Administrator stated that he was the Risk Manager for the facility and had just learned on June 20, 2007 during a discussion with 2 surveyor that the police had been called to find Resident #5 on March 17, 2007. He confirmed that no one day or fifteen day Adverse Incident Report had been completed and therefore no investigation to determine the steps to take to prevent reoccurrence was completed. When the Facility Administrator was asked how he is made aware of incidents he stated that he sees the incident report. When the FA was asked how staff would know who is at nisk of wandering or elopement he stated, "Staff can te)] who is at nsk.” 14, An incident report, dated March 20, 2007, revealed that at 5:20 a.m. Resident #5 P.@4 JiJ_-28-20887 13:25 AHCA 233 338 2372 P.@5 was found in the main kitchen in the facility. The report indicated that the resident was to be continually monitored. There was no documentation that indicated that the resident was continuously monitored. 15. A review of a security incident report that was written on June 21, 2007 revealed that on June 5, 2007 at 3:20 p.m. a security guard reported seeing some clothing in the lake located by the receiving area and employee parking. Upon closer inspection, it was determined that the object was a human body. The body was later identified as Resident #5. 16. An interview with the Medical Examiner on June 21, 2007 at about 10:30 am. confirmed that the cause of death for Resident #5 was drowning. 17. An interview with the Facility Administrator on June 20, 2007 at 3:30 p.m. revealed that since the death of Resident #5 there have bcen no interventions put in place to prevent another drowning. The Facility Administrator stated that the elopement policy is currently being revised and he is looking at some designs for signs that can be placed by the sidewalks alerting residents to stay away from the lake. 18. Observation of the area where Resident #5's body was found on June 20, 2007 revealed that the area where the resident’s body was located had no sidewalks. 19. On June 21, 2007 at 12:00 p.m. the Facility Administrator stated there was no documentation of a facility based investigation into the drowning death of Resident #5 other than what was reported to law enforcement and to the Agency. 20. The Respondent’s deficiencies, conduct, conditions or occurrences, constituted a class I violation in that they related to the operation and maintenance of a facility or to the personal care of residents, which presented 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. JiJL-28-2887 13:25 AHCA 233 338 2372 21. Pursuant to section 429.19(2)(a), Florida Statutes (2006), the Agency shall impose an administrative fine for a class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. An administrative fine may be levied notwithstanding the correction of the violation. 22. The Respondent’s deficient practices described in this count, constituted, in part, the basis for the Emergency Order of Immediate Moratorium on Admissions that the Agency imposed upon the Respondent on or about June 22, 2007, pursuant to sections 120.60, 408.814, and 429.15, Florida Statutes (2006), and Rule 58A-5.033(6), Florida Administrative Code (2006). 23. The Agency provided the Respondent with a mandatory correction date of July 21, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five thousand dollars ($5,000.00). COUNT The Respondent Failed To Provide Care And Services Appropriate To The Needs Of Residents Accepted For Admission To The Facility In Violation Of Florida Administrative Code 58A4-5.0182 24. The Agency re-alleges and incorporates paragraphs 1 through 5. 25. Pursuant to Rule 58A-5.0182, Florida Administrative Code (2006), an assisted living facility is required to provide care and services appropriate to the needs of residents accepted for admission to the facility. 26. Based upon a review of emergency reports, facility records, resident records, as well as facility staff and resident interviews, the Respondent failed to comply with Rule 58A- 5.0182, Florida Administrative Code (2006). P.@5 JUL-28-2867 13:26 AHCA 233 338 2372 P.67 27. On or about June 20 and 21, 2007, the Agency conducted a biennial survey of the Respondent. 28. Based on observation, interview, and record review, the facility failed to provide appropriate care and services to meet the needs of 1 (Resident #5) of 1 closed sampled resident as evidenced by the drowning death of Resident #5 and 1 (Resident #7) of 1 random resident observed as evidenced by the lack of adequate monitoring. 