May 3 2010 15:19 85/63/2018 15:11 8509210158 ° PAGE 41/47 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, 7 CaseNo. 2010002171 . 2010002172 vs. SHRINATHII, INC., d/b/a CARDEN HOUSE, Respondent, / ara ADMINISTRATIVE C COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and theough the undersigned counsel, and files this Administrative Complaint against SHRINATHII, INC., d/b/a ‘CARDEN HOUSE (bereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2009), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s licensure to operate an assisted living facility in the State of Florida pursuant to §§ 408.815 and 429.14, Florida Statutes (2009) and to impose an administrative fine in the amount of four thousand ($4,000.00) based upon two (2) cited State Class 11 deficiencies and two (2) cited uncorrected Stete Class [Il deficiencies pursuant to § 429.19(2)(b) and (c), Florida Statutes (2009), and the imposition of a survey fee of five hundred dollars ($500.00) pursuant to the provisions of § 429.19(7), Florida Statutes (2009) for a total assessment of four thousand five hundred dollars ($4,500.00). JURISDICTION AND VENUE I. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part Il, and 429, Part 1, Florida Statutes (2009). May 3 2010 15:20 05/63/2818 15:11 8509210158 PAGE 42/47 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 60-bed assisted living facility located at 2349 Central Avenue, St. Petersburg, Florida 33713, and is licensed as an assisted living facility with limited mental health (LMH) and limited nursing services (LNS), license number 7919. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT 1 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida Jaw, an individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license ... (f) Any special dietary needs can be met by the facility. Rule 58A-5.0181(1)(), Florida Administrative Code. If the resident no longer mects the criteria for continued residency, or the facility is unable to meet the resident’s needs, as determined by the facility administrator or health care provider, the resident shall be discharged in accordance with Section 429.28(1), F.S. Rule 58A-5.0181(5), Florida Administrative Code. 8. That pursuant to Florida law, when food service is provided by the facility, the administrator or a person designated in writing by the administrator shall ... (c) Provide regular meals which meet the nouwitional needs of residents, and therapeutic dicts as ordered by the May 3 2010 15:20 05/83/2018 15:11 8509210158 , PAGE 43/47 resident’s health care provider for resident’s who require special diets. Rule 58A-5.020(1(c), Florida Administrative Code. ; 9. That pursuant to Florida law, therapeutic diets shall be prepared and served as ordered by the health care provider ... The facility shall document a resident’s refusal to comply with a therapeutic diet and notification to the resident’s health care provider of such refusal. If a resident refuses to follow a therapeutic diet after the benefits are explained, a signed statement from the resident or the resident’s responsible party refusing the diet is acceptable documentation of a resident’s preferences. In such instances daily documentation is not necessary. Rule S8A- 5.020(2)(c), Florida Administrative Code. 10. That on December 3, 2009, the Agency conducted a complaint survey (CCR# 2009013142) of the Respondent facility. 1L. That Respondent was cited on said date for the failure to provide prescribed therapentic diets to residents finding, inter alia: a. Residents numbered six (6) and seven (7) had been prescribed a diabetic diet by the residents’ physicians when the respective physician had completed the residents’ health assessment forms, b. The Respondent’s cook was unaware thet residents of the facility required . specialized prescribed diabetic diets, she did not prepare a diabetic diet for any residents, and that Respondent did not maintain menus which would serve a diabetic regime; c. No menus prepared and approved for facility use in accord with law would meet the needs of an individual requiring a diabetic diet. | 12. That the failure to ensure that prescribed menus are provided to residents places residents at risk of medical complications resulting from health complications related to diet, including but May 3 2010 15:20 65/83/2018 15:11 8509210158 . PAGE 44/47 not limited to, nutritional deficit and diabetic complications ranging from circulatory deficiencies, diabetic come, and other debilitation resulting from glucose imbalance. 13. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations and cited Respondent for a State Class III deficiency. 14. That Respondent was given a mandatory date of correction of January 3, 2010. 15, That on January:27, 2010, the Agency conducted a revisit to the complaint survey (CCR# 2009013142) of the Respondent facility. | 16. That based upon the review of records and interview, Respondent failed to ensure that it provided prescribed special dietary needs for two (2) sampled residents who were prescribed diabetic: diets, and or admitted or failed to discharge residents requiring special diets not provided by Respondent, the same being contrary o the minimum requirements of law. 17. That Petitioner’s representative interviewed Respondent's Medication Technician (Med Tech) during the survey who indicated that two (2) residents in the facility were diabetic. 18. That Petitioner’s representative reviewed Respondent’s records related to residents numbered five (5) and six (6) during the survey and noted as follows: a. Resident number five (5): i. The Health Assessment, Form 1823, for the resident, dated September 9, 2009, indicated the resident has a diagnosis of Diabetes Mellitus II, ii. The resideot's physician mandated that the resident should have a diabetic diet; iii. A November 11, 2009 Laboratory result indicated a blood glucose level of 140 which was described as being high; May 3 2010 15:21 05/03/2018 15:11 8509216158 PAGE 45/47 b. Resident number six (6): i. The Health Assesement, Form 1823, for the resident, dated August 28, 2009, indicated the resident has a diagnosis of Diabetes Mellitus Il, ii. The resident’s physician mandated that the resident should have a diabetic diet. 19. That Petitioner’s representative interviewed Respondent's cook on January 27, 2010 who indicated as follows: "a. She was unaware that the facility had any residents prescribed diabetic diets; b. No diabetic menu was available in the facility; c. She did not prepare any foods differently for the two residents who have been prescribed diebetic diets. . 20, That Petitioner's representative reviewed Respondent's menus approved for use within the facility in accord with the mandate of law related to dietary services and poted that all menus utilized by Respondent were for regular diets. 21. The Petitioner’s representative interviewed resident number five (5) during the survey who indicated as follows: a. The resident often cats at a friend’s house in the neighborhood; 'b. The resident had a bagel for breakfast and sausage for dinner the previous night; c. The resident does not follow a diabetic diet nor is the resident served any different foods from the rest of the residents in the facility. 22. That the above reflects situations where the failure to provide therapeutic meals may negatively affect resident glucose levels, results in. resident non-compliance with physician orders, and does not provide residents with the prescriptive nutritional levels which the resident's physical health demands. May 3 2010 15:21 65/83/2818 15:11 8589210158 PAGE 46/47 23. That the failure to ensure that prescribed menus are provided to residents places residents at risk of medical complications resulting from health cousplications related to diet, including but not limited to, nutritional deficit and diabetic complications ranging from circulatory deficiencies, diabetic come, and other debilitation resulting from glucose imbalance. 24. That the above reflects Respondent’s failure to ensure that required menus are available and prepared, Respondent's acceptance of and ‘maintenance of residents requinng menus ‘for ’ which Respoodent is unprepared or unwilling to provide, and Respondent’s knowing failure to correct the deficient practice despite actual knowledge thereof. 25, That the Agency provided a mandated correction date of February 27, 2010. 26. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2009). 27. ‘That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violation and cited Respondent for a State Class II deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Fla, Stat. (2009). | COUNT II 28. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. That pursuant to Florida law, when food service is provided by the facility, the administrator or a person designated in writing by the administrator shall ... (b) Perform his/her duties in a safe and sanitary manner. Rule 58A-5.020(1)(b), Florida Administrative Code. “ 5/03/2018 15:11 May 3 2010 15:21 8509210158 PAGE 30. That on December 3, 2009, the Agency conducted a complaint survey (CCR# 2009013142) of the Respondent facility. 31. That Respondent was cited on said date for the failure to maintain a safe and sanitary dietary program finding on said date, inter alia: & b. A refrigerator had six (6) Jarge containers of food products that were undated; The Respondent's cook indicated that the date the food products therein had been prepared was unknown, The outside of the refrigerator had notable dirt build up ont the handle; A box fan with notable and visible dust buildup was located in the comer of the kitchen; Kitchen containers were unclean, A large unmarked trash bag of food product was located in a freezer, . The Respondent’s cook indicated that the trash bap contained chicken nuggets that were to be utilized for resident consumption, In the refrigerator, two (2) unmarked large tub totes were located which contained approximately eight (8) gallons each of a chicken and red sauce mixture with mold visibly growing on both tubs; "The Respondent's cook indicated that she was unsure of how old this mixture was; A freezer contained a bin of uncovered sandwich meat which was unmarked and open to contamination of the freezer or air. 32. That the failure to ensure that food service is maintained in a safe and sanitary mcthod places residents at risk of food n=bome contaminants or illness. 97/47 May 3 2010 16:01 @5/03/2018 16:21 8509210158 PAGE 2/47 33. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class ! or class Il violations and cited Respondent for a State Class Il deficiency. 34. That Respondent was given a mandatory date of correction of January 3, 2010. 35. That on January 27, 2010, the Agency conducted a revisit to the complaint survey (CCR# 2009013142) of the Respondent facility. 36. That based upon observations and interview, Respondent failed to cnsure that its food service designee ensured that food service was provided. in a safe arid sanitary manner as © evidenced by unclean counters and equipment in the kitchen, inadequate supplies of dinnerware, undated milk, old food products designated for resident consumption, and dirty utensils, disbes and plastic ware that contained food products, the same constituting a violation of law. 37. That Petitioner’s representative observed Respondent’s facility kitchen throughout the day on January 27, 2010, interviewed staff, and noted the following: a. A refrigerator had four (4) gallons of what appeared to be watered down milk in them. The label was dated January 10, 2010 and was identified as whole milk, b. Respondent’s cook indicated at approximately 12:05 p.m. that she makes - powdered milk daily and puts it in old milk cartons, but does not label them with the date or contents; c. The outside of the refrigerator had potable dirt build up along the handle; d. Kitchen counters were unclean and the stove and stove plates were rusty; e. A large unmarked trash bag of bread was located on the counter, f. Respondent's cook indicated that the trash bag contained donated bread that was to be utilized for resident consumption; May 3 2010 16:01 05/03/2818 16:@1 8589218158 , PAGE 63/47 g. A refrigeretor contained two (2) heads of lettuce that were brown and withered and tomatoes and orange peppers that were bruised and withered; ) bh ‘Several carrot sticks were stored in a garbage bag; i. Plastic ware containing flour, sugar, and dry milk were greasy and dirty; j. Ditty plates were stored with clean plates, | k. Clean utensils were stored in dirty, stained and greasy utensil bins, |. Respondent’s cook indicated at approximately 12:05pm. that the facility does not have enongh drinking cups or utensils for all residents im the facility. 38. That the above reflects Respondent’s failure to ensure that its dietary services are provided in a safe and sanitary nvanner where food expiration dates are not maintained, rotting or wasted food products are maintained, cleanliness of food preparation areas are not maintained, clean and dirty food service items are not segregated, and insufficient table ware for resident needs are not maintained. . 39. That the failure to maintain clean and sanitary dietary services places residents, who often suffer from compromised immune systems, at needless increased risk of food bome contagion, and Respondent’s knowing failure to correct the deficient practice despite actual knowledge thereof. 40. That the Agency provided a mandated correction date of February 27, 2010. 41. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2009). 42. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class | violation and cited Respondent for a State Class II deficiency. May 3 2010 16:01 05/03/2818 16:01 8509210158 PAGE 4/47 43, That in addition to the above alleged violations, Respondent had previously been cited for this deficient practice in the recent past and has not taken steps to ensure continued compliance. 44, That pursuant to Florida law, for purposes of this section, in determining if'a penalty is to be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious: physical or. emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rales were violated. (b) Actions taken by the owner or administrator to ‘correct violations. (c) Any previous violations. (d) The financial benefit to the facility of commnitting or continuing the violation. (c) The licensed capacity of the facility. (4) Each day of continuing violation after the date fixed for termination of the violation, as ordered by the agency, constitutes an additional, separate, and distinct violation. Section 429.19(3) and (4), Florida Statutes (2009). | 45. That on or about April 2, 2009, the Agency completed a complaint survey of the Respondent. 46. That Respondent was cited during said survey for violation of this same regulatory provision, Rule 58A~5.020(1), Florida Administrative Code, based on the following facts: a. During the survey two (2) five (5) pound packages of ground beef were observed sitting in a large pan on a table in the center of the kitchen at 10:15 AM, the meat cool to the touch; . . b. No thermometer was available in the room, but the kitchen was wann, c. Respondent's owner indicated the meat was to be used for dinner that evening; 4 At 1:15 PM, the meat was again observed on the counter feeling warsaex to the touch; May 3 2010 16:02 85/83/2018 16:81 9569210158 PAGE 05/47 e. Respondent’s cook, when asked, could not produce a thermometer to test the temperature of the rneat, indicated the facility did not maintain a thermometer, and acknowledged the meat had been sitting on the counter since 10:15 AM, f. Leaving raw meat unrefrigerated for long periods of time is not a safe and sanitary _ food practice; g. The thermometer of the facility freezer read thirty-five (35) degrees at 10:15 AM while at 2:55 PM the thermometer read thirty-six (36) degrees, neither temperature adequate to maintain frozen foods; h. In the kitchen cooler at 10:20 AM, the following was observed: Undated wacovered leftover grits; undated uncovered leftover mashed potatoes, an uncovered undated leftover meat dish; an open jug of mayonnaise, a meat dish in a blue bowl, butter, and salad dressings were opened but undated. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand five hundred ($1,500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2\b), Fla. Stat. (2009). COUNT Il 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. That pursuant to Florida law, the ALF shall be Jocatcd, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents. Rule 58A-5.023(1)(a), Florida Administrative Code. 49. That on December 3, 2009, the Agency conducted complaint survey (CCR# 2009013142) of the Respondent facility. 05/83/2810 16:81 May 3 2010 16:02 8589210158 PAGE 50. That based upon observation and interviews, Respondent fa failed to maintain the facility in a safe home-like environment, the same being contrary to law. 51. That Petitioner’s representative toured the Respondent facility on December 3, 2009 and noted the following: © Dirty floors were observed on all three (3) floors especially in the corners where the linoleum meets the baseboard or wall in the stairwells and hallways, Walls were not clean in the hallways adjacent to the movie room near the laundry room and meny doors throughout the facility were dirty with a brown smeared looking substance around doorknobs, A shared living quarters bathroom for room #103 had a urine odor and the shower | was filthy with an orange brown growth on the bottom of the shower curtain; This was brought to the attention of a housekeeper who demonstrated the scum could be easily cleaned; The housekeeper further stated they (housekeepers) have certain days they were "supposed to clean it; The shower curtain was torn in two (2) places and the floor was also wet, The air conditioner vent had an accumulation of dust on it; Room #104 had an area on the wall near the aix conditioner with a white chalky build up, the shower floor was dirty, and the base of the toilet was dirty; Rooms 103 and 104, occupied by residents, were very dark with 00 windows; The floor in the back area leading outdoors where residents exit to smoke was dirty. . The foliowing observations on the second floor were made: i. The hallway near room #202 was dirty, 2 06/47 85/83/2018 16:@1 8589210158 ti viii. May 3 2010 16:02 PAGE “ii. A box spring, wrapped in plastic, was observed leaning against a wall at the end of the hall; There was peeling yellow paint in a hallway near a fire extinguisher that looked like possible water damage; The ends of hallways were very dark, The second floor had at least two (2) occupied rooms, #202 and #208, but was mostly unoccupied with renovations in process according to interview with the administrators during the investigation, i. No active renovation work was observed during the investigation, The unoccupicd open rooms floors were generally very dusty; Room #204 had a single bed and box spring wrapped in plastic, #213 had part of a bed frame, the light was on, #214 had a box spring on its side, and a dresser, another room with a #214 had clothing on the floor and a can of paint on a chair, #215 had part of a bed frame, dresser with a mirror, a very thin mattress on the floor, a few sport jackets and other clothing was on the floor, the light was on, 219 (dresser only), 220 (part of a dresser), 221 (fan and screws on a dresser), a room designated #9 was empty of furniture but had numerous small pieces of broken glass on the ix. floor, new blinds and paint, room #10 was empty except for what looked like new blinds, room #12 was empty; — One occupied resident room. #208, was observed to have a clean floor, the single bed was made, the shower was clean however the resident indicated the toilet did not work and used the general bathroom down the hall; - 87/47 May 3 2010 16:02 05/83/2018 16:81 8509210158 PAGE 88/47 x. The general bathroom did not have a working light in the tub area and the tub was filthy; xi. Music was heard coming from room #202, but numerous unsuccessful attempts to have the resident open the door prevented observation of the - room. L The third floor room #320 bad reportedly no hot water in the shower or sink; m. The resident floor in room 321 was wet, the resident had just come out of the shower; . , “n. The general bathroom on the 3rd floor had no toilet paper, no light at the sink where the bathtub is located, the sink was rusty and filthy, and the hot water felt lukewarm after waiting three (3) minutes; o. The hallway had two (2) empty buckets and a caution sign wet floor next to room #323. 52. That the above reflects Respondent’s failure to ensure that the facility is designed, equipped, and maintained to promote a residential, non-medical environment where facilities and equipment is not maintained and or sanitary conditions are not maintained. 53. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class J or class I violations. 54. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2\(c), Florida Statutes (2009). , 55. That the Agency provided a mandated correction date of January 3, 2010. May 3 2010 16:03 5/83/2010 16:01 8589210158 PAGE 69/47 56. That on January 27, 2010, the Agency completed a revisit to the complaint survey (CCR# 2009013142) of the Respondent facility. 57. | That based upon observation, Respondent fniled to maintain the premiscs in a comfortable and home like environment, the same being contrary to law. 58. That Petitioner’s representative toured the Respondent facility on January 27, 2010 and noted the following: a, In Room 320 there were no hot and cold shower handles making the shower unable to be used by resident, In addition, the sink in the room had no warm water. The water was cold to the touch after having been Jeft running for several minutes. The staff member who accompanied the surveyor on the tour stated it "takes a while” for the water to be warm; b. The common bathroom on the third floor was found to have a tub which was heavily stained and had standing water. In addition the common bathroom had light bulb over the toilet which left the area in the dark; c. Rooms 103 and 104 had paint cans stored in them, dressers were dirty and chipped, a box spring was tom with the batting falling out of it and the toilet and shower were stained; d. Sheets, blankets and pillows were dirty, stained, had holes in them or were missing, rooms 104, 300, 311, 321, and 329. 59. That the above reflects Respondent's failure to ensure that the facility is designed, equipped, and maintained to promote a residential, non-medical environment where facilities and equipment is not maintained and or sanitary conditions are not maintained. 60. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or May 3 2010 16:03 65/83/2818 16:@1 8509218158 PAGE 18/47 potentially threaten the physical. or emotional health, safety, or security of clients, other than . class Tor class II violations. 61. ‘That the Agency provided a mandated correction date of February 27, 2010. 62. 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), Fla. Stat. (2009). - COUNT IV 63. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth 64. ‘That pursuant to Florida law, the facility’s physical structure, including the interior and extenor walls, floors, roof and ceilings shall be structurally sound and in good repair. Peeling psint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. . Windows, doors, plumbing, and appliances shall be functional and in good working order. All furniture and furnishings shali be clean, functional, freo-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed. Rule 58A-5.023(1)(b), Florida Administrative Code. 65. That on December 3, 2009, the Agency conducted complaint survey (CCR# 2009013142) of the Respondent facility. 66. ‘That based upon observation and interviews, Respondent failed to assure windows, doors, plumbing and appliances were in good working order, the same being contrary to law. 67. That Petitioner's representative toured the Respondent facility on December 3, 2009 and noted the following: . a. Missing screens were observed in rooms #104 and #320, May 3 2010 16:03 5/03/2014 16:01 8509218158 PAGE b. A toilet was reported as not working in room #208, c. Hot water was reported as not working in room #320. d. Doors that did not have handles from the inside causing a potential safety hazard included rooms 300, 304, 308, 312, 311, 317, 321 and 322. c. What the doors were equipped with was a tum-bolt from the inside of the resident room that was accessed by key from the outside and a door pull handle also on the outside of the door. f. There was nothing to grab onto from the inside of the room except the bolt that locked the door. g. Interview with the other assistant administrator at 11:35 a.m. revealed there bad - been an incident with the resident of room #300 the previous day where the resident could not get out and the staff had to unlock the door from the outside. h. Three new replacement door handles were shown to the surveyor but at least eight . (8) doors needed the new handles. i, The interview with both assistant administrators also revealed that the hot water source is shared thexefore if one has hot water, all should have hot water. 68. That the above reflects Respondent's failure to maintain windows, doors, plumbing and appliances as functional and in good working order. 69. . That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. 70. