RICK SCOTT ; ELIZABETH DUDEK GOVERNOR Better Health Care for all Floridians SECRETARY June 1, 2011 Administrator Cunningham Elderly 2909 Courtland Blvd. Deltona, FL 32738 Dear Administrator: This letter reports the findings of a state licensure unannounced appraisal visit that was conducted on May 18, 2011 by a representative of this office. Attached is the provider's copy of the State (3020) Form, which indicates the deficiencies that were identified on the day of the visit. Section 408.811(4), Florida Statutes, requires that you correct these deficiencies within thirty days of the date of this letter unless the Agency has approved another timeframe. Staff from this office will conduct a review after July 1, 2011 to verify that the necessary corrections are in place to correct the deficiencies identified on your survey. The Quality Assurance Questionnaire has long been employed to obtain your feedback following survey activity. This form has been placed on the Agency's website at http://ahca myflorida.com/Publications/Forms.shtml as a first step in providing a web-based interactive consumer satisfaction survey system. You may access the questionnaire through the link under Health Facilities and Providers on this page. Your feedback is encouraged and valued, as our goal is to ensure the professional and consistent application of the survey process. Thank you for the assistance provided to the surveyor. Should you have any questions please call this office at 904/798-4201. Sincerely, Kathe. Keisha Woods Health Facility Evaluator Supervisor Division of Health Quality Assurance JPL/K W/sm Enclosure , Headquarters 2727 Mahan Drive Tallahassee, FL 32308 http://ahca.myflorida.com Jacksonville Field Office 921 N. Davis St., Bldg. A, Suite 115 Jacksonville, FL 32209 Phone (904) 798-4201; Fax (904) 359-6054 Filed October 6, 2011 4:57 PM Division of Administrative Hearings ~ a i2f ¥Q "TO BE COMPLETED BY FACILITY: : Resident’s Name (REAND GENERAL OVERSIGHT ASSESSMENT—MI SDICATIONS (MUST BE CARE PROVIDER BY MEANS OF A FACE=TO-PACE EXAMINA TION SECTION: 2B: SEL ~ GOMPLETE! A. Please list all current medications prescribed below {additional pages may be attached): B. Does the individual need help with taking his or her medications (meds)? Yes N_ No___. Ifyes, please place a checkmark (”) in front of the appropriate box below: C. ADDITIONAL COMMENTS /OBSERVATIONS (Use additional page If necessary): Kh 2D OBS. OT z 3) fise1o7he CANT MED PVs a ~EiLE NOTE: MEDICAL CERTIFICATION IS INCOMPLETE WITHOUT THE FOLLOWING INFORMATION: NAME OF EXAMINER (Please Print): al ra) Cu yt . YY - SIGNATURE OF EXAMINER: hy yn PR MEDICAL LICENSE #: PHONOD 2 aporessor examiner: _ [Koto S$Gs40n wh yok Sr 38 Dolton EL 4Q42S qeverHone#: _ BOW GPY- IYAD _ TITLE OF. EXAMINER (Please cheok the appropri DATE OF EXAMINATION: 21a ia AHCA Form 1823, October 2010 Rule 58A-5.0181, F.A.C. For Resistor! apex —— 4 HOME HEALTHCARE SERVICES Excellence Through Senior Advocacy (386) 775-0164 RN siperbor DERBI Team Assistant _\+ Registered Nurse hey Tine Bo ae hy Licensed Practical Nurse Home Health Aide Physical Therapist Ror J Rob pra Occupational Therapist CHARLES Speech Therapist Social Worker__.___—=———— Other. 775 Harley Strickland Blvd, Suite 108 Orange City, FL 32763 AHC24-06 ' Lic # HHA299993632 You can cq} oO more Wn dlormal Tia) apne < HOME HEALTHCARE SERVICES Excellence Through SeniorAdvocacy’ emer L AHCA: Background Screening rage sur. Agency for Health Care Administration Wednesday, August 31, 2011 Background Screening Section 2727 Mahan Orive Bldg. 3, Mail Stop #40 Tallahassee, FL 32308 Agency for Health Care Administration ~ Background Screening Search Results Eligibitity Status: KRYSTAL PANCILLA JOSEPH Agency for Health Care Administration Eligibility Status Person Information Eligibility Information Name KRYSTAL PANCILLA JOSEPH Eligibility Status ELIGIBLE SSN XXX-XX-2700 Eligibility Status Date 08/02/2010 '| Date of Birth 09/22/1987 8B F Florida Department of Health Screening Results Department of Health background screening results are not available at this time. This service will be restored in the near future. hitps://apps.ahca.myflorida.com/bgsweb/printresults.aspx 8/31/2011 @ eo STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, - Petitioner, vs. . Case No. 2011006371 CUNNINGHAM ELDERLY, LLC, d/b/a CUNNINGHAM ELDERLY, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency’’), by _ and through the undersigned counsel, and files this Administrative Complaint against CUNNINGHAM ELDERLY, LLC, d/b/a Cunningham Elderly (hereinafter “Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to. impose an administrative fine in the amount of two thousand dollars ($2,000.000) based upon two (2) cited State Class II deficiencies pursuant to Section $429,19(2)(b), Florida Statutes (2010). JURISDICTION. AND VENUE 1, The Agency has jurisdiction pursuant to Sections§§ 20.42, 120.60 and 429.07, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2010). 