May 28 2009 14:34 MAY-28-2889 15:47 AGENCY HEALTH CARE ADMIN 856 921 4158 P.@?/35 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2009001704 ; 2009001705 CATALINA GARDENS HEALTH CARE 2009001706 ASSOCIATES, LLC, d/b/a THE BROOKSHIRE, 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 CATALINA GARDENS HEALTH CARE ASSOCIATES, LLC, d/b/a THE BROOKSHIRE (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2008), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate an assisted living facility in the State of Florida pursuant to §§ 408.415 Florida Statutes, and 429,14, Florida Statutes (2008), and to impose an administrative fine in the amount of five thousand dollars ($5,000.00) based upon four (4) repeat cited State Class III deficiencies and six (6) uncorrected cited State Class III deficiencies pursuant to §429,19(2)(c), Florida Statutes (2008), JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part II, and 429, Part I, Florida Statutes (2008). 2. Venue lies pursuant to Florida Administrative Code R. 28-106,207, May 28 2009 14:35 MAY-28-2889 15:47 AGENCY HEALTH CARE ADMIN 856 921 4158 P.@835 PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part H, and 429, Part I, Florida Statutes, and Chapter 584-5, Florida Administrative Code. 4. Respondent operates a 125-bed assisted living facility located at 85 Bulldog Blvd, Melbourne, Florida 32901, and is licensed as an assisted living facility with limited nursing services (LNS) and extended congregate care (ECC), license number 7354. 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. COUNTI 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 7. That pursuant to Florida law, limited nursing services may only be provided as authorized by a health care provider's order, a copy of which shall be maintained in the resident’s file. Rule 58A-5.031(2)(c), Florida Administrative Code. 8. That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# 2008011802) of the Respondent facility. 9. That based upon the review of records and interview, Respondent failed to ensure that Limited Nursing Services (LNS) for one (1) of twenty-two (22) sampled residents were provided only as authorized by a health care provider's order with a copy of said order maintained in the resident's file, the same being contrary to law. May 28 2009 14:35 MAY-28-2889 15:48 AGENCY HEALTH CARE ADMIN 856 921 4158 P.@9/35 10.‘ That Petitioner's representative noted during the tour of the facility in the secured unit on December 1, 2008 at approximately 1] AM that resident number eighteen (18) was observed with gauze on the left elbow and right arm. 11, That Petitioner's representative reviewed the November 2008 Medication Observation Record (MOR) for resident number eighteen (18) and noted the following documentation of wound care treatments started on November 21, 2008: Clean skin tear with normal saline with dressing with gauze twice daily 7-3 and 3-11. 12. That Petitioner's representative reviewed the November 2008 Medication Observation Record (MOR) for resident number eighteen (18) and noted the following documentation of wound care treatments started on November 28, 2008: 1. Right wrist steri strips, keep dry and monitor for signs and symptoms of infections on the 7-3, 3-11 and 11-7 shifts. 2. Left Elbow -steri strips keep dry and monitor for signs and symptoms of infections on the 7-3, 3-11 and 11-7 shifts. 3. Right knee normal Saline cleanse, triple antibiotic ointment with Band-Aid twice daily till healed 3-11 and 11-7 shifts (AM, PM not documented). 13. That Petitioner’s representative reviewed Respondent’s records related to resident number eighteen (18) during the survey and noted as follows: a. A progress note dated November 29, 2008 documented that the resident had skin tears to the right wrist, left elbow and right knee and the resident could not state how they got there; b. There was no order for the treatment to the right wrist, left elbow and right knee that began on November 28, 2008. 14.‘ That Petitioner’s representative interviewed Respondent’s director of nursing during the survey who indicated as follows: May 28 2009 14:35 MAY-28-2889 15:48 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 1835 a, That she was not aware that the above treatments to resident number eighteen (18) wete nursing services and required a physicians order; b. She provided an unsigned order dated November 28, 2008 that the nurse had completed to give to the resident’s health care provider for the above treatments; c. That the order did not list the gauze that was applied to resident number eighteen (18); d, The nurses had placed the gauze on the resident because the resident had started Picking at the skin tears and they were bleeding; e, There was no order signed by the health care provider for the limited nursing services provided to resident number eighteen (18). 15. That the failure to ensure that treatments are provided with the advise and consent of a treating physician places the resident at risk for inappropriate treatment in accord with the resident’s complete care. 16. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 17.‘ That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2\(c), Florida Statutes (2008). 18. That the Agency provided a mandated correction date of December 17, 2008. 19. That on January 14, 2009, the Agency completed a re-visit to the Complaint Survey (CCR# 2008011802) of the Respondent facility. 20, That based upon the review of records and interview, Respondent failed to ensure that Limited Nursing Services (LNS) for one (1) of thirteen (13) sampled residents were provided May 28 2009 14:36 MAY-28-2889 15:48 AGENCY HEALTH CARE ADMIN 856 921 @158 P.11/35 only as authorized by a health care provider's order with a copy maintained in the resident's file, the same being contrary to law. 21. That Petitioner's representative toured the Respondent facility on January 13, 2009 at around 10 am, and noted ostomy bags and tubes of ostomy paste in the room of resident number seven (7), a resident whose condition prevented meaningful interview. 22. ‘That Petitioner's representative reviewed Respondent’s records regarding resident number seven (7) during the survey and noted as follows: a, The resident’s Health Assessment form 1823 identified diagnoses of hypertension, dementia, peripheral edema, chronic renal insufficiency, colon cancer and colostomy car: b. The resident was under the care of Hospice who provided ostomy care until December 2008 when the resident was discharged from hospice service; c. There was no indication in the record of who would continue to provide the ostomy care nor was there a physicians order for the continued ostomy care. 23. ‘That Petitioner’s representative interviewed Respondent’s director of nursing during the survey who indicated as follows: a. She started providing the ostomy care to resident number seven (7) when Hospice services stopped; b. She was changing the ostomy bag and the wafer; c. There was no order signed by the health care provider for ostomy care, a licensed limited nursing service provided to resident number seven (7). 24. — That the failure to ensure that treatments are provided with the advise and consent of a treating physician places the resident at risk for inappropriate treatment in accord with the May 28 2009 14:36 MAY-28-2089 15:49 AGENCY HEALTH CARE ADMIN 856 921 4158 P1235 resident’s complete care. 25. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 26. That the Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 27. That the Agency provided a mandated correction date of January 31, 2009. 28. That this constitutes an uncorrected violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,.19(2)(c), Florida Statutes (2008). COUNT IL 29, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 30. That pursuant to Florida law, records for limited nursing services include (a) A record of all residents receiving limited nursing services under this license and the type of service provided, shall be maintained, (b) Nursing progress notes shall be maintained for each resident who receives limited nursing services. (c) A nursing assessment conducted at least monthly shall be maintained on each resident who receives a limited nursing service. Rule 58A-5.031(3), Florida Administrative Code. 31. That on August 22, 2007, the Agency completed an Assisted Living Facility (ALF) with Limited Nursing Services (LNS) and Extended Congregate Care (ECC) Change of Ownership (CHOW) survey of the Respondent facility, May 28 2009 14:36 MAY-28-2889 15:49 AGENCY HEALTH CARE ADMIN 856 921 @158 P.13/35 32. That based upon the review of records and interview, Respondent failed to ensure a nursing assessment was conducted at least monthly for one (1) of three (3) residents who received Limited Nursing Services (LNS), the same being contrary to law. 33. That Petitioner’s representative reviewed Respondent’s records regarding resident number eight (8) duzing the survey and noted as follows: a. The resident’s health assessment form 1823 dated January 31, 2007 noted diagnoses of status post carbon dioxide poisoning; b. A physician's order dated July 10, 2007 required a soft boot while in wheelchair as tolerated; c. The nursing assessment conducted on August 22, 2007 was conducted and signed by the Licensed Practical Nurse (LPN); d. The Advanced Registered Nurse Practitioner's (ARNP) monthly assessment for August 2007 on the resident did not address the use of the soft boot. 34. That Petitioner’s representative interviewed Respondent's Director of Nursing on August 22, 2007 who stated resident number eight (8) was on Limited Nursing Services for application of the soft boot. | 35, That resident number eight (8) was observed during the tour of the facility to have the boot on the leg. 36. That nursing assessments are beyond the scope of practice for a licensed practical nurse under the controlling provisions of law. See, Chapter 464, Part I, Florida Statutes (2007). 37, That Petitioner’s representative interviewed Respondent’s administrator and director of nursing who indicated that they were not aware that the monthly nursing assessments were to be conducted and signed by a Registered Nurse (RN) as mandated by Chapter 464 F.S. (Nurse May 28 2009 14:37 MAY-28-2089 15:49 AGENCY HEALTH CARE ADMIN 856 921 4158 P1435 Practice Act). 38, That the failure to ensure that monthly nursing assessments are conducted and maintained place residents at risk that nursing practices utilized are not weighed for efficacy, other effects, and complications noted and addressed. 39. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 40. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2007). 41. That the Agency provided a mandated correction date of September 6, 2007. 42. That during a re-visit survey conducted October 10, 2007 the Agency determined that the Respondent had corrected the deficiency. , ' 43. That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# . 200801 1802) of the Respondent facility. 44, That based upon the review of records and interview, Respondent failed to ensure that a nursing assessment conducted at least monthly was maintained for one (1) resident in a sample of twenty-two (22) who received a limited nursing service (LNS), said failure being contrary to law. 45, That Respondent’s administrator identified during the entrance conference on December 1, 2008 that resident number nineteen (19) received limited nursing services for the application and removal of thrombo embolism-deterrent (TED) hose. 46, That Petitioner’s representative observed, on December 1, 2008 at approximately 12:30 PM, that resident number nineteen (19) was not wearing TED hose and that the facility nurse May 28 2009 14:37 MAY-28-2889 15:58 AGENCY HEALTH CARE ADMIN 856 921 @158 P.15/35 approached the resident and discovered that the hose were in the resident's pocket. 