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). “UW 11/47 @5/03/2818 16:01 May 3 2010 16:03 8589216158 PAGE 12/47 7\. That the Agency provided a mandated correction date of January 3, 2010. 72. That on January 27, 2010, the Agency conducted a revisit to the complaint survey (CCR# 2009013142) of the Respondent facility. 73. That based upon observation, Respondent failed to assure windows, doors, plurobing and appliances were in good working order, the same being contrary to law. 74. That Petitioner’s representative toured the Respondent facility on January 27, 2010 and noted the following: b. f. g. Rooms 104 and Rooms 320 had not screens on the windows; Rooms 304, 308, 311, 312, and 321 had no inside door handles which would allow safer access from the rooms by the residents; Room 104 had two ceiling aur conditioning vents that were not covered; The outdoor patio had a torn and broken table on it; The staff bathroom in the comspon area contained fecal matter in the stool and was without toilet tissue and soap. When interviewed, the Med Tech stated "I don’t use the bathrooms here, I hold it;” Room 300 had no hot water, The resident stated that it has never been hot. 75. That the above reflects Respondents failure to maintain windows, doors, plumbing and appliances as functional and in good working order. 76.‘ That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than. class J or class II violations. May 3 2010 16:04 85/83/2018 16:01 8589218158 PAGE 13/47 71. ‘That the Agency cited the Respondent for an uncorrected Class I violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). 78. That the Agency provided a mandated correction date of February 27, 2010. 79. That this constitutes an uncorrected violation as provided by law. 80. | That Respondent bas previously been cited for this deficient practice in the recent past and has not taken steps to ensure continued compliance. 81. That pursuant to Florida law, for purposes of this section, in determining if'a penalty is to . be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rules were violated. (b) Actions taken by the ‘owner or administrator to correct violations. (c) Any previous violations. (d) The financial benefit to the facility of committing or continuing the violation. (¢) The licensed capacity of the facility. (4) Each day of continuing violation after the date fixed for termination of the violation, as ordered by the agency, constitutes an additional, scparate, and distinct violation. Section 429.19(3) and (4), Florida Statutes (2009). 82, That the Agency completed a complaint survey of the Respondent on or about January 8, 2008. 83. That Respondent was cited during said survey for violation of this same regulatory provision, Rule $8A-5.023(1), Florida Administrative Code, based on the observation of January 8, 2008 of a door to room number 321 which could not be opened or closed 2without great difficulty in that the top portion of the door was damaged with the wood scparating, this portion of the door rubbing and or dragging against the door jamb or entranceway. May 3 2010 16:04 @5/83/2018 16:81 8509210158 PAGE 14/47 _ WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Fla. Stat. (2009). COUNT V 84. The Agency re-alleges and incorporates paragraphs (1) through (5) and Counts I through IV as if fully set forth herein. . “85. That pursuant to Section 429.19(7), Florida Starutes (2009), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2009), to verify the correction of the violations. 86. That on or about December 3, 2009 and January27, 2010, the Agency completed complaint investigations at the Respondent Facility that resulted in a violation that is the subject. of the complaint to the Agency. 87. That pursuant to Section 429.19(7), Florida Statutes (2009), such a finding subjects the Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or $500.00. 88. That Respondent is therefore subject to a complaint survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2009). WHEREFORE, the Agency intends to impose an additional survey fee of five bundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(7), Florida Statutes (2009). 20 May 3 2010 16:04 @5/03/2018 16:01 8509218158 PAGE 15/47 OUNT VI 89. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Counts I through IV of this Complaint as if fully recited herein. 90, That the Agency may revoke any license issued under Part I of Chapter 429 Florida Statutes (2009) for (a) An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility, and (1) Any act constituting a ground upon which application for licensure may be denied. Section 429.14(1)(a) and (1), Florida Statutes (2009). An applicant must demonstrate compliance with the requirements in this part, authorizing statutes, and applicable mules during an inspection pursuant to s. 408.811, as requixed by authorizing statutes. Section 408.806(7)(a), Florida Statutes (2009). - 91. 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, (c) 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 (2009). 92, That Respondent has violeted the minimum requirements of law of Chapters 429, Part Il, and Chapter 58A-5, Florida Administrative Code as described with particularity within this complaint. 93. That Respondent has a duty to maintain its operations in accord with the minimum sequirements of law and to provide care and services at mandated minimum standards. 94. That Respondent bas violated the provision of Chapter 429, Part I, Florida Statutes (2009, and Chapter 58A-5, Florida Administrative Code. 2 May 3 2010 16:04 05/83/2818 16:81 8589218158 PAGE 16/47 95. 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. 96. That Respondent has been cited with a total of eighty-cight (88) deficient practices between the period November 25, 2008 and January 27, 2010', a period of just over fourteen (14) months, as evidenced by the survey reports attached hereto as composite exhibit “A” and the allegations therein incorporated herein as if fully recited. 97. That the deficient practices cited from November 25, 2008 and January 27, 2010 involve woultiple areas of facility operations and the violation of minimum standards regulated said operations including, but not limited to, General Licensing Standards (one citation), Facility Records (fifteen citations), Resident Records (three citations), Administrative Criteria (three citations), Staffing Standards (twenty-three citations), Resident Care Standards (five citations), Nutritional and Dietary Standards (seven citations), Emergency Management Standards (two citations), Physical Plant Standards (eleven citations), Medication Standards (three citations), Limited Mental Health Standards (two citations), and Staff Records Standards (thirteen citations). 98. That the deficient practices identified in surveys from November 25, 2008 to January 27, 2010, and the allegations of this complaint, reflect a pantern of deficient practices by Respondent in the operation of its assisted living facility. | 99. 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 " A total of sixteen (16) surveys were necessitated during this period, ten (10) of which. were focused solely on the subject of a complaint of third pertics. ? Monetary sanctions in accord with law have been imposed for some of the referenced citations. 27 May 3 2010 16:05 Q5/63/2018 16:01 8589210158 PAGE 17/47 over a brief period of time. 100. 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, Fiorida Statutes (2009). . Respectfully submitted thi / day of March, 2010. 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, Bidg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 2] 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 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been _by US. Certified Mail, Retum Receipt No. 7008 0500 0001 9560 8674 on March 2010, to Haresh Hirani, Administrator, Carden House, 2349 Central Avenue, St. Petersburg, Flonda 33713 and by U.S. Certified Mail, Return Receipt No. 7008 0500 0001 9560 8681 to Sachin Amin, Registered Agent, 8300 ~ 97" Street, Seminole, Florida, 33777. General Counsel! 23 @5/03/2018 16:01 8509218158 Haresh Hirani, Administrator Carden House 2349 Central Avenue St. Petersburg, Florida 33713 (U.S, Certified Mail) ° Kathleen Varga : Facility Evaluator Supervisor _| 525 Mirror Lake Dr., 4” F1. St. Petersburg, Florida 33701 (Interoffice) May 3 2010 16:05 Sachin Amin Registered Agent 8300 — 97" Street Seminole, Florida 33777 (U.S. Certified Mail) Thomas J.: Walsh Ul, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) 24 PAGE 18/47 May 3 2010 16:05 85/03/2018 16:@1 8569210158 PAGE 19/47 PRINTED: 03/50/2010 FORM APPROVED ‘STATEMENT OF DEFICIENCIES CORRECTION CONSTRUCTION AND OF (02) MULTIPLE CO! NAME OF PROMDER OR SUPPLIER CARDEN HOUSE 7398 CENTRAL AVENUE SAINT PETERSBURG, Fi. 33713 GA} PREFIX ' (GACH MUST TAG REGULATORY OR LEO IDENTIFYING INFORMATION) A 000, INITIAL COMMENTS " ASSISTED LIVING FACILITY BIENNIAL LICENSURE SURVEY ‘41/2508 Deficiencies were cited. . The facility was found not to be in compliance ’ with Florida Statutes, Chapter 429, Part |, and the Florida Administrative Code S6A-5. A 201i FACILITY RECOROS STANDARDS ’ An up-to-date admission and discharge log must be maintained listing the names of all residents and each resident's. 1. Date of admission, 2. Place from which the resident was admitted, 3. Admission with a stage 2 pressure sore, if : ap 4 [4 Date of discharge: 5. Reason for discharge, 6. The facility to which the rasident is j discharged or home address, or if the person ie : deceased, the date of death. : 429.41(1)(6), FS. * §8A-5.024(1)(b), F A.C. ' This STANDARD is not met a8 evidenced by: Based on record review and itera, th foci | failed to maintain an up- to-date . admission/discharge log Findings include: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE 3 SIGNATURE ; STATE FORM - LOMP11 ; mw 1031 ne | 05/03/2018 16:01 8589218158 gency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (NAME OF PROVIDER OR SUPPLIER May 3 2010 16:05 PAGE 28/47 PRINTED: 03/10/2010 ' FORM APPROVED STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33712 (Xa) 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A201 Continued From page 1 During facility record review it was determined that the admission/dicharge log did not contain , any information on the admission or su _ discharge of 1 of 6 residents reviewed (#6).An interview with the administrator on 11/25/08 at approximately 9:20 a.m. confirmed that the admisston/discharge log was not current. Class il] MCO 11/28/08 A214| FACILITY RECORDS STANDARDS Agancy reports which pertain to any agency survey, inspection, monitoring visit, or complaint investigation must be available to the residents "and the public. 429.35(1), FS. 5BA-5.024(4)(c), FAC. This STANDARD is not met as evidenced by: Based on observation and intarview, the facility . failed to post agency reports for public view. Findings include: During the factiity tour it was noted that agency reports, including survey reports, were not posted for public view. Interviews with residents on 11/25/08 throughout the survey contimad that they had never seen any evidence of agency visits. An interview with the administrator on 11/25/08 at approximately 11:20 a.m. confirmed that she had not posted any agency reports CA Form 3020-0001 STATE FORM 1D PROVIDER'S PLAN OF CORRECTION pus) PREFU (EACH CORRECTIVE ACTION SMOULD BE TAS CROSS-REFERENCED TO THE APPROPRIATE. DATE ' DEFICIENCY) Az 1 A224 i : - LOMP1t It continuation sheet 2 of 31 May 3 2010 16:06 85/03/2018 16:@1 8589210158 PAGE 21/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES TION AND PLAN OF CORRECTION (2) MULTIPLE CONSTRUC A. BUILDING STREET ADDRESS. CITY. STATE, ZIP CODE 7349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 04) 10 SUMMARY STATEMENT OF DEFICIENCIES i re) an: PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREF (EACH CORRECTIVE ACTION SHOULD BE + COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A214 Continued From page 2 Class il! "MCD 11/28/08 A222 Facility Records Standards Facility records shall include the factiity ‘s rasident elopeamant response policies and procedures. 58A-5.024(1){q), F.A.C. This STANDARD is not met as evidenced by. Based on record review and interview, the facility . , failed to develop and maintain resident i elopement responses policies and prcadures. Findings include: The Facility Administrator confirmed during an interview on 11/25/08 at 10:20 a.m. that there - were no facility policy and procedures on resident slopement. She stated, “I haven't done it yet” Class I! Carrecton Date: 11/28/08 A223 Faciity Recdrds Standards A223 The facility conducts a minimum of two resident elopement prevention and responae drills per year. 4629.41(1)(a)3., F.S. 428.41(4)()), F.S. 5BA-5,0182(8)(c), F.A.C. STATE FORM - LOMP11 tcontinuayon stroct 3 of 31 May 3 2010 16:06 85/63/2818 16:@1 8509210158 STATEMENT OF DEFICIENCIES PUSUPPLIERICLIA TIPLE CONSTRUCTION AND PLAN OF CORRECTION TOENTIFICATION NUMBER: oa) AL11982424 STREET ADDRESS, CITY. STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 PAGE 22/47 PRINTED: 03/10/2010 FORM APPROVED (003) DATE SURVEY COMPLETED 11/26/2008 _, SUMMARY STATEMENT OF DEFICIENCIES : 1 ; PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE (EACH DEFICIENCY MUST BE PRECEDED BY FULL A223 Continued From page 3 This STANDARD is not met as evidenced by: Baeed on interview, the facility failed to conduct ‘ resident elopement drills within the past year. Findings include: During an intarview with the Facility Administrator 0n.11/26/08 at 10:20 a.m., she indicated to the best of her knowledge, the facility has not held - any elopemert drills within the past year. Class Iti ; Correction Date: 11/28/08 A224 Facility Recorda Standards Tha facility documents resident elopement response drilla and ensures the drills are conducted consistent with tte facility's resident elopement policies and procedures. A29.41(1)(a)3., F.S. 429.41(1)(), FS. 58A-5.024(1)(r), FAC. This REQUIREMENT is not met as evidenced | by: Based on record review and interview, the facility failed to ensure resident elopament response drille wera conducted and documented. Findings include: - OEFICIENCY)... Form 3020-0001 . STATE FORM ~” LQMP11 ft cortruation sheet 4 of 31 May 3 2010 16:06 05/03/2018 16:81 8589210158 PAGE 23/47 PRINTED: 03/10/2010 FORM APPROVED for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (1) PROVIDER/SUPPLIER/CLIA ~ | @ca) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: AL11932426 STREET ADDRESS, CITY. STATE. ZIP CODE 2340 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES D PROVWER'S PLAN OF CORRECTION oa (EACH DEFICIENCY MUST BE PRECEDED @Y FULL PREFIX {EACH CORRECTIVE ACTION SHOULD 82 COMPLETE REGULATORY OR LSC IDENTIFYING INFORIMATION) at CROSS REFERENCED YO THE APPROPRIATE DATE A224 Continued From page 4 The Facility Administrator stated in an interview at 10:20 a.m. on 11/25/08 that no resident elopement drills ware conducted and, therefore, not documented. : Class til Correction Date: 11/28/08 RESIDENT RECORDS STANOARDS The resident's record must include a copy of the * resident's contract with the facility, executed at or prior to admission, including any addendums to | the contract. 5BA-5.024(3)(i) FAC. 428.24(1) F.S. - 429.24(5), F.S. 5BA-5.025(1), F.A.C. t . This STANDARD is not met as evidenced by. figaed on record review and interview, the facility failed to have a contract on file for | of 6 resident records reviewed (#1), who was admitted to the * facility on 6/4/08. Findings include: During resident record raview it was determined _ that the file for resident #1 did not contain a copy of the executed contract. An interview with the administrator on 11/25/08 at approximately 11:10 a.m. confirmed that there was no contract on file for resident #1. Class Iit MCD 11/28/08 STATE FORM - LoMPt1 it curonvadon sheet 5 of 31 May 3 2010 16:06 @5/63/2018 16:61 8589218158 PAGE 24/47 PRINTED: 03/10/2010 _FORM APPROVED STATEMENT OF DEFICIENCIES 001) PROVIDERJSUPPLIERUCLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION JOENTIFICATION NUMBER: A BUILDING AL11932424 . ‘STREET ADDRESS, CITY, STATE, ZIP CODE 2343 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 SUMMARY STATEMENT OF OFFICIENCIES : (EACH DEFICIENCY MUST BE PRECEDED BY FULL : (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) : CROBS REFERENCED TO APPROPRIATE A416 ADMISSIONS CRITERIA STANDARDS Medical examinations completed after the admission of the resident to the facility must be completed within 30 days of the date of | _ admission and must be recorded on the Resident Hastth Assessment for Assisted Living Facilities, AHCA Form 1823, January 2006. 5BA-5.0181(2)(b), F.A.C. ' This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to assure that medical examination reports ' (1823) were completed for 1 of 6 residents ‘ sampled (#1) within 30 days of admission. Findings include: During resident record review it was determined that resident #1 had been admitted to the facility on 8/4/08 and did not have a meical examination report on file. An interview with tha adminiatrator on 11/25/08 at approximately 9:65 a.m. confirmed that rasidnet #1 did not have a medical examination raport on file. Class III MCD 11/28/08 STAFFING STANDAROS If the administrator is employed on of after STATE FORM . ~ LOMP11 Woontinumtion sheet 6 of 31 May 3 2010 16:07 05/83/2018 16:01 8509210158 PAGE 25/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES ROVIDER/SUPPL (3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: : COMPLETED AL11992426 : 1112512008 STREET ADORESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE CARDEN HOUSE . | SAINT PETERSBURG, FL 337123 SUMMARY STATEMENT OF DEFICIENCIES 1D _ PROVIDER'S PLAN OF CORRECTION {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO Mig APPROPRIATE A503 Continued From page 6 08/15/90, he/she must have a high school diploma or G.E.D, or have been an operator or administrator of a icansed assisted living facility in the State of Florida for at least one of the past 3 years in which the facility has met minimum standards Administrators employed on or after 10/30/95 must have a high school diploma or G.E.D. 58A-5.019(1)(a)2. F.AC. This STANDARD is not met as evidenced by: ! Based on Interview, the faotlity failed to ensure — the Adminisiratar's personnel file containing evidence of her high school diploma or G.E.D. was in the facility for review. Findings include: The Facility Administrator stated in an Interview on 11/25/08 at approximately 10:30 a.m. that her personnel file was not al the facility. Class III Correction Date: 11/28/08 STAFFING STANDARDS Administrators and managers must successfully complete the aszistad living facility core training requirements within 3 months from the date of becoming s facility administrator or manager. Successful compilation of the core training requirements includes passing the competency test. . STATE FORM wee LOMP11 Ncontinuation sheet 7 of 31 May 3 2010 16:07 05/83/2010 16:@1 8509218158 PAGE 26/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIDER/SUPPLIERICLIA (2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION . A BUILDING B. WING __ NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY. STATE, ZIP CODE 2849 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL $3715 \TEMENT PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL : (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROGS-REF ERE riiehe THE APPROPRIATE A504 Continued From page 7 58A-5.0191(1)(b), FAC. This STANDARD is not met as evidenced by: Based on interview, the facility failed to ensure the Administrator's personne! file containing _ evidence of completion of Core Training was in the facility for review. Findings include: | The Facility Administrator stated in an interview on 11/25/08 at approximately 10:30 a.m. that her personnel file was not at the facility. + Claas Itt Correction Date: 11/28/08 A505. STAFFING STANDARDS ASS The administrator shall participate in. 12 hours of continuing education in topics related to assisted living every 2 years. 3.428,52(4),F.S. | §BA-5.0191(1)(c). F.A.C. | { This STANDARD is not met as evidenced by. Based on interview, the facility failed to ensure | the Administrator's personnel file containing | AHCK Form 3020-0001 : STATE FORM - LOMP14 Ifeontnuation sheet 5 of 31 May 3 2010 16:07 5/83/2018 16:@1 8589218158 PAGE 27/47 PRINTED: 63/10/2010 FORM APPROVED . STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPUERICLIA AND PLAN OP CORRECTION IDENTIFICATION NUMBER; AL11932424 STREET ADDRESS, CITY, STATE, ZiP COOE 2249 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES ° CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD 8 REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFFRENCED FO THE APPROPRIATE. A505 Continued From page 8 evidence of 12 hours af continuing education ’ related to aszisted living topics was in the facility for review. Findings include: The Facility Administrator stated in an interview on 11/25/08 at approximately 10:30 am. that her personnel fie was not at the facility. : Class lil . Correction Date: 11/28/08 A509: STAFFING STANDARDS A\l employees hired on or after October 1, 1998 “who perform personal gervices shall be in compliance with Levei 1 background screening. 429.174(2), FS 5BA-5.019(3).F.A.C. _ Chapter 435, FS. This STANDARD is not met 8s evidencad by: Based on record review and interview, the facility failed to ensure the parsonnet file of one (Employee #1) of three direct care staff were in compliance with Level 1 background screenings. | Findings inctude: Review of the personned file of Employee #1 did not contain evidence of a Lavel 1 background screen prior to employment. The Facility Administrator stated in an interview at approximately 10:00 a.m, that Employee #1 AHCA Form 3020-0001 : STATE FORM . . - LOMP11 ff conunuggon sheet 9 oF 31 May 3 2010 16:07 @5/@3/201@ 16:01 8509210158 PAGE 28/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION EET ADORESS. CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 Heel (EACH DEFICI my oy BE PRECEDED ®Y FULL a : PREFIX H HENCY MU! PREFIX : TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE SATE NAME OF PROVIDER OR SUPPUER CARDEN HOUSE A609 Continued From page 9 stated s/he had it and would bring it in. Class Ill Correction Date’ 11/26/08 Staff who provide direct care to residents, other than nurses, certified nursing assistants, or home health aids trained in accordance with Rule 59A-8.0095, must receive a minimum of 1 hour - in-service training in infaction control, including universal precautions, and facility sanitation procedures before providing personal care to residents. | 5aA-5.0191(2\a), FAC. A510 STAFFING STANDARDS : . A510 58A-5.0191(11)(a), FAC. | This STANDARD is not met as evidenced by: , Based on record review and interview, the facility faifed to ensure the personnel file of three (Employees #1, $2 and #3) of three direct care employees cantained evidence of at least one hour inservice training in infection control and fackity sanitation procedures. Findings include: Review of the personne! files of Employaes #1, #2 and #G did not contain evidence of inservice training in infection control and facility sanitation procedures, The Facility Administrator was informed on 11/25/08 at approximately 12:30 p.m. that the required inservices did not appear to be in the employee personnel files. STATE FORM . one 1LQMP11 (f continuation sheet 10 of 31 May 3 2010 16:08 85/03/2018 16:01 8589210158 PAGE 29/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIOER/SUP! 1 (3) DATE SURVEY AND PLAN OF CORRECTION. x) Provo ERVSUPPLIERICLIA oa) wae CONSTRUCTION 4 TED A BUILDING PLE AL11932424 & wag —________-~— 14/28/2008 NAME OF PROVIOER OR SUPPLIER STREET ADORESE. CITY. STATE, ZIP CODE CARDEN MOUSE SAINT PETERSBURG, FL. a3743 SUNMARY STATEMENT OF OFFICIENCIES r+) PROVIDER'S PLAN OF CORRECTION {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS REFERENCED. TO THE APPROPRIATE AS10 Continued From page 10 Class Ji) Correction Date: 11/28/08 STAFFING STANDARDS Staff who provide direct care to residents must receive a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1. Reporting of major incidents. 2. Reporting adverse incidents. 3. Facility emergency procedures including chain . of command and staff roles relating to emergency evacuation. 58A-5.0191(2)(b), F.AC. 58A-5.0191(14)(a), FAC. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to ensure the personne! file of three : (Employees #1, #2 and #2) of three direct care employees contained evidence of inservices in reporting of incidences and facility emergency procedures. Findings include: Review of tha personnel files of Employees #1, #2 and #3 did not contain a hire date nor evidence of inservices in reporting of incidences and facility emergency procedures. The Facility STATE FORM , -_ LOMP11 eontiquation sheet 11 of 31 May 3 2010 16:08 85/03/2018 16:81 95092108158 PAGE 30/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA ANDO PLAN OF CORRECTION IDENTIFICATION NUMBER: AL11932424 ; NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE. : 2349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES 7 PROVIDER'S PLAN OF CORRECTION {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROGS- REFERENCED Tr TO THE APPROPRIATE A511 Continued From page 11 Administrator was informed in an interview on 11/25/08 at approximately 12:30 p.m. that the required inservices did not appear to be: in the employee personnel files. Class lit Correction Date: 11/28/08 STAFFING STANDARDS “ Staft who provide care to residents, who have not ! taken the core training program. shall receive a minimum of 1 hour in-service training within 30 days of amployment that covers the following " subjects: "1, Resident rights in an assisted fiving facility. 