2. Venue lies pursuant to Fla. Admin, Code R, 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapters 429, Part I, 408, Part II, Florida Statutes, and Chapter 58A-5 Florida Administrative Code, respectively. 4, Respondent operates a 6-bed assisted living facility located at 2909 Courtland Bivd., Deltona, Florida 32738, and is licensed as an assisted living facility license number 10202. 5.» Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. That the Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7, That on May 18, 2011, the Agency conducted an unannounced appraisal visit of the Respondent facility, | 8. That pursuant to Fla, Admin. Code R. 58A-5.0181(1), 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: (a) Have been determined by the facility administrator to be appropriate for admission to the facility, The administrator shall base the decision on: 1, An assessment of the strengths, ‘needs, and preferences of the individual, and the * medical examination report required by Section 429.26, F.S., 9, That pursuant to § 429.26:¢1), Florida Statutes (2010); 1): Fhe owner-or-administrater of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident’s representative or designee or the resident’s family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the department or the Department of Children and Family Services, the administrator must notify the appropriate contact person in the applicable department, 10. That based on resident record review, an interview with staff and resident interview, the . facility failed to ensure that one of three residents. reviewed (#1) was appropriate for admission... to the assisted living facility. 11. A review of Resident #1 records revealed the resident was required to have assistance with medications. 12, The records revealed the resident was diagnosed with Type II Diabetes; 13, The records revealed the resident required routine accuchecks (blood sugar checks) and the administration of insulin by intramuscular injection. 14, The facility did not employ licensed staff to provide this service. 15. An interview with Resident #1 on May 18, 2011 at 3:00 PM revealed that the resident was giving themself insulin and accuchecks, despite the physician having written orders to the contrary, - 16. An interview with.staf€ on May: L8,.2011.at,2:00.PM confirmed, that.the ABCA. Earn... 1823 read the resident required assistance with self-administration of their medications. 17. That the administrator failed to confirm with the medical provider the status of Resident #1's medication assistance needs and admitted a resident to the facility without the ability to meet their needs. 18. That the Agency determined that the above constitutes grounds for the imposition of a Class II deficiency in that it relates to the operation and maintenance of a facility or the personal care of residents which directly threatens the physical or emotional health, safety, or security of resident. 19. That the Agency provided Respondent with a mandatory correction date of May 21, 2011, 20. . That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2010). 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. (2010). COUNT II 21, The Agency re-alleges and incorporates paragraphs one (1) through five (S) of this complaint as if fully set forth herein. ; 22, . That on May 18, 2011, the Agency conducted an unannounced appraisal visit of the Respondent facility. 23. That pursuant to §435.05(1), Florida Statutes (2010), (c) for level 2 screening, the employer or agency must submit the information necessary for screening to the Department of Law Enforcement within 5 working days after receiving it. The Department of Law Enforcement shall perform a criminal history record check of its records and request that the Federal Bureau of Investigation perform a national criminal history record check of its records for each employee for whom the request is made. The Department of Law Enforcement shall respond to the employer or agency, and the employer or agency must inform the employee whether screening has revealed disqualifying information. 