47. That Petitioner’s representative reviewed Respondent’s records regarding resident number nineteen during the survey and noted a healthcare provider's order dated May 7, 2008 requiring TED hose to the lower extremities "on in AM and off at bedtime," however the records were devoid of any monthly nursing assessments of the resident. 48. That Petitioner’s representative interviewed Respondent’s contract advanced registered nurse practitioner who had been contracted by the facility to provide monthly nursing assessments who indicated that she had not been made aware that resident number nineteen (19) was using TED hose and in need of LNS, and therefore she did not conduct monthly nursing assessments. 49. That the failure to ensure that monthly nursing assessments are conducted and maintained place residents at risk that nursing practices utilized are not weighed for efficacy, other effects, and complications noted and addressed. 50. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 51. That the Agency cited the Respondent for a repeat Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008), . 52. That the Agency provided a mandated correction date of December 17, 2008. 53. That this constitutes a repeat violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). May 28 2009 14:37 MAY-28-2889 15:58 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 1635 COUNT II 34. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 35. That pursuant to Florida law, nursing progress notes shall be maintained for each resident who receives limited nursing services. Rule 58A-5.031(3)(b), Florida Administrative Code. 56. That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# 2008011802) of the Respondent facility. 57. That based upon observations, the review of records, and interview, Respondent failed to ensure nursing progress notes were maintained for two (2) residents of twenty-two (22) sampled residents who receive Limited Nursing Services (LNS), the same being contrary to law. 58. That Petitioner’s representative noted during the tour of the facility in the secured unit on December 1, 2008 at approximately 11AM¢ that resident number eighteen (18) was observed with gauze on the left elbow and right arm. 59. That Petitioner’s representative reviewed the November 2008 Medication Observation Record (MOR) for resident number eighteen (18) and noted the following documentation of wound care treatments started on November 21, 2008: Clean skin tear with normal saline with dressing with gauze twice daily 7-3 and 3-11. 60. That Petitioner’s representative reviewed the November 2008 Medication Observation Record (MOR) for resident number eighteen (18) and noted the following documentation of wound care treatments started on November 28, 2008: 1. Right wrist steri strips, keep dry and monitor for signs and symptoms of infections on the 7-3, 3-11 and 11-7 shifts. 2. Left Elbow -steri strips keep dry and monitor for signs and symptoms of infections on the 7-3, 3-11 and 11-7 shifts. 3. Right knee normal Saline cleanse, triple antibiotic ointment with Band-Aid May 28 2009 14:33 MAY-28-2889 15:58 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1?/35 twice daily till healed 3-11 and 11-7 shifts (AM, PM not documented). 61. That Petitioner’s representative reviewed Respondent's records related to resident number eighteen (18) during the survey and noted a progress note dated November 29, 2008 documenting that the resident had skin tears to the right wrist, left elbow and right knee and the resident could not state how they got there, 62. That Petitioner's representative reviewed Respondent’s records regarding resident number nineteen (19) during the survey and noted as follows: a, The resident’s health assessment report dated May 6, 2006 reflected that the resident was afflicted with CAD, HTN, dementia, A fibs and CHF; b. A healthcare provider's order dated May 7, 2008 required TED hose to the lower extremities on in AM and off at bedtime; c. Respondent’s limited nursing services notes from November 12 to December 1, 2008 revealed that the notes dated November 12, 13, 14, 15, 18, 20, 21, 23, 25, 26, 27 and 28, 20/08 documented "Ted Hose on - no edema.” d. The notes dated November 16 and 22, 2008 documented "TED hose off~ edema." e. Anote dated November 19, 2008 documented "Ted hose on 4 PM and removed at 10:30 PM." £ Notes dated November 29, 30, and December 1, 2008 simply indicated "Ted Hose." 63. That absent ftom Respondent’s records of limited nursing services maintained in its identified binder were any other nursing “progress notes” or "progress reports," a written record of nursing services provided to each resident who receives such services completed by the nurse May 28 2009 14:33 MAY-28-2889 15:51 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 1835 who delivered the service that describes the date, type, scope, amount, duration, and outcome of services rendered; the general status of the resident's health; any deviations; any contact with the resident's physician; with the signature and credential initials of the person rendering the service, to confirm each time the skin/wound care treatments and the application and removal of TED hose were conducted. 64. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey who indicated as follows: a. She was not aware that resident number eighteen (18) needed to be admitted to limited nursing services for the simple wound care; b. There were no progress notes completed each time the treatments were conducted; c. For resident number nineteen (19), nursing notes were not written every time the TED hose were removed and/or applied. 65. That the failure to maintain nursing notes places residents at risk that other health care providers will not be aware of services provided, assessments, and efficacy of nursing services. 66. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 67. That the Agency cited the Respondent for a Class II violation in accordance with Section 429, 19(2)(c), Florida Statutes (2008). 68. That the Agency provided a mandated correction date of December 17, 2008. 69. That on January 14, 2009, the Agency completed a re-visit to the Complaint Survey (CCR# 2008011802) of the Respondent facility. May 28 2009 14:33 MAY-28-2889 15:51 AGENCY HEALTH CARE ADMIN 856 921 @158 P.19/35 70. ‘That based upon the review of records and interview, Respondent failed to maintain nursing progress notes for one (1) of thirteen (13) sampled residents who received Limited Nursing Services (LNS), the same being contrary to law. 71. That Petitioner's representative toured the Respondent facility on January 13, 2009 at around 10 am, and noted ostomy bags and tubes of ostomy paste in the room of resident number seven (7), a resident whose condition prevented meaningful interview. 72. ‘That Petitioner’s representative reviewed Respondent's records regarding resident number seven (7) during the survey and noted as follows: a. The resident’s Health Assessment form 1823 identified diagnoses of hypertension, dementia, peripheral edema, chronic renal insufficiency, colon cancer and colostomy sear; b. The resident was under the care of Hospice who provided ostomy care until December 2008 when the resident was discharged from hospice services; c. There was no indication in the record of who would continue to provide the ostomy care nor was there a physicians order for the continued ostomy care. 73. That Petitioner’s representative interviewed Respondent's director of nursing during the survey who indicated as follows: a. She started providing the ostomy care to resident number seven (7) when Hospice services stopped; b. She was changing the ostomy bag and the wafer; c. There was no progress notes completed each time the ostomy care was done for resident number seven (7). May 28 2009 14:39 MAY-28-2889 15:51 AGENCY HEALTH CARE ADMIN 856 921 4158 P2835 74. That absent from Respondent's records of limited nursing services maintained in its identified binder were any other nursing “progress notes” or "progress reports,” a written record of nursing services provided to each resident who receives such services completed by the nurse who delivered the service that describes the date, type, scope, amount, duration, and outcome of services rendered; the general status of the resident's health; any deviations; any contact with the resident's physician; with the signature and credential initials of the person rendering the service, to confirm each time the ostomy care was provided for resident number seven (7). 75. That the failure to maintain nursing notes places residents at risk that other health care providers will not be aware of services provided, assessments, and efficacy of nursing services. 76. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 77, That the Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 78. That the Agency provided a mandated correction date of January 31, 2009. 79. That this constitutes an uncorrected violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT IV. 80. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. May 28 2009 14:39 MAY-28-2889 15:52 AGENCY HEALTH CARE ADMIN 856 921 4158 P.21/35 81. That pursuant to Florida law, the service plan shall be reviewed and updated quarterly to reflect any changes in the manner of service provision, accommodate any changes in the resident’s physical or mental status, or pursuant to recommendations for modifications in the resident’s care as documented in the nursing assessment. Rule 58A-5.030(7)(d), Florida Administrative Code. 82. That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# 2008011802) of the Respondent facility, 83. That based upon the review of records and interview, Respondent failed to ensure that the Extended Congregate Care (ECC) service plan was updated quarterly for one (1) resident of twenty-two (22) sampled residents who received ECC services, the same being contrary to the minimum requirements of law. 84, That Petitioner’s representative reviewed Respondent’s records regarding resident number thirteen (13) during the survey and noted as follows: a. The resident’s health assessment form 1823 dated December 13, 2007 reflected diagnoses of Hypertension and Alzheimer's; b. The resident required total assistance with bathing, dressing and grooming; ¢. The resident was admitted to the ECC program in November 2006 for total care with activities of daily living; d. The most recently dated ECC service plan available for review was last updated in March 2008; e. There were no service plan quarterly reviews completed for June and September 2008. May 28 2009 14:39 MAY-28-2889 15:52 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 22/35 85. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey who indicated that resident number thirteen (13) did receive ECC services and the above service was provided to the resident and there was no other documentation available for review to prove that the service plan was update quarterly as required. 86. That the Agency determined that this deficient practice was related to the operation and maintenance of the F: acility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 87, — That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008), 88. That the Agency provided a mandated correction date of December 17, 2008. 