2. Recognizing and reparting reaident abuse, Neglect, and explortation. | 58A-5.0191(2\(C), FAC. | | ' | 58A-5.0181(11)(a), F.A.C. This STANDARD is not met as evidenced by: Based on cacord review and interview, the facility failed to ensure the perzonnel fila of three (Employees #1, #2 and #3) of three direct care amployess contained evidence of at least one hour Inservice training in resident rights and recognizing and reporting abuse, neglect, and exploitation within 30 days of amployment. STATE FORM one LQMP11 Weontinuazon wheat 12 of 31 May 3 2010 16:08 85/03/2018 16:61 8589210158 STATEMENT OF DEFICIENCIES PROVIOERYSUPPLIER/CUA, CONSTRUCTION AND PLAN OF CORRECTION (42) MALTIPLE STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT 0 OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IRENTIFING INFORMATION) A512 Continued From page 12 Review of the personnel files of Employees #1, #2 and #3 did not indicate a hire date and not contain evidence of inservice training in resident | fights and recognizing and reporting abuse, neglect, and exploitation infection control and facility sanitation procedures. The Facility Administrator was Informed on 11/25/08 at approximately 12:30 p.m. that the required , inservices did not appear to be in the employee | personnel files. - | | Chass III Correction Date: 11/28/08 A513 STAFFING STANDARDS A513 Staff who provide direct care to residents, other than nurses, CNAs, or home health sides trained three (3) hours of in-service training within 30 days of employment that covers the following subjects: 1. Resident's behavior and needs. 2. Providing assistance with activibes of daily living. $8A-5.0191(2)(d), F.AC. 58A-5.0191(11)(a), F:A.C. This STANDARD is not met as evidenced by: Basad on record review and interview, the facility . failed to ensure the personnel fie of three STATE FORM : ~_ LOMP11 PAGE 31/47 PRINTED: 03/10/2010 FORM APPROVED Moontinuaton sheet 13 of 31 May 3 2010 16:08 @5/83/2018 16:81 8509210158 PAGE 32/47 PRINTED: 03/10/2010 FORM APPROVED my cE OE NUNOER. (02) MULTIPLE CONSTRUCTION NTIFICATION NUMBER: AND PLAN OF CORRECTION AL1149324624 STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERS@URG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE (x4) 10 SUMMARY STATEMENT OF DEFIOR:NOIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A513 Continued From page 13 - (Employees #1, #2 and #3) of three direct care employees contained evidence of three hours of inservice training in resident’s behavior and needs and providing aasistance with activities of daity living within 30 days of employment. | Findings include: Review of tha personnel files of Employees 81, #2 and #3 did not indicate a hire date and not contain evidence af inservice training In resident's behavior and needs and providing easistance with activities of living. The Facility Administrator was informed on 11/25/08 at approdmataly 12:30 p.m. that the required inservices did not appear to . be in the employee personnel files. Class il _ Correction Date: 11/28/08 STAFFING STANDARDS " All facility staff must receive in-service training regarding the faciilty " s resident elopement respones policies and procedures within thirty (30) days of employment. S5BA-6.0191(2)(f), FAC. This STANDARD is not met as evidenced by: STATE FORM m LOMP11 Hf continuslian sheet 14 of 31 May 3 2010 16:09 05/83/2018 16:01 8589210158 ; PAGE 33/47 PRINTED; 03/10/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) PROVIDERIBLIPPLIER/CLIA MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION =— IDENTIFICATION NUMBER “ 8. WING AL.11932424 NAME OF PROVIDER OR SUPPLIER STREET ADDAESS, CITY, STATE, ZIP CODE 2340 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL. 33713 (x4) 10 ‘SUMMARY STATEMENT OF DEFICIENCIES wo PROVIOER'S PLAN OF CORRECTION PREFLC DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TaG CROSS-REFERENCED TO THE APPROPRIATE A514 Continued From page 14 Based on record review and interview, the facility | failed to ensure the personnel file of three (Employees #1, #2 and #3) of three dkect cara employees contained evidence of three hours of inservice training regarding the facility's resident elopement response policies and procedures within 30 days of employment, Findings include: Review of the personnel fies of Employees #1, #2 and #3 did not indicate 2 hire date and not contain evidence of inservice training regarding the facility’s resident alopament response policies and procedures. The Facility Administrator was informed an 11/25/08 at approximately 12:30 ! p.m. that the required inservices did not appear to be in the employee personnel files. Class Il Correction Date: 11/28/08 A518 STAFFING STANDARDS Facilities shall maintain the following minimum - staff hours per week: Number of Staffing Hours. Residants Weekly AHCA Form . STATE FORM - LOMP11 ff continuation sheet 15 of 31 May 3 2010 16:09 5/03/2018 16:81 8589210158 , PAGE 34/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES ‘AND PLAN OF CORRECTION (0c) OATE SURVEY {X1) PROVIDER/SUPPLIERICLIA ° COMPLETED PU ADENTIFICATION NUMBER: AL11992424 11/25/2008 STREET ADORESS, CITY, STATE, ZIP CODE 2549 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIOER'S PLAN OF CORRECTION os (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION BHOULO.CE «COMPLETE REGULATORY OR LSG IDENTIFYING INFORMATION) TAG CROBS-REFERENCED YO THE APPROPRIATE ==—s«éATE A518 Continued From page 15 For every 20 residents over 95 add 42 staff hours per week. 58A-5.019(4)(a)1, F.AC. This STANDARD is not met as evidenced by: Based on record review and interview, the facility _ failed to maintain minimum weekly direct care staffing hours of 335 for a census within the range of 36 to 45 residents. , . Findings include: ‘The facility provided the staffing schedule for the weeka 11/19/08 through 12/01/08. The schedule listed staff by "Mad Techs,” “Night Security,” “Housekeeping,” “Management,” "Food Service” and "Maintenances." The Administrator stated in an Interview at 10:00 a.m, on 11/25/08 that “only the Med Techs provide care. Night Security, Housekeeping, Management, Food Service and Maintenance do not provide direct care. Our residents only naed medication assistance.” ne The week prior to the survey (11/19/08 - 11/25/08) was selected for review, which indicated a total of 128 hours for direct care staff, 207 hours below the minimum required hours of 335 for a cansus of 39 to 42 residents. Form 3020-000 : : STATE FORM — LOMP11 if contiouauon ehest 16 of 31 May 3 2010 16:09 05/03/2018 16:81 8509218158 PAGE 35/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES DER/SUPPLIERICLIA AND PLAN OF CORRECTION 1 PROM (X2) MULTIPLE CONSTRUCTION A. BUILDING 8, WING NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 33713 PROVIDER'S BLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A518 Continued From page 16 The direct care staffing hours were reviewed with the Administrator at 10:00 a.m. on 11/25/08 who verified the 128 hours of direct care staff was correct. The Administrator stated they were hiring Med Techs today. Ciaae It Carrection Date: 11/28/08 { { ! STAFFING STANDARDS | AS24 At least one staff member who is trained in First Aid and CPR, as provided under Rule 5BA-5.0191, shall be within the facility at all times when residents are in the facility. BBA-5.019(4)(a)4., F.A.C. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to ensure at least one direct cere staff member trained in First Aid and CPR (Cardio-Pulmonary Resuscitation) was in the facility when residents were present. Findings Include: The facility provided the staffing schedule for the | period 11/19/08 through 12/01/08. The fallowing was identified: 1. Employee #1 was/ie schaduled to work 7:00 AHTA Form 3020-0001 STATE FORM : : one LOMP 11 Weontnuaton sheet 17 of 31 May 32010 16:09 05/83/2018 16:@1 8589210158 PAGE 36/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDER/SUPPLIERICUA IDENTIFICATION NUMBER: (2) MULTIPLE CONSTRUCTION ABULOING — B.WNG STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE on GUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION oxy PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROGS-REFERENCED TO we APPROPRIATE DATE A526 Continued From page 17 a.m. to 5:00 p.m. on Mondays, Tuesdays and Wodneadays and 7:00 a.m. to 3:00 p.m. on Thursdays and Fridays. Per the Administrator in an interview on 11/26/08 at 10:00 a.m., other employees lated on the schedule during the time Employee #1 is at the facility are not direct care staft, The personnel file of Employee #1 did not | contain evidence of approved training in First Aid and CPR. : : 2. Employee #2 waavis scheduled to work 5:00 p.m. to 11:00 p.m. on Mondays, Tuesdays and | Wednesdays, 3:00 p.m. to 11:00 p.m. on * Thuredays and Fridays, and 7:00 p.m. to 7:00 a.m. on Saturdays and Sundays. Employee #2 is the only scheduled staff rember at the faciitty : from 7:00 p.m. to 7:00 a.m. on Saturdays and Sundays. The personnel file of Employee #2 contained documentation training in CPR expired | October, 2008. : 3. Employee #3 wanlis scheduled to work 7:00 a.m. to 7:00 p.m. on Saturdays and Sundays. The only other staff member at the facility during this time is a food service employee. The personnel file of Employee #3 contained : documentation training in CPR expired October, 2008. : 4. The schedules lists a “Night Security" employee scheduled to work 11:00 p.m. to 7:00 a.m. Mondays through Friday. This "Night Security” employee is the only scheduled staff at the facility . during these times and was identified by the Facility Administrator as not being a direct care staff employee: in an interview on 11/25/06 at approximately 10:00 a.m. Class tt Correction Date: 12/28/08 AHCA Form 3020-0001 STATE FORM — - LQMP11 fF continuakon sheet 18 of 31 May 3 2010 16:10 85/83/2018 16:61 8589210158 PAGE 37/47 PRINTED: 03/10/2010 FORM APPROVED or Health STATEMENT OF OFFICIENCIES AND PLAN OF CORRECTION DENTIFICA’ ‘ (X2) MULTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 7349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERABURG, FL. $3713 SUMMARY STATEMENT OF DEFICIENCIES [+ PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL. (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A525 STAFFING STANDARDS {n tacilities with 17 or more residents, there shal! be one staff member awake at all hours of the day and night. 429.41 (1)(C), F.S. 5BA-5.019(4)(a)3, F.A.C. This STANDARD is not met as evidenced by: Based on record review and Interview, the facility failed to ensure one direct care staff member was awake al afl hours when more than 17 residents were In the facility. . Findings include: Review of the staffing schedule for the weeks of 11/19/08 through 12/01/08 revealed the only staff member on duty from 11:00 p.m.to 7:00 a.m. | Mondays through Fridays was kientified as "Night | - Security." The Facility Administrator stated in an interview on 12/25/08 at 10:00 a.m. the cansus was approximately 40 residents and the employee identified aa "Night Secunty* is not a direct care staff employee. "Class Il : Correction Date. 11/26/08 AHCA Form 3020-0001 STATE FORM . on LOQMP11 @ conenuetion shest 19 of 31 May 3 2010 16:10 95/83/2018 16:01 8509210158 PAGE 38/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION (62) MULTIPLE CONSTR! BTREET ADDRESS, CITY, STATE, Z1P CODE 2248 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 %4)10 ‘SUMMARY STATEMENT OF DEFICIENCIES PREFIX (GACH DEFICIENCY MUBT SE PRECEDED 8Y FULL REGULATORY OR L8G IDENTIFYING (FORMATION) A714 Continued From page 19 AT11 RESIDENT CARE STANDARDS An activities calendar shall be posted in common | areas where residents normally congragate. 5BA-5.0182(2)(c), F.AC. This STANDARD is not met a3 evidenced by: Based on observation and interview, the facility failed to post an actitivites calandar in the common area of the facility. , Findings include: * During the facility tour It was determined that the | activities calendar was not posted for public view. | | An interview with the administrator on 11/25/08 at approximately 10:55 a.m. confirmed that the i activities calendar was not posted for public view. | Class Wl MCD 11/28/08 | A808 NUTRITION & DIETARY STANDARDS ; A806 : All regular and therapeutic menus to be used by | the facility shall be reviewed annually by a registered dietitian, licansed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietittan ar licensed dietitan/nutitionist to enaure the meals are commensurate with the | nutritional standards. | 5BA-5.020(2)(c), F.A.C. AHCA Form 3020-0001 STATE FORM -“ LOMP11 Woontinuation sheat 20 of 31 May 3 2010 16:10 85/83/2018 16:81 8589218158 PAGE 39/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X41) PROVIDER/SUPPLIERICLIA (03) DATE SURVEY AND PLAN OF CORRECTION Lait ashen Aiep ting COMPLETED AL11932424 : ST 11/25/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, Z" CODE 7349 CENTRAL A CARDEN HOUSE SAINT PETEREGURG, FL FL 33713 SUMMARY STATEMENT OF DEFICIENCIES io PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROBS-REFERENCED TOT Yo THE APPROPRIATE A806 Continued From page 20 This STANDARD is not met as evidenced by: Based on record review and interview, the facility falled to have the menu reviewed annually bya | registered dietitian. Findings include: During record review it was determined that the menu in use wae not signed or dated by a registered dietitian. An intarview with the administrator an 11/25/68 at apprwoamately 11:05a.m. confirmed that she had a new menu _ @pproved by a registered dietitian but it was not in ' use yet, It could be determined that the menu currently in use was meeting the residents’ nulribonal requirements. Class Ill MCD 11/28/08 A810 NUTRITION & DIETARY STANDARDS ’ Planned menus shall be conspicuously pasted or easily available to residents. 58A-5.020(2)(d), F.AC. This STANDARD is not met as evidenced by: Based on observation and interview, the facility foiled to post manus for public view. Findings include: ANCA Form 3020-0001 STATE FORM bed LOMP11 fF conunuadon shwet 21 of 31 May 3 2010 16:10 85/83/2018 16:01 8589210158 , PAGE 40/47 PRINTED: 03/10/2010 FORM APPROVED PI JERICLIA IDENTIFICATION NUMBER: xt) (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION AL11932624 NAME OF PROVIDER OR SUPPLIER f ; 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33715 0D SUMMARY STATEMENT OF DERCIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED RY FULL REGULATORY OR L&C IDENTIFYING INFORMATION) A810 Cantinued From page 21 During the facility tour it was noted that menus were not posted for public view. Interviews with random residents on 11/25/08 ,during the course of the survey, confirmed that menus were not posted for public view.An interview with the _ administrator on 11/25/06 at approximately 10:25 a.m.confirmed that the menu was not posted for public view. Class 11 MCO 11/28/08 NUTRITION & DIETARY STANDARDS . A supply of eating ware sufficient for all residants, including adaptive equipment if needed by any resident shall be on hand. 5BA-5.020(2)(g), FAC. . Thig STANDARD is not met as evidenced by. Based on observation and intarview, the facility failed to supply eating ware other than paper ' plates and bows for all residents. | Findings include: During the facility tour it was observed that the residents were served food on paper plates and bowls.Random residant interviews on 11/25/08 canfirmed that this was normal practice. An interview with the owner on 11/26/08 at approximately 11:45 a.m. confirmed that he does not usé china plates because residents throw or STATE FORM : - LOMP11 Woontinusfion sheet 22 of 31 May 32010 16:11 @5/03/281@ 16:81 8509210158 PAGE 41/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES (41) PROVIDERUPPLIER/CLA MULTIPLE CONSTRUCTION ANDO PLAN OF CORRECTION ) WENTIFICATION NUMBER: on LONG AL41992624 BMNe STREET ADDRESS. CITY, STATE, ZIP CODE 2848 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL , (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSSREFERENCED oe APPROPRIATE A818 Continued From page 22 MCD 11/28/08 A619 NUTRITION & DIETARY STANDARDS A3 day supply of non-perishable food, based on the number of weekly maais the facility has contracted with residents to serve, shall be on hand at all times. 58A-5.020(2)(h), F.A.C. ‘ { This STANDARD i¢ not mat as evidenced by: | : Based on observation and interview, the facility falied to assure that there was a 3 day supply of _ non-perishable food available at all times. It was algo noted that there was no drinking water available to the resktents. _ Findings include: During the facility tour it was noted that there were 5 loaves of bresd, 17 aggs, powdered milk, 2 turkeys, onions and potatoss, 2 108 oz. cans of! ravioli , 6 large cans of vegetables and a large pot of chicken noodle soup on hand for a census of 44, thus falling far short of the required minimum food supplies An interview with the cookon =} 11/25/08 at approximately 10:25 a.m. confirmed | that that day was shopping day and he anticipated having enough food on hand for the | Thanksgiving holiday Subequent interviews with | | the owner and administrator confirmed that the water cooler was broken and they would have to supply a new water cooler and cups for resident use. Clase Ill STATE FORM LOMP11 ; : Woontinustion sheet 23 of 31 May 3 2010 16:11 @5/03/2018 16:01 8589210158 PAGE 42/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF OEFICIENCIES OVIDERJBUPPLIERICLIA AND PLAN OF CORRECTION (<1) PRI (02) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A BUILDING $$ 8. WING STREET ADORESS, CITY, STATE, 2” CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 04) 1D 1D PROVIDER'S PLAN OF CORRECTION * PREFIX PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG tN) TAG CROBS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A819 Continued From page 23 MCD 11/28/08 A902 EMERGENCY MANAGEMENT A\l staff must be trained in their duties and are responsible for implementing the ernergency management plan. _ 428.41(1\(b), F.S. 58A-5.026(3)(a), F.AC. This STANDARD jg not met aa evidenced by. Based on record review, the facility failed to ensure the personnel file of three (Employees #1, #2 and #3) of three direct care employees contained evidence of training in the facility's emergency management plan. Findings include: Review of the personnel files of Employees #1, #2 and #3 did not contain evidence of inservice training In the facility's emergency management plan. Class I'l | Correction Date: 11/28/08 | A1100 STAFF RECORDS STANDARDS A1100 Each staff member's personnel record contains a copy of the original employment application with references. 429.275(4), F.S 5B8A-5.024(2){a), FAC. STATE FORM band LOMP11 Moontinustion sheet 24 of 31 May 3 20 85/03/201@ 16:01 8589210158 STATEMENT OF DEFICIENCIES 4) PROVIDER/SUPPLIERICLIA TIPLE CONSTRUCTION AND PLAN OF CORRECTION mn IDENTIFICATION NUMBER: . hme WING AL11992624 . STREET ADDRESS. CITY, STATE, 21? CODE 7349. CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DBFICIENCIES iD 10 16:11 PAGE 43/47 PRINTED: 03/10/2010 FORM APPROVED 'S PLAN OF {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREF (EACH CORRECTIVE ACTION SHOULD @E REGULATORY OR LSC IDENTIFYING (NFORMATION) TAG GROSS-REFERENCED TO THE APPROPRIATE A1100 Continued From page 24 | A1100 This STANDARD is not met ag avidenced by: Based on record review and interview, the facility failed to ensure the personnal file of three (Employees #1, #2 and #3) of three direct care employees contained an amployment application’ with references. Findings include: Review of the personne! files of Employees #1, #2 and #3 did not indicate a hire date and not _ contain evidence of inservice training in resident's behavior and needs and providing assistance with activities of living. The Facility Administrator : war Informed on 11/2508 at approximataly 12:30 . p.m. that the requirad inservices did not appear to be in the employee personnel files. | | | Ciaas Ill Correction Date: 11/26/08 STAFF RECORDS STANDARDS Personnel records contain veritication of fraedom from communicable disease including tuberculosis. 429.275(4), F.3. 58A-5.024(2)(a), FAC. This STANDARD ie not met as evidenced by: Based on record review and interview, the facility failed to ensure the parsonne! file of two (Employeas #1 and #3) of three direct care employees contained evidence freedom from STATE FORM badd LOMP11 Mf continuation sheat 25 of 31 May 3 2010 16:12 05/83/2816 16:81 8509210158 PAGE 44/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 1) PROVIDER/SUPPLIERJCLIA IDENTIFICATION . AL11832424 NAME OF PROVIDER OR SUPPLIER ‘STREET ADORESS, CITY, STATE, JP CODE 7449 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 33713 ID SUMMARY STATEMENT OF DEPIGIENTIES: re) PROVIDER'S PLAN OF CORRECTION xs) polka (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE. REGULATORY OR USC IDENTIFYING INFORMATION) TAS CROSS-REFERENCED TO ‘THE APPROPRIATE. DATE A1101 Continued From page 25 - communicable disease including tuberculosis (TB). : Findings include: Review of the personnel files of Employees #1 and #3 did not contain evidence of freedom from communicable diseases including tuberculosis. | The fila af Employee #1 did contain a billing t involce for a TB test, but it did not contain an | indication of the results of the tast, Tha Facility | Administrator was informed on 11/25/08 at approximately 10:00 a.m. that the required test results did not appear to be in the employee - \ personnel files. ¢ { : Class lit Carrection Date: 11/28/08 A1104 STAFF RECORDS STANDARDS New facility staff must obtain an initial training on HIV/AIDS within 30 days of employment, unieas the new staff person previously completed the Initial training and has maintained the biennial continuing education requirement. All facility employees must complete biennially, a continuing education course on HIV and AIDS. 420.275(2), F.S. | 5BA5.0191(3), FAC. 58A-5.024(2){a)1., FAC. ! 58A-5.0191(11), FAC. | This STANDARD is not met as evidenced by: Based on record review and interview, the facility L AHA Form 3020-0001 STATE FORM _ LOMP11 ff continuation sheet 26 of 37 May 3 2010 16:12 @5/03/2018 16:01 8589218158 PAGE 45/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (2) MULTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE STREET ADORESS, CITY, STATE. ZF CODE 2349 CENTRAL AVENUE SAINT PETERSBURG; FL 33713 x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 03) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {BACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ; CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1104 Continued From page 26 failed to ensure the personnel file of three (Employses #1, #2 and #3) of three direct care contained evidence of training on HIV/AIDS. Findings indlude: Review of the personnel files of Employees #1, 92 snd #3 did not indicate a hire date and not contain evidence of Inservice training in ‘HIV/AIDS. The Facility Administrator was informed on 11/26/08 at approximately 12:30 p.m. that the required Inservices did not appear to be in the employee personnel files. ‘ Clase ll Correction Date: 11/28/06 STAFF RECORDS STANDARDS Personnel records contain documentation of current certification in an approved First Aid and CPR course. 429.275(2), F.S. - 6BA-5.024(2)(a)1., F.A.C. 5B8A-5.0191(4), F.AC. This STANDARD is not mat as evidenced by: | Based on record review and interview, the facility failed to ensure the personnel records of three (Employees #1, #2 and #3) of three direct care staff contain documentation of certification in an approved First Ald and/or CPR (Cardio-Pulmonary Resuscitation) course. Findings include: STATE FORM — LOMP11 i comimuation sheet 27 of 31 May 3 2010 16:12 85/03/2018 16:01 8589210158 PAGE 46/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE ZMS CENTRAL AVENUE SAINT PETERSBURG, FL 33713 Lo) SUMMARY STATEMENT OF DEFICINCIES [) PROVIDER'S PLAN OF CORRECTION xs) Senn (EACH DEFICIENCY MUST BE PRECEOED BY FULL. PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAS REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (CROSS-AEFERENCED TO THE APPROPRIATE DATE A1105 Continued From page 27 _ The facility provided the staffing schedule for the period 11/18/08 through 12/01/08. The following was identified: 1. The personnel file of Emplayee #1 did not * contain evidence.of approved training in First Aid ; or CPR. Employee #1 was/is scheduled to work 7:00 a.m. to 5:00 p.m. on Mondays, Tuesdays - and Wednesdays and 7:00 a.m. to 3:00 p.m. on Thursdays and Fridays. Per the Administrator in: an interview on 11/25/08 at 10:00 a.m., other employeas {inted on the schedule during the time Employee #1 is at the facility are not direct care _2. The personnet file of Employee #2 contained i documentation training in CPR expired October, 2008. Employee #2 was/is scheduled to work \ 5:00 p.m. to 11:00 p.m. on Mondays, Tuesdays =; and Wednesdays, 3:00 p.m. to 11:00 p.m. on Thuradays and Fridays, and 7:00 p.m. to 7:00 a.m. on Saturdays and Sundays. Employee #2 is the only scheduled staff member at the facility ; from 7:00 p.m. to 7:00 a.m. on Saturdays and ' Sundays. 