29. Observation of the facility and its premises during the survey on June 20, 2007 and June 21, 2007 revealed that the facility is located on a parcel of land that contains numerous lakes and/or retention ponds that are not fenced. The facility is connected to an independent living section and a skilled nursing section via a series of hallways. 30. A review of the resident record for Resident #5 on June 20, 2007 revealed that the resident was re-admuitted to the facility on February 15, 2005 with a diagnosis of, but not limited to, Alzheimer's disease. The resident had a durable power of attomey (DPOA) and a health care surrogate dated September 10, 2002. The DPOA was the person who had made decisions regarding business and medical treatment decisions regarding Resident #5. 31, A review of a nurse's note located in the resident record that was not timed, but was dated March 17, 2007, revealed Resident #5 was seen on the outside of the building, walking in the driveway and disappeared in the dark. Law enforcement was called to assist in locating Resident #5. Law enforcement found Resident #5 and handed Resident #5. over to facility staff. 32. An incident report, dated March 20, 2007, revealed at 5:20 a.m. Resident #5 was found in the main kitchen area of the facility. The "additional comments" section of the report indicated that a physician order for a wander guard (a bracelet like device that triggers an audible alarm when the wearer passes by a sensor), continuous monitoring of the resident's whereabouts, JUL-28-2887 13:26 AHCA 233 338 2372 and a psychological evaluation. 33. A review of the psychiatric evaluation, performed by a mental health Advanced Registered Nurse Practitioner (ARNP), located in the resident 's record and dated March 20, 2007 revealed Resident #5 had dementia with behavioral changes including agitation. The note indicated that the resident had some confusion and refused care. "The stated resident is up all night without stopping. The resident will eat while walking, but no stopping." The ARNP's impression of the Resident # 5’s condition was "Dementia with psychosis." Recommendations made by the ARNP included: 1. Seroquel 50mg (milligrams) by mouth at bedtime. Seroquel is a medication used to control certain behaviors. 2. If the resident refused medications by mouth, use Haldol gel lmg topically at 6:00 p.m. Haldol is similarly used to control certain behaviors. 3. Consider move to locked area. 34. A review of the physician's orders on June 20, 2007 in Resident #5’s record revealed that on March 20, 2007 orders for a wander guard, a psychological evaluation, and Seroquel 50mg by mouth at bedtime were obtained. On April 3, 2007, the physician’s order for the wander guard was discontinued due to the resident refusing to wear the device. On April 18, 2007, an order to discontinue the Seroquel was obtained. There was no reason for the discontinuance of the medication noted in the resident record. 35. The resident record did not contain any documentation that the Haldol gel or transfer to a locked unit was considered. 36. A review of the nurses’ notes for Resident #5 revealed that on June 5, 2007 at P.@8 JUL-28-2887 13:26 AHCA 239 338 2372 12:40 p.m. the resident was told by the Certified Nursing Assistant to go to the dining room for lunch. He went to the dining room and tumed around and left. There are no further notes regarding the monitoring of the resident's whereabouts until 3:40 p.m. when the resident was noted missing from his room. 37. An interview with the Security Manager on June 21, 2007 at 12:25 p.m. revealed that on June 5, 2007 at 3:20 p.m., a Security Guard was amiving at the loading dock of the facility in a golf cart. The Security Guard noted what appeared to be clothing in the Jake by the fountain and reported it to the Security Manager. Upon closer examination the Security Manager stated it appeared that a mannequin or a body was in the lake. The Security Manager obtained a canoe from the facility yacht club and paddled to the body. Upon recognition that it was a body, 911 was called and the facility staff was alerted to check for missing residents. The time of the alert was at approximately 3:40 p.m. At approximately 4:30 p.m. a tentative identification of the Resident #5 was made. 38. An interview with the Medical Examiner on June 21, 2007 at about 10:30 a.m. confirmed that the cause of death for Resident #5 was drowning. 