89. That on January 14, 2009, the Agency completed a re-visit to the Complaint Survey (CCR# 2008011802) of the Respondent facility, 90. That based upon the review of records and interview, Respondent failed to ensure that the Extended Congregate Care (ECC) service plan was updated quarterly for one (1) resident of thirteen (13) sampled residents who received ECC services, the same being contrary to the Ininimum requirements of law. 91. That Respondent’s administrator identified resident number nine (9) as a resident receiving extended congregate care services. 92. That Petitioner's representative reviewed Respondent's records regarding resident number nine (9) during the survey and noted as follows: a. The resident received ECC services for total care with activities of daily living; b. The resident’s health assessment form 1823 dated December 31, 2007 reflected diagnoses of Alzheimer's disease, Parkinson's disease, dementia and HTN: May 28 2009 14:39 MAY-28-2889 15:52 AGENCY HEALTH CARE ADMIN 856 921 4158 P2335 c, The assessment indicated that the resident required total care with bathing and dressing; d. A physicians order dated November 11, 2008 required daily blood pressures and an order dated December 16, 2008 required simple wound care for a skin tear; e. The last documented review and update of the service plan on file was on March 6, 2008; f. There was no service plan review which included the physician’s orders of November and December 2008 and the additional services required. 93. That Petitioner’s representative interviewed Respondent’s Registered Nurse ECC Supervisor who indicated that she did not know that the service plan needed updating. 94. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 95. That the Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429,19(2)(c), Florida Statutes (2008). 96. That the Agency provided a mandated correction date of January 31, 2009. 97, That this constitutes an uncorrected violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT V 98. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. May 28 2009 14:40 MAY-28-2889 15:52 AGENCY HEALTH CARE ADMIN 856 921 4158 P2435 99. That pursuant to Florida law, licensed nursing staff in an extended congregate care program may provide any nursing service permitted within the scope of their license consistent with the residency requirements of this rule and the facility’s written policies and procedures and the nursing services are: 1. Authorized by a health care provider’s order and pursuant to a plan of care; 2. Medically necessary and appropriate for treatment of the resident’s condition; 3. In accordance with the prevailing standard of practice in the nursing community; 4. A service that can be safely, effectively, and efficiently provided in the facility; 5. Recorded in nursing progress notes; and 6, In accordance with the resident’s service plan. Rule 58A-5,030(8)(c), Florida Administrative Code. 100. That on August 22, 2007, the Agency completed a Change of Ownership Survey of the Respondent facility. 101. That based upon the review of records and interview, Respondent failed to ensure that licensed nursing staff provided services requiring licensure for a resident as Respondent utilized inadequately licensed staff in the conduct of nursing assessments and utilized non-licensed staff for the application and removal of TED stockings for one (1) extended congregate care (ECC) resident, the same being contrary to law, 102. That Petitioner's representative reviewed Respondent’s records regarding resident number one (1) during the survey and noted as follows: a. The tesident's health assessment, form 1823 dated September 27, 2007, reflected diagnoses of Parkinson's disease, urinary tract infection, gastro-intestinal bleed, hypertension, and chronic leg ulcers; b. The resident had a physician’s order dated August 1, 2007 which required the used of TED hose, a support stocking, to be placed on in the AM and off at 18 May 28 2009 14:40 MAY-28-2889 15:53 AGENCY HEALTH CARE ADMIN 856 921 4158 P2535 bedtime; c. Progress notes reflect that the resident received ECC services from August 1 through August 22, 2007 for the application and removal of the resident’s TED hose; d. A monthly assessment dated August 19, 2007, was annotated as completed and signed by a licensed practical nurse, 103. That Petitioner’s representative observed resident number one (1) during the survey and noted that the resident was wearing the prescribed TED hose. 104. That Petitioner’s representative interviewed Respondent's caregivers numbered one (1) and two (2) during the survey who indicated as follows: a. That Respondent’s certified nursing assistants sometimes applied and removed the TED hose for resident number one (1); b. That Respondent’s licensed practical nurses sometimes applied and removed the TED hose for resident number one (1). 105. That Petitioner’s representative interviewed Respondent’s administrator and director of nursing during the survey who indicated as follows: a. That unlicensed staff sometimes apply or remove the TED hose for resident number one (1); b. Thata licensed practical nurse conducted the monthly nursing assessments and the advanced registered nurse practitioner cosigned the assessments at a later date; c. That they were unaware that the conduct of nursing assessments by a licensed practical nurse exceeded the scope of such a professional’s duties under the applicable licensing act, Florida Statute Chapter 464. May 28 2009 14:40 MAY-28-2889 15:53 AGENCY HEALTH CARE ADMIN 856 921 4158 P2635 106. That the application and removal of TED hose is a nursing service requiring proper licensure. 107. That the conduct of assessments exceeds the scope of licensure of a licensed practical nurse. See, Section 464.003(1)(b), Florida Statutes. 108. That the failure to ensure that appropriately licensed staff perform nursing services places Tesident’s at risk in that appropriately trained and experienced persons are not conducting those services and making the required assessments of care, 109, That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. , 110. That the Agency cited the Respondent for a Class IT] violation in accordance with Section 429.19(2)(c), Florida Statutes (2007). 111. That the Agency provided a mandated correction date of August 23, 2007, 112. That the Agency determined that Respondent had corrected the deficiency on October 10, 2007. 113. That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# 2008011802) of the Respondent facility. 114. That based upon the review of records and interview, Respondent failed to ensure that nursing services were provided in accordance with the prevailing standard of practice in the nursing community when the Licensed Practical Nurses (LPN) conducted the monthly nursing assessment with the Advanced Registered Nurse Practitioner's (ARNP) co-signature for one (1) of twenty-two (22) residents, the same being contrary to law. 20 May 28 2009 14:41 MAY-28-2889 15:53 AGENCY HEALTH CARE ADMIN 856 921 4158 P.2?/a5 115. That during the entrance conference, Respondent’s administrator identified resident number thirteen (13) as a resident receiving extended congregate care (ECC) service for total care with activities of daily living. 116. That Petitioner's representative reviewed Respondent’s records regarding resident number thirteen (13) and noted that the resident’s monthly nursing assessment dated January 2008 was signed by the Respondent’s licensed practical nurse and then co-signed by an advanced registered nurse practitioner while the assessments dated June, July, August and September were not dated. 117. That Petitioner’s representative interviewed during the survey the advanced registered nurse practitioner who had signed the above-referenced assessment who indicated as follows: a. That since she did not see the residents on the day to day basis, Respondent’s nurses completed a portion of the assessments and monthly, if the records were given to her, she would co-sign the assessments; b. She did not know all of the residents who received ECC services because the facility staff did not always giver her all the records to review and therefore, those resident assessments would remain without her signature. 118, That the conduct of assessments exceeds the scope of licensure of a licensed practical nurse. See, Section 464.003(1)(b), Florida Statutes. 119. That the failure to ensure that appropriately licensed staff perform nursing services places resident's at risk in that appropriately trained and experienced persons are not conducting those services and making the required assessments of care. 120. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or 21 May 28 2009 14:41 MAY-28-2889 15:54 AGENCY HEALTH CARE ADMIN 856 921 4158 P.28/35 potentially threatened the physical or emotional health, safety, or security of Facility residents. 121. Thatthe Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 122. That the Agency provided a mandated correction date of December 3, 2008, 123, That the same constitutes a repeat deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT VI 124. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 125, The Agency re-alleges and incorporates Count V above as if fully set forth herein. 126. That on January 14,2009, the Agency completed a re-visit to the Complaint Survey (CCR# 2008011802) of the Respondent facility. 127. That based upon the review of records and interview, Respondent failed to ensure nursing services were recorded in nursing progress notes for one (1) Of thirteen (13) residents reviewed who received extended congregate care (ECC) services and required nursing services, the same being contrary to law. 128. That during the entrance conference on January 13, 2009, Respondent’s administrator identified resident number nine (9) as receiving ECC services for total care with activities of daily living (ADLs). 129, That Petitioner's representative reviewed Respondent’s records regarding resident number nine (9) during the survey and noted as follows: 22 May 28 2009 14:41 MAY-28-2889 15:54 AGENCY HEALTH CARE ADMIN 856 921 4158 P2935 a. The resident’s health assessment, form 1823 dated December 31, 2007, indicated diagnoses of Alzheimer's disease, Parkinson's disease, dementia and HTN; b. The assessment indicated that the resident required total care with bathing and dressing; c. A physician's order dated December 16, 2008 required "Neosporin to skin tear daily; normal saline cleansing, cover with Telfa and Kling" d, The December Medication Observation Record (MOR) listed the treatment and contained staff initials that the treatment was performed from December 17 through 25, 2008 and indicated on December 26, 2008 "healed." 130. That absent from the records regarding resident number nine (9) were any nursing progress notes that documented each time the skin care treatment was provided. 131. That Petitioner's representative interviewed Respondent’s registered nurse and ECC supervisor during the survey who indicated as follows: a, That nursing notes were not available for the nursing services provided to resident number nine (9) because it was the nurses' understanding that nursing notes were not needed for ECC: b. The nurses have become confused between ECC for total care with ADLs and ECC for nursing services provided to residents on ECC. 132. That the failure to ensure that appropriately licensed staff perform nursing services record said services as required by law resident’s at risk that other health care providers, including but _ hot limited to emergency personnel, are unaware of services provided and may hinder the ability of health care providers to evaluate the efficacy of prescribed treatment. 