3. The personne! file of Employee &3 contained documentation training in CPR expired October, 2008. Employes #3 was/is scheduled to work 7:00 a.m. to 7:00 p.m. on Saturdays and Sundays. The only other staff member at the ’ facility during this time is a food sarvice employee. Class ill Correction Date: 12/26/08 A115 STAFF RECORDS STANDARDS, Personnel records contain documentation of STATE FORM = Lampert Weonbnuation sheet 28 of 31 May 3 2010 16:12 @5/03/2018 16:81 8509210158 PAGE 47/47 PRINTED: 03/10/2010 : FORM APPROVED or Health Care Adminis ‘STATEMENT OF DEFICIENCIES (1) PROVIDER/BUPPLIERICUA MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: x AL11932624 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 2349 CENTRAL AVENUE CARDEN HOUSE. SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES . PROVIDER'S PLAN OF CORRECTION (CACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) a eeeadaie APPROPRIATE A1115 Continued From page 28 compliance with level 1 background screening for all staff subject to screening requirements. 429.275(2), FS. 58A-5.019(3), F.A.C. 5BA-5.024(2)(a)3., FAC. This STANDARD is not met as evidenced by: Based on racord review and interview, the facility failed to ensure the personnel file of one (Employee #1) of three direct care staff were in compliance with Level 1 background screenings. : Findings include: Review of the personne! fie of Employee #1 did nat contain evidence of a-Level 1 background screen prior to amployment. The Facility Administrator stated in an interview at approximately 10:00 a.m. that Employee #1 - stated s/he had it and would bring it in. Chass lit Correction Date: 11/28/08 STAFF RECORDS STANDARDS Records shail include a copy of the job description given to each staff member for faclities with a licansed capacity of 17 or more residents. 420.275(A), F.S. 5BA-5.0192)(e)1 . F.A.C. 58A-5.024(2\a}4.. FAC. STATE FORM : ad LOMP11 ” Heonunuation sheet 28 af 21 May 3 2010 16:22 @5/03/2810 16:22 8589214158 PAGE 2/47 _PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION ANO PLAN OF CORRECTION STREET ADDRESS. CITY, STATE. ZIP CODE 2349 CENTRAL AVEN! | SAINT PETERSBURG, ‘FL 33713 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY on LSC IDENTIFYING (NFORMATION| A1117 Continued From page 29 This STANDARD Is not met as evidenced by: Based on record review and interview, the facility falled to ensure the personnel file of three _ (Employees #1, #2 and #3) of three direct care ‘ employees contained an written job description. Findings include: Review of the personnel files of Employees #1, #2. and #3 did not indicate a hire date and not contain a copy of their pacific jab deacription. The Facility Administrator was Informed on 11/25/08 at approximataly 12:30 p.m. that the required job descriptions were not locatad in the employee personnel files and was not able ta provide a copy. Claas Il Correction Date: 11/28/08 Staff Records Standards The facility maintaina documentation of facility direct care staff and administrator participation in resident elopement drills. 5BA-5.024(2)(a)5, FAC. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility © failed to ensure resident elopement response drils were conducted and documented. Findings include: Form 3020-0001 . STATE FORM . Lead LOMP11 Hcondnustion sheet 30 of 31 May 3 2010 16:23 5/83/2818 16:22 85039210158 STATEMENT OF DEFICIENCIES 011) PROVIDER/SUPPLIERICLIA (K2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: AL11932624 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP COOE 2349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 33713 PAGE 03/47 PRINTED: 03/10/2010 FORM APPROVED SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE DEFICIENCY) A1121_ Continued From page 30 The Facility Administrator stated In an interview at 10:20 a.m. on 11/26/08 that no resident elopement drills were conducted and, therefore, not documented. Clags tl! Correction Date: 11/28/08 Form 3020-0001 STATE FORM -” LOMP11 APPROPRIATE W continuation shest 31 of 31 May 3 2010 16:23 Q5/83/2018 16:22 98589210158 PAGE 04/47 PRINTED: 03/10/2010 FORM APPROVED ‘STATEMENT OF DEFICIENCIES (0) DATE SURVEY AND PLAN OF CORRECTION IDENTI COMPLETED 11/28/2008 STREET ADDRESS, CITY, STATE, UP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (GACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULO BE REGULATORY OR LSC IDENTIFYING INFORMATION) acedieee te APPROPRIATE D L000 INITIAL COMMENTS ASSISTED LIVING FACILITY .. LIMITED MENTAL HEALTH LICENSURE SURVEY 11725408 A deficiency was cited on the LMH license. The facility wax found not to be in compliance | with Florida Statutes Chapter 429, Part |, and 58A-5 of the F.AC. FACILITY/RESIDENT RECORDS STANDARDS ' The facility maintains an up-to-date admission and discharge log containing the names and dates of admission and discharge of all mental health residents. : . 5BA-5.029(2)(a), F.A.C. This STANDARD is not met aa evidenced by: Based on record review and interview, the facility | failed to maintain an up to date admission and discharge log containing the names of afl mental heatth residents Findings include: During facility record review it was determined that the facility had no master lit of residents receiving mental health services. An interview with the administrator on 11/25/08 at approximately 9:45 a.m. confirmed that she was not able to identify those residents receiving or needing mental heaith services. TITLE (Xe) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM om LOMP(1 Weontinuason sheet 1 of 2 85/03/2018 16:22 8589218158 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION AL11932424 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE (X1) PROVIDERYSUPPLIERYCLIA IDENTIFICATION NUMBER: May 3 2010 16:23 PAGE 5/47 PRINTED: 03/10/2010 FORM APPROVED (X2) MULTIPLE CONSTRUCTION STREET ADORESS, CITY, STATE. ZF CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED @Y FULL REGULATORY OR LSC IDENTIFYING INFORMATION) L100 Continued From page 1 MCD 11/28/08 ANCA Fonm 3020-0001 STATE FORM PROMIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE . CROSS-REFERENCED YO THE APPROPRIATE LOMPT1 DEFICIENCY) Weontinuaton shest 2 of 2 May 3 2010 16:23 @5/03/2818 16:22 8589210158 PAGE 06/47 PRINTEO: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION ) IDENTIFICATION NUMBER: saa AL119392624 : NAME OF PROVIDER OR SUPPLIER “STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE CARDEN HOUSE . SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES: (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY Of LSC IDENTIFYING INFORMATION) NOU INITIAL COMMENTS ASSISTED LIVING FACILITY LIMITED NURSING SERVICES (LNS) LICENSURE SURVEY No deficiencias were cited on the LNS license. \ 1 , 11125108 | | ' | The facility was found not to be in compliance with Florida Statutes Chapter 429, Patt, and 58A-5 of the F.AC. due to deficiencies that ware | cited on the Standard license and the LMH license. TITLE 948) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE — STATE FORM Leste “LQMP11 Weontinuavon sheat 1 of 1 May 3 2010 16:23 85/83/2018 16:22 8509218158 PAGE 07/47 PRINTED: 03/10/2010 FORM APPROVED ‘STATEMENT OF DEFICIENCIES PROVIDER/SUPPLIERICUA MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 0) MULTIPLE AL119392424 / STREET ADDRESS, CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 ‘SUMMARY STATEMENT OF DEFICIENGES CORRECTION eRe {EACH DEFICIENCY MUST BE PRECEDED BY FULL (FACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) _ CROBS-REFERENCED TO THE APPROPRIATE OATE A000 INITIAL COMMENTS ASSISTED LIVING FACILITY * CORH2008010541 11/25/08 ’ Deficiencies were cited. The facility was found not to be in compliance . With Florida Statutes Chapter 429, Part |, and 58A-5 of the FAC. A615 MEDICATION STANDARDS 1 The facility must maintain a daily medication observation record (MOR) for each resident who receive agsistance with self-administratian of medications or medication administration. 58A-5.0185(5)(b), F.A.C, This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to maintain a daily medication observation racord (MOR) for 3 of 6 (#1,#2 and #6)residents. Findings include: During facility record review it waa determined that resident #6 had been discharged on an unknown date and the MOR could not be located. It could not be detmerined it the resident had been discharged with his/her madications. There was no MOR for resident #1 so it could not be datermined if s/he was receiving any assistance with medications. The MOR for resident #2 had TITLE 08) DATE LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM : cro, 3J6G11 Woomtnuaion sheet 1 of 3 May 3 2010 16:24 @5/@3/28618 16:22 8509210158 PAGE 88/47 PRINTED: 03/10/2010 | FORM APPROVED gency for Hegith Care Administration STATEMENT OF DEFICIENCIES PROVIOER/SUPPLIERICLIA TLE CONSTRUCTION (3) DATE SURVEY AND PLAN OF CORRECTION on IDENTIFICATION NUMBER: 002) MULTIPLE un AL11932424 (66) ID SUMMARY STATEMENT OF DEFICIENQES ‘ PROVIDER'S PLAN OF CORRECTION oo PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR L9C IDENTIFYING INFORMATION) TAS CROSS-REFERENCED TO THE APPROPRIATE . DATE DEFICIENCY) A615 Continued From page 1 A615 ~ : no indication that the rasident had received assiatance with medication on 11/7/08, 11/8/08, 41/15/08, 11/16/08, 1 1/20/08, 11/2 . 1008, 11/23/08 and 11/24/08. : An interview with the administrator on 41/25/06 at approximately 10:10 a.m. confirmed that she did not know if the residents were being asziatad with _ Medications because the documentation wae , incomplete or missing. Class Ill MCD 11/2808 A1106, STAFF RECORDS STANDARDS A1106 | Unlicensed persons wtio will be providing assistance with self-administered medications must receive a minimum of 4 hours of training _ prior to assuming this responsibility, 429,258, F.S. 479.52(5), F.3. 5BA-5.0191(5), FAC. 58A-5.024(2Xa)1., FAC. This STANDARD is not met as evidenced by: ’ Based on record review and interview, the facility failed to assure that unficensed persons providing assistance with self-edministered medications receive 4 hours of training prior to assuming this responsibility. . Findings include: During staff record review it was determined that 1 of 3 staff members assisting with medications farm 3020-0004 STATE FORM an 3sGii ; Hconbrvation sheet 2 of 3 May 3 2010 16:24 85/83/2818 16:22 8589210158 PAGE 9/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES ; xa) DATE 5 AND PLAN OF CORRECTION DeNTIFICN PPUERICUA BAMATPLE CONSTRUCTION yRvEY A. BUILDIN COMPLE: B. WING 11/26/2008 STREET ADDRESS, CITY, STATE, DP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY BTATEMENT OF DEFICIENCIES 0 PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OF LSC IDENTIFYING INFORMATION) CROSS-REF ERENCED TO THE APPROPRIATE ' DEFICIENCY) A1108' Continued From page 2 | A1106 (#1) did not have proof that she had received the 4 hour training. There was an undated, unsigned training certificate from Seminole Pharmacy Management in her personnel file. An interview with the administrator on 11/25/08 at approximately 11:00 a.m.cnfirmed that the certificate was nat signed or dated. Claas lil »MCD 11/28/08 AHGA Form 3020-0001 STATE FORM -_ 26611 . continuation sheet 3 of 3 May 3 2010 16:24 85/83/2018 16:22 8509210158 PAGE 16/47 AH Form Approved 3/10/2010 a nw Eo State Form: Revisit Report (71) Provider/Bupplier (GLIA? —=S~*«*(Y2) Mt l8iple Gonmtruction To 0¥3) Dnt OF Reet Identification Number A Bulding : 12/1/2008 - ALNB824 BM Name of Facility : Street Addrems, City, State, Zip Code 2349 CENTRAL AVENUE CARDEN HOUSE oo SAINT PETERSBURG, FLSS713 ‘Thee report a completed by a Size surveyor to show inoss detciencies parviounly reported that have heen corrected and the date much corrective sation wane mccomtpsahed Each Geftioncy shoul be fuly diertifed using aither tre regulation or LSC provision number and the Ideanticetion prefix code previously shown on the Siete Survey Report (orefix ondes shown to Ina tefl of each requirement on Me survey report form). eee 1) tom) em) tem HS) te (YA) Item (8) _. Correction Correctian ‘ : Correction Completed Complieted Completed ID Prefix a0eis 1270112008 (D Prefor 41106 1201/2008 1D Prefix _ Reg. # Reg # Reg. # uc 7 we 7 : isc” eS ee eae : — . Correction ; Correction Correction Completed Complemd | Completed ID Prefix 1D Prefix ' ID Prefix _ Reg. # i Reg. # ' Rag. # (oa : ie 7. : ie 7 7 SS eee ———. —— -—— Cormection Corraction Correction Completed Completed Completed ID Prefix 1D Prefix ID Prefix _ Reg. # | Reg. ® ‘ Reg. # [oo isc TOT usc 7 Completed Completed Completed ID Prefax Le ID Pref ID Pref a Reg. # Reg. # . Reg. # Lsc ~ ~ ~ uc _ ‘ isc CT ~~ Correction Coreaion - Correction Completed Completed Completed 1D Prefix __ ID Prefix, 1D Prefix __ Reg. # Reg. # Reg. # Lsc OO ~~ isc oo iwc ~ — — . —- ee _—_ —_.._-- Reviewed By Reviewed By Oute: _ Signature of Surveyor: Date: Smpagny ee Reviewed By — — Raviewsd By Date: Signature of Surveyor: Dare: cms RO : . Followup to Burvey Completed on: : ° “Check for any Uncorrected Deficiencies. Was a Summary a ‘ a : Unenrrarted Deficiencies (CMB-2567) Seni to the Facility? ver oun May 3 2010 16:24 85/03/2818 16:22 8589218158 PAGE 11/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIERICLIA TRUCTION AND PLAN OF CORRECTION MO OENTIFICATION NUMBER. 02) MULTIPLE CONB A BUILDING BANG AL11992426 (NAME OF PROVIDER OR SUPPLIER STREET ADURESS, CITY, STATE, ZIP COOE CARDEN HOUSE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 © (X4} 1D SUMMARY STATEMENT. OF DEFICIENCIES PREF ¢ (ACH DEFICIENCY MUST 8 PRECEDED BY FULL REGULATORY GR LSC IDENTIFYING INFORMATION) {A 000) INITIAL COMMENTS {A 000} , ASSISTED LIVING FACILITY REVISIT TO THE BIENNIAL LICENSURE . SURVEY OF 11/25/08 ‘ REVISIT CONDUCTED 12/1/08 Deficiencios wore found to be corrected and , uncorrected. The facility was found not to be in compliance with Florida Statutes, Chapter 429, Part |, and the ' Florida Administrative Code 58A-5. {A 222) Facility Records Standards {A222} i Facility records shail include the facility ' s | raaident elopement response policies and procedures. , S8A-5.024(1)(q), F.A.C. : This STANDARD is not met as evidenced by: Based on record review and interview, the facility _ failed to develop and maintain resident - elopement responses policies and procedures. Findings include: : During record review It was determined that the facility had not yet daveapled resident eiopement policies and procedure. An interview with the “owner on 12/1/08 at approximately 9:30 a.m . Confirmed that the policies and procedures for resident elopement had not yet been developed. Form 3020-0001 : THLE (0) DATE LABORATORY DIRECTOR'S OR PROVIDEA/GUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM : -~ LOMP12 Weortiquation aheat 1 of 16 May 3 2010 16:25 @5/83/2018 16:22 8589210158 PAGE 12/47 PRINTED: 03/10/2010 FORM APPROVED Agency for Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (2) MULTIPLE CONSTRUCTION MAME OF PROVIDER OR SUPPLIER CARDEN HOUSE STREET ADDRESS, CITY. STATE, Z¥ CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 EMENT OF DEFICIENCIES PROMIDER'S PLAN OF CORRECTION 4) + PRE! [EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE ! COMPLETE e THON) “las CROSS REFERENCED 10 Ue APPROPRIATE. OATE {A 222} Continued From page 1 ; UNCORRECTED * Class Ii! M.C.0. 1/02/09 {A 2234 Facility Records Standards The facility conducts a minimum of two resident alopament prevention and response drills per . year. 429.41(1)(a)3., F.S. 429.41{1)(\), F.S. 58A-5.0182(8\(c), F.A.C. _ This STANDARD is not met as evidenced by: Based on interview, the tacility failed to conduct . | resident elopament drills withisy the past year. = Findings include: . During an interview with the owner on 12/01/08 at approximately 9:35a.m., it was confirmed that the facility had not conducted any resident elopement ; Orilis during the past year. ! Class Ill UNCORRECTED M.C.D. 1/02/09 {A 224). Facility Records Standards The facility documents resident elopement response drills and ensures the drifts are conducted consistent with the facility's resident STATE FORM : : - LOMP12 . Nonntiousion sheet 2 of 18 May 3 2010 16:25 @5/83/2018 16:22 8569218158 PAGE 13/47 PRINTED: 03/10/2010 FORM APPROVED ‘STATEMENT OF DEFICIENCIES ) PROVIDERSUPPLEERICUA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: STREET ADORESS, CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 PROVIDER'S PLAN OF CORRECTION an {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC (OENTIFVING INFORMATION) JAG —s«CROGS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {A 224} Continued From page 2 elopement policies and procedures. “ 429.41(1)(9)3., F.S. 429.41(1)()), FS. 58A-6.024(1)(0), FAC. This REQUIREMENT is not met as evidenced by: Based an record review and interview, the facility failed to ensure reekient elopament response drills were conducted and documented. | Findings inctude: The owner stated in an interview at 9:40 a.m. on , 12/01/08 that no resident elopement drilis were * conducted, and, therefore, not documented. _ UNCORRECTED Class lil M.C.D. 1/02/08 {A 503}. STAFFING STANDARDS (f the administrator is employed on or after 06/15/80, ha/ahe must have a high school * diploma or G.E.D, or have been an operator or administrator of a licensed assisted kving facility in the State of Florida for at laast one of the past , 3 years in which the facility has met minimum standards. Administrators employed on or after 10/30/95 must have a high school diploma or G.E.D. ANCA Form 3026-000 . STATE FORM . —_ LQMPI2 It cantinuagion sheet 3 of 16 May 3 2010 16:25 05/83/2018 16:22 8569210158 PAGE 14/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION STREET ADORESS, CITY, STATE. ZIP COOE 2349 CENTRAL AVENUE. SAINT PETERSBURG, Fl. $3713 nD SUNBIARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION 5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREF (EACH CORRECTIVE ACTION SHOULD 8E comvuere TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TE GROSS-REFERENCED YO THE APPROPRIATE OATE DEFICIENCY} {A503}' Continued From page 3 5BA-5.019(1)(a)2, FAC. This STANDARD is not met as evidenced by: Based on interview, the facility failed to ensure the administrator's personnel file containing evidence of her high school diploma or G.E.D. _ was In the facility for review. Findings include: The owner confirmed in an interview on 12/01/08 . al approximately 10:30a.m. that the personne! of | the administrator did not contain evidence of her educatian. UNCORRECTED Class It! M.C.D. 01/02/09 {A505} STAFFING STANDARDS ~ {A 606} “The administrator shall participate in 12 hours of continuing education in topics related to assisted living every 2 years. 3,429.52(4).F.S. 58A-5.0191(1}(c), F.AC. . This STANDARD is not met as evidenced by: Form 3020-000 ” STATE FORM - w LOMP12 Hoontinuaton shest 4 of 16 May 3 2010 16:25 05/83/2018 16:22 8509210158 PAGE 15/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 2) AL11832424 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL. 397(3 SUMMARY STATEMENT OF DEACIENCIES PROVIDER'S PLAN OF CORRECTION DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (CACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) 1° CROSS-REFERENCED TO THE APPROPRIATE : : DEFICIENCY) {A 505} Continued From page 4 Basad on interview, the facility failed to ensure _ the administrator's personne! file containing ' evidence of 12 hours of continuing education ‘ related to assisted living topics was in the facility for review. - Findings include: The cwner confirmed in an interview on 12/1/08 at approximately 10:31a.m. that there was no . documentation of 12 hours of continuing | education for the administrator in her personnel file. UNCORRECTED | Clase tit MC.D. 1/02/09 {A 508}, STAFFING STANDARDS. All employees hired on or after October 1, 1998 | who perform personal services shall be in compliance with Level 1 background screening. _ 429.174(2), F.3. " 5BA-5,019(3),F.A.C. Chapter 435, F.S. This STANDARD ts nat met as evidenced by: Based on interview, the facility failed to ensure the pareonnal fle of one (Employes #1) of three direct care staff were in compliance with Level 1 STATE FORM on LOMP12 (feontinuation sheet § of 16 M : 25/03/2018 16:22 9599219158 By $2010 16:26 PAGE 16/47 " PRINTED; 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES (Xt) PROVIDERSUPPLIERICLIA AND PLAN OF CORRECTION 01a) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER. STREET 2349 CENTRAL AVENUE © SAINT PETERSBURG, FL SS713 ADDRESS. CITY, STATE, ZiP CODE NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE 4) 10 PREFIX TAG {A609} Continued From page & Findings Include _ During an interview with the owner on 12/1408 at approximately 10:45 a.m. It was confirmed that a background screen for employee #1 was nat available for review. UNCORRECTED Class It MC.D. 10209 (A510) STAFFING STANDARDS {A510} i Staff who provide direct care to rusidents, other than nurses, certified nursing assistants, or home health aids trained in accordance with Rule 59A-8.0095, must receive a minimum of 1 hour in-service traming in infactian control, including ’ universal precautions, and facility sanitation procedures before providing personal care to residents. S8A-5.0191(2)(a), F.A.C. 58A-5.0191(11){a), FAC. This STANDARD is not met as evidenced by: _ Based on record review and interview on 12/01/08, the facility failed to ensure the personnel file of three (Employees #1, #2 and #3) of direct care employees contained evidence af at; least one hour inservice training in Infection contol and facility sanitation procedures. Findings include: AHCA Form 3020-0001 STATE FORM om LOMP12 (continuation sheet 6 of 16 May 3 2010 16:26 @5/03/201@ 16:22 8589210158 PAGE 17/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEPICIENCIES (41) PROVIDER/BUPPUER/CLIA (02) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: AL11932424 STREET ADORESS, CITY, STATE. 21° CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION NCY MUST GE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC WWENTIFYING INFORMATION) . : CROSS-REFERENCRD TO THE APPROPRIATE {A 510} Continued From page & ’ Review of the personnel files of Employees #1, #2 and $3 on 12/01/08 still did not contain evidence of inservice training in infection control owner stated that the required insericas were . Not completed. Claas II! M.C.0. 01/02/09 {A 511} STAFFING STANDARDS : Staff who provide direct care to residents must : fecelve @ minimum of 1 hour in-service training - within 30 days of employment that covers the | following subjects: 1. Reporting of major incidents. 2. Reparting adverse incidents. 3. Factlity emergency procedures including chain of command und staff roles retating to amargency evacuation. 5BA-5.0191(2)(b), F.A.C. _ 58A-5.0191(11)(a), FAC. This STANDARD is not met as evidenced by: _ Based on record review and interview on 42/01/08, the facility failed to ensure the personne! file of threa (Employees #1, #2 and #3) direct care employees contained evidence of ineervices in reporting of incidences and facility STATE FORM Cal LQMP12 I aontinuation sheet 7 of 16 : May 3 2010 16:26 85/03/2018 16:22 98509210158 PAGE 18/47 PRINTED: 03/10/2010 FORM APPROVED AND PLAN OF Col STREET ADDRESS, CITY, STATE, DP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 NAME OF PROVIOER OR SUPPLIER CARDEN HOUSE (xa) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION os PREF {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE _ COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) PROPRIATE Dare CROBS-REFERENCED TO THE AP! : DEFICIENCY) {A511} Continued From page 7 Findings include: Review of the personnel files on 12/01/08 of Employees #1, #2 and #3 still did not contain a” hire date nor evidence of inservices in reporting of incidences and facility emergency procadures. 1 The facility owner acknowledged that the inservices were not. completed. Class Ul M.C.D. 01/02/00 {A512} STAFFING STANDARDS A 517} , Staff who provide care to residents, who have not ' taken the core training program, shall receive a minimum of 1 hour in-service training within 30 days of employment that covers ine following subjects: 1. Resident rights in an assisted living facility. 2. Recognizing and reporting resident abuse. neglect, and exploitation * §8A-5.0191(2)(c), F.A.C. 58A-5.0191(11){a), F.A.C. This STANDARD is not met as evidenced by: Based an record review and interview on 12/01/08, the facility failed to ensure the personne! fle of thrae (Employees #1, #2 and #3) of three direct care employees contsined evidence of at least one haur inaervice training in STATE FORM baad LOMP12 Ht continuation sheet 8 of 16 May 3 2010 16:26 05/83/2018 16:22 8589218158 , PAGE 19/47 PRINTED: 03/10/2010 FORM APPROVED gency for Fiegy STATEMENT OF OEFICIENCIES (%1) PROVIDER/SUPPLIERUCLIA MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION (DENTIFIGATION NUMBER: vay A BUILDING EE AL11932424 NAME OF PROVIDER OR SUPPLIER BTREET ADDRESS, CITY. STATE, ZIP CODE CARDEN HOUSE 7349 AVENUE SAINT PETERSBURG, FL. 33713 (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION os PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD oe COMPLETE REGULATORY OR LSC JOENTIFYING INFORMATION) CROSS REFERENCED TO THE APPROPRIATE ATE {A 812} Continued From page 8 reaident rights and recognizing and reporting abuse, naglect, and exploitation within 30 days of employment. Findings include: Review of the personnel files on 12/01/08 of Employees #1, #2 and #3 still did not indicate = hire dete and not contain evidence of inservice training in resident rights and recognizing and reporting abuse, neglect, and exploitation infection control and facility sanitation procadures. The facility owner wee aware that the training was not completed. Class fl) 'M.C.D. 01/02/08 {A 513} STAFFING STANDARDS _ Staff who provide direct care to residents, other than nurses, CNAs, or home health aides trained in accordance with rule SGA-8.0095, must tecaive _ Uhree (3) hours of in-service training within 30 days of employment that covers the following subjects: 4, Rasktent's behavior and needs. 