39. During an interview on June 21, 2007 at 1:15 p.m., a Certified Nurses Aide (CNA) stated she knows who needs to be watched by reading the assignment sheet. She stated, "The residents who have special things to watch for are listed at the bottom of the sheet." When asked how the residents are monitored she stated, "Watch for them in the hall and someone is always up front at the desk so they will see them if they try to leave.” She mentioned the name of a resident on the list and said he wanders and is confused. Review of the CNA's assignment sheets for June 20, 2007 and June 21, 2007 revealed the resident (Random Resident #7) was listed as "monitor whereabouts." Observation of this resident on June 21, 2007 at 2:30 p.m. revealed he was standing in a lounge area. There were no staff in the area and the room could P.@9 JIJL-28-2087 13:26 AHCA 239 338 2372 P.18 not be seen from the other hall. At 2:45 p.m. the resident was walking in the hall near his room. without being monitored by staff. The resident was not oriented and kept telling another resident he/she was in his room. 40. Observation on June 21, 2007 at 1:20 p.m. revealed there was no one at the front desk. The Director of Nurses was in the Wellness Room but behind the door and unable to see the front door. At 2:00 p.m. there was still no one at the front desk but there were three staff in the Wellness Room. None were facing the front door. At 2:15 p.m. no one was at the desk and one staff person was in the Wellness Room, again unable to see the front door. 41. The Respondent’s deficiencies, conduct, omissions, conditions or occurrences, constituted a class I violation in that they related to the operation and maintenance of a facility or to the personal care of residents, which presented 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. 42. Pursuant to section 429.19(2)(a), Florida Statutes (2006), the Agency shall impose an administrative fine for a class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. An administrative fine may be levied notwithstanding the correction of the violation. 43. | The Respondent’s deficient practices described in this count, constituted, in part, the basis for the Emergency Order of Immediate Moratorium on Admissions that the Agency imposed upon the Respondent on or about June 22, 2007, pursuant to sections 120.60, 408.814, and 429.15, Florida Statutes (2006), and Rule 58A-5.033(6), Florida Administrative Code (2006). . 44. The Agency provided the Respondent with a mandatory correction date of July 21, 2007. JUL-28-2887 13:26 AHCA 2393 338 2372 WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five thousand dollars ($5,000.00). COUNT IY The Respondent Failed To Offer Personal Supervision, As Appropriate For Each Resident, Including The Genera] Awareness Of The Resident’s Whereabouts, In Violation Of Florida Administrative Code 58A-5.0182(1)(c) 45. The Agency re-alleges and incorporates paragraphs 1 through 5. 46. Pursuant to Rule 58A-5.0182(1)(c) Florida Administrative Code (2006), an assisted living facility is required to offer personal supervision, as appropmate for each resident, including the general awareness of the resident’s whereabouts. 47. Based upon a review of emergency reports, facility and resident records and staff interview, the Respondent failed to comply with Rule 58A-5.0182(1)(c) Florida Administrative Code (2006), by not providing personal supervision, as appropriate for each resident, including the general awareness of the resident’s whereabouts. 48. On or about June 20th and 21st, 2007, the Agency conducted a biennial survey of the Respondent. 49, Based on observation, interview, and record review, the facility failed to personally supervise and maintain an awareness of the whereabouts of 1 (Resident #5) of 1 closed records as evidenced by the death of Resident #5, who had a documented history of wandering behavior and drowning in a lake and/or retention pond and 1 (Resident #7) of 1 random resident observed as evidenced by the lack of adequate monitoring. 50. Observation of the facility and its premises during the survey on June 20, 2007 and June 21, 2007 revealed that the facility is located on a parccl of land that contains numerous © lakes and/or retention ponds that are not fenced. The facility is connected to an independent P. il JUL-28-2887 13:26 AHCA 233 338 2372 living section and a skilled nursing section via a series of hallways. 51. A review of the resident record for Resident #5 on June 20, 2007 revealed that the resident was re-admitted to the facility on February 15, 2005 with a diagnosis of, but not limited to, Alzheimer's disease. The resident had a durable power of attorney (DPOA) and a health care surtogate dated September 10, 2002. The DPOA was the person who had made decisions regarding business and medical treatment decisions regarding Resident #5. 