23 May 28 2009 14:42 MAY-28-2889 15:54 AGENCY HEALTH CARE ADMIN 856 921 4158 P3835 133. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 134. That the Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 135. That the Agency provided a mandated correction date of January 15, 2009. 136. That this constitutes an uncorrected violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT VII 137, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 138. That pursuant to Florida law, the facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors, The MOR must be immediately updated each time the medication is offered or administered, Rule 58A-5.185(5)(b), Florida Administrative Code. 24 May 28 2009 14:42 MAY-28-2889 15:55 AGENCY HEALTH CARE ADMIN 856 921 4158 P.31/35 139. Thaton August 22, 2007, the Agency completed an Assisted Living Facility (ALF) with Limited Nursing Services (LNS) and Extended Congregate Care (ECC) Change of Ownership (CHOW) survey of the Respondent facility, 140. That based upon observations and the review of records, Respondent did not ensure that an up-to-date daily medication observation record was maintained for one (1) of eight (8) sampled residents who received assistance with self-administration of medications, the same being contrary to law. 141. That Petitioner's representative reviewed Respondent's records related to resident number six (6) during the survey and noted as follows: a. The resident’s health assessment form 1823 dated Jume 13, 2007 which documented diagnoses of Non-insulin Dependent Diabetes Mellitus (NIDDM), cerebrovascular accident (CVA), hypertension and blindness; b. Physician's orders dated August 14, 2007 required Novolog (insulin) sliding scale coverage before meals as follows: i. 151-175 =2 units ii. 176-200 =3 units iii. 201-225 = 4 units iv. 226-250 =5 units v. 251-275 =6 units vi. 276-300 =7 units vii. 301-325 =8 units viii, 326-350 = 9 units ix, 351-400 =10 units 25 May 28 2009 14:42 MAY-28-2889 15:55 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 32/35 x. more than 400 call Medical Doctor (MD) c. The resident’s August 2007 medication observation record reflected the following: i. There was no documentation that the insulin coverage was given on August 16, 2007 at § AM where blood sugar was 189 and the amount of insulin to be given was 3 units as the record was blank; ii, On August 17, 2007 at 8 AM the blood sugar reading was 172, and thus the amount of insulin to be given was 3 units, but the record was blank. 142. That Petitioner's Tepresentative interviewed Respondent’s administrator and the director of nursing on August 22, 2007 who indicated that the nurse forgot to chart that the medication was given, 143. That the failure to ensure that medication records are maintained current and up-to-date places residents at risk of medication errors and inhibits health care providers from assessing the efficacy of prescribed treatments or resultant reactions. 144, That the Agency determined that this deficient practice was related to the operation and maintenance of the.Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 145. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2007). 146. That the Agency provided a mandated correction date of August 23, 2007. 147, That during a re-visit survey conducted October 10, 2007 the Agency determined that the Respondent had corrected the deficiency. 26 May 28 2009 14:42 MAY-28-2889 15:55 AGENCY HEALTH CARE ADMIN 856 921 4158 P3335 148. That on December 1-2, 2008, the Agency completed a Complaint Survey.(CCR# 2008011802) of the Respondent facility. 149, That based upon observations, interviews, and the review of records, Respondent failed to ensure that a daily medication observation record (MOR) for each resident who received _ assistance with self-administration of medications was maintained current and up-to-date for five (5) of twenty-two (22) sampled residents and two (2) of sixteen (16) randomly sampled residents, the same being contrary to law. 150. That Petitioner’s representative reviewed Respondent’s records related to the below listed residents, and noted on their November 2008 medication observation records that there were blank spaces with no initials or other documentation for various days and there was no explanation for the omissions on the back of the record or elsewhere in the resident's record, Resident #10 151. The resident’s health assessment form 1823 dated August 26, 2008 indicated diagnoses of COPD, seizures, osteoporosis and bi-polar disorder and the resident’s medication observation records reflected the following errors or omissions: Century senior capsules one daily -blank on 11/3, and 11/24/08 Docusate sodium 100 mg one daily at bedtime- blank on 11/4, 11/14, 11/23 and 11/24/08 Remeron 30 mg one at bedtime - blank on 11/3 and 11/14 Senna laxative two tabs at bedtime; ~ Simvastatin 20 mg one at bedtime: . Trazodone 50 mg one at bedtime - blank on 11/6, 11/8 and 11/23/08 Aspirin 81 mg one daily - blank on 11/14 and 11/24 Sio-niacin 500 mg in the morning - blank on 11/24 Valproic Acid 250 mg one twice daily (9 AM & 5 PM) - blank on 11/15 AM and 11/25 AM Calcium with D one twice daily (9 AM & 5 PM) - blank on 11/6 PM, 11/16 AM, 11/22 PM and 11/28 AM 27 May 28 2009 14:43 MAY-28-2889 15:56 AGENCY HEALTH CARE ADMIN 856 921 @158 P. 34/35 Resident #11 152, The resident’s medication observation records reflected the following errors or omissions: Atenolol 50 mg one every twelve hours was left blank at 9 PM on 11/6, 11/11-11/13, 11/23. Resident #12 153. The resident’s medication observation records reflected the following errors or omissions: Folic Acid 1 mg daily at 9 AM was left blank on 11/24, 11/28, 11/29, 11/30; Lantus 100U/ML Vial inject 8 units Sub-Q every day in the morning was left blank at 7:30 AM on 11/9; Carvedilol 25 mg one twice daily (hold for HR<55) was left blank at 9 AM on 11/9; Clonidine HCL 0.2 mg one every 12 hours was left blank at 8 AM on 11/9. Resident #20 154, The resident’s medication observation records reflected the following errors or omissions: Temazepam 15 mg one at bed time was left blank at 9 PM on 11/1 1, L1/21/, 11/29; Lumigan 0.03 % 5 ML drops instill 1 drop into both eyes at bedtime was left blank at 9 PM on 11/5, 14/14, 11/26-11/30, Resident #21 185, The resident’s medication observation records reflected the following errors or omissions: Prednisone 1 mg one at bedtime was left blank at 5 PM on 11/14, 11/19, 11/21: Loratadine 10 mg one daily in the evening -blank at 5 PM on 11/14, 11/19, 11/21. Random Resident #9 156. The resident’s medication observation records reflected the following errors or omissions: Omeprazole 20 mg one daily in the AM was left blank at 7 AM on 11/24; Effexor XR 150 mg two once a day was left blank at 9 AM on 11/7, 11/16; Zyprexa 15 mg one at bedtime 28 May 28 2009 14:43 MAY-28-2889 15:56 AGENCY HEALTH CARE ADMIN 856 921 @158 P.3535 was left blank at 9 PM on 11/3; Doxazosin Mesylate 1 mg one at bedtime was left blank at 9 PM on 11/3. Random Resident #12 157, The resident’s medication observation records reflected the following errors or omissions: Nystatin cream to groin for rash twice daily at 7-3 and 3-11 was left blank at 7-3 on 11/10 and 11/22 and was left blank at 3-11 on 11/17, 11/21, 11/22, 11/24 tol 1/30/08. 158. That Petitioner’s representative interviewed Respondent’s administrator during the survey who indicated that she had reviewed all the above referenced medication observation records and agreed with the survey team assertions and could not say whether or not the medications were given because the records did not document that the medications were given and/or the reasons for the blank spaces. 159. That the failure to ensure that medication records are maintained current and up-to-date places residents at risk of medication errors and inhibits health care providers from assessing the efficacy of prescribed treatments or resultant reactions. 160. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 161. That the Agency cited the Respondent for a repeat Class II violation in accordance with Section 429,19(2)(c), Florida Statutes (2008). 162. That the Agency provided a mandated correction date of December 3, 2008, 163. That this constitutes a repeat violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of 29 TOTAL FP. 35 May 28 2009 13:55 MAY-28-2889 15:68 AGENCY HEALTH CARE ADMIN 856 921 @158 Pa Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT VIit 164. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 165. 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. Facilities shall offer personal supervision, a8 appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community, (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. Rule 58A-5.0182, Florida Administrative Code. 166, That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# 2008011802) of the Respondent facility. 167. That based upon the review of records and interview, Respondent failed to provide care and services appropriate to the needs of sixteen (16) of twenty-two (22) residents accepted for 30 MAY-28-2889 15:69 May 28 2009 13:55 AGENCY HEALTH CARE ADMIN 856 921 @158 admission including the failure to follow physician's orders for the administration of insulin, Vitamin B12 injections, blood pressure checks, weekly weights and medications received as ordered, the same being contrary to law. Resident #1 168. That Petitioner’s representative reviewed Respondent’s records regarding resident number one (1) during the survey and noted as follows: a, The medication observation record for November 2008 documented (Vit. B 12) Cyanocobalamin 1,000 MCG inject monthly on the 26" ‘There was a block drawn on the space for the 26" and the block was blank, an indication that the injection was not administered; The resident’s Health Assessment Form (1823) dated June 2, 2008 included diagnoses of Diabetes and Hypertension, The resident required assistance with the self administration of medications; There was no indication on the medication observation record or in the resident's record to indicate why the resident did not receive the Vitamin B12 injection as prescribed. Resident #2 169. That Petitioner’s representative reviewed Respondent’s records regarding resident number two (2) during the survey and noted as follows: a. b, The medication observation record for November 2008 documented Blood Pressure (BP) weekly on Friday; There was a block drawn on the space for the 7g (Friday) and the block was blank; 31 MAY-28-2889 15:69 May 28 2009 13:55 AGENCY HEALTH CARE ADMIN 856 921 @158 The resident’s health assessment form 1823 dated June 28, 2008 identified diagnoses including Osteoporosis, Deep Vein Thrombosis, Chronic Obstructive Pulmonary Disease; . The resident required assistance with the self administration of medications; A Physician Order Sheet (POS) dated September 5, 2008 signed by the health care provider documented Blood Pressures on Fridays, There was no indication on the medication observation record or in the resident's record to indicate why the resident did not receive the Blood Pressure Checks on Fridays as prescribed. Resident #4 170, That Petitioner’s representative reviewed Respondent’s records regarding resident number four (4) during the survey and noted as follows: a The medication observation record for November 2008 indicates "weekly weights" to be taken and recorded; There were no weights recorded on the medication observation record, The medication observation record for November 2008 indicates Cyanocobalamin 1,000 MCG inject monthly on the 19™ There was a block drawn on the space for the 19" and the block was blank; A Physician Order Sheet (POS) dated September 5, 2008 signed by the health care provider that ordered weekly weights and Cyanocobalamin 1,000 MCG inject monthly on the 19"; The resident’s health assessment form 1823 dated September 30, 3008 included diagnoses of Alzheimer's and arthritis; 32 May 28 2009 13:55 MAY-28-2889 15:89 AGENCY HEALTH CARE ADMIN 856 921 4158 P.