2. Providing assistance with activities of daily Wing. oo, §6A-5.0191(2)(d), F.A.C. 58A-5.0191(11)(a), FAC. STATE FORM - LOMP12 May 3 2010 16:27 65/03/2010 16:22 8509218158 PAGE 20/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECT! IDENTIFICATION BUMBER: AL11932424 STREET ADORESS, CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LEC IDENTIFYING INFORMATION) C CROSS-REFERENCED TO THE APPROPRIATE {A 513} Continued From page 9 ’ This STANDARD is not met as evidenced by: Based on record review and interview on 12/01/08, the facility failed to ensure the personnal file of three (Employeas #1, $2 and #3) : of three direct care employees contained evidence of three hours of inservice taining in resident's behavior and needs and providing assistance with activities of dally living within 30 days of employment. | . Findings include: -Review of the personnel files of Employees #1, #2 and #3 on 12/01/08 still did not indicate a hire , date and not contain evidence of Inservice ' training In resident's behavior and needs and providing assistance with activities of ving. The facility owner acknowledged that the training was : not completed, Class tl M. C.D. 01/0209 {A 514) STAFFING STANDARDS All facility staff must receive in-service training tegarding the facility " s.resident elopement response policies and procedures within thirty (30) days of employment. 58A-5,0191(2)(f), F.A.C. AHCA Form 3020-0001 . . STATE FORM ome LQMP12 Woontnustion sheet 10 of 16 May 3 2010 16:27 85/03/2018 16:22 8589218158 PAGE 21/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION STREET ADDRESS. CITY. STATE, ZIP CODE 7349 CENTRAL AVENUE SAINT PETERSBURG, FL 33715 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR L&C IDENTIFYING INFORMATION) ait at ng APPROPRIATE. , Y) A514} Continued From page 10 (A514) This STANDARD is not met a6 evidencad by: Based on record review and interview on 12/01/08, the facility faited to ensure the personnel file of three (Employees #1, #2 and #3) of three diract care employees contained . evidence of three hours of inservice training regarding the facility's resident slopament response policies and procedures within 30 days of employment. Findings include: Raview of the personnel files on 12/01/08 of | Employees #1, #2 and #8 still did not indicate a hire date and not contain evidence of inservice training regarding the facility's resident slopement _ Tesponse policies and procedures, The facility” owner was aware that the training had not been conducted. ‘Claas Ili M.C.D. 01/02/09 {A 518}. STAFFING STANDARDS Facilities shail maintain the following minimum staff hours per week: Number of Staffing Hours Residents Weakly STATE FORM -_ LQMP12 Hf continuation sheet 11 of 16 May 3 2010 16:27 05/03/2818 16:22 8509218158 PAGE 22/47 PRINTED: 03/10/2010 FORM APPROVED — STATEMENT OF DEFICIENCIES 1) PROVIDERW/SUPPLIERCLIA (002) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION (OENTIFICATION NUMBER, A. BUILDING . WING: AL11932424 8 NAME Of PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP COOE 2349 CENTRAL AVENUE CARDEN HOUSE BAINT PETERSBURG, FL. 33713 04) 1D ‘SUMMARY STATEMENT OF OEFICIENCIES PROVIDERS PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OF USC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE . OEFICIENCY) (A518) Continued From page 11 56-65 88-75 76-B6 66-95 For every 20 residents over 95 add 42 staff hours par week. 58A-5.019(4)(a)1, FAC Based on record review and interview, the facility - failed to maintain mmimum weekly direct care - staffing hours of 335 for a canaus within the range of 36 to 46 residents. This STANDARD 1s not met as evidenced by: . Findings Include: The facility provided the most current staffing schedule for review. The schedule listed staff by “Med Techa," "Night Security,” “Housekeeping,” t,” "Food Service’ and “Maintenance.” Interview with the facility owner on 12/01/08 revealed that the housekeeping staff also assist residents with personal care, but it fa not reflected on their job descriptions. The facility still fell short of the mimimum staffing hours required for the census. Class Il AHCA Farm 3020-0001 ; STATE FORM _ LOMP12 Mf continuason sheet 12 of 16 May 3 2010 16:27 85/03/2018 16:22 8549210158 PAGE 23/47 PRINTED: 03/10/2010 FORM APPROVED 0X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: AL11992426 STREET ADDRESS, CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, Fi 33713 BUMMAARY STATEMENT OF DEFICIENCIES Es PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX. ac REGULATORY OR LSC IDENTIFYING INFORMATION) TAG {A 518) Continued From page 12 MC.D. 01/02/09 {A 902}. EMERGENCY MANAGEMENT All staff must be trained in their duties and are responsible for implementing the emergency management plan. 429.41(1)(b), F.S. 58A-5.028(3)(a), F.A.C. This STANDARD is not met as evidenced by: Baged on record review on 12/01/08, Ihe facility - failed to ensure the personnel file of three i (Employees #1, #2 and #3) direct care employees contained evidence of training in the facility's emergency management plan. Findings include: © Review of the personnal files an 12/01/08 of . Employees #1, #2 and #3 still did not contam : evidence of Inservice training in the facility's _ emergency management plan. Class It! M.C.D. 01/02/09 {A1101} STAFF RECORDS STANDARDS {A101} Personnel records contain venfication of freedom from communicable disease Including tuberculosis. 429.275(4), F.S. 5BA-S.024(2)(a), F_A.C STATE FORM : - LOQMP12 (foormmnustion sheet 13 of 16 May 3 2010 16:28 05/83/2818 16:22 8509210158 PAGE 24/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION on) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER. NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE Qs) ID SUMMARY STATEMENT OF DEFICIENQES wo : PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG . CROSS REFERENCED TO THE APPROPRIATE . GATE {A1101) Continued From page 13 - This STANDARD | not met as evidenced by: Based on record review and interview, the facility failed to ensure the personnel file of two _ (employees #1 and #3 ) of three direct care _ employees contained evidence freedom from communicable disease inciuding tuberculosis (TB). " Findings include: Raview of the personnel file of employes #1 and #8 did not contain evidence of freedom from . communicabia diseases including tuberculosis. _. | The file of mployee #1 did contain The owner was informed on 12/1/08 at approxi 10:00a.m. that the required test rasults did not - appear to be in the employee personnel files. © - UNCORRECTED Class NI MC.0. 1/02/00 {A1104, STAFF RECORDS STANDARDS {1104} New facility staff must obtain an initial veining on HIVIAIDS within 30 days of employment, unless the new staff person previously completed the initial training and has maintained the biennial continuing education requirement. All facility employees must complete biennially, a continuing education course on HIV and AIDS. 429.275(2), F.S. 5 STATE FORM - LOMP12 W continuation sheat 14 of 16 5/83/2018 16:22 8589218158 STATEMENT OF DEFICIENCIES 4 OWI (ANO PLAN OF GORRECTION un DeNTWICAT JUPPLIERICLIA. ICATION NUMBER; AL11932424 May 3 2010 2349 CENTRAL AVENUE | SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES: BE PRECEOED BY FULL (EACH DEFICIENCY REGULATORY OR LSC IDENTIFYING INFORMATION) {A1104} Continued From page 14 SBA-5.024(2\(a)1., FAC. 58A-6.0191(14), FAC. This STANDARD ia not met as evidenced by: Based on record review and interview on 12/01/08, the facility failed to ensure the persanne! file of thrae (Employees #1, #2 and #3) of three direct care contained evidence of training on HIV/AIDS. Findings include: Review of the personnel files of Employees #1, #2. and #3 still did not indicate a hire date and not _ contain evidence of inservice training in : HIV/AIDS. The facility owner waa aware the training had not been completed. Class tI) .C.D. 01/02/09 {A1115}. STAFF RECORDS STANDARDS Personne! records contain documentation of compliance with level 1 background screening for all staff subject to screening requirements. 429.275(2), F.S. 58A-5.019(3), FAC. 5BA-5.024(2\a)3., F.A.C. This STANDARD is not mat as evidanced by: Based on record review and interview, the facility AHCA Form 3020-0001 STATE FORM {A1115) 16:28 PAGE 25/47 PRINTED: 03/10/2010 FORM APPROVED STREET ADDRESS, CITY, STATE. ZIP CODE PROVIOER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE LQMP12 IEFERENCED TO THE APPROPRIATE" DEFICIENCY) H continuation sheet 16 of 16 May 3 2010 16:28 65/03/2018 16:22 8589218158 PAGE 26/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIDER/BUPPUIERICLIA 02) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION {IDENTIFICATION NUMBER: A BULUING AL11932424 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (A1116}" Continued From page 15 ‘ {A1115} failed to ensure the personne! file of ona (employee #1) of three direct care atalt were in compliance with Léevel 1 background screenings. Findings include: _ Review of the personne! file of amployee #1 did not contain evidence of a Level 1 background screen prior to employment. The owner stated in an interview at approximately 11:00 a.m.on * 42/1/08 that employes #1 still did not have a Leval | background screen. UNCORRECTED _— cr | HCA Form 3020-0001 z STATE FORM . Leal LOQMP12 : Wconmimuntion sheet 16 of 16 May 3 2010 16:28 85/83/2018 16:22 8509218158 PAGE 27/47 AH Form Approved 3/10/2010 a State Form: Revisit Report “(vi) “Provider Suppler/CLIAT SCY) MutpinCormmuctton (¥3) Dew ct Reve Identification Number A Building 1123/2009 _ ALN19G2424 me 8. Wing a eee Name of Facility : ~ 7" street Addreas, Clty, State, Zip Code CARDEN HOUSE 2349 CENTRAL AVENUE ee _ _. _____ SAINT PETERSBURG, FL 33713 ‘This report la complated by @ State msrvayor to show those deicsencies previously reparted thal have bean corrected and the date such corrective econ wes sonipianed, Esch deficsency should ba fully antifed using effMer the reguiatian or LSC provision nuriber and the identification oreffx code previously shown on the State Survey Report (prefix codes shown fo the jeff of each requirement on the survey report form) (14) tam (75) Onto (8) them YS) atm (VA) ftom _ _{Y5) _ Outs . Correction Correction Correction Completed Comp! , Compiated \D Prefix aozzz atasra009 (D Prefix agama sO 1D Prof an226 o1/eaz008 Reg. # Reg. # Reg. # iwc” 7 ic isc Correction Correction Correction Completed Compliemd 'D Profix Q603 ___owa3i2009 (0 Pref ag506 . D1/24/2008 'D Prefix anaos ot2a/2008 Rag. # Rag. # : Reg. # isc ic 7. isc —— —— He. — —_ Correction Corredion * Correction Completed Completed Completed ID Pref aesto == _Otzzo08 (Pref aos ovzarz008 1O Prefix aosia = sétvz 32009 Reg. # Rag. ® Reg. ue 7 7 isc we —_ — —- .- —_— —_— — Corraction Correction — Correction Completed Completed Completed IO Prefx aosis (sO ID Prefe aosi¢ ss _ 1/23/2008 \0 Prefix agpte o1vas2008 Rag. # Reg. # . Reg. # we isc ue Correction Correction Correction Completed Completed Completed (DPrefx aoge2 = __s(2372000 Prefix aviot — —orvaaizao8 IDPrefx aitoe = ONz3/2008 Reg. # Reg. # Reg. # ise use use ee Reviewed Gy Reviewed By Deve: Signature of Surveyor: Oste: Smweagency ae ee _ a Raviewed By — Peviewsd By Date: Signeture of Surveyor. Date: MS RO STATE FORM: REVISIT REPORT (8/09) - Page taf2 Event 10: LOMP13 May 3 2010 16:29 05/83/2010 16:22 9509218158 PAGE 28/47 AH Form Approved 3/10/2010 a State Form: Revisit Report (14) Provider / Suppllar } GLIA / “(rp ahipe Contnction "(¥3) Date of Ravintt Identification Number A. Building 12372000 AL11932424 we Bg ee eee eee Nem ofFectty ss” Street Address, City, Stute, Zip Coda CAR 2349 CENTRAL AVENUE DEN HOUSE SAINT PETERSBURG, FL 33713 _ “Thm part , Ihave deficiencies previcuty repored thal nave Deer corrected and Woe dae such corrective acting nie mesaretmns, E#ch The is completed by a State surveyor to show ao shuld ba filly identified Using ether the regutelion ar LEC provision umber end the identifcetion presix code predously shown detuancy codes shou t the left of each requirement on the survey report form). _ "en — Completed 10 Prefix 01148 0123/2009 Regt se i Reviewed By Reviewed By Date Signature of Surveyor: Date: State Agency ek _ —_— _ . ee Reviewed By -. -— Reviewed By Dam: Signature of Surveyor: Date: CMS RO ee. “Followup & Survey Completed on; Check for any Uncorrected Deficiencies. Wes Summary of =: a 42 anata (ake OEE Gant ta the Facliliv? = uce aun May 3 2010 16:29 85/03/2018 16:22 8589210158 PAGE 29/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PUAN OF CORRECTION (42) MULTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP COOE 7349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 CARDEN HOUSE ap ‘SUMMARY STATEMENT OF OEFICIENCIES 1D PROVIDER'S PLAN PREFIX H DEFICIENCY MUST BE PRECEOED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR USC MENTIFYING INFORMATION) TAG CROSS-REFERENCED 10 THE APPROPRIATE {L 000} INITIAL COMMENTS ASSISTED LIVING FACILITY REVISIT TO THE LIMITED MENTAL HEALTH LICENSURE SURVEY OF 11/25/08 REVISIT CONDUCTED ON 12/01/08 An uncorrectad deficiency was cited on the LH license. The facility was found not to be in compilance with Florida Statutes Chapter 429, Part |, and 5BA-5 of the FA.C. {L 100) FACILITY/RESIDENT RECORDS STANDARDS The facility maintains an up-to-date admission and discharge log containing the names and dates of admission and discharge of all mental health residents. 5BA-5.029(2)(a), F.A.C. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to maintain en up to date admission and discharge log containing the names of ail mental health residents. Findings include: During facility record review on 42/01/08, It was determined that the facility had no master list of residents receiving mental health services. An imterview with the owner an 12/1/08 at approximately 10:00a.m, confirmed that he was not able to Kentify those residents receiving or neading manta) health services, f TITLE 80) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATNES. SIGNATURE . STATE FORM ~ LOMP12 Wooniinustion sheet 1 of 2 May 3 2010 16:29 85/03/2818 16:22 8509210158 PAGE 30/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1 (43) DATE SURVEY Piel OF ron (0X1) PROVIDER/BUPPLIERJCLIA IDENTIFICATION NUMBER: {COMPLETED : . R . AL119392424 12101/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, BP COOE ; 7349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 33713 (4) 10 SURMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} — CROSS-REFERENCED TO THE APPROPRIATE DEFICENCY) : {L 100) Continued From page 1 Class It M.C.0, 01/02/09 AHCA Form 30 STATE FORM ” LOMaP 12 Wcontruation sheet 2 of Z May 3 2010 16:29 05/03/2818 16:22 8589218158 STATEMENT OF DEFICIENCIES NO PLAN OF CORRECTION Xt) PROVIDER/SUPPLIERICLA (02) MULTIPLE CONSTRUCTION AL11932624 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZF CODE 2340 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL. 33713 PAGE 31/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION SUMMARY (BACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE REGULATORY OR LSC IOENTIFYING INFORMATION) CROSS REFERENCED m {N 000} INITIAL COMMENTS ASSISTED LIVING FACILITY LIMITED NURSING SERVICES (LNS) LICENSURE SURVEY RE-VISIT 12/1/08 - Remains uncorrected due to uncorrected survey of 11/25/08 " No deficiencies were cited on the LNSS license, The facility was found not to be in compliance with Florida Statutes Chapter 429, Part |, and | 58A-6 of the F.A.C. due to deficiencies that were cited on the Standard license and the LMH ftcense. LABORATORY DIRECTOR'S OR PROVIDERASUPPLIER REPRESENTATIVES SIGNATURE STATE FORM - LOMP12 ACTION SHOULD BE THE APPROPRIATE. Icy) May 3 2010 16:29 @5/83/2018 16:22 8509210158 PAGE 32/47 AH Form Approved 3/10/2010 © a State Form: Revisit Report i) Procter! Sapper CUA’ =~ VEN Mutipe Commision «Yeti identification Number A Building 42172008 __ AL11892424 a. 8. Wing 2 ee Name of FacBity ; : ” T Strest Addrene, City, State, Zip Code CARDEN HOUSE ; 2349 CENTRAL AVENUE we __ SAINT PETERSBURG, FL 33713 |__ ‘This report = cornpland by a State eareeyos 10 show thoae dafidencies previgvaly reported thet have bean corrected nd Yue data such corrective action waa accomptahed. Each deficiency should be kay WGandifed using wither fe regulation of LEC provision number and the idertificetion prefix code previously shown on the State Survey Report (prefix codes shown Wo ive le? Of each requirement on the survey raport form). . oo (4) tem YB) ate (4) mV) te VA) em YE) _ te __ Correatian Correction Correction Completed Compintad Completed 1D Prefix _aqzot _‘zo1z008 ID Prefix agate 2001/2008 1D Prefix aosoe _van208 Reg. # Reg Rag. # wc ”rti‘s™sSCS ie wc 7 _ ' ee eens —_— Correction Cormection * Correction Complated . Completed Campleted ID Prete aos 1201/2008 ID Pref agscs = tzmnmes (0 Pref ansag 12700 Reg. # Rag. # | Reg. # ise 1 wo isc Coredion Correction Correction Com Completed © Completed 10 Prefix agsas __.vannez008 10 Prefix ao7it _ 1270172008 1D Prefix agaos 2701/2008 Reg. # 1 Regt : Reg. # lsc . we ‘ use — nn —_— — - — Correction Correction Correction Compteted ‘Completed - Completed ID Prefix agsto. 1290112008 (D Pref apni q2zovz008 10 Prefix “nosis _ 1201/2008 Rag. @ . Reg. # Reg. # uc : isc”= ic 7 nee ce eee ; Correction Correction Correction Completed Campleted . . _ Completed {OPrefx aivoo = __ 1200172008 (DPrefx a1os 42/08/2008 OPreix aitt7 122008 Reg @ Rey.f ; Reg. # isc TD se usc : . Reviewed By Reviewed By Date: Signature of Burveyor: Date: Swemagecy oo wee — Reviewed By —— Reviewed By Date: Signature of Survayor: Date: CMs RO STATE FORM: REVISIT REPORT (5/98) Page 1 of 2 : Event ID: LQMP12 May 3 2010 16:30 @5/03/2818 16:22 8589210158 PAGE 33/4? AH Form Approved 10/2010 a ; State Form: Revisit Report “Wty Provider! Supplier CLIA/ ===) Muiple Construction ee —— Weyoeeotreviet | iden@fication Number A. Building . 12/1/2008 _ _Abites242¢ | 9 LL, Name of Facility ‘Skeet Address, City, Starts, Zip Cade CARDEN HOUSE ; 2349 CENTRAL AVENUE : . _ SAINT PETERSBURG, FL 33713 | __ Thuropat ia comgltiea by Site surveyor vhow iawn Gerclencon preity reported hut Nee been corrected athe date such crac schon ws sense tee Each ea ree ey Ce kil herein uur eter a guaaton or USC provi rasmber and tha idatation prefix code presiousy sow on the Bee Swrvey Repo (ort: podas how to ihe laft of each requirement on the survey report form). . yo mem YS) ate (YA) Hom __. %)_Dete__ — — _— c : x Completed IOPref az 1201/2008 Reg. # ise —_— - Reviewed yy __ Reviewed By ~ “Date: : Signature of Surveyor: - Date: StatwAgency = ee ee ee _— — —_ «He Reviewed By .— Raviewed By Date Signature of Surveyor: Date: "Followup sup to Survey Completed on: a oe Check for any Uncorrectad Deficiencies. Was a Sumeury ; Uncorrectad Deficiencies (CMS-2967) Sent tothe Faciilty? yes = NO CMs RO May 3 2010 16:30 05/43/2018 16:22 8589210158 PAGE 34/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES (43) DATE SURVEY (22) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: ) COMPLETED A BUILDING B. WING AL11932624 0002/2008 WAME OF PROVIDER OR SUPPLIER STREEY ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES : : PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDEO BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) eRe ENE RICENCT) APPROPRIATE. A 00 INITIAL COMMENTS. ASSISTED LIVING FACILITY ' APPRAISAL VISIT _ April 2, 2000 No discernible deficiencies were identified relative to the Appraisal Visit. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM —_ Q9L511 f continuation sheel 1 of 1 TITLE (x6) GATE May 3 2010 16:30 85/03/2018 16:22 8589210158 PAGE 35/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION - IDENTIFICATION NUMBER: A. BUILDING 8. WING AL11932424 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 CARDEN HOUSE 4) 1D SUMMARY STATEMENT OF DEFICIENCIES ol PROMOER'S PLAN OF CORRECTION os) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFK (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LBC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE care A000. INITIAL COMMENTS ASSISTED LIVING FACILITY COMPLAINT INVESTIGATION _ CCR# 2008004054 April 2, 2009 “The facility was found not to be in compliance with the Florida Statues Chapter 428, Part!, and the Florida Administrative Code 58A.5. A217 Facility Records Standard.. An up-to-date record of adverse incidents _acourting within the last 2 years must be - maintained. 429.23(2), F.S. i} This STANDARD is not mat as evidenced by: Baged upon interview and record review, the facility failed to maintain @ record of major ‘ incidents leaving administration and statt unaware of happenings in the facility. _ Findings include: ‘ : Areview of the shift reports for December 2008 . reveals a sampling of the incomplete information. | The 1:00 p.m. to 1:00 a.m. staff on 12/13/08 wrote in the shift log that the police were callad as Resident #4 and another resident, “shout & want to rumble when police came than went to the room." There Is no incident report regarding this incident requiring police intervention. Fam 3020-0001 TITLE ote) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE STATE FORM — QQ4Ht1 Wt continumBon wheet 1 of 12 May 3 2010 16:30 85/83/2010 16:22 8589210158 PAGE 36/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, 2 CODE : 2349 CENTRAL AVENUE CARDEN HOUSE : SAINT PETERSBURG, FL 23713 (xa 10 SUMMARY STATEMENT OF DEFICIENCIES PREFIX. (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A217 Continued From page 1 Resident #4, according to the 7 a.m. to3 p.m. - shift repost on 12/18/08, was Baker Acted. There is no documentation of where, when, or why this was done. There is no incident report. The shift report for 12/20/08 7 a.m. to 7 p.m. shift - details two Incidents in which police came to the facility due to resident altercations. Realdents are not fully identified on the report. The facility has fo incident reports for the police involvement. - On 12/22/08 the 3 p.m. to 11 p.m. staff wrote that Resident #4, " was sent to PEMS for threatin " another resident and the staff, " wit a broke piece of glass.” There is no incident report. Interviewed, at 4:00 p.m. on 04/02/08, the facility administrator stated that she was not sure of what defined an adverse incident and therefore | the facilty nad not been maintaining adverse incident | reports. Ciass Ill MCD. 8/02/09 A210 Facility Records Standard All icansed assisted living facilities (ALF's) must * aubmit to the Agency (AHCA) a preliminary report of all adverse incidents within one (1) business day after the occurrence. The report must include tthe following: 1. Information regarding the identity of the affected resident; _2. The type of adverse incident, and " 3. The status of the facility's investigation of the incident. 429.23(3) F.S. STATE FORM : mn QQ4H11 ff continuation sheat 2 of 12 May 3 2010 16:3 85/03/2018 16:22 8589210158 , PAGE 37/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x1) PROMI IDESUSUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION JOENTIFICATION NUMBER: AL11932424 STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 CARDEN HOUSE x4) 1D SUMMARY STATEMENT OF OEFICAENCIES op PROVIDER'S PLAN OF CORRECTION as PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL PREFIX (EACH CORRECTIVE ACTION SHOULO BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) yaa CROSS-REFERENCED TO THE APPROPRIATE DATE A218 Continued From page 2 This STANDARD in not met as evidenced by: Based on record review and interview the facility - failed to submit adverse incident reports within one day #8 required by law. Findings include: . Interviewed at 4:00 p.m. an 04/02/09, the facility administrator acknowledged that the facility had not written or submitted adverse incident reports ; despite numerous adverse incidents described by staff in shift reports. She stated that the facility was unaware of the definition of an adverse . incident and therefore did not know that they should be reporting Incidents. Class Il! M.C.D. 5/0208 A219’ Facility Records Standard Within fiftean (15) days all licensed facilites must : provide to the Agency a full report of the adverse incident. The report must include the results of the facility's investigation into the adverse incident ' 429.23(4), F.S. This STANDARD is not met as evidenced by: Based upon interview the facility failed to submit adverse incident reports within fifteen days as required by law. Findings include: Interviewed at 4:00 p.m. on 04/02/09, the facility adrniniatrator acknowledged that the facility had not written or submitted adverse incident reports STATE FORM m QQ4H11 Weontnuaton ahoot 3 of 12 May 3 2010 16:31 85/83/2018 16:22 8589210158 PAGE 38/47 PRINTED: 03/10/2010 FORM APPROVED (2) MULTIPLE CONSTRUCTION A. BUILOING B. WANG. STREET ADDRESS, CITY. STATE, 2 CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL $3713 SUMMARY STATEMENT OF DEFICIENCIES 10 PROWDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST GE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) ! CRO RE ERE EEN THE APPROPRIATE A219 Continued From page 3 despite numerous adverse incidents described by ataff in shift reports. She stated that the facility was unaware of the definition of an adverse incident and therefore did not know that they should be reporting Incidents. Class Jil ™.C.0. 