52. A review of a nurse's note located in the resident record that was not timed, but was dated March 17, 2007, revealed the resident was seen on the outside of the building, walking in the driveway and disappeared in the dark. Law enforcement was called to assist in locating Resident #5. Law enforcement found Resident #5 and handed Resident #5 over to facility staff. 53. An incident report dated March 20, 2007 revealed that at 5:20 am. Resident #5 was found in the main kitchen area of the facility. The “additional comments" section of the report indicated that a physician order for a wander guard (a bracelet like device that triggers an audible alarm when the wearer passes by a sensor), continuous monitoring of the resident's whereabouts, and a psychological evaluation. 54. A review of the psychiatric evaluation, performed by a mental health Advanced Registered Nurse Practitioner (ARNP), located in the resident’s record and dated March 20, 2007, revealed Resident #5 had dementia with behavioral changes including agitation. The note indicated that the resident had some confusion and refused care. "The stated resident is up all night without stopping. The resident will eat while walking, but no stopping." The ARNP's impression of Resident #5’s condition was "Dementia with psychosis." Recommendations made by the ARNP included: 1. Seroquel 50mg (milligrams) by mouth at bedtime. Seroquel isa medication used to control certain behaviors. P.12 JUL-28-2887 13:26 AHCA 233 338 2372 P. 2. If the resident refused medications by mouth, use Haldol gel Img topically at 6:00 p.m. Haldol is similarly used to control certain behaviors. 3. Consider move to locked area. 55. A review of the physician's orders on June 20, 2007 in Resident #5’s record revealed that on March 20, 2007 orders for a wander guard, a psychological evaluation, and Seroquel 50mg by mouth at bedtime were obtained. On April 3, 2007, the physician’s order for the wander guard was discontinued due to the resident refusing to wear the device. On April 18, 2007, an order to discontinue the Seroquel was obtained. There was no reason for the discontinuance of the medication noted in the resident record. 56. The resident record did not contain any documentation that the Haldol gel or transfer to a locked unit was considered. 57. A review of the nurses’ notes for Resident #5 revealed that on June 5, 2007 at 12:40 p.m. the Resident was told by the Certified Nursing Assistant to go to the dining room for lunch. He went to the dining room and turned around and left. There are no further notes regarding the monitoring of the resident's whercabouts until 3:40 p.m. when the resident was noted missing from his room. 58. An interview with the Security Manager on June 21, 2007 at 12:25 p.m. revealed that on June 5, 2007 at 3:20 p.m., a Security Guard was arriving at the loading dock of the facility in a golf cart. The Security Guard noted what appeared to be clothing in the lake by the fountain and reported it to the Security Manager. Upon closer examination the Security Manager stated that it appeared that a mannequin or a body was in the lake. The Security Manager obtained a canoc form the facility yacht club and paddled te the body. Upon recognition that it JUL~28-2887 13:26 AHCR 233 338 2372 was a body, 911 was called and the facility staff was alerted to check for missing residents. The time of the alert was at approximately 3:40 p.m. At approximately 4:30 p.m. a tentative identification of the Resident #5 was made. The Security Manager stated a security camera monitors the facility receiving area and employee parking area had been inoperable at the time of the drowning (June 5, 2007) and for about 2 months prior to Resident #5's drowning death. 59. An interview with the Medical Examiner on June 21, 2007 at about 10:30 am. confirmed that the cause of death for Resident #5 was drowning. 