@S g. The resident required assistance with the self administration of medications; h. There was no indication on the medication observation record or in the resident's record to indicate why the resident did not receive the Cyanocobalamin 1,000 MCG injections as prescribed and why the weights were not taken and recorded as ordered by the physician. Resident #6 171. That Petitioner’s representative reviewed Respondent’s records regarding resident number six (6) during the survey and noted as follows: a. The resident’s health assessment dated June 25, 2008 indicated diagnoses of HTN, COPD, anemia and advanced Alzheimer's disease; b. A prescription label indicated “Cordarone 200 mg take half-tablet every day. Hold if pulse is less than 50” c. The resident's November 2008 medication observation record indicated the above order and noted that the medication was taken, as evident by staff initials, but a pulse rate was not documented on November 7, 8, 14, and 28; d, An order dated October 23, 2008 required weekly blood pressure; e. The resident's November 2008 medication observation record indicated the order, however it was blank, an indication that weekly blood pressures were not taken and recorded as ordered: f. A physicians order dated November 11, 2008 required to monitor and chart behavioral problems (shouting, pacing, difficult to redirect); g. The resident’s November 2008 medication observation record indicated that charting would be done during the 11-7, 7-3 and 3-11 shifts; 33 May 28 2009 13:57 MAY-28-2889 15:89 AGENCY HEALTH CARE ADMIN 856 921 4158 h. The medication observation record was blank on November 11 AM & night, November 12 AM & PM, November 13, 26 and 27 - blank all shifts, November 14 PM & night, November 15 - blank all shifts, November 16 - AM, November 17 - AM & PM, November 18 - night, November 19 - AM , November 20, 21 - AM & PM, November 22 - AM, November 23 - AM & PM, November 25 - AM & night, November 28 and 29 - blank on AM & PM; i. There was no indication on the medication observation record or in the resident's record to indicate why the resident did not receive the weekly blood pressure monitoring as prescribed and why behavioral problems were not charted as ordered by the physician. Resident #8 172. That Petitioner's representative reviewed Respondent’s records regarding resident number eight (8) during the survey and noted as follows: a. The resident’s November 2008 medication observation record documented Fasting Blood Sugar twice daily altemating before meals and at bedtime with Novolin R/Humulin R for coverage per sliding scale; b. The sliding scale was documented as follows: i. 151-200=2 units 201-250 = 4 units ii. 251-300=6 units iii. 301-350=8 units iv. 351-400 =12 units v. Greater than 400 call the health care provider c. On the following days there were blocks drawn in the spaces of the 34 May 28 2009 13:57 MAY-28-2889 15:18 AGENCY HEALTH CARE ADMIN 856 921 @158 Pa? medication observation record to indicate that the accu-checks were required and some of the days blood sugar results were documented and insulin was required yet there was none documented as administered and some of the blocks were left blank and there was no explanation on the reverse: i. November 8 at 7 AM the blood sugar was 163 - 2 units were needed - none was documented as given; ii. November 10 at 7 AM the blood sugar was 182 - 2 units were needed - none was documented as given iii. November 14 at 7 AM the blood sugar was 164 - 2 units were needed - none was documented as given; iv. November 28 at 7 AM the blood sugar was 194 - 2 units were needed - none was docurnented as given, v. November 2 at 11 AM the blood sugar was 253 - 6 units were needed - none was documented as given; vi. November 3 at 11 AM the blood sugar was 253 - 6 units were néeded - none was documented as given; vii. November 5, 21 and 29 at 11 AM the blocks were left blank and there was no explanation on the back; viii. November 16 at 4:30 PM the blood sugar was 164 - 2 units were needed - none was documented as given; d. A physician order sheet dated September 5, 2008 signed by the health care provider ordered the above sliding scale order; 35 MAY-28-2889 15:18 L-7 May 28 2009 13:57 AGENCY HEALTH CARE ADMIN 856 921 4158 The resident’s health assessment form 1823 dated June 2, 2008 included diagnoses of Hypertension and Diabetes and required assistance with the self administration of medications. Resident #9 173. That Petitioner’s representative reviewed Respondent’s records regarding resident number nine (9) during the survey and noted as follows: a. That resident’s health assessment dated September 16, 2008 indicated diagnoses of DVT, DM, mild dementia and HTN; A healtheare provider's admission note dated September 16, 2008 indicated diagnosis of osteoporosis; The weight log review revealed that the resident had a weight loss of 8 Ibs from September to October; A healthcare providers order dated November 4, 2008 indicated "Re-weigh resident if 8 lbs weight loss accurate - weekly weights x 4 then re-eval" The resident’s November 2008 medication observation record indicated weekly weights which were only taken and recorded once, on November 5, 2008; There was no indication in the resident record as to why the weights had not been taken and recorded as ordered; An order dated November 21, 2008 required “BP (blood pressure) daily while on dose pack and Medrol dose pack as directed" The residents medication observation record indicated that the Medrol tapered pack was started on November 23, 2008 for 6 days and ended on November 28, 2008 and that blood pressure was to be taken while on Medrol pack; 46 May 28 2009 13:53 MAY-28-2889 15:18 AGENCY HEALTH CARE ADMIN 856 921 4158 P.@9 i. The blood pressure readings were not taken and recorded as ordered on November 27 and 28, 2008 and charting for the Medrol was blank on November 24 at 6 PM and 9 PM and November 27 at 9 PM, an indication it may not have been given. Resident #10 174. That Petitioner’s representative reviewed Respondent’s records regarding resident number ten (10) during the survey and noted as follows: a. The resident's health assessment form 1823 dated August 26, 2008 indicated diagnoses of COPD, seizures, osteoporosis and bi-polar disorder; b. A physician's order sheet dated November 5, 2008 by the advanced registered nurse practitioner indicated weekly weights on Fridays; c. The resident’s November 2008 médication observation record indicated weekly weights on Friday; however the weight was only documented as taken on November 13, 2008; d. Weights should have been taken and recorded on November 7, 14, 21, and 18, 2008. Resident #11 175. That Petitioner's representative reviewed Respondent’s records regarding resident number eleven (11) during the survey and noted as follows: a. The resident’s health assessment form 1823 dated June 2, 2008 included diagnoses of Hypertension, and Alzheimer's Dementia; b. The resident required assistance with the self administration of medications; c. The Physician Order Sheet (POS) on file dated September 5, 2008 signed 37 May 28 2009 13:53 MAY-28-2089 15:11 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1a by the health care provider documented Blood Pressures daily: 7-3 and 3- 11 shifts (AM, PM not documented); d, The resident’s November 2008 medication observation record documented blood pressure to be taken twice daily at 7 -3 shifts and 3-11 shift; e. The resident’s November 2008 medication observation record documented blood pressure readings as follows: i. November 1-(3-11)-No blood pressure documented; ii. November 8-(3-11)-No blood pressure documented; iti. On Novernber 9, and 11 through 19, the blood pressure was documented once sideways on the medication observation record and there was no way to determine on what shift the blood pressure was taken. Resident #12 176. That Petitioner's representative reviewed Respondent’s records regarding resident number twelve (12) during the survey and noted as follows: a. The resident’s November 2008 medication observation record docurnented blood pressure two times daily prior to giving Clonidine at 7:30 and at & PM, b. The blood pressure was not documented on the following days: November 10 at 7:30 and on November 5, 15, 23, 28, and 29 at 8 PM; c. The resident’s November 2008 medication observation record documented Clonidine HCL 0,2. Mg one tablet every twelve hours for Systolic blood pressure greater than 120; 38 May 28 2009 13:53 MAY-28-2089 15:11 AGENCY HEALTH CARE ADMIN 856 921 4158 P.ii d, The medication observation record documented that the medication was given at 8 AM and 8 PM and was marked as given every day except on November 9 at 8 AM and November 23 at § PM; e. These spaces were left blank with no explanation, an indication that the medication was not given; f£ The resident’s November 2008 medication observation record documented the resident was to have Fasting Blood Sugar three times daily with Novolog for coverage per sliding scale; g. The sliding scale was documented as follows: i. 151-175= 2 units ii. 176-200 =3 units ii, 201-2254 units iv, 226-250=5 units v. 251-275 =6 units vi. 276-30057 units vii. Greater than 300 call the health care provider h. On the following days blood sugar results were documented which would reflect that insulin was required and there was no documentation of the administration of insulin: i. November 9 at 7 AM the blood sugar was 203- 4 units were needed-none was documented as given; ii. November 10 at 7 AM the blood sugar was 208- 4 units were needed-none was documented as given; 39 MAN -28-2889 1S:14 i. iit. vii. viii. ix. xi. There was no physicians order to give insulin for blood sugars greater than May 28 2009 13:53 AGENCY HEALTH CARE ADMIN 856 921 4158 November 11 at 7 AM the blood sugar was 214- 4 units were needed-none was documented as given; November 13 at 7 AM the blood sugar was 156- 2 units were needed-none was documented as given; November 16 at 7 AM the blood sugar was 155- 2 units were needed-none was documented as given; November 19 at 7 AM the blood sugar was 181- 3 units were needed-none was documented as given; November 13 at 7 AM the blood sugar was 175-2 umits were needed-none was documented as given; November 10 at 5 PM the blood sugar was 233- 5 units were needed-none was documented as given November 16 at 5 PM the blood sugar was 160- 2 units were needed-none was documented as given; November 13 at § PM the blood sugar was 19-0 3 units were needed-none was documented as given; The blood sugar was documented as 370 on November 20 and 7 units of insulin were documented as given, so based on the order, the health care provider was to be called. 