cad STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. Case No. 2012005357 BLOOMFIELD MANOR, INC, d/b/a BLOOMFIELD MANOR Respondent. aT | TRAT. OMPL, COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned coun, and files this Administrative Complaint against the Respondent, Bloomfield Manor, Inc, d/b/a Bloomfield Manor (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of $5,000.00 based upon one State Class II deficiency (Count I) and to assess a survey fee of five hundred dollars ($500,00) (Count Il), The total assessment is for $5,500.00. | JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and Chapters 408, Part Il, and 429, Part I, Florida Statutes (2011). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIE, 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted 1 Filed July 11, 2012 11:57 AM Division of Administrative Hearings living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A- 5, Florida Administrative Code (‘F.A.C.’), respectively. . 4,.. Respondent operates a six bed assisted living facility (‘ALF’) located at 2774 Wesleyan Dr., Palm Harbor, FL 34684, and is licensed as an ALF, license number 9893. 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. co I-CLASS LF 5. The Agency re-alleges and incorporates paragraphs one through five as if fully set forth herein. 6. Florida regulatory law states the following concerning resident care and elopement standards at an ALF: 58A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION, Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts, The resident may travel independently in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed; of any significant changes as defined in . subsection 58A-5,0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. (8) ELOPEMENT STANDARDS (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement shall be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility shall make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention shall be directed towards. residents 2 assessed at high risk te elopement, with special attention aiven to those with Alzheimer’s disease and related disorders assessed at high risk. Rule 58A-5.0182, F.A.C. 7. Acomplaint survey, CCR # 2012000332, was performed on 9 February, 2012, in conjunction with a biennial state licensure survey of this ALF with extended congregate care. 8. The Agency’s surveyor reviewed facility records and interviewed facility staff and determined that the facility failed to provide adequate supervision to ensure the health and safety of a vulnerable 97 year old female resident, which resulted in her eloping from the facility in the early morning hours on 5 January, 2012, a very cold morning where tlie temperature dropped to as low as 39-42° F. She was found early that morning by law enforcement with a broken nose and bruised eyes. She had no identification on her and she was too confused to state her name. She was identified by law enforcement only after the caregiver called law enforcement at between 7.00 — 7:45 am to report the missing resident, 9. The following information was learned from the records review and staff interviews ducing the Agency’s survey: a. This resident was admitted to the facility as a respite (short stay) resident by her-son on 1/1/12 to stay for a week while he was going to be away. b. A formal health assessment was not required for respite care for a stay of less than 30 days. The facility administrator/owner’s brief notes indicated that he had asked the son questions about his mother’s routine, behaviors, diet, and her general needs regarding her activities of daily living, The notes included no milk, no smoking, some confusion, no wandering, regular diet, no falling and supervision with dressing. He listed her age as 97. c. Additional unsigned handwritten notes on resident observation log sheets stated that she was confused, and she had stated that she was leaving and her son was going to come and _ get her. ) . When the administrator came to the facility on 1/1/12, he and the live in caregiver (#1) (she stayed there five days a week) agreed to activate the front ‘door alarm as a preventative step because of this particular resident's confusion. This was done the following day. There was no documentation of a plan to provide closer supervision. After the new door. alarm was installed the: next day, there was no documentation indicating that this resident had ever gone out the door and set off the alarm but it was documented that she continued to be confused and kept saying she was going to leave, that her son was coming for her. After a day of the alatm going off frequently due independent residents coming and going, the caregiver removed it the next day, 1/3/12, and contacted the administrator to let him know. The administrator acknowledged during his interview that he had been contacted as indicated by this caregiver. This caregiver said that she removed the door alarm because residents said it bothered them. Additionally, she did not see exit seeking behaviors from this respite resident, only confusion, and she stayed in the living room and kept a close eye on her. However, the caregiver did describe seeing the resident going from toom to room, touching different doors and having difficulty finding the restroom. At one point duting the night, the caregiver heard noise from the resident’s room and found her fooling with her travel bag which she had put on top of her bed. She described the inability of the resident to follow simple commands such as putting on clean clothes that had been selected for her to put on after she showered. Instead, she put on the same clothes she had worn previously. Her appetite was described as good. . The caregiver further stated that she had verbally briefed the incoming replacement staff member (caregiver #2) on 1/4/12 before getting off at 9:00 am. She did not mention ' anything to her replacement about the door alarm being activated and then deactivated 4 iy . but she did relate that the resident was confused. She did not say that this resident needed more supervision than the other residents. There were no written notes in the resident's file to describe for the benefit of the replacement the behaviors that had been observed that would have called for constant supervision or possible discharge to a higher level of care than could be provided at this facility. i, A confidential interview during the survey with a different resident revealed he had heard and felt someone touch his feet during the early hours of 1/5/12 and thought it was a burglar in his room but then realized it was the respite resident who immediately left his room, He recalled this happening between 3:00 - 3:30 am. He said he got up and rolled into the living room and found the caregiver (#2) asleep on the chair. Shortly after that he said he heard noises coming from behind his closet where the respite resident's closet backed up to his but the noises stopped and he did not think any more about it. He said the