60. During an interview on June 21, 2007 at 1:15 p.m., a Certified Nurses Aide (CNA) stated she knows who needs to be watched by reading the assignment sheet. She stated, "The residents who have special things to watch for are listed at the bottom of the sheet. When asked how the residents are monitored she stated, “Watch for them in the hall and someone is always up front at the desk so they will see them if they try to leave," She mentioned the name of a resident on the list and said he wanders and is confused. Review of the CNA's assignment sheets for June 20th, 2007 and June 21st, 2007 revealed the resident (Random Resident #7) was listed as “monitor whereabouts." Observation of this resident on June 21, 2007 at 2:30 p.m. revealed he was standing in a lounge area. Therc were no staff in the area and the room could not be seen from the other hal]. At 2:45 p.m. the resident was walking in the hall near his room without being monitored by staff. The resident was not oriented and kept telling another resident he/she was in his room. 61. Observation on June 21, 2007 at 1:20 p.m. revealed there was no one at the front desk. The Director of Nurses was in the Wellness Room but behind the door and unable to see the front door. At 2:00 p.m. there was still no one at the front desk but there were three staff in the Wellness Room. None were facing the front door. At 2:15 p.m. no one was at the desk and one staff person was in the Wellness Room, again unable to see the front door. P. 14 JUL-28-2887 13:25 © AHCA 233 338 2372 P.45 62. The Respondent’s deficiencies, conduct, omissions, conditions or occurrences, constituted a class I violation in that they related to the operation and maintenance of a facility or to the personal care of residents, which presented 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. 63. Pursuant to Section 429.19(2)(a), Florida Statutes (2006), the Agency shall impose an administrative fine for a class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. An administrative fine may be levied notwithstanding the correction of the violation. 64. The Respondent’s deficient practices described in this count, constituted, im part, the basis for the Emergency Order of Immediate Moratorium. on Admissions that the Agency imposed upon the Respondent on or about June 22, 2007, pursuant to Sections 120.60, 408.814, and 429.15, Florida Statutes (2006), and Rule 58A-5.033(6), Florida Administrative Code (2006). . 65. The Agency provided the Respondent with a mandatory correction date of July 21, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five thousand dollars ($5,000.00). COUNT IV The Respondent Violated The Resident’s Right To Live In A Safe And Decent Living Environment, Free From Abuse And Neglect, In Violation Of Section F.S. 429.28(1)(a) 66. The Agency re-alleges and incorporates paragraphs 1 through 5. 67. Pursuant to Section 429.28(1)(a), Florida Statutes (2006), no resident of a facility JUL-28-2887 13:27 AHCA 239 338 2372 P.16 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. Every resident of a facility shall have the right to live in a safe and decent living environment, free from abuse and neglect. 68. Onor about June 20 and 21, 2007, the Agency conducted a biennial survey of the Respondent. 69. — Based on observation, interview, and record review, the facility failed to comply with the Resident Bill of Rights, specifically the right to live in an environment that is safe and free from abuse and neglect, for 1 (Resident #5) of 1 closed record and 1 (Resident #7) of 1 random resident observed. 70. Observation of the facility and its premises during the survey on June 20th, 2007 and June 21st, 2007 revealed that the facility is located on a parcel of land that contains numerous lakes and/or retention ponds that are not fenced. The facility is connected to an independent living section and a skilled nursing section via a series of hallways. 71. A review of the resident record for Resident #5 on June 20, 2007 revealed that the resident was re-admitted to the facility on February 15, 2005 with a diagnosis of, but not limited to, Alzheimer's disease. The resident had a durable power of attorney (DPOA) and a health care surrogate dated September 10, 2002. The DPOA was the person who had made decisions regarding business and medical treatment decisions regarding Resident #5. 72. A review of a nurse's note located in the resident record that was not timed, but was dated March 17, 2007, revealed Resident #5 was seen on the outside of the building, walking in the driveway and disappeared in the dark. Law enforcement was called to assist in locating Resident #5. Law enforcement found Resident #5 and handed Resident #5 over to facility staff. JiJL-28-2087 13:27 AHCA 239 338 2372 P.1i? 73. An incident report, dated March 20, 2007, revealed that at 5:20 a.m., Resident #5 was found in the main kitchen area of the facility. The "additional comments" section of the report indicated that a physician order for a wander guard (a bracelet like device that triggers an audible alarm when the wearer passes by a sensor), continuous monitoring of the resident's whereabouts, and a psychological evaluation. 