05/0209 RESIDENT RECORDS STANDARDS Resident records shall be maintained on the premises. 58A-5.024(3), FAC. ‘This STANDARD ia not met as evidenced by: Based upon interview and record review, the facility failed to maintain a resident record for 1 : OF 1 (#6) 9 sampled residents, Findings include: A review of the shift report logs revealed a note written on 11/25/08 for the 3 p.m. to 11 p.m. shift, ’ reeident #6 “ stays in the lobby and sleep on ona of the couch. He has no permanentroom,” The 11p.m. to 7 a.m. shift noted that the resident, “ has not been given a permanent room, please see fo it.” The staff on the 7 p.m. to 7 a.m. shift on 11/29/08 noted at 9:00 p.m. that resident #6, " arrived take his/her medicine.” It was nated by the 3 p.m. to 11 p.m. staff on 12.03.09 that resident #6, “came at 6:20 ask his/her MED. . But his/her name in MORs (medicetion observation record] out - after talking to [the facility administrator] | gave his/her MED at 6:45." The 11 p.m. to 7 a.m. staff wrote that the resident “has come back and is staying in Room No. 309. Went out to wark at 3a.mn. morning. ” On 12/14/08 the 7a.m. to 3p.m. staff stated that STATE FORM om qasni : Mf continuation shat 4 of 12 5/03/2818 16:22 8589210158 STATEMENT OF DEFICIENCIES 1 w AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CARDEN A300 ) PROVIDERISUPPLIERICL IDENTIRICA TION NUMBER: May 3 2010 16:31 PAGE 39/47 PRINTED: 03/10/2010 FORM APPROVED STREET ADORERS, CITY, BYATE, BP CODE 7349 CENTRAL AVENUE HOUSE SAINT PETERSBURG, FL. 33743 DEFICIENCIES (EACH DEFICIENCY MUBT BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 the raaident had been diacharged. The administrator, interviewed at 12:00p.m. on 04/02/08, seid that this resident did not have a record. The facility did not create ane for this person as they said that s/he was at the facility only a few days. At 12:15p.m. the care giver on duty stated this resident had been dropped off at the facility by a case manager and had (eft quickly. The facility owner, at 2:15p.m., said that this resident had only been at the facility for an hour before baking off. All acknowledged that no racord was created despite staff notes describing services including medication administration. . Class tit Astt MCD. 502/00 STAFFING STANDARDS Staff who provide direct care to residents must receive a minimum of 1 hour in-service taining ’ within 30 days of employment that covers the ‘orm STATE FORM following subjects: 1. Reporting of major incidents. 2. Reporting adverse incidents. 3. Facility emergency procedures including chain of command and staff roles relating to emergency, evacuation. §8A-5.0191(2)(b), F.A.C. 58A-5.0191(11)(a), F.A.C. This STANDARD is not met as evidenced by: 020-000 {EACH CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) QQ4H11 feontnuation sheat & of 12 May 3 2010 16:31 @5/03/281@ 16:22 98589210158 PAGE 40/47 PRINTED: 03/10/2010 FORM APPROVED Agency for Haalth STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERITLIA (0X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION WENTIFICATION NUMBER: AL119324624 NAME OF PROVIDER OR SUPPLIER : STREET ADDRESS, CITY, STATE, ZIP COOE 2343 CENTRAL AVENUE CARDEN HOUSE : SAINT PETERSBURG, Fi. 38713 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LBC IDENTIFYING INFORMATION) CROSS REFERENCED TO THE APPROPRIATE A511 Continued From page 5 Based on record review, the facility failed to have documentation that 2 of 4 employees ( #3, # 4) had campleted one hour in-service training in reporting of major incidents, reporting adverse incidents, and facility emergency procedures including the chain of command and staff roles relating to emergency evacuation within 30 days of amployment. Findings Include: Record review of personnel files on 4/2/09 at approximataly 3:00PM revealed that for employees &3 and # 4 thare was no documentation that indicated the employees had ever received the one hour in service training in reporting of major incidents, and facility emergency procedures including chain of command and staff roles relating to emergency " evacuation within 30 days of employment. CLASS. Ill M.C.D. 5/2/09 STAFFING STANDARDS * Notwithstanding the minimum staffing ratio, all facilities, Including those composed of apartments, aha have enough qualified staff to provide resident supervision, and pravide or arrange for resident services in accordance with fesident scheduled and unscheduled service need, resident contracts, and resident care standards. 58A-5.019(4){b), FAC. AHCA Fonn 3620-0001 STATE FORM a cid QQ Moontnuation sheet 6 of 12 May 3 2010 16:32 65/03/2018 16:22 8589216158 PAGE 41/47 PRINTED: 03/10/2010 FORM APPROVED (X1) PROVIDER/SUPPLIER/CLIA (42) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: AL11932424 NAME OF PROVIDER OR SUPPLIER . STREET ADDRESS, CITY, STATE, ZIP CODE 2949 CENTRAL AVENUE CAROEN HOUSE SAINT PETERS@URG, FL. 33713 SUMBAARY BTATEMENT OF DEFICIENCIES o (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION REGULATORY OR L&C IDENTIFYING INFORMATION) _ TAS CROSS REFERENT TO APPROPRIATE A522 Continued From page 8 This STANDARD is not met am evidenced by: . Based on record raview, observation and interviews the facility failed to ensure there was sufficient staff to provide supervision, for residents needs in accordance wilh care standards. Findings include: _ During racord raview on 4/2/09 at approximately _ 4.30p.m. it was ravealed that the staffing hours included the owner and the adminiatrator who do not provide resident care. Algo a phone interview with staff revealed that only one person is available at the facility for each shift during * weekends. that there wasn't any supervisor on the week ends. Residents are able to come and go undetected until the doors are locked at 11.00p.m. Observation on 4/2/09 at approximately 4:30p.m. and Interview with the administrator confirmad that there wes not a system in place to account as to what time residents were leaving, at what time they left or when they planned to return. CLASS Ill M.C.D. 5/2/08 A610 MEDICATION STANDARDS A610 : | STATE FORM -_ QQ4Hi1 Wconsnustion aheat 7 of 12 May 3 2010 16:32 @5/03/201@ 16:22 8509210158 PAGE 42/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPUERYC (%3) DATE SURVEY AND PLAN OF CORRECTION a FROMDER SUE Mae ‘COMPLETED AL11982424 : oOo 04/02/2009 STREET ADDRESS. CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE _| SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEPRCIENCIES , PROVIDER'S PLAN OF CORRECTION DEFICIENCY MUST BE PRECEDED BY FULL : (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) : ceili ee APPROPRIATE, A610 Continued From page 7 If providing assistance with self-administration of | medication, staff must observe the resident take the medication. 58A-5.0185(3)(c), F.A.C. A trained designated staff person assists the resident to ssif-administer medications in the following manner. ' Medication, in its dispensed, properly labeled " container, shall be taken fram where il Is stored and brought to the resident. 429.256(3)(a), F.S. Verbally prompt a resident to take medications as _ prescribed, _ 68A-6.0188(3)(b), F.A.C. In the presence of the resident, read the label, open the container, remove a prescribed amount of medication from the container, and close the container. . 429,256(3\b), F.S. Place an oral dosage In the resident's hand or place the dosage in another container and help , the resident by iifting tha container to his or her * mouth. 429,256(3\(c), F.S. 429,256(3)(d), F.S. { ; ; t Apply topical madications. 7 t Returning tha medication container to proper CA Fonm 3020-0001 . STATE FORM Cad QO4H{1 Hoontnuatan sheet 6 of 12 May. 3 : 85/83/2818 16:22 8589210158 , ann PAGE 43/ 43/47 PRINTED: 03/10/2010 FORM APPROVED (12) DATE SURVEY AND PLAN OF CORRECTION (42) MULTIPLE CONSTRUCTION COMPLETED ABULDNG = STREET ADDRESS, CITY, STATE, ZIP COUE 2349 CENTRAL AVENUE PETERSBURG, FL 33713 PREFIX TAG REGULATORY OR LEC IDENTIFYING AG@10 Continued From page 8 storage. 429.258(3)(8), F.S. Keeping a record of when a resident receives assistance with self-administration. : 428.258(3)(f), F.S. Medication which appears to have been contaminated, must not be retumed to the container. | _ BBA-5.0188(3)(b), F.A.C. | | ‘This STANDARD is not met as evidenced by: Based on observation and interview, the Facility failed to assist residents to self-administer : medications in the proper manner by not ensuring that medication is taken from where it is stored” and brought to the resident. Findmgs inciude: During observation of the medication pass on 4/01/09 at approximately 4:30p.m. it was observed that the med tach never left the med cart and only the residents that came to the cart from the 3rd floor to the 1st floar received medication. Interview with the med tach revealed | that they never looked for raakients, it was understood that the only time staff would go fo the room with medication was if the resident was unable bacause s/he was sick. STATE FORM - agen . Hf condnuation shewt 9 of 12 May 3 2010 16:32 85/03/2018 16:22 8589210158 PAGE 44/47 PRINTED: 03/10/2010 FORM APPROVED 061) PROVIDERISUPPLIERVCLIA IDENTIFICATION NUMBER, AL11932424 : STREET ADDRESS. CITY, STATE, 2” CODE 2349 CENTRAL AVENUE SUMMARY STATEMENT OF DEFICIENCIES ID (PACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX ( CORRECTIVE ACTION SHOULD BE REGULATORY.OR LSC IDENTIFYING INFORMATION) TAG CROSS REFERENCED TO THE APPROPRIATE A610 Continued From page 9 Class til M.C.D. 05/02/09 A801 NUTRITION & DIETARY STANDARDS The administrator or food service designee must perform his/her duties in a safe and sanitary manner. ‘ | 5BA-5.020(1)(b), F.A.C. This STANDARD is not met as evidenced by: Based upon observation and interview the facility failed to store food in a safe and sanitary manner putting the residents at risk of food borne fliness. Findings include: 1. Durmg a kitchen tour, beginning al 10:15 a.m. on 04/02/09, two five pound packages of ground beef ware observed sitting in a large pan on the table in the center of the room. The packages of _ Ineat felt coo} to the touch. Thera wes no thermometer in the room to measure room temperature, but it felt warm in the room. Per the facility owner, the meat was to be used for dinner that night. : Another observation, at 1:55 p.m. found the meat still sitting on the table. The packages felt warmer. The facility cook was asked for a : thermometer to magsure the temperature of the meat. He said that the facility did not have a food thermometer. He acknowledged that the meat ‘ had been sitting on the table continuously since the 10:15 a.m. observation. | 2. The refrigeratorMreezer was observed during AHCA Form 3020-0001 STATE FORM ad QOH if continuation shest 10 of 12 May 3 2010 16:33 05/83/2018 16:22 8589218158 PAGE 45/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA. AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING B. WIG AL11832424 NAME OF PROVIDER OR SUPPLIER STREET ADDRESE, CITY, STATE, ZIP CODE ; 2349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, Fi 33713 SUMMARY STATEMENT OF DEFICIENCIES 0 PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSE- REFERENCED TO THE APPROPRIATE A801 Continued From page 10 the tour beginning at 10:15a.m. The freezer temperature was observed, using the facility thermometer, at 35 degrees. A follow up observation at 2:55p.m. found the temperature af the freezer to be 36 degrees. . 3. Tha kitchen cooler was observed at 10:20a.m. A pan of leftover grits, a pan of leftaver mashed . potatoes, and a pan of a leftover meat dish were in the cooler uncovered, and therefore undated. Additionally an open jug of mayonnaise, meat . leftovers in a blue bowl, butter and salad dressings had been opened but were undated. Class Ill ‘M.C.D. — os/navo9 1002 PHYSICAL PLANT STANDARDS - The facility's physical structure, including the interior and exterior walls, floors, roof snd ceilings shall be structurally sound and in good repair. 58A-6.023(1)(b), FAC. This STANDARD is not mot as evidenced by: Based on observation and staff interview of the dining area It was revealed that due to a water leak from the second floor, a ceiling tie that held a ceiling fan in the dining area was swollen, ' damaged and there {s concem that it could fall down hitting a reaident. Findings include: During tour of the facility on 4/2/09 at approximately 9:45a.m. it was observed that the dining room has @ ceiling fan mounted to a tile that is swollen from a water leak. The | AHCA Form 3020-000 STATE FORM Lal QQ4H11 HW ooagruacion sheet 11 of 12 May 3 2010 16:33 85/83/2018 16:22 8509210158 STATEMENT OF DEFICIENCES ] ULTIPLE CONSTRUCTION AND PUAN OF CORRECTION a IDENTIFICATION NUMBER: 02) MULTIPLE AL119324024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, Z#P CODE 2340 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL. 33713 | SUMMARY STATEMENT OF DEFICHENCIES PAGE 46/47 "PRINTED: 03/10/2010 FORM APPROVED o OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED SY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A1002 Continued From page 11 administrator stated they had repaired a water leak, that they were aware of the damaged tile and were planning to replace tomorrow. CLASS ill “MCD. 6709/09 , Staff Records Standards The facility maintains documentation of facility direct care staff and administrator participation in resident elopement duiis. 58A-5.024(2)(a)5, FAC. This REQUIREMENT is not met as evidenced by: : Based on record raview and interview the facility failed to ensure that 4 of 4 employces( #1, #2, # 3, # 4) ali direct staff and the administrator participated in two elopement drilis a year. Findings include: During review of staff racords on 4/2/09 at approximately 4:00p.m. it was revealed thal there was not any correctly conducted elopement drills for the last year. The administrator stated that she has been reviewing the files since she has startad her employment and plans to bring this up to date. CIASS ltl STATE FORM - Qa4hi H continuation sheat 12 of 12 May 3 2010 16:33 @5/83/2018 16:22 98589210158 PAGE 47/47 AH Form Approved 3/10/2010 State Form: Revisit Report (1) Provider/Buppliec/CLIAL = S=S*«C«CY 2) Muttiplo Commuction = ss—ti—<“ ‘SUMMARY STATEMENT OF DEFICIENCIES 10 PLAN OF CORRECTION ar) PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LEC IDENTIFYING INFORMATION) TAG CROBS-REFERENCED | Tor ne APPROPRIATE ATE A408 Continued From page 1 Interview conducted on 12/02/09 at 8:40 a.m. with the cook for the facility revealed that she wae unawere thet the facility had ary residents i prescribed diabetic diets; no diabetic menu was available and the cook Indicated that she did not i prapare diabetic meale. Record review of the * facility’ s dietary menu reveated that the menus ‘ were for regular diets, Record review of Resident #6 revealed a Health Assessment, 1823, dated 08/28/08, which _ indicated the resident to have a diagnosis of Diabetes Meltitus II; the physician indicated that - the resident should have a diabatic diet. Record review of Resident #7 revealed a Health Assesament, 1623, dated 09/09/09, which . i indicated the rasident to have = diagnosis of : ' Diabetes Mellitus Il; the physician Indicated that ‘ tho resident should have a diabetic diet. ' CLASS Ill M.C.0. 01/03/10 A708 RESIDENT CARE STANDARDS The facility shall consult with the residents in selacting, planning, and acheduling ectivitias, The facility shall demonstrate resident participation through one or more of the fofiowing mathods: resident meetings, committees, & resident council, suggestion box, group discuasions, questionnaires, or any other form of communication appropriate to the sze of the facility. 58A-5.0182(2)(b), F.A.C. STATE FORM ~ OTEMI1 Wooninualon sneet 2 of (5 May 3 2010 16:46 05/83/2018 16:45 8589210158 PAGE 08/47 PRINTED: 03/10/2010 FORM APPROVED . Age Q STATEMENT OF DEFICIENCIES PROVIDERSUPPLERIC AND PLAN OF CORRECTION IDENTIFICATION NUMBER AL11932424 STREET ADDRESS, CITY, STATE. ZIP COE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE 4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES o. PLAN OF CORRECTION os) PREFIX (EACH OEFICIENCY MUST BE PRECEDED BY FULL PREFIX. (EACH CORRECT! IVE ACTION SHOULD BE . COMPLETE TAG, REGULATORY OR L8C IDENTIFYING INFORMATION) TAG. CROS5-REFERENCED TO JHE APPROPRIATE DATE A709 Continued From page 2 This STANDARD is not met as evidenced by: Based on record reviaw, observation and interview, the facility failed to demonstrate that it had consulted with the residents in selecting. planning and scheduling activities. Findings include: Record review of the posted daily activity calendar revealed that the same activities were scheduled on a dally basia: 7:00 a.m. fo 8:00 a.m., Exercise show on the big screen; 9:00 a.m. - to 11:00 a.m., News discussion over coffee, 1:00 p.m. to 3:00 p.m., Arts and Crafts & Movie, 4:00 to 5:00 p.m., Bingo and/or Board Games. . Observations conducted on. 12/03/08, between 8:35 a.m. and 1:30 p.m. revealed no structured Interview conducted on 12/03/09 at 9:30 a.m. with direct care staff member #7 revealed that she normally conducts the activities with the residents ona daily basis; on the day of urvey, she was ' the only direct care staff member present in the © facifity until 9:40 a.m.. she was observed to pass the medications to the residents, but, no activities were conductad, Interview conducted an the date of survey with the administrator revealed that the facility did not have a resident council or any meelings with the residents to solicit resident preference in regards to preferred activities. CLASS It “M.C.D. 01/03/10 A721 RESIDENT CARE STANDARDS : A721 | 4 STATE FORM _ OTEM11 The statewide toll-free telephone number of the | Florida Abuse Hotline 1-800-96-ABUSE or 1-800-962-2873 shall be posted in full view in a 20-000 tf oontiuation mest Sof 16 May 3 2010 16:47 @5/83/2010 16:4 ; 5 9589218158 PAGE 89/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICA (42) MULTIPLE CONSTRUCTION A. BURDING STREET ADORESS, CITY. STATE, ZIP CODE. 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES . wo PROVIDER'S PLAN OF CORRECTION DEFICIENCY MUST BE PRECEDED BY FULL ‘ RI {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCEO Dat APPROPRIATE A721 Continued From page 3 common area accessible to all residents. 58A-5.0182(6)(d), F.AC. This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility falled to ensure that the statewide toll-free telephone: number of tha Florida Abuse Hotine , 1-800-96-ABUSE or 1-800-962-2873 was posted In full view in a common area accessible to all residents. Findings include: | Observations conducted an 12/03/08 of the facility‘ s common areas revealed no posting of the statewide toll-free telephone number of the ’ Florida Abuse Hotline 1-800-96-ABUSE or - 1-800-962-2873. Interview conducted on 12/03/09 at 1:15 p.m. with the Administrator confirmed that there was no posting of the required phone number for residents in the common area of the facility. CLASS Hl M.C.D. 01/03/10 ; NUTRITION & DIETARY STANDARDS _ The administrator of food service designee must perform his/her duties in a safe and sanitary manner. 58A-5.020(1)(b), FAC. STATE FORM ; - OTEM11 Ueonnuation sheet 4 of 15 May 3 201 4 85/03/2018 16:45 8589210158 , Stee PAGE 16/47 PRINTED: 03/10/2010 FORM APPROVED (003) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (K1) PROVIDER/SUPPUERICLIA (DENTIFICATION NUMBER: STREEV ADDRESS. CITY. STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSAURG, FL 33713 wD PROVIDER'S PLAN OF CORRECTION os) PREF (PACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG G ERENCED TO THE APPROPRIATE DATE DEFICIENCY) A801 Continued From page 4 This STANDARD is not met as evidenced by: - Based on observations and staf interview, the food service designee failed to perform hia/her duties in a safe and sanitary manner with regards to unlabeled food products for resident consumption, dirty box fan in kitchen, unclean counters In kitchen, moldy food products designated for residential consumption and procurement of food products from unknown sources. Findings include: Obeervetions conducted on 12/03/09 between 6:35'a.m. and 9:00 a.m. in the facility kitchen revesied the faliowing: A refrigerator had 6 large containers of food products that were undated, interview conducted with the cook at 6:40a.m. confirmed that the date | the food products were prepared was unknown. The outside of the refrigerator had notable dirt build up along the handle. A bax fan with notable t dust hanging on it was (ocated in the corner of the kitchen. Kitchen counters were unclean. A large unmarked trash bag of food product was located in the freazer, interview conducted with the cook confirmed that the trash hag contained donated chicken nuggets that were to be utilized for resident consumption. In a refrigerator, two unmarked, large tub totes, which contained approximately 8 galions each of a chicken and red sauce mixture, mold was growing in areas of both tubs; interview conducted with the cook confirmed that she was unaware of how old the imioture was. A freezer contained a bin of uncovered sandwich loaf meat; this was unmarked and open to the STATE FORM - OTEM11 Wcontinuaton shest 6 oF 15 May 3 2010 16:47 5/03/2018 16:45 8589210158 STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION en) IDENTIFICATION NUMBER: 0 _ AL11932424 : : NAME OF PROVIDER OR SUPPLIER . STREET AODRESS, CITY, STATE, 21” CODE 2348 CENTRAL AVEN! CARDEN HOUSE SAINT PETERSGURG, ri 33713 SUMMARY STATEMENT OF DEFICIENCES . {EACH DEFIGENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A801 Continued From page 5 elements of the freezer. _ Repeat Deficiency from prior visit of 4/02/08. CLASS III M.D. 01/03/10 PHYSICAL PLANT STANDARDS The ALF shall be located, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents. 5BA-5.023(1)a), F.A.C. This STANDARD ie not met as evidenced by: . Based on observation and interviews, the facility failed to maintain the facility in a sate home-like environment. Findings Include: During the tour of the facility on 12/3/09 beginning ! at 8:45 a.m. and again during a walk through with the aasistant administrator the following observationr wera made: Dirty floors were observed on all 3 floors especially in the corners where the linoleum meets the baseboard or wall in the stairwells and hallways. Walls were not clean in the hallways adjacent to the movie room near the teundry” room and many doors throughout the facility were dirty with a brown smeared looking substance =| ground daorknobs. HCA Form 3020-0001 STATE FORM - OTEM11 PAGE 11/47 PRINTED: 03/10/2010 FORM APPROVED ioonunyation sheet 6 or 15 95/03/2818 16:45 ssegz1e1se May 3 2010 16:47 PAGE 12/47 PRINTED: 03/10/2010 FORM APPROVED gency for Health Care STATEMENT OF DEFICIENCIES: AND PLAN OF CORRECTION PLIERICUA (83) DATE SURVEY 4) PROVIDERISUP| IDENTIFICATION NUMBER: COMPLETED NAME OF PROVIDER OR SUPPLIER 2349 CENTRAL AVENUE . SAINT PETERSBURG, Fl. 33713 (x4}10 ‘SUMMARY STATEMENT OF DEFICIENCIES . PROVIDER'S PLAN OF CORRECTION PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAR CROSS-REFERENCED Tor APPROPRIATE DATE CARDEN HOUSE A1001 Continued From page 6 A shared lining quarters bathroom (rm #103) had a urine odor and the shower was filthy with an orange brown growth on the bottom of the shower curtain. This was brought to the attention . ofa housekeeper who demonstrated the scum could be easily desned. The housekeeper further stated they (housekeapers) have certain days they were supposed to clean it. The shower curtain was torn in 2 places and the floor was also wet. The air conditioner vent had an accumulation of dust on it. Rm #104 had an area on the wall near the air conditioner with a white chalky build up. The shower floor was dirty, the base of the toilet was dirty. Two rooms occupied by residents were very dark with no windows (rm #103 and #104) The floor in the back area leading outdoors where residents exit to emoke wae dirty. | The following observations on the second floor were made: the hallwey near room #202 was ditty, a boxapring wrapped in plastic was observed laaning against a wall at the end of the hall. There was peeling yellow paint in & hallway near a fire extinguisher thet looked like possible water damage. The ends of haiways were very dark. The second floor had at least 2 occupied rooms (#202 and #208) but was mostly unoccupied with renovations In process according to interview with the administrators during the investigation. No active renovation work was observed during the investigation. The unoccupied open rooms floors were generally very dusty. Rm #204 (single bed, boxspring wrapped in plastic), #213 had part of a bedframe, the light was on, #214 had a boxapring on its side, and a dresser, another room with a #214 Form 3020-0001 STATE FORM - OTEM11 : Hoonunuation shew 7 of 15 05/83/2018 16:45 9509218158 May 5 2010 16:48 PAGE 13/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES ‘AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILOING $$ 2 WING ADDRESS, CITY, STATE. ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, FL 38713 (xo 1D SUMMARY STATEMENT OF DEFICIENCIES io PROVIDER'S PLAN OF CORRECTION PREFIX {EACH DEFICIENCY MUST GE PRECEDED BY FULL PREFIX (PACH CORRECTIVE ACTION SHOULD BE ca REGULATORY OR LST IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIA' TE OATE 1001 Continued From page 7 had clothing on the floor and a can of painton a; chair, #215 had part of a bedirame, dresser with a mirror, a very thin mattress on the floor, a few and other clothing was on the floor, the light was on, 219 (dreaser only), 220 (part of a dresser), 221 (fan and screws on a dresser), a room designated #9 was empty of furniture but had numerous smail pieces of broken glass on the floor, naw binds and paint, rm #10 was empty except for what looked like naw blinds, rm #12 --was empty. One occupied resident room (#208) was observed to have a clean floor, the single bed was made, the shower was clean however the resident (deaf) indicated the toilet did nat work and used the general bathroom down the hall. The ganeral bathroom did not have a working light in the tub erea and the lib was | filthy. Music was heard coming from rm #202 but numerous unsuccessful attampts to have the resident open the door prevented observation of the room. Tha third floor rm #320 had reportedly no hot water in the shower or sink. The resident floor in rm 321 was wet, the resident had just come out of the shower. The general bathroom on the 3rd floos had no toilet paper, no light at the sink 1 where the bathtub is located, the sink wars rusty and fitthy, the hot water felt lukewarm after | waiting 3 minutes. The hallway had 2 empty | \ | buckets and a caution sign wet floor next to rm #323. CLASS III M.C.D. 01/03/10 A1002 PHYSICAL PLANT STANDARDS STATE FORM - OTEM11 Treontavadion sheet 6 of 15 May 3 2010 16:48 @5/03/2018 16:45 8589210158 PAGE 14/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES ) RISUPPLE! (X2) MULTIPLE CONSTRUCTION: AND PUAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING AL11932424 STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 GUMMARY STATEMENT OF DEFICIENCIES (BACH DEFICIENCY MUSY SE PRECEDED BY FULL REGULATORY OR LSC (DENTIFVING INFORMATION) 1002 Continued From page 8 shall be structurally sound and in good repair. 58A-5.023(1)(b), F.A.C. This STANDARD is not met as evidenced by: Based on observation and interview the facility falied to assure the facility's physical structure: was in good repair. Findings include: L 7 During the initial tour beginning at 8:45a.m. and again during a walk through with. the assistant administrator the following observations were | made: Rm #103 had 2 holes on a wall of the bedroom, one about 6 fi. up from the floor, the other was located where the door handle hits the | wall when the-door is opaned. Rm #320had a. | - Jarge (over 1 foot diameter) piece of shower calling missing as weil as buckling of the front of the shower wall (facet side). Rm #300 had an unstable door with the door panel insert loosely peated, you could see into the room at the bottom of the panel which also had a hole in it. Two cement stairways had several narrow gauges in the steps. Repeat deficiency from prior visit of 4/02/09 CLASS Ill PHYSICAL PLANT STANDARDS a1G03 1 “ M.C.D. 01/03/10 | | Peeting paint or walipaper, missing ceiling or floor tiles, or tom carpeting shall be repaired or STATE FORM - OTEM11 Uf continuation sheet 9 of 15 05/03/2018 16:45 8589210158 May 3 2010 16:48 PAGE 15/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES ) AND PLAN OF ION (X1) PROVIOER/SUPPLIERICUA (12) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: AL11912424 AME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE CARDEN HOUSE 2248 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES iD (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 18) PREFIX TAR DEFICIENCY} 1003 Continued From page 9 58A-5.023(1)(b), FAC. ‘This STANDARD is not met as evidenced by: The facility failed to assure peeling paint was repaired. : Findings include: . | During the initial physical plant tour baginning at 8:45 a.m. and again during a walk through with the assistant administrator the following observations were made: above the main slairwell (about 5 steps up)paint was peeling at the ridge where the second floor bagins; Rm #104 had a white chalky build up on the wall near + . the air conditioner unit and the same wall tad "| - - toe several shiny paint smears that did not match the room paint reportadly made by a resident no _ longer living at the facility, peeling paint was also noted on the second floor hallway near a fire extinguisher. CLASS IN M.C.D. 01/03/10 ; PHYSICAL PLANT STANDARDS Windows, doors, plumbing, and appliances shail be functional and in good working order. 5BA-5.023(1)(0), F.A.C. This STANDARD ig not met as evidenced by. AHCA Fonn 3020-000 STATE FORM - Weontnustion sheal 10 of 1S OTEMI1 May 3 2010 16:49 85/03/2018 16:45 8589210158 PAGE 16/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES CONSTRUCTION AND PLAN OF CORRECTION 012) MULTIPLE PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: AL11922424 ‘STREET ADORESS, CITY, STATE, 21? CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33743 ou) ID SUMMARY STATEMENT OF DEFICIENCIES a PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IOENTIFYING INFORMATION) 1004 Continued From page 10 Based an observations and interviews, the facility failed to assure windows, doors, plumbing and appliances were in good working order. Findings include: Observations made during the initial tour * beginning at 8:45 a.m. and again during aw walk through with the assistant administrator included: missing screens were observed in rooms #104 and #320, a toilet was reported as not working in room 208, hot water was reported as not working - in mom #320. Doors that did not have handles from the inside causing a potential safety hazzard included raoms 300, 304, 308, 312, 311, 317, 321 and 322. What the doors were equiped with ' was a turnbott from the inside of the resident room that was accessed by key fram the outside and a door pull handle afao on the outside of the door, There was nothing to grab onto from the. = |" "~~ inside of the room except the bolt that locked the door. Intarview with the other assistant : administrator at 11:35 a.m. revealed there had been an incident with the resident of room #300 the previous day where the resident could not get out and the stelf had to unlock the daor from the outside. Three naw replacement door handles were shown to the surveyor but at least § doors needed the new handles. The interview with bath assistant administrators also revealed that the hot water source is shared therefore if one has hot water, all should have hot water. CLASS Ill M.C.D. 01/03/10 : A005 PHYSICAL PLANT STANDARDS All furniture and furnishings shail be clean, functional, free-of-odors, and in good repair. AHCA Form 30 STATE FORM baal OTEMU . TW cominuetion ahewe 11 oF 15 M : @5/83/2018 16:45 8589210158 ay 5 2010 16:49 PAGE 17/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES CONSTRUCTION AND PLAN OF CORRECTION (42) MULTIPLE CONSTR STREET ADDRESS. CITY, STATE. ZIP CODE 2340 CENTRAL AVENUE SAINT PETERSSURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE (a) 1D SUMMARY STATEMENT OF DEFICIENCIES D PROVIDERS PLAN OF CORRECTION om PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED 10 THE ‘APPROPRIATE A1005 Continued From page 11 _ 58A-5.023(1}(b), F.AC. This STANDARD is not met as evidenced by: Based on observations and interviews the facility failed to assure the furniture and furnishings were clean and in good repair. : | The findings include: Observations during the tour of the facility at 8:45 a.m, and again in the aftemoon during a walk i through with the assistant administrator included the following: two sofas used by residents located in the movie area leading to the outside ' patio were visibly dirty with medium and dark brown stain (one sofa had cream colored upholstery and the dirt was more Visbie). Three _ other sofas were covared in a loose fitting green ~~ material, there was a small brownish color stain noted on one of them. The assistant administrator commented that a lot of money had - peen pald for the cream colared sofa. A dming chair located in the dining room was missing ane armrest and had a pointed exposed piece of wood that posed a danger to residents. CLASS Ill _M.C.0. 01/03/10 PHYSICAL PLANT STANDARDS A change in the use of space that involves converting an area to resident use, which has not previously been inspected for such use shail not | be made without prior approval from the Agency Field Office. 58A-5.016(4). F.A.C. AMHCA Form 3020-0001 STATE FORM -m oTeM11 Woongnuation sheet 12 of 16 May 3 2010 16:49 05/43/2818 16:45 98509210158 PAGE 18/47 PRINTED: 03/10/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X1) PROVIDERSUPP! TON (43) DATE SURVEY AND PLAN OF CORRECTION ix IDENTIFICATION fob . (52) MULTIPLE CONBTRUG: . COMPLETED A. BUILDING B WING AL11932424 127032000 STREET ADDRESS, CITY, STATE, ZIP CODE 7349 CENTRAL AVENU! CARDEN HOUSE SAINT PETERSBURG, FL 33713 Row GUMMARY STATEMENT OF DEFICIENCIES wo PROVIDER'S PLAN OF CORRECTION fre) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULO BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG GROSS- REFERENCED | TO THE APPROPRIATE DATE , ENCY) A1010 Continued From page 12 A1010 \ This STANDARD Is not met as evidenced by: Based on observations and interview, the facittty - failed to ensure that change in the use of space that invalved converting an area to residential use for the 2nd floor of the facility was appropriately | inspected and approved by the Agency. Findings include: - Record review of the floor plang submitiad by the _ facility for licensure revealed that the facitity had identified that the 1st and 3rd floor were to be lkcansed. Observations conducted on 12/03/09 during the survey af the facility revealed that Tesidents were currently residing on the 2nd ficor- |- of the facility. Interview conducted on 12/02/09 at | 9:30 a.m. with a direct care staff mamber confirmad that 3 residents were currently residing on the 2nd floor. Interview conducted on 12/03/09 at 12:30 p.m. with the administrator revealed that he was unsure that he had to notify the Agency of the change of use of spece for | _ allowing residents to reside on the 2nd floor of the facility and that it had not been inspected or approved by the Agency. CLASS IW M.C.D. 01/03/10 A1038 PHYSICAL PLANT STANDARDS A1038 Sole access to a toilet or bathtub or shower shall + Not be through another resident's bedroom, except in apartments within a facility. ACA Fon 3020-0001 STATE FORM woe OveEMi1 UW consioustion sheat 13 of 15 M : 05/83/2818 16:45 9509210158 Ay $ 2010 1609 PAGE 19/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF ECTION (X1) PROVIDER/SUPPLIERICLIA 62) MULTIPLE CONSTRUCTION WWENTIFICATION NUMBER A BUILDING BWING AL11932624 STREET ADDRESS, CITY, STATE, ZIP COOE 2349 CENTRAL AVENUE ; SAINT PETERSBURG, Fl 33715 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE (m4) 1 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION oS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC {DENTIFYING INFORMATION) TAG: CROSS-REFERENCED TO THE APPROPRIATE TE 1039 Continued From page 13 68A-5.023(5)(d), F.A.C. This STANDARD is not met as evidenced by: | Based an observations and interviews, the facility | failed to assure residents had access to a bathroom without going through another resident's room Findings include: Room #103 had one resident ling there and would need to go through the ‘adjoining resident's roam in order to gain access the restroom unless using the other doar that led outside the facility. Room #104 (occupied by 4 residents) hed the same type accass, a door to the outside af the facility was the only way to not access the adjoining room (2 residents) in order - es to access the restroom. Interview with the assistant administrator revealed the resident in : the adjoining room to rm #103 would be moved into nm #103. CLASS Il M.D. 01/03/10 A108 STAFF RECORDS STANDARDS 1109 The administrator or person designated by the administrator aa responsible for the facility's food service and the day-to-day supervision of food senice staff obtains, annually, a minimum of 2 hours continuing education in topics pertinent to | nutrition and food service in an ALF. : | 429.52(6), F.S. 5BA-5.0191(6), F.A.C. 5BA-5.020(1)(d), F.A.C. HCA Form 3020-0001 : STATE FORM - OTEM11 Iteontinuation shaet 14 of 15 May 3 2010 16:50 05/83/2018 16:45 98589210158 PAGE 20/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA 2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IOENTIFICATION NUMBER, | a, BUILDING —— 8. WING aLsi93z624 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZP CODE 2340 CENTRAL AVEN CARDEN HOUSE SAINT PETERSBURG, ML sa713 SUMMARY STATEMENT OF OEFICIENCIES. ley DEFICIENCY MUST wy FULL . (EACH CORRECTIVE ACTION SHOULO BE (EACH BE PRECEDED REGULATORY OR LGC IDENTIFYING INFORMATION) : CROSS-REFERENCED ¥O THE APPROPRIATE A1109 Continued From page 14 58A-6.024(2)(a)1.,F AC This STANDARD is not met as evidenced hy: Based on staff interview, the facility failed to enaure that the administrator had completed a minimum of 2 hours of continuing education in topics pertinent to nutrition and food service in the an ALF. | | Findings include: | . Interview conducted on 12/03/08 at 12:30 p.m. with the administrator confirmed that he was responsible for the day to day operation of the : food service for the facility; he confirmed that he did not have 2 hours of continuing education in topics pertinent to nutrition and food service in an CLASS III M.C.D. 01/03/10 STATE FORM = OTEM11 Fr consimuston sheet. 13 of 15 May 3 2010 16:50 05/03/2818 16:45 8589210158 PAGE 21/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES OY PROVIDER/SUPPLIER/CLIA ANDO PLAN OF CORRECTION » IDENTIFICATION NUMBER: AL11832424 2348 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL. 33713 Qe) 10 : QUMMARY STATEMENT OF DEFICIENCIES . D : ~ PROVINER’S PLAN OF CORRECTION PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAQ CROSS-REFERENCED TO THE APPROPRIATE + A000 INITIAL COMMENTS ‘ ASSISTED LIVING FACILITY APPRAISAL VISIT 12122109 No discernible deficiencies were identified relative to this Appraisal Visit. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE . STATE FORM - uuswit Weoontinuetion sheet tof 1 May 3 2010 16: 05/03/2018 16:45 8509218158 , i PAGE 22/47 PRINTED: 03/10/2010 FORM APPROVED 4 ‘ PROVIDERISUPPLIERICLIA 02) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: AL11932424 STREET ADDRESS, CITY. STATE. JP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 rye BUMMARY STATEMENT OF DEFICIENCIES ; D PLAN OF CORRECTION = PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) __ GROBS-REFERENC £D YO. oe APPROPRIATE DATE a ood INITIAL COMMENTS * ASSISTED LIVING FACILITY : COMPLAINT INVESTIGATION : CCR# 2009014210 . 1221108 _Adeficiancy was identified and cited. ‘ The facility was found not to be in compliance with with Florida Statues Chapter 429, Part t, and : SOA-5 of the F. A.C. 011. PHYSICAL PLANT STANDARDS ' When outside temperatures are 65 degrees Fahrenhait or below, an indoor tamperatura of at ' Jgast 72 degrees Fahrenheit shall be maintained tn all areas used by residents during hours when ‘ residents ara normally awake. | 5BA-5.023(2\{a), FAC. f This STANDARD Is not met as evidenced by. Baazed on observation and mterview with administrator, the facility tailed to provide ' adequate heating to all areas used by residents _ during hours when residents are nonnatly awake. - Findings include: During an observation and assessment of ‘ tamperature contro! on 12/21/09 at approximately 2:30p.m and 12/22/00 at 8:00a.m., it was , revealed the thermostat In the common grea read Form 3020- A TITLE (x8) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER, REPRESENTATIVES SIGNATURE . STATE FORM : -” “'BS3411 Woonknuation snset 1 of Z 65/83/2018 16:45 8509218158 May 3 2010 16:50 PAGE 23/47 PRINTED: 03/10/2010 FORM APPROVED (X1) PROVIDER/SUPPLIERICLIA (02) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A BUADING AL11932424 STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 ‘SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR 1.8C IDENTIFYING INFORMATION) A1011 Continued From page 1 78 degrees Fahrenheit while the temperature outside was recorded to be 70 degrees Fahrenheit on 12/21/09. On 12/22/09 at 8:00 a. m the temperature In room 104 in the rear right side of the facility was recorded at 68 degrees with an extemal thermometer. The right raar of the facility has a common area with a door that is freq opened to a smoking area. It was _ found to be loft ajar by resident that step out to smoke. The outside temperature was 64 degrees on 12/22/09 at 8:00a.m. Itwas observed that some of the residents rooms on the third floor ware provided with portable oii heaters in their rooms. Intarview with six residents revealed _ extra: blankets were provided. Some resident's quarters were found to have their windows ! opened and/or fans running at the same time. Clase til Mc. D. 21110 AHCA Form 3020-000 STATE FORM — BS3411 Htcominuation wheat 2 of 2 May 3 2010 16:51 05/83/2018 16:45 8589218158 PAGE 24/47 AH Form Approved 3/10/2010 nn i a State Form: Revisit Raport WH) Provides Sapplir TELA Ten wolipia Coma eo. — - Mantification A. Buliding (V3) Date of Ravialt Number __ ALttea2024 ewe 2 ee Neme of Facility Street Address, City, State, Zip Code CARDEN HOUSE 2349 CENTRAL AVENUE ___2 SAINT PETERSBURG, FL 33713 _ “Tne report e completed by @ Stata surveyor fo show thone deficiersies previously raporied that hawe been corrected and] ihe Gute such corrective action was aocompAshied, Each dutcarcy shoud be haly dariiied using other the reguialion oF LSC provision Umber and the Kiandlicadion prefix code previously shown on the Stete Surwey Report (erator codes shown Lo the left of eech requirement on the survey report for) (v4). tom «Bt 44) Kom 3) 08) ites (YS) Date Conrection Correction Carrection Completed Completed Completed 1D Prefix att _ovzrian18 10 Profi __ ‘1D Prefix __ Reg. # Reg. # Reg. # se ; tse TT us¢ TO Correction Correction Correction Completed Completed Completed 10 Prefix a 1D Prefix 1D Prosfox _ Reg. # Rag. @ | Reg. # ie hse 7 isc Correction Comection Corracton Completed Completed Completed 1D Prefix __ (D Prefix ' 10 Prefix Reg. # Reg. # Reg. # iwc ' isc . Lsc 7 ~~ -_— — oe ee —. —— Correction Correction Correction Completed Completed ID Prefix __ tD Profix __ 1D Prefix _ __ Reg. # . Reg. # Reg. # Lsc in we 7 ue 7 7 ee oe : —_— .- Correction Correction Corraction Completed Completed Compieted ID Prefix __ ID Prefix _ {D Prefix __ __ Rag. # Reg. @ Reg. # we isC we Oe Reviewed By | Raviswed By Date: Signature of Surveyor: Date; StmeAmency eee Reviewed By .. — Reviewed By Date: Signature of Surveyor: Oute: CMs RO Followup to Survey Completed on: _ Check for any Uncorectad Deficiencies, Was a Summary of : 42/21/2008 _ Uncorencted Deficiencies (CMB-2567) Sent tn the Facility? yes NO Ma : 05/03/2018 16:45 9509210158 y 5 2010 16151 PAGE 25/47 PRINTED: 03/10/2010 FORM APPROVED (0) MULTIPLE CONSTRUCTION A BLILDING —_ * 1 963) DATE SURVEY COMPLET! R 01/27/2010 'SYREET ADDRESS, CITY. STATE, ZIP COUE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIOER OR SUPPLIER CARDEN HOUSE (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES Le] PREFIX (EAGH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR L&C IDENTIFYING INFORMATION) 44.000} INITIAL COMMENTS ASSISTED LIVING FACILITY REVISIT TO COMPLAINT INVESTIGATIONS OF 01/27/10 REVISIT CONDUCTED 01/27/10 The following uncorrected deficiencies were identified relative to the Revisit to CCR# 2009013142: A408 and A801. The following new deficiencies were identified relative to this Revisit, A002, A201, A212, A206, A208. A310, A707, and A720. The following uncorrected deficiencies were | Kdentified retative to the Revisit to CCR# 2009013483: A1001 and A1004. The facility was found not to be in compliance _with Florida Statutes Chapter 423, Part |, and 58A-5 of the F.A.C. GENERAL LICENSE STANDARDS The license Is displayed inside the ALF in a conspicuous place. 429.07(6), F.S. This STANDARD is not met as evidenced by. Based on observation and interview, it was determined the facility had not posted it's ALF : license in a conspicuous location, in that itwas i posted in the office which was not open to the public. . 520-0001 AHCA Fon TITLE (Ke) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENT. TATIVES SIGNATURE STATE F - OTEMI2 Hoonunuation sheel {of 14 5/83/2018 16:45 9509210158 Ney 3 2010 16:51 PAGE 26/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES CONSTRUCTION AND PLAN OF CORRECTION 0) MULTIPLE AL11932424 STREET ADDRESS, CITY, STATE, ZIP. CODE 2343 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE 4) 10 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE. PRECEDED 6Y FULL ‘PREFIX (EACH CORRECTIVE ACTION SHOULD RE TaG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED DEFICIENCY) A002 Continued From page 1 Findings include: During the tour of the facility on 1/27/10 at 9:15a.m., it was obaerved that the facility's current assisted living facility license was not posted In a conspicuous location where residents and the general public could view. It was later observed posted In the management office, which the owner confirmed in an intenvaw on 1/27/10 at approximately 10a.m.was not open to the public. The owner further stated that residents would frequently ramove the license when it had heen placed out in the common areas but that other methods to ensure it's availability to residents and the ganeral public had not been attempted. Class IV M.C.D. 2/27/10 FACILITY RECORDS STANDARDS An up-to-date admission and discharge log must be maintained listing the names of all residents and each resident's: 1. Date of admission; 2. Place from which the resident was admitted; 3. Admiasion with a stage 2 pressure sore, It applicabie, : 4. Data of discharge, 5. Reason for discharge; 6. The facility to which the resident is discharged or home address, or if the person is deceased, the date of death. 429.41(1)(e), FS. 58A-5.024(1}(b), FAC. STATE FORM : . — OTEMi2 Htoontinuation shaet 2 of 14 5/83/2018 16:45 8509210158 May 5 2010 16:51 PAGE 27/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUDPPLIERICUA WENTIFICATION NUMBER AL11932624 STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION os) DEFICIENCY MUST BE PRECEOED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE are. DEFICIENCY) A201 Continued From page 2 This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the facility had not ensured that the admission and discharge record was kept current and complete in that thraa (Residents # 4, 33, and #4) of the six reaidents in the survey sample did not have documented the location fram where admitted or date and location of diacharge. ’ Findings include: Review of the facility admission and diacharge i ‘ record found the following omissions: 1. Resident #1 was documented as being admittad on 12/8/09 with no location from where he/ahe was admitted, 2. Resident #3 was documented as being admitted on 10/28/09 with no location from where he/she was admitted: 3. Resident #4 was discharged on 1/5/10 per interview with the factity medication technician on 127/10 at approximately 11:00am. but review of the admission and discharge record found no _date or focation of discharge documented... 4. Tha medication technician confirmed that the location from where admitted for Residents #1 and #3 and the date and location of discharge for Resident #4 were not documented on the log. Claas IV Mandatory Correction Date: 22710 A206 FACILITY RECORDS STANDARDS AHCA Form STATE FORM ; -~ OTEM1z Itoontinustion sheet Sof 14 May 3 2010 16:52 05/03/2018 16:45 85892198158 PAGE 28/47 PRINTED: 02/10/2010 FORM APPROVED STATEMENT OF OEFICIENCIES PROVIDER/SUPPLIERICLIA 2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER, NAME OF PROVIDER OR SUPPLIER . STREET ADDRESS, CITY. ia 2348 CENTRAL A’ CARDEN HOUSE / : SAINT SETERSGURG, rl 339713 PLAN OF CORRECTION (FACH CORRECTIVE ACTION SHOULD BE CROSS-REPERENCED TO THE APPROPRIATE A 208 Continued From page 3 The facility maintains the admission package with ; all required camiponents and Is presented to new or prospective residents, 429.41(1\(e), F.S. 58A-5.024(1)(1), F.A.C. 5BA-5.0181(3), FAC. This STANDARD is not met a8 evidenced by: Based on record review and interview, it was determined the facly had not Incuded the all requirad information, ae it od nak inclode Be taclly policy on Do Not Resuscitate (D.N.R.) orders and Advance Directives and did not include the facility elopement policy and procedures Findings include: Review of the facility admission package found it | _ did not contain the following required information: | 1. The facility Do Not Resuscitate (D.N.R.) policy 2. The facility elopament policy and procedures. The Owner confirmed on 1/27/10 at approximately 11 a.m. that this information was nat in the admission package. Class If! Corraction Date: 2/27/10 A208 FACILITY RECORDS STANDARDS STATE FORM - OTEM12 If continuation sheet 4 of 14 05/03/2018 16:45 9589210158 May 3 2010 16152 PAGE 29/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x2) MULTIPLE CONSTRUCTION A BUILDING ee STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, Fl. 33715 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE 4) 1D BUNAAARY STATEMENT OF DEFICIENCIES 1D (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL PREFIX (EACH CORRECT! REGULATORY OR LSC IDENTIFYING INFORMATION) . NCED A208 Contnued From page 4 The facility maintains a grievance procedure for * receiving and responding to resident complaints and recammendations. 