300 as on November 20 and there was no documentation found to determine why the resident was given 7 units of insulin on November 20 when the resident’s blood sugar was 370; 40 P.i2 May 28 2009 13:59 MAY-28-2089 15:11 AGENCY HEALTH CARE ADMIN 856 921 4158 P.13 j. There was no documentation found that the health care provider was contacted as order when the BS was over 300 on November 20; k. A health care provider's order dated November 11, 2008 required the above sliding scale; 1. The November 2008 medication observation record reflected B12 - 1,000 MGG inject once a week for 4 weeks then once a month at 9 AM. with Sunday documented and underlined; m. The first injection was documented on Sunday November 23, 2008 and was marked as given; n. There was a box drawn on the space for Sunday November 30, 2008 and the box was left blank and there was no explanation as to what occurred or if the injection had been given or not; 9. That during medication review located was a bag with 3 vials of B12-1000 MCG inside of the medication cart with a prescription fill date of November 22, 2008; p. There should have only been 2 vials of B12 left on the day of the survey had the medication was given as ordered and given on Sunday as the medication observation record documented; q. The resident’s health assessment form 1823 dated October 23, 2008 included diagnoses of Hypertension and Diabetes; x, The resident required assistance with the self administration of medications; s. A physician’s order sheet dated September 5, 2008 was signed by the 4l May 28 2009 13:59 MAY-28-2889 15:12 AGENCY HEALTH CARE ADMIN 856 921 4158 P.14 health care provider and required blood pressure two times daily prior to giving Clonidine at 7:30 (AM, PM not documented) and at 8 PM and Clonidine and HCL 0.2. Mg one table every twelve hours for Systolic BP greater than 120 and also for the above sliding scale coverage; t. A health care provider's order dated November 21, 2008 required B12- 1,000 MCG inject once a week for 4 weeks then once a month for anemia. 177. That Petitioner’s representative interviewed Respondent’s director of nursing (DON) during the survey, regarding resident number twelve (12). who indicated as follows: a. She had reviewed the medication observation records and did not know whether or not the blood pressures were taken as ordered because it was not documented; b. She did not know why the B12 was not given as ordered; c. She did not know why the nurse gave 7 units of insulin without documenting that if the nurse had called the health care provider for instructions because she could not contact the nurse that was on duty. Resident #13 178. That Petitioner’s representative reviewed Respondent’s records regarding resident . Number thirteen (13) during the survey and noted as follows: a. The resident’s November 2008 medication administration record documented blood pressure to be taken weekly on Saturday at 9 AM; b. There was a block drawn on the space for November 29, 2008 (Saturday) and the block was blank and there was no explanation on the back explaining the omission; c. The resident’s health assessment form 1823 dated June 2, 2008 included diagnosis 42 May 28 2009 13:59 MAY-28-2889 15:12 AGENCY HEALTH CARE ADMIN 856 921 4158 P.is of Hypertension, Alzheimer’s; d. A Physician’s Order dated November 11, 2008 signed by the health care provider required weekly blood pressures. 179, That Petitioner’s representative interviewed Respondent’s administrator who indicated that she had reviewed the medication observation record and did not know whether or not the blood pressures had been taken as ordered because it was not documented. Resident #15 180. That Petitioner’s representative reviewed Respondent’s records regarding resident number fifteen (15) during the survey and noted as follows: a. The resident’s health assessment form 1823 dated October 23, 2009 included diagnoses of HTN, CVA with aphasia and IDDM; b, The physician’s order sheet dated and signed November 5, 2008 indicated blood sugars to be taken three timed daily along with an insulin sliding scale: c. The scale is follows: i. 151-175=2 units (U); ti, 176-220=31); iii. 201-225=4U; iv. 226-250=5U; v. 251-275=6U; vi, 276-300=7U; vii. 301-325-8U; viii. 326-350=9U; 43 May 28 2009 14:00 MAY-28-2889 15:12 AGENCY HEALTH CARE ADMIN 856 921 4158 P.16 ix. Greater than 350=10 U and call MD. d. The resident's November 2008 medication observation record indicated as follows: | i. November 8 @ 7 AM the blood sugar was 151 and no insulin was given; ii. November 9 @ 11:30 the blood sugar test was blank; iii. November 12 @ 7 AM the blood sugar was 179 and no insulin was given; iv. November 15 @ 4:30 the blood sugar test was blank; y. November 17 @ 7 AM the blood sugar was 191 and no insulin was given; vi. November 20 @ 7 AM blood sugar was 376 and no insulin was given; vii. November 21 @ 7 AM blood sugar was 174 and no insulin was given; viii. November 25 @ 7 AM blood sugar was 179 and no insulin was given; ix, November 26 @ 7 AM blood sugar was 186 and no insulin was given, x. November 27 @ 7 AM blood sugar was 172 and no insulin was given. e. The resident was also to receive Lantus 20 units every morning @7:30 AM; 44 May 28 2009 14:00 MAY-28-2889 15:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1? f. The medication observation record for the Lantus was blank on November 24, 2008; g. The November 2008 medication observation record indicated Digoxin 125 mg one daily hold for pulse (heart rate) less than 60; h. The November 2008 medication observation record indicated that the resident took the medication on November 3, 7, 8, 10, 14, and 21, 2008 but no pulse was recorded as taken. Resident #16 181. That Petitioner’s representative reviewed Respondent’s records regarding resident number sixteen (16) during the survey and noted as follows: a. The resident’s health assessment was not dated and did not list the resident's diagnoses; b. An order dated August 2008 and ongoing November 1, 2008 indicated that blood pressure was to be taken twice daily; c. The resident’s November 2008 medication observation record indicated that on November 8, 10, 11 through 22, 24, and 26 through 30, 2008, the blood pressure was noted as taken once daily. Resident #18 182. That Petitioner’s representative reviewed Respondent’s records regarding resident number eighteen (18) during the survey and noted as follows: a. The resident’s November 2008 medication observation record documented blood pressure to be taken once daily 7-3 (AM-PM not documented); b. Blood pressure was not documented and there was no explanation on the back 45 May 28 2009 14:00 MAY-28-2889 15:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P.18 explaining the lack of blood pressure for the following days: November 3, 10, and 14, 2008; c. The resident’s health assessment form 1823 dated August 15, 2008 indicated diagnoses that included Hypertension and Dementia; d, The resident required assistance with the self administration of medications and Tequired assistance with bathing and supervision with dressing, grooming and toileting; e. A physictan’s order sheet dated September 8, 2008 that was signed by the health care provider ordered blood pressure daily. 183. That Petitioner's representative interviewed Respondent’s administrator who indicated that she had reviewed the medication observation record and did not know whether or not the blood pressures had been taken as ordered because it was not documented. Resident #19 184. That Petitioner’s representative reviewed Respondent’s records regarding resident number nineteen (19) during the survey and noted as follows: a. The resident's health assessment form 183 dated May 6, 2006 reflected diagnoses of CAD, HTN, dementia, A-fib and CHF; b. A healthcare provider's orders dated May 7 and November 5, 2008 indicated that blood pressure measurements were to be twice daily and indicated "Clonidine 0.1 mg one tablet three (3) times a day as needed for SBP ( systolic blood pressure) greater than 180 and DAP (diastolic blood pressure) greater than 95.” c. The resident’s November 2008 medication observation record indicated "BP twice daily", however the blood pressure was taken and recorded once a day on 46 May 28 2009 14:00 MAY-28-2889 15:15 AGENCY HEALTH CARE ADMIN 856 921 4158 November 10 through 13, 15, 16, 21, 23, 24, and 28 through 30, 2008; d. On November 14, 2008, no blood pressures were recorded; e. The Clonidine was not marked as taken for the month of November. Resident #20 185. That Petitioner's representative reviewed Respondent’s records regarding resident number twenty (20) during the survey and noted as follows: a, The resident's November 2008 medication administration record documented Cyanocobalamin 1,000 MCG inject every month; b. There was a block drawn on the space for the 24" at 9 AM and the block was blank and there was no explanation of why the entry was blank on the back: c. A bag with | vial of B12-1000 McG inside was noted with a prescription fill date of September 30, 2008; d, The resident’s health assessment form 1823 dated June 2, 2008 identified a diagnosis of Hypertension and the resident required assistance with ambulation and bathing and needed assistance with the self administration of medication; e. A physician’s order dated December 7, 2007 signed by the health care provider prescribed Cyanocobalamin 1,000 MCG inject every month. 186. That Petitioner’s representative interviewed Respondent’s administrator who indicated that she had reviewed the medication observation record and did not know whether or not the resident received the ordered Cyanocobalamin 1,000 MCG as ordered and she did not know why the vial was found in the medication cart if it was given as ordered, Resident #21. 187. That Petitioner’s representative reviewed Respondent’s records regarding resident 47 P.1i9 May 28 2009 14:01 MAY-28-2889 15:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P.28 number twenty-one (21) during the survey and noted as follows: a. The resident's November 2008 medication observation record documented Alendronate Sodium 70 mg 1 prior to breakfast with 8 oz of water once a week on Thursday ~ do not lay down; b. There was a block drawn on the space for the 27" at 7 AM and the block was blank and there was no explanation on the back; c. The resident’s health assessment form 1823 dated July 15, 2008 included diagnosis of Hypertension and Osteoporosis and that the resident needed assistance with ambulation, bathing, and dressing and needed assistance with the self administration of medication. 188. That Petitioner’s representative interviewed Respondent’s administrator on December 2, 2008 regarding the above referenced resident records who indicated as follows: a. She had reviewed the medication observation records; b. She did not know whether or not the medications were given as ordered because it was not documented; c. She did not know if there were weekly weights taken as ordered because they were not documented: d. No additional documentation was available. 189. That the above facts reflect Respondent’s failure to provide care and services ag appropriate to the needs of residents where Respondent failed to ensure that the physician's orders for the administration of insulin, Vitamin B12 injections, blood pressure checks, weekly weights and medications received were followed and administered as ordered, 48 May 28 2009 14:01 MAY-28-2889 15:14 AGENCY HEALTH CARE ADMIN 856 921 4158 P.2i 190. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 191. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2\(c), Florida Statutes (2008). 192. That the Agency provided a mandated correction date of December 3, 2008. 193. That on January 14, 2009, the Agency completed a re-visit to the Complaint Survey (CCR# 200801 1802) of the Respondent facility. 