74, A review of the psychiatric evaluation, performed by a mental health Advanced Registered Nurse Practitioner (ARNP), located in the resident's record and dated March 20, 2007 revealed that Resident #5 had dementia with behavioral changes including agitation. The note indicated that the resident had some confusion and refused care. "The stated resident is up all night without stopping. The resident will eat while walking, but no stopping.” The ARNP's impression of Resident #5’s condition was "Dementia with psychosis." Recommendations made by the ARNP included: 1. Seroquel 50mg (milligrams) by mouth at bedtime. Seroquel is a medication used to control certain behaviors. 2. If the resident refused medications by mouth, use Haldol gel lmg topically at 6:00 p.m. Haldol is similarly used to control certain behaviors. 3. Consider move to locked area. 75. A review of the physician's orders on June 20, 2007 in Resident # 5’s record revealed that on March 20, 2007 orders for a wander guard, a psychological evaluation, and Seroque] 50mg by mouth at bedtime were obtained. ‘On Apnil 3, 2007, the physician’s order for the wander guard was discontinued due to the resident refusing to wear the device. On April 18, 2007, an order to discontinue the Seroqucl was obtained. There was no reason for the JUL-28-2887 13:27 AHCA 233 338 2372 P.18 discontinuance of the medication noted in the resident record. 76. The resident record did not contam any documentation that the Haldol gel or transfer to a locked unit was considered. 77. A review of the nurse's notes for Resident #5 revealed that on June 5, 2007 at 12:40 p.m. the Resident was told by the Certified Nursing Assistant to go to the dining room for lunch. He went to dining room and tumed around and left. There are no further notes regarding the monitoring of the resident's whereabouts until 3:40 p.m. when the resident was noted missing from his room. 78. An interview with the Security Manager on June 21, 2007 at 12:25 p.m. revealed that on June 5, 2007 at 3:20 p.m., a Security Guard was amiving at the loading dock of the facility in a golf cart. The Security Guard noted what appeared to be clothing in the lake by the fountain and reported it to the Security Manager. Upon closer examination the Security Manager stated that it appeared that a mannequin or a body was in the lake. The Security Manager obtained a canoe form the facility yacht club and paddled to the body. Upon recognition that it was a body, 911 was called and the facility staff was alerted to check for missing residents. The time of the alert was at approximately 3:40 p.m. At approximately 4:30 p.m. a tentative identification of the Resident #5 was made. 79. An interview with the Medical Examiner on June 21, 2007 at about 10:30 am. confirmed that the cause of death for Resident #5 was drowning. 80. During an interview on June 21, 2007 at 1:15 p.m., a Certified Nurses Aide (CNA) stated she knows who needs to be watched by reading the assignment sheet. She stated, "The residents who have special things to watch for are listed at the bottom of the sheet.” When asked how the residents are monitored she stated, “Watch for them in the hall and someone is always up front at the desk so they will see them if they try to leave." She mentioned the name JiIL-28-2887 13:27 AHCA 239 338 2372 P.19 of a resident on the list and said he wanders and is confused. Review of the CNA's assignment sheets for June 20, 2007 and June 21, 2007 revealed the resident (Random Resident #7) was listed as "monitor whereabouts." Observation at this resident on June 21, 2007 at 2:30 p.m. revealed he was standing in a lounge area. There were no staff in the area and the room could not be seen from the other hall. At 2:45 p.m., the resident was walking in the hall near his room without being monitored by staff. The resident was not oriented and kept telling another resident he/she was in his room. 81. . Observation on June 21, 2007 at 1:20 p.m. revealed there was no one at the front desk. The Director of Nurses was in the Wellness Room but behind the door and unable to see the front door. At 2:00 p.m., there was still no one at the front desk but there were three staff in the Wellness Room. None were facing the front door. At 2:15 p.m., no one was at the desk and one staff person was in the Wellness Room, again unable to see the front door. 82. The Respondent’s deficiencies, conduct, omissions, conditions or occurrences, constituted a class I violation in that they related to the operation and maintenance of a facility or to the personal care of residents, which presented 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. 