24. = That pursuant to §435.05(2), Florida Statutes (2010), (2) Every employee must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer. 25. That pursuant to §408.809(1), Florida Statutes (2010), a level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the following persons, who are considered employees for the purposes of conducting screening under chapter 435: (e) | Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor’s employer or the licensee, 26. That pursuant to §408.809(2), Florida Statutes (2010), (2) Every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in..such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person’s fingerprints to the Federal Bureau of Investigation for a national criminal history record check. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s. 943 .05(2)(g), the person must file a complete set of fingerprints with the agency and the agency shall forward the fingerprints to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints’ to the Federal Bureau of Investigation for a national criminal history record check, The fingerprints may be retained by the Department of Law Enforcement under s. 943.05(2)(g). The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. Proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651 satisfies the requirements of this section if the person subject to screening has not been unemployed for more than 90 days and such proof is accompanied, under penalty of perjury, by an affidavit of compliance with the provisions of chapter 435 -and this section using forms provided by the agency. 27. . That based on employee record review and an interview with staff, the facility failed to document that one of four employees has completed level If background screening (#2). 28. A review of employee records revealed that Employee #2 did not have documentation of Level II background screening, 29. That this was confirmed in an interview with staff on May 18, 2011 at 2:00 PM, 30. That the agency determined that the above constitutes grounds for the imposition of a Class II deficiency in that it relates to the operation and maintenance of a facility or the personal care of residents which directly threatens the physical or emotional health, safety, or security of resident. 31. That the Agency provided Respondent with a mandatory correction date of May 21, 2011. 32. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2010). WHEREF ORE, 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. (2010). | CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1, Makes findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine as set forth above. 3. Orders any other relief authorized by law that is just and appropriate. ear Respectfully submitted this cy day of August, 2011, [ize Me: Vikram Mohan, Senior Attorney Florida Bar No. 49402 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served to Krystal’ Joseph,. Administrator, Cunningham elderly, 2909 Courtland Blvd., Deltona, -Florida 32738 by U.S. Certified Mail, Return Receipt Requested (7003 1010 0000 9715 4747) and to Esther Miles, 2909 Courtland Blvd., Deltona, Florida 32738 by U.S. Mail on this C4 ay of August, 2011. Vikram Mohan, Senior Attorney ‘Copy furnished to: Rob Dickson, FOM 5 US. Postal Service, CERTIFIED MAIL. RECEIPT CLEC EY Only;-No Insurance Coverage Provided) Postage Cottilled Fee Retum Reclept Fea (Endorsement Required) Restioted Delivery Feo (Endorsement Required) Total Postage & Faes 7003 1010 ooo F?L5 4Pyr ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired, @ Print your name and address on the reverse 80 that weigan A Signature ' CX Who My, B. leceived by Printed.Name) D. WSdelivery address different from item 4 If YES, enter delivery address below: return the card to you, to the back of the mailpiece, if space permits, I Certified Mail Express Mail O Registered 0 Return Receipt for Merchandise O insured Mat C1 C.0.0. 4. Restricted Delivery? (Extra Fea) °003 1010 o000 VPLS 4Py? PS Form 3811, August 2001 Domestic Return Receipt 102695-02-M-1035 ! 0 Yes

Docket for Case No: 11-004938