194, That based upon interview and record review including medications, the facility did not provide the care and services appropriate to the needs of two (2) of thirteen (13) sampled residents accepted for admission in Respondent’s failure to follow physician's orders to do . weekly blood pressure monitoring and hold antihypertensive medications for a systolic blood pressure of less than 110, the same being contrary to law, 195. That Petitioner’s representative reviewed Respondent’s records regarding resident number four (4) during the survey and noted the following: a. The resident’s health assessment form 1823 dated July 15, 2008 documented diagnoses of hypertension (HTN), and a Cerebrovascular Accident (CVA) with left side weakness; | | b. The resident needed assistance with self-administration of medications; c, A physician's order dated December 1, 2008 required weekly blood presaure monitoring: d. The resident’s December 2008 medication observation record was not available for review in the chart; 49 May 28 2009 14:01 MAY-28-2889 15:14 AGENCY HEALTH CARE ADMIN 856 921 4158 e. Respondent’s staff could not produce a medication observation record to reflect that blood pressures were being done weekly as indicated by the physician. 196. That Petitioner’s representative interviewed Respondent’s administrator during the survey who indicated that she checked the resident’s medication observation record for the month of December and found that the blood pressures were being done every other week and not weekly as ordered, 197. That no physician's order was located which would authorize or direct that blood pressures be completed every other week. 198. That Petitioner's representative reviewed Respondent’s records regarding resident number ten (10) and noted as follows; a. The resident’s health assessment form 1823 dated March 18, 2008 reflected diagnoses of hypertension (HTN), Cerebrovascular Accident (CVA) and Diabetes Mellitus (DM); b. The resident needed assistance with self administration of medications; c. A physician's order dated December 2, 2008 required Atenolol (for high blood pressure) 25 milligrams (mg) daily, hold for systolic blood pressure less than 110 and Lisinopril (for high blood pressure) 10 mg 1 % tablets daily, hold for systolic blood pressure (SBP) less than 110; d. The resident’s December 2008 medication observation record (MOR) revealed the Atenolol and/or the Lisinopril were not held for systolic blood pressure Jess than 110 at 9 AM on the following dates: i. December 11 - BP 98/65 - the Atenolol and the Lisinopril were not held; 50 May 28 2009 14:02 MAY-28-2889 15:14 AGENCY HEALTH CARE ADMIN 856 921 @158 P23 iit. December 12 - BP 100/unable to read - the Atenolol was not held; iii, December 16 - BP 102/75 - the Atenolol and the Lisinopril were not held; iv. December 19 - BP 107/62 - the Atenolol and the Lisinopril were not held; v. December 24 - BP 95/65 - the Atenolol and the Lisinopril were not held. e. The reverse of the medication observation record did not indicate why the medication was not held as prescribed. 199. That Petitioner's representative interviewed Respondent’s administrator and nurse during the survey who indicated that they could not determine whether or not the blood pressure medications were held according to the physician's order. 200, That the above facts reflect Respondent’s failure to provide care and services as appropriate to the needs of residents where Respondent failed to ensure that the physician's orders for blood pressure checks and the administration of medications received were followed and administered as ordered. 201. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 202. That the Agency cited the Respondent for an uncorrected Class IJ] violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 203. That the Agency provided a mandated correction date of January 31, 2009. 204. That this constitutes an uncorrected violation as provided by law, 31 May 28 2009 14:02 MAY-28-2089 15:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P24 WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(c), Florida Statutes (2008). COUNT IX 205. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 206. That pursuant to Section 429.41, F.S., the use of physical restraints shall be limited to half-bed rails, and only upon the written order of the resident’s physician, who shal] review the order biannually, and the consent of the resident or the resident’s representative. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance shall not be considered a physical restraint. Rule 58A-5.0182(6)(h), Florida Administrative Code. 207. Tha pursuant to Florida law, "Physical restraint" means a device which physically limits, restricts, or deprives an individual of movement or mobility, including, but not limited to, a half- bed rail, a full-bed rail, a geriatric chair, and a posey restraint. The term “physical restraint” shall also include any device which was not specifically manufactured as a restraint but which has been altered, arranged, or otherwise used for this purpose. The term shall not include bandage material used for the purpose of binding a wound or injury. Section 429.02(17), Florida Statutes (2008). 208. That on August 22, 2007, the Agency completed a change of ownership survey of the Respondent facility. 209. That based upon observation, the review of records, and interview, Respondent failed to obtain physicians orders and the consent of the resident or the resident's representative for the §2 May 28 2009 14:02 MAY-28-2089 15:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P.25 use of physical restraints for four (4) of eight (8) sampled residents, the same being contrary to law. 210. That Petitioner's representative toured Respondent facility on March 17, 2007 at approximately 9:15 AM and noted as follows: a. Residents numbered one (1), two (2), three (3), and six (6) had half side bed rails on their beds: b. Residents numbered one (1), two (2), three (3), and six (6) were not independent with the use of the half side rails. 211. That Petitioner’s representative reviewed Respondent’s records regarding residents numbered one (1), two (2), three (3), and six (6) during the survey and noted as follows: a. There was no indication that resident number one (1) had consented to the use of the half side rails: b, There was no indication that resident number two (2) had consented to the use of the half side rails and there was no physician’s order for the use of the side rails; c. There was no indication that resident number three (3) had consented to the use of the half side rails and there was no physician's order for the use of the side rails; d. There was no indication that resident number six (6) had consented to the use of the half side rails. 212. That Petitioner’s representative interviewed Respondent’s administrator during the survey who indicated that written consents of the resident or the resident’s representative had not been completed as she was not aware a consent for use of the rails was required. 213. ‘That the failure to ensure that restraints are utilized only where appropriate places residents at risk of injury from such devices and is contrary to the requirements of law. 53 May 28 2009 14:03 MAY-28-2889 15:15 AGENCY HEALTH CARE ADMIN 856 921 @158 P26 214. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility, or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents. 215. That the Agency cited the Respondent for a Class III violation in accordance with Section 429,19(2\(c), Florida Statutes (2007). . 216. That the Agency provided a mandated correction date of September 6, 2007. 217. That during a re-visit survey conducted October 10, 2007 the Agency determined that the Respondent had corrected the deficiency. 218. That on January 14, 2009, the Agency completed a Biennial Licensure Survey of the Respondent facility. 219. That based upon observations, the review of records, and interview, Respondent failed to ensure that the use of physical restraints was limited to half-rails and only with a written order from the resident's physician who reviewed the order biannually and that the facility obtained the consent of the resident or the resident's representative for two (2) of thirteen (13) sampled residents, the same being contrary to law. 220. That Petitioner’s representative toured Respondent facility during the survey and noted as follows; a. On January 13, 2009 at approximately 10 AM it was noted that resident number ten (10) had half-bed-rails in place; b. On January 14, 2009 at approximately 1 PM, resident 'number ten (10) was noted , in bed with the side rails up and stating the need for assistance from the staff with bathing, dressing and transferring; 54 May 28 2009 14:03 MAY-28-2889 15:16 AGENCY HEALTH CARE ADMIN 856 921 4158 P.2? c. On January 13, 2009 at approximately 10 AM it was noted that the hospital bed for resident number thirteen (13) had half-bed rails in place; d. Resident number thirteen (13) indicated an inability to move the rails up and down at will due to left side paralysis. 221. That Petitioner's representative reviewed Respondent's records regarding residents numbered ten (10) and thirteen (13) during the survey and noted as follows: a. -A health assessment form 1823 dated March 18, 2008 indicated diagnoses of Cerebrovascular Accident (CVA), hypertension, and diabetes for resident number ten (10); . b. There was an order from the physician for resident number ten (10) dated April 1, 2008 for the use of the rails; c. There was no documentation or other indication Respondent had ensured that the physician of resident number ten (10) had reviewed the order biannually, due October 1, 2008, for the continued use of the side rails; d. A health assessment form 1823 dated October 29, 2008 indicated a diagnosis of CVA for resident number thirteen (13); e. That absent from the records was a physician’s order for the use of side bed rails for the resident or any indication of the consent for the use of the restraint by Tesident number thirteen (13) or the resident’s representative. 222. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey who indicated that resident number ten (10) was not independent with the use of the side rails and there was no updated order from the physician for the use of the side rails. 55 May 28 2009 14:03 MAY-28-2889 15:16 AGENCY HEALTH CARE ADMIN 856 921 @158 P.28 223. That Petitioner’s representative interviewed Respondent’ s administrator during the survey who indicated that a physician's order for the half-bed rails and the resident's consent for the use of the rails were not available for resident number thirteen (13). 224. That the failure to ensure that restraints are utilized only where appropriate places residents at risk of injury from such devices and is contrary to the requirements of law. 225. Thatthe Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 226. That the Agency cited the Respondent for a repeat Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 227. That the Agency provided a mandated correction date of January 15, 2009. 228. That this constitutes a repeat violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility im the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT X 229. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 230. That pursuant to Florida law, all residents assessed at risk for elopement or with any history of elopement shall be identified so staff can be alerted to their needs for support and supervision... As part of its resident elopement response policies and procedures, the facility shall make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. 