83. Pursuant to section 429.19(2)(a), Florida Statutes (2006), the Agency shall impose an administrative fine for a class | violation in an amount not Jess than $5,000 and not exceeding $10,000 for each violation. An administrative fine may be levied notwithstanding the correction of the violation. 84. The Respondent’s deficient practices described in this count, constituted, in part, the basis for the Emergency Order of Immediate Moratorium on Admissions that the Agency imposed upon the Respondent on or about June 22, 2007, pursuant to sections 120.60, 408.814, JIJL-28-2887 13:27 AHCA 239 338 2372 P.28 and 429.15, Florida Statutes (2006), and Rule 58A-5.033(6), Florida Administrative Code (2006). 85. The Agency provided the Respondent with a mandatory correction date of July 21, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five thousand dollars ($5,000.00). COUNT V 86. The Agency re-alleges and incorporates paragraphs 1 through 85 as if fully set forth herein. 87. Pursuant to Section 429.19(10), Florida Statutes (2006), the Agency is authorized to, in addition to any administrative fines, 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 the initial . complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 429.28(3)(c), Florida Statutes (2006), to verify the correction of the violations. 88. Pursuant to the provisions of law, the Petitioner agency must conduct a monitoring survey the next year of Respondent facility, Section 429.428 (3) (c), Florida Statutes (2006). 89. Said fee must be assessed though the survey will occur in the future. See, Agency for Health Care Administration v. Luz Home for the Elderly, Inc., d/b/a Luz Home for the Elderly, Case No. 02-263PH (Agency for Health Care Administration). 90. Respondent is therefore subject to a monitoring fee in the amount of five hundred JUL-28-2807 13:27 AHCA 233 338 2372 dollars ($500.00), pursuant to Section 429.19(10), Florida Statutes (2006). WHEREFORE, the Agency for Health Care Administration intends to impose a survey fee against the Respondent, an assisted living facility in the State of Florida, in the amount of five hundred dollars ($500.00), pursuant to Section 429.19(10), Florida Statutes (2006). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent: 1. Make findings of fact and conclusions of law in favor of the Agency as set forth above. 2. Impose an administrative fine against the Respondent in the total amount of twenty thousand dollars ($20,000.00). 3. Assess a survey fee against the Respondent in the amount of five hundred dollars ($500.00). 4. Enter any other relief that this Court deems just and appropnate. Respectfully submitted this 3 day of July, 2007. QB ve ™.,. L Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the Genera] Counsel 2295 Victoria Avenue Fort Myers, Florida 33901 Telephone: (239) 338-3203 P.2i JUL-28-2087 13:27 ARCA 239 338 2372 P.22 bs @ Lan Facsimile: (239) 338-2699 07 , LEP MIRON Ee NOTICE MS 7p OF THE RESPONDENT IS NOTIFIED THAT IT HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS FORM. THE RESPONDENT JS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM SHALL BE MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION AND DEL{VERED TO: AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served to: Ed Kunzweiler, Administrator, Inn of Cypress Cove, 10300 Cypress Cove Drive, Fort Myers, Florida 33908, by U.S. Certified Mail, Retum Receipt No. 7006 2760 0003 7781 4875, and Douglas A. Dodson, Registered Agent, Cypress Cove at Healthpark Florida, Inc., 9800 Healthpark Circle Palms, Suite 405, Fort Myers, Florida 33908, by U.S. Certified Mail, Retum Receipt No. 7006 2760 0003 7781 4882, on July avd , 2007. Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel] 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901-3884 Telephone: (239) 338-3203 Facsimile: (239) 338-2699 JiJL-28-2807 13:27 AHCA Copies furnished to: Ed Kunzweiler Administrator Inn of Cypress Cove at Health Park 10300 Cypress Cove Drive Fort Myers, Florida 33908 (U.S. Certified Mail) Douglas A. Dodson Registered Agent 9800 Healthpark Circle Palms Suite 405 Fort Myers, Florida 33908 233 338 2372 Andrea M. Lang, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice) Kriste Mennella Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340 Fort Myers, Florida 33901 (U.S. Certified Mail) (Interoffice) P.23

Docket for Case No: 07-003468