429.28(1)(1), FS. 5BA-5.024( 1k), F.A.C. This STANDARD is not met as evidenced by: | ' Based on observation and interview, t was determined tha facility had not maintained a grievance procedure for residents to make ’ complaints and recommendations regarding care and Services . Findings include On 127/10 at approximately 10:30 am. the owner of the facility reported that the process where residents could make compiainte or - grievances wok a suggestion bax which was kept in the resident common area. During the tour of the facility on 1/17/10 at 9:15 am., this box was not observed anywhere in the resident common areas. Later on 1/27/10 at approximately 11 | a.m., the Owner exhibited the suggestion box which was in the management office and had been there "about a week”. The owner etated residents and the general public were not permitted in the office. Class I! Mandatory Correction Date: w27inro FACILITY RECORDS STANDARDS The facility maintains all sanitation inspection reports Issued by the county health department within the last 2 years. STATE FORM ” OTEMI2 May 3 2010 16:52 85/43/2018 16:45 8509218158 , PAGE 30/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION o”) a (OENTIFICATION NUMBER: AL11932424 STREET ADDRESS, CITY, STATE, JP COOE 2349 CENTRAL AVENUE. SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE (4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION oo) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD 8 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROBS-REFERENCED TO THE APPROPRIATE GATE . DEFICIENCY) _ A212 Continued From page 5 429.41(1)(d), F.S. 58A-5,020(3), FAC. 58A-5.024(1)(n), F.A.C. This STANDARD is not met as evidenced by: Based on record review and interview, the facility did not have available for review reports of the * County reakdential health inspection . Findings include: Review of facility records found no evidence of residential building inspection reports by the _ County Health Department. On 1/27/10 at | approximately 9:45 a.m. the awner reported that an inspection was due but was unable to find any copies of the most recent or any inspection af the residential unit by the County Health Department. SS Class Ill M.C.D. 2/27/10 RESIDENT RECORDS STANDARDS Each reaident’s contract contains a list of the services and accommodations to be provided by the facility, including LNS, ECG, or LMM It applicable. 5BA-5.025(1)(a) FAC. This STANDARD is not met as evidenced by: Based on record review and interview, it was STATE FORM : bad OTEM12 ; It continuation sheer 6 of 14 M : 05/83/2018 16:45 98509210158 ay 5 2010 16:52 PAGE 31/47 PRINTED: 03/10/2010 FORM APPROVED (09) DATE SURVEY COMPLETED ‘STATEMENT OF DEFICIENCIES. ANO PLAN OF CORRECTION STREEY ADDRESS. CITY, STATE, ZIP CODE. 2349 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 1D ‘SUMMARY STATEMENT OF DEFICIENCIES 0 PROVIDER'S PLAN OF CORRECTION ne) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {RACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) cl OaTE A310 Continued From page 6 determined that the facility resident contract did not include all services and accommodations provided by the facility in that It did not address thet Limited Nursing Services was available in the facility. .. Findings include: Review of the resident contract found that although the facility wes currently licensed to provide Limited Nursing Services, this services | was not addressed on the resident contractas =| being available to the residents. On 127110 at approximately 11:00a.m., the facibty representative confirmed this was not in the contract. Class Itt M.C.D. 2/27/10 {A 406} ADMISSIONS CRITERIA STANDARDS Any special dietary neads can be met by the facility. 5BA-5.0181(1)(f}, FAC. This STANDARD is not met as evidenced by: | Based on record review and staff interview, the facility failed to ensure that it could pravide for special dietary needs for 2 (#5 and #8) of 2 | sampled residents who were prescribed diabetic diets. Findings include: | Interview conductad on 1/27/10 al approximately | 11:45p.m. with the Medication Technician (Med — AHCA Form 3020-000 STATE FORM . Lid OTEM12 Ht continuation sheet 7 of 14 May 3 2010 16:53 05/03/2810 16:45 8509218158 , PAGE 32/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDERJSUPPLIER/CLIA AND PLAN OF (02) MULTIPLE CONSTRUCTION (OENTIFICATION NUMBER: AL1193246246 "STREET ADORESS, CITY, STATE. ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 WAME OF PROVIDER OR SUPPUER, CARDEN HOUSE 04) 1D BUMMARY STATEMENT OF DEF D ; PROVIDER'S PLAN OF CORRECTION *0) PREFIX DEFICIENCY MUST BE PRECEDED 8Y FULL PREPX === (EACH CORR ACTION SHOULD COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) Ta CROBS-REFERENCED YO THE APPROPRIATE oaTE {A 406) Continued From page 7 Tech) who was assisting the sutvey taam | revealed that two residents in the facility were diabatic. . . A review of the Health Assessment, Form 1823 | for resident #5 dated 9/9/09 indicated the resident has a diagnosis of Diabates Melitus Il. The physician indicated that the resident should have a diabetic diet. A review of 11/4/09 Laboratory results also indicated a blood glucose level of 140 which was described as being high. Record review of Resident #6 revealed a Health Assessment, Farm 1823, dated 08/28/09, which indicated the resident has a diagnosis of Diabetes Mellitus II. The physician indicated that the resident should have a diabetic diet. " Interview with the facitity cook on 1/27/10 at 12:05p.m. revealed that ehe was uneware that tha facility had any residents prescribed diabetic : diets; no diabetic menu was available and that | -. she did Not prepare any foods differently for the - two residents who have been prescribed diabetic diets. . Record review of the facility's dietary menu in use by the facility revealed that the menus were for regular diets. Interview with Resident #6 at 12:40p.m. revealed that he often eats at his frienda house in the neighborhood, that he had a bagel for breakfast _ and sausage for dinner the previous night. He does not follow a diabetic diet nor is he served any different foods from the rest of tha residents in the facility Uncorrected deficiency from 12/04/08 visit CLASS Ii N.C.D. 02/27/10 STATE FORM : an OTEM1Z Hoontinuation sheat 6 of 14 85/03/2818 16:45 9599210158 May 5 2010 16:55 PAGE 33/47 PRINTED: 03/10/2010 FORM APPROVED gency for Healt ( STATEMENT OF OEFICIENCIES: (AND PLAN OF CORRECTION U1) PROVIDER/BUPPLIERICUA IDENTIFICATION NUMBER: AL14992424 STREET ADDRESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE 4) ID ‘SUMMARY BTATEMENT OF DEFICIENGES: 1 PROVIDER'S PLAN OF CORRECTION 3) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROBS-REFERENGED TO." a APPROPRIATE DATE A720 Continued From page 8 A720 RESIDENT CARE STANDARDS The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in & common area accessible to ail residents. The addresses and telephone numbers are: the District Long-Term Care Ombudsman Council, 1 (888) 631-0404; the Advocacy Center for Parsons with Disabilities, 1 (800) 342-0823; the Florida Local Advocacy Council, 1 (800) 342-0825, and the Agency Consumer Hotline: 1 (868) 419-3456. " §8A-5.0182(6)(c). FAC. This STANDARD {s not met as evidenced by: Based on observation and interview it was datermined that the facility did not have posted the telephone number and address of the Agency for Health Care Administration Consumer Hotline | uo (1-888-419-3456) and the Advocacy Center for Persons with Disabilities (1-800-342-0823). Findings include: 1. Agency for Health Care Administration Consumer Hotline (1-886-419-3456) 2. Advacacy Center for Persons with Disabilities | (1-800-342-0823) | STATE FORM . — OTEMI2 {fconeruaiion sheet 9 of 14 May 3 2010 16:53 05/83/2018 16:45 9589216158 PAGE 34/47 . PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLA (82) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: AL11932424 STREET ADORESS, CITY, STATE. ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL. 33713 (xa) 10 SUMMARY STATEMENT OF OEPICIENCIES iD . PREFIX {GACH DERICIENCY MUST BE PRECEDED BY FULL PREFIX. REGULATORY OR LEC IDENTIFYING INFORMATION) TAG A720 Continued From page 9 M.C.D. 2/270 {A801} NUTRITION & DIETARY STANDARDS The administrator ar food service designee must parform his/her duties in a safe and sanitary manner. 58A-S.020(1)(b), FAC. This STANDARD ts nat met as evidenced by:. Based on observations and staff interview, the food service designes failed to perform hisfher — duties tn a safa and sanitary manner with regards to unclean counters and equipment in the kitchen, inadequate supply of dinnerware, undated milk, old food products designated for ragident consumption and dirty utensils, dishes and plasticware that contained food products. Findings include: Observations conducted on 1/27/10 throughout the day in the facility kitchen revealed the following: 1. A refrigerator had 4 gallons of what looked like watered down milk in them. The tabel was dated | 1/10/10 and was Kdentified as whole milk. | Interview with the cook at approximately 12:05 p.m. revealed that she makes powdered milk daily and puts it in old milk cartons but does not label them with the date or contents. AHCA Farm 3020-0001 STATE FORM . ad OTEM12 . Woontinuation sheet 10 of 14 May 3 2010 16:54 @5/03/2018 16:45 8589216158 PAGE 35/47 PRINTED: 03/10/2010 FORM APPROVED Agency for Health Care STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION BTRUET ADDRESS. CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, Fi. 35713 ua) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. fl PROVIDER'S PLAN Of CORRECTION ow PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) - - TAG CROSS-REFERENCED TO THE APPROPRUATE DATE {A 801} Continued From page 10 2. The outside of the refrigerator had notable dirt” _ build up along the handle. 3. Kitchen counters were unclean and the stove | and stove plates were rusty. | 4. Alarge unmarked trash bag of bread was located on the counter, interview conducted with the cook confirmed that the trash bag contained donated bread that was to be utilized for resident consumption. 5 5. A refrigerator contained 2 heads of lettuce that were brown and withered and tomatoes and orange peppers that were bruised and withered. Several carrot sticks were stored in a garbage bag. 6. Plastic ware containing flour, sugar, and dry milk-were gragay and dirty. : 7. Dirty plates were stored with clean plates. 8. Clean utensils were stared in dirty, stained and greasy utensil bins. | 9. Interview with the cook at approwmately \ 12:05p.m. revealed that the factity does not have enough drinking cups or utensils for ail residents in the facllity. . Repaat deficiency from prior visit of 4/2/09 Uncorrected deficiency from survey of 12/3/09 Class I] | | M.C.D. 2/27/10 STATE FORM —_ oTeM1i2 Woondinuston aewt 11 of 14 85/03/2818 16:45 8589218158 Care Administration STATEMENT OF DEFICIENCIES, AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: AL11932424 NAME OF PROVIDER OR SUPPLIER . CARDEN HOUSE (M4) 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LST IDENTIFYING INFORMATION) {A1001} Continued From page 11 {A1001}, PHYSICAL PLANT STANDARDS The ALF shall be located, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents. 58A-5.023(1)(a). FAC. This STANDARD is not met as evidenced by: Based on observation it was determined the facility failed to maintain the pramisea in a comfortable and home fika environment. Findings include. May 3 2010 16:54 PAGE 36/47 PRINTED: 03/10/2010 FORM APPROVED (2) MULTIPLE CONSTRUCTION {A1001) {A1001} During the tour-of the facility on:1/27/10 between | 9:15 a.m. and 11: Sam. the following were observed: 4. In Room 320 there were no hot and cold shower handles making the shower unabie to be used by resident. tn addition, the sink In the room had no warm water. The water was cold to the _ touch after having been left running for several minutes. The staff member wha accompanied the surveyor on the tour stated it “takes a while . for the water to be wam. 2. The common bathroom on the third floor was. found to have a tub which was heavily stalnad and had standing water. in addition the common bathroom had light bulb over tha toilet which left the area in the dark 3. Rooms 103 and 104 had paint cans stored in them, dressers were dirty and chipped, a box ICA Form 3020-0001 STATE FORM STREET ADDRESS, CITY, STATE. ZIP COOE 2349 CENTRAL AVEN SAINT PETERSBURG, ‘FL 33713 PROVIDER'S PLAN OF CORRECTION (BACH CORRECTIVE ACTION SHOULD BE OTEM12 DATE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY) Woontnuallon sheet 12 of 14 @5/03/2818 16:45 98509210158 May 5 2010 16754 PAGE 37/47 PRINTED: 03/10/2010 FORM APPROVED ge ; STATEMENT OF DEFICIENCIES UCTION AND PLAN OF CORRECTION (42) MULTIPLE CONSTR STREET ADDRESS, CITY, STATE. ZIP CODE 249 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE Xe) SUMMARY STATEMENT OF DEFICIENCIES : : PROVIDER'S PLAN OF CORRECTION os PREF {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSG IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE oare DEFICIENCY) {A1001} Continued From page 12 spring was tom with the batting falling out of it and the toilet and shower were stained. (A1001} 4. Sheets, blankets and pillows were dirty, stained, had holes in them or were missing (Rooms 104, 300, 311, 321, and 328) UNCORRECTED DEFICIENCY FROM SURVEY _ OF 12/3/08 CLASS Il M.D, 2/27/10 (A1004} PHYSICAL PLANT STANDARDS ' Windows, doors, plumbing, and appliances shall be functional and in good working order. SBA-5.023(1}(b), F.A.C. This STANDARD is nat met as evidenced by: Based on observation and interview, Ht was | determinad the facility failed to assure windows, | doors, plumbing and appliances were ingood © | working order. _ Findings include: During the tour of the facility on 1/27/10 at 9:15a.m. the following was noted: 1. Rooms 104 and Rooms 320 had not screens | on the windows | 2. Rooms 304, 308, 311, 312, and 321 had no inside door handles which would allow safer STATE FORM ome OTEM12 W continuation sheet 13 of 14 May 3 2010 16:54 : 85/03/2018 16:45 8589210158 PAGE 38/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES (2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION A BUILDING B. WING MAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, SYATE, ZIP CODE 2349 CENTRAL AVENUE CARDEN HOUSE SAINT PETERSBURG, FL 83713 SUMMARY STATEMENT OF.DEFICIENCIES wo PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEOEO BY FULL {EACH CORRECTIVE SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE {A1004} Continued From page 13 access from the rooms by the residents. -3. Room 104 had two ceiling alr conditioning vents that were not covered 4. The outdoor patio had a tom and broken tabla on it | i 5. The staff bathroom in the common area contained fecal matter in the stool and was: _ without toilet tissue ard soap. When interviewed, | the Med Tech stated "I don't use the bathrooms =| here, | hold tt’; 6. Room 300 had no hot water. Resident stated that it has never been hot UNCORRECTED DEFICIENCY FROM SURVEY. OF 12/3/09 CLASS Ill "M.C.D. 227/10 Form 3020-0001 : STATE FORM — OTEMI2 _ tHeantinuetion sheet 16 of 14 May 3 2010 16:55 85/03/2018 16:45 8589216158 PAGE 39/47 AH Farm Approved 3/10/2010 oe State Form: Revisit Report tae of Revit “(vt) “Provider /Suppler/CLIAL (72) Multiple Construction (dentification Number A, Building 1/27/2010 . AL11832424 B, Wing Maree of Facilizy ~ — . Street Address, a, Clty, State, Zip Code CARDEN HOUSE 2349 CENTRAL AVENUE _ nee ee ________SAINT PETERSBURG, FL 39713 _— This report ie complered by & State surveyor 10 show thase deficienclos previously reported that have been comacted and the dete such corrective action was socompiahed: Each deficiency should be RA iderdtiied usny ether the regulaion or LEC provision number end the idaruieation prefix code previously show cn tke Siete Survey Report (prefix codes shawn to the left of each requirement on the survey report form). (4) team £05) _ Date YA) Moen (7)_Onte (WO) ern (VE) _ Dat Correction Correction Correction Completed . Completed Completed IDPref soroa osrzrraore ID Prefix agr21 ss otva7/2010 (DPrefx atonz —=—=——(isss«tv2 TRON Reg. # Reg. # Reg. # Lec Oe we Lsc — — _ —— we ——~_- Correction Correction Correction Completed Completed Completed ID Prefix asoo3 01/47/2010 \DPrefix atoos (st 7/2010 (OPrefx aio ——_(iss«ZTIZONO Reg. # Reg. # . t Reg. : ise — — ise ise Correction Carrection Correction , Tompletad Completed Campteved 'D Prefix aioss 0 ON/27/2010 ID Prefix atop sotsz7vani0 Pram Reviewed By | Reviewed By Oate; Signature of Surveyor. Dew: Boteagency me a Reviewed By Raviewed By ” Date: Signature of Surveyor: Date: CMS RO : ‘Followup to Survey Compitadon: ~~" SRk tor any Uncorrected Deficiencies. Was a Summary of 12/3/2008 a Uncorrected Deficiencies (CMS-2587) Sent to the Factitty? veg NO Comat ine TEMA? May 3 2010 16:55 65/03/2018 16:45 8589210158 PAGE 40/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION Xt) PROVU IDERVSUPPLERICLIA (02) MULTIPLE CONSTRUCTION JORNTIFICATION NUMBER: AL 11932624 STREET ADOREGS, CITY. SUE 2p CODE 2343 CENTRAL AVEN SAINT PETERSBURG, ra 33713 iD ‘SUMMARY SUMMARY STATEMENT C OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION pisel lad . (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (GAGNCORRECTIVE ACTION SHOULD BE COMPLETE TAR REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS- REFERENCED FO APPROPRIATE NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE A000 INITIAL COMMENTS ASSISTED LIVING FACILITY COMPLAINT INVESTIGATION CCR& 2010000489 s27H0 . " Deficiencies were identified and cited. The facility was found nat to be in compliance - with Florida Statutes Chapter 428, Part |, and 584-5 of the Florida Administrative Coda. Agi2, MEDICATION STANDARDS _ When a resident who receives assistance with medication is away from the facility and from _ facility staff, the following options are available to enable the resident to take medication as : prescribed: 1, The health care provider may prescribe a medication schedule which coincides with the resident's presence m the facility, 2. The medication container may be given to the | resident or a frend or family member upon _ leaving the facility, with this fact noted in the resident's medication record, 3. The medication may be transferred to a pill _ organizer, and given to the resident or a frend or family member upon leaving the facility, with this _ fact nated in the resident's medication record; or 4. Medications may be separately prescribed and _ dispensed | in an easiar (0 use form, such as unit Tm (8) DATE: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM - WZCGI1 Woonlinualion sheet 1 of 5 @5/03/2018 16:45 8589218158 May 3 2010 1655 PAGE 41/47 PRINTED: 03/10/2010 FORM APPROVED gency fo ‘STATEMENT OF DEFICIENCIES ANO PLAN OF CORRECTION . gay PROVIDER/QUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING ——_— BWING AL11932424 GTREET ADORESS, CITY, STATE, ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 38713 payio * SUMMARY STATEMENT OF DEFICIENCIES ; PROVIDER'S PLAN OF CORRECTION PREF (EACH DEFICIENCY MUST BE PRECEDED @Y FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSG IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE A612 Continued From page 1 58A-5.0185(3)(d), F.A.C. This STANDARD is not met as evidenced by: Based on cbservation, interview, and review of medication observation records (MORS) for _ random residents during the moming distribution and for 7 (Reskent #5 2. 7,8,9,10,11,and 12) of 7 . resident records reviewed for noon medication distribution, it was determined that the faciity failed to enaure that residents who are away from | the facility are given options to enable them to receive their prascribed medications - Obeervation of random MORS at approximately 9:16a.m. on 1/27/10 revealed that several _ residents who were to receive 8:00a.m. medications had not yet received them in that the _MORS were not completed. Intarview with the Med Tech revealed that 11 residents still had nat shown up for their medications. She stated that sometimes sha has fo go to their roome with the medication but that she also needs to remain at the desk in case they * show up. Interview with the Med Tach at 1:00p.m. revealed that about 6 residents had not received their noon medications. A review of the MORS for 7 residents who afe preecribed noon medications revealed that they had not received them in that the MORS were not compieted. STATE FORM - w2zcatt May 3 2010 16:55 85/03/2018 16:45 8589210158 PAGE 42/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PUAN OF CORRECTION STREET ADDRESS, CITY, STATE, ZIP CODE 2348 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 SUMMARY STATEMENT OF DEFICIENCIES (GACH DEFICIENCY MUST BE PRECEDED BY FULL (facn REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED ro ay APPROPRIATE. A612 Continued From page 2 ' The medications not distributed induded Artane, Vistaril, Buspar and Ativan. Interview with the second Med Tech In the facility who waa asuisting ' the survey team revealed that the medications were available. Both Med Techs reported that this is a frequent occurrence. There was no evidence that the _ facility had a syste in place to ensure residents who may be away from the facility during med pass recaive their meds, ara counseled, ar that ; the rasidents' health care provider is consulted with regarding the resident not receiving meds as ordered. CLASS Il! I “N.C.D. 02/27/10 A 700| RESIDENT CARE STANDARDS _ An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. * §8A-5.0182, F.A.C. This STANDARD is not met as evidenced by: Based on observations, interviewa and record faviews, it was determined thal the facility failed to provide adequate staff in order to provide care and services to meet the individual neads of the residents. Findings include: Although the staffing schedule met the minimum fequirament for hours of work, it was not accurate. Two scheduled staff did not work the STATE FORM ; en WZCG11 Voonbauation sheet Sof 5 05/03/2018 16:45 8589210158 May 3 2010 16:56 PAGE 43/47 PRINTED: 03/10/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDERSSUPPLIER/CLIA TION FT UT CORRECTION an (02) MULTIPLE CONSTRUC WDENTIFICATION NUMBER: AL11992626 STREET ADDRESS, CITY, STATE. ZIP CODE 7248 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 CARDEN HOUSE my 10 ‘SUMMARY STATEMENT OF DEFICIENCIES (0 p PREFIX (EACH DERCIENCY MUST BE PRECEDED BY FUU. PREFIX (FACH CORRECTIVE ACTION SHOULD REGULATORY OR LEC IDENTIFYING INFORMATION) CROSS REFERENG ED TO THE APPROPRIATE A700 Continued From page 3 day of the survey. The facility's failure to meet _ minimum standards related to the lack of provision of therapeutic diets, residents not Teceiving medications as preacribed, failure to ‘ provide activites and failure to provide a safe, homelike environment t was detarmined that the care and services based on individual needs, interests and capabilities were not met. Observation of random MORS (Medication Observation Record) at approximately 9'15a.m. on 1/27/10 revealed that several reaidents who were to receive §:00a.m. medications had not yet received them in that the MORS were not completed. interview with the , Medication Technician (Med Tech) revealed thet ‘41 residents still had not shown up for their medications, She stated that sometimes she has to go to thelr rooms with the medication but that she also needs to remain at the dask incase they show up. She stated she is generally too busy to ge to their rooms and just waits for them fo show up. . _— Interview with the Med Tech at 1:00p.m. reveaiod that about 6 residents had not received their noon medications, A review of the MORS for 7 residents who are prescribed noon medications revealed that they had not received them in that tha MORS were not completed. The medications not distributed included Artane, ' Viateril, Buspar and Ativan. Interview with the second Med Tach in the facility who was assisting the survey team reveated that the medications were available. Both Med Techs reported that this is a fraquent occurrence. One Med Tech stated that the distribution and supervision of medications takes STATE FORM —_ wzcGci Woentinuation sheet 4 of 5 May 3 2010 16:56 05/83/2018 16:45 8589210158 PAGE 44/47 PRINTED: 09/10/2010 FORM APPROVED Ot) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING ——$$$__———- SYAVEMENT OF DEFICIENCIES (02) DATE SURVEY AND PLAN OF CORRECTION COMPLETED B.WING AL11932624 “01/27/2010 STREET ADDRESS, CITY, STATE. ZIP CODE 2349 CENTRAL AVENUE SAINT PETERSBURG, FL 33713 NAME OF PROVIDER OR SUPPLIER CARDEN HOUSE DEFICIENCY) 4) ID SUMMARY STATEMENT OF DEFICIENCIES, "> PROVIDER'S PLAN OF CORRECTION PREFIL (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG RIEGULATORY OR LSC IDENTIFYING INFORMATION) as CROSS-REFERENCED TO THE APPROPRIATE DATE A700 Continued From page 4 ; up most of her time from when she arrives until the lata afternoon. Because of this, the activities ' that the faciity has scheduled to take place do not, The scheduled exercises and newspapers _ did not take place on the day of the survey. The cook arrived at the facility at approximately 11:45a.m. for tha noon meal on 1/27/10. She. served the residents soup from the pan in the Kitchen as residents lined up in front of her. The cook did nat leave the kitchen and if residents wanted seconds or drinks, they had to go to the kitchen, The cook left at 1:00p.m. A resident woes observed cleaning the dining area, washing the dishes, and cleaning the kitchen. i A tour of the facility with staff who was assisting . _ the survey team in all areas of the survey revealed a lack of supplies, furnishings in need of repair, tom and dirty mattresses, linens that