56 May 28 2009 14:03 MAY-28-2889 15:16 AGENCY HEALTH CARE ADMIN 856 921 4158 P.29 Staff attention shall be directed towards residents assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease and related disorders assessed at high risk. Rule 58A-5.0182(8)(a), Florida Administrative Code. 231. That pursuant to Florida law, facilities are required to conduct a minimum of two resident elopement prevention and response drills per year. All administrators and direct care staff must participate in the drills which shall include a review of procedures to address resident elopement. Facilities must document the implementation of the drills and ensure that the drills are conducted in a manner consistent with the facility's resident elopement policies and procedures. §429.41(1)(a}(3), Florida Statutes (2008). 232, That pursuant to Florida law, the establishment of specific policies and procedures on resident elopement. Facilities shall conduct a minimum of two resident elopement drills each year. All administrators and direct care staff shall participate in the drills. Facilities shall © document the drills. §429.41(1)(), Florida Statutes (2008), 233. That on December 1-2, 2008, the Agency completed a Complaint Survey (CCR# 2008011802) of the Respondent facility. 234. That based upon the review of records and interview, Respondent failed to ensure that all residents assessed at risk for elopement or with any history of elopement were identified and maintained on their person identification so staff can be alerted to their needs for support and supervision for three (3) residents, the same being contrary to law. 235. That Petitioner’s representative reviewed Respondent's records regarding resident number twenty-two (22) during the survey and noted as follows; a. The resident’s health assessment 1823, not dated, indicated diagnoses of vascular dementia, Alzheimer's dementia and HTN; 37 May 28 2009 14:04 MAY-28-2889 15:17 AGENCY HEALTH CARE ADMIN 856 921 @158 P.3a b. The form indicated the resident was pleasantly confused; c. A facility note dated November 30, 2008, 7-3 shift, indicated that the resident was in the elevator and tried to leave the secure unit; d. A facility note dated November 30, 2008 at 12:34 indicated that the resident took the stairs and headed out of the building, two staff followed the resident, and the writer called the police. The resident continued to walk to where the police were where they picked the resident up and brought the resident back to facility; e. A facility note dated November 30, 2008 at 4 PM indicated that the resident left the building and sat outside the front of the facility, redirection was unsuccessful. Ativan 1 mg IM was given and resident redirected and returned to the second floor, 236. That Petitioner’s representative the administrator during the survey who indicated that there were three (3) residents at risk for elopement but none had identification on their person as she was waiting for identification bracelets to come in. 237. That the failure to ensure residents at risk of elopement maintain identification on their person places residents at risk as staff are unaware of the individuals who engage in elopement behaviors and the residents, if successful in eloping, do not have identification to aid in their location and safe retum. 238. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 239. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2008). 38 May 28 2009 14:04 MAY-28-2889 15:17 AGENCY HEALTH CARE ADMIN 856 921 4158 P.ai 240. That the Agency provided a mandated correction date of December 4, 2008. 241. Thaton January 14, 2009, the Agency completed a re-visit to the Complaint Survey (CCR# 2008011802) of the Respondent facility. 242, That based upon the review of records and interview, Respondent failed to ensure that all residents assessed at risk for elopement or with any history of elopement were identified and maintained on their person identification so staff can be alerted to their needs for support and supervision for three (3) of five (5) sampled residents, the same being contrary to law. 243, That Petitioner’s representative reviewed Respondent’s book of residents identified to be at risk for elopement revealed there were five (5) residents identified at risk and they all resided in the secure unit. 244. That Petitioner's representative observed the five (5) residents identified at risk for elopement on January 14, 2009 at approximately 10:30 AM and noted that only two (2) of the five (5) residents wore the identification bracelets the facility used for at-risk residents. 245. That at-risk resident number one (1) was observed in bed and was not wearing the identification bracelet. 246. That at-risk resident number two (2) was observed walking and did not have an identification bracelet. 247. That at-risk resident number three (3) was observed sitting in the front room with no identification bracelet. 248, That Petitioner’s representative interviewed Respondent’s staff member on said date at _ about 10:40 AM who indicated that the identification of at-risk resident number three (3) was on the walker which was at the opposite end of the hallway and not on the resident as required. 59 MAY-28-2889 15:17 May 28 2009 14:04 AGENCY HEALTH CARE ADMIN 856 921 4158 249. That continued interview revealed that all the residents assessed at-risk are constantly - taking off their identification bracelets. 250. That the failure to ensure residents at risk of elopement maintain identification on their person places residents at risk as staff are unaware of the individuals who engage in elopement behaviors and the residents, if successful in eloping, do not have identification to aid in their location and safe return. 251. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 252. That the Agency cited the Respondent for an uncorrected Class I] violation in accordance with Section 429,19(2)(c), Florida Statutes (2008), 253, That the Agency provided a mandated correction date of January 31, 2009. 254. That this constitutes an uncorrected violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2008). COUNT XI P32 255, The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Counts [ through X of this Complaint as if fully recited herein. 256. That the Agency may revoke any license issued under Part | of Chapter 429 Florida Statutes (2008) for the citation of one (1) or more cited Class I deficiencies, three (3) or more cited Class II deficiencies, or five (5) or more cited Class III deficiencies that have been cited on a single survey and have not been corrected within the specified time period. Section 60 May 28 2009 14:05 MAY-28-2889 15:17 AGENCY HEALTH CARE ADMIN 856 921 4158 429.14(1)(e) Florida Statutes (2008). 257, That the Respondent has been cited with three (3) repeat Class III deficiencies on an Agency complaint survey completed December 2, 2008. 258. That the Respondent has been cited with six (6) uncorrected Class IE deficiencies on an Agency complaint survey completed January 14, 2009. 259. That Florida law provides that in addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: (b) An intentional or negligent act materially affecting the health or safety of a client of the provider, (¢} A violation of this part, authorizing statutes, or applicable rules, and (d) A demonstrated pattern of deficient performance. Section 408.815(1)(a), (c), and (d), Florida Statutes (2008). 260. That Respondent has violated the minimum requirements of law of Chapters 429, Part Il, and Chapter 584-5, Florida Administrative Code as described with particularity within this complaint. 261. That Respondent has a duty to maintain its operations in accord with the minimum Tequirements of law and to provide care and services at mandated minimum standards, 262. That the above reflect grounds for which the Agency may revoke Respondent’s licensure to operate and assisted living facility in the State of Florida. 263. That Respondent has a duty to maintain its operations in accord with the minimum standards of law and its actions or inactions as described with particularity within this complaint constitute intentional or negligent acts which are in violation of the mandates of law and materially effected the health or safety of residents, and represent a pattern of deficient practices over an extended period of time. 61 P.33 May 28 2009 14:05 MAY-28-2889 15:18 AGENCY HEALTH CARE ADMIN 856 921 4158 P34 264, That based thereon, individually and collectively, the Agency seeks the revocation of the Respondent’s licensure. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815 and 429.14, Florida Statutes (2008). Respectfully submitted this day of April, 2009. Fla, Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration ° 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120,569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 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 IT HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 5182 on April Z ¥ 2009 to Leasa R. Phenix, Administrator, The Brookshire, 85 Bulldog Blvd, Melbourne, Florida 3290] and by U.S. Mail to Corporation Service Company, Registered Agent, 120] Hays Street, Tallahassee, Florida 32301-2525, Tho: alsh I] Senfof Attorney 62 MAN -28-2889 15:18 AGENCY HEALTH CARE ADMIN Copies furnished to: May 28 2009 14:06 856 921 4158 Leasa R. Phenix, Administrator The Brookshire 85 Bulldog Blvd Melbourne, Florida 32901 (U.S. Certified Mail) Doris Spivey Facility Evaluator Supervisor Hurston South Tower 400 W Robinson St., #309 Orlando, Florida 32801 (U.S. Mail) Corporation Service Company Registered Agent 1201 Hays Street Tallahassee, FL 32301-2525 (U.S. Mail) Thomas J. Walsh II, Esq. Asst. General Counsel Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interofficc) 63 P.35 May 28 2009 14:06 MAY-28-2889 15:16 AGENCY HEALTH CARE ADMIN 856 921 @1i58 P.36 _.._-—s STATE-OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: CATALINA GARDENS HEALTH CARE CASENO: 2009001704 ASSOCIATES, LLC, d/b/a THE BROOKSHIRE 2009001705 2009001706 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be an Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. Your Election of Rights must be returned by mail or by fax within twenty-one (21) days of the date you receive the attached Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine, If your Election of Rights with your elected Option is not received by AHCA within twenty-one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a Final Order will be issued. Please use this form unless you, your attorney or your representative prefer to reply in accordance with Chapter! 20, Florida Statutes (2008) and Rule 28, Florida Administrative Code. PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: 850-922-5873 . Fax: 850-921-0158 ' PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) sd: admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and 1 waive my right to object and to have a hearing, I understand that by giving up my right to a hearing, a Final Order will be issued that adopts the proposed apency action and imposes the penalty, fine or action. OPTION TWO (2) ____—‘_ admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) __ I dispute the allegations of fact and law contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. May 28 2009 14:06 AGENCY HEALTH CARE ADMIN 856 921 4158 P.a? MAY-28-2889 15:19 PLEASE NOTE: Choosing OPTION THREE (3) by itself is NOT sufficient to obtain a formal hearing, You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120,573, Florida Statutes may be available in this matter if the Agency agrees, License Type: (Assisted Living Facility, Nursing Home, Medical Equipment, Other) Licensee Name: License Number: Contact Person: Name Title Address; Street and Number City State Zip Code Telephone No, Fax No. E-Mail (optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the above licensee. Signature: Date: Print Name; Title: TOTAL P.3?

Docket for Case No: 09-002941