caregiver (#2) came into his room sometime around 5:00 am he thought and asked him if he had seen the respite resident. He told her that he had not seen her since earlier that morning when she had come into his room. He said the caregiver then began a full search. | Review of the 1 day and 15 day Adverse Incident reports submitted on 1/15/12 and "2/5/12 (submitted late and cited as a separate deficiency) revealed the respite renident was discovered missing on 1/5/12 at approximately 7:30 am at which time the administrator was notified. By that time, the resident had already been picked up by law enforcement and taken to a nearby hospital with a fractured nose, . Review of the facility's elopement drills revealed they were completed timely. Caregiver #1’s personnel file reflected all required training, ) 1, Caregiver #2’s personnel! file was missing so it could not ve reviewed. The administrator thought that that caregiver might have taken it from his office when she returned for the rest of her personal items on 1/20/12 after being terminated on 1/5/12. 10, The. information set forth above reflects Respondent’s failure to ensure care and services appropriate to the needs of a resident accepted for admission to the facility including personal supervision where Respondent knew of or should have known of the resident’s confusion, tisk of elopement, and possible injury, but nevertheless deactivated the alarm needed to ensure the continued safety of an obvious at-risk resident. 11. 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 violations. 12. The same constitutes a State Class II offense, defined as follows: ; . 408.813 Administrative fines; violations,—As a penalty for any violation of * + this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. (2) Violations of this. part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients, ... Violations shal! be classified on the written notice as follows: (bo) Class “II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an administrative fine as provided by law for a cited class II violation. A fine shall be levied notwithstanding the cotrection of the violation. Section 408.813, Florida Statutes (2011) 13. The fine for a Class II violation is set forth as follows: ! 429.19 Violations; imposition of administrative fines; grounds. (1) In addition to the requirements of part Il of chapter 408, the agency shall i impose an administrative fine in the manner provided in chapter 120 for the : violation of any provision of this part, part Il of chapter 408, and applicable rules : by an assisted living facility, for the ... actions of a facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a 6 ) resident of the facility. (2) Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents, The agency shall indicate the classification on the written notice of the violation as follows: a } (b) Class “I?” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. (3) 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 hatm 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, ; (e) The licensed capacity of the facility. (1) In addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $500; to cover the cost of conducting initial complaint investigations that result in the finding of a violation that- was the subject of the complaint or monitoring visits conducted under s. 429.28(3) (c) to verify the correction of the violations. Florida Statute 429.19, Florida Statutes (2011). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an ALF in the State of Florida, pursuant to Section 429.19 (2) (b) and (3), Florida Statutes (2011). COUNT I- ASSESSMENT OF A SURVEY FEE 14. The Agency. re-alleges and incorporates paragraphs 1 through 5 and Count I as if fully set forth herein, 15. Pursuant to Section 429.19 (7), Florida Statutes (2011) (paragraph 13 above), in addition to any administrative fines imposed, the Agestcy 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, to verify the correction of the violations. 16. The citation of the Class II deficient practice based on the 9 February, 2012, survey was the subject of a complaint. 17. Respondent is therefore subject to a survey fee of $500.00, pursuant to Section 429.19 (7), Florida Statutes (2011). WHEREFORE, the Agency intends to impose a survey fee of $500.00 against Respondent, an ALF in the State of Florida, pursuant to Section 429.19 (7), Florida Statutes (2011). Submitted this ? day of June, 2012. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building §25 Mirror Lake Dr. N., Suite 330H St. Petersburg, FL 33701 Ph: (727) 552-1942 Fax: 552-1440 By: Chee Q : Edwin D. Selby, Esq. Fla, Bar No. 262587 Attorney for Petitioner NOTICE OF RIGHTS 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 ave 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) 412-3630, CERTIFICATE OF SERVICE IHEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. A. Certified Mail, Return Receipt No. 7003 1010 0001 3600 4491 on June 7 , 2012, to Haifa Harb, Administrator and Registered Agent, Bloomfield Manor, 2774 Wesleyan Dr., Palm Harbor, FL 34684, Chet oO, Edwin D. Selby, Esq. Copy furnished to: Patricia Caufinan, Field Office Manager, Area 5/6, AHCA ) | STATE OF FLORIDA / AGENCY FOR HEALTH CARE ADMINISTRATION RE: Bloomfield Manor, Inc., d/b/a Bloomfield Manor CASE NO. 2012005357 ELE F ‘This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint, If your Election of Rights with your selected option is not received by ANCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158, PLEA, LEC V1 3 OPTIO, OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing, I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced, OPTION THREE (3)___——iI- dispute the allegations of fact contained in the Notice of Intent . to Empose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing, You also must file a written petition in order to obtain a formal heating before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. Tt must be received by the Agency Clerk at the address above within 21 ous of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4,. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, : : License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC | i 1 | | 1 { i i . USPS.com® - Track & Confirm ‘English Customer Servive UAPS Mobile ta USPSCOW Quick Toots. Ship a Package Send Mail Track &. Confirm GETEMAIL UPDATES PRINT DETAILE YOURLABEL HUBER service ‘STATUS OP YOUR ITEM 70031010000136004401 Delivered Processed though USPS Son Facitty Check on Another Item What's your label (or recefpt) number? , Find LEGAL ON USPS.COM Privacy Polley » Government Services + Terms of Use > Buy Stamps & Shdp » FOIA) Printa Lobel with Postage > No FEAR Act REO Data» . Customer Service > Site Index » Copyright® 2012 USPS. All Rights Reserved. Manage Your Mall DATH & TIME dune 09, 2042, 12:61 pm shine 08, 2012, 1:23 ern ON ABOUT.USP8.COM ‘Ahout USPS Hone > Newsroom > Mell Service Updates > Foms & Pubticalons » Careeray https://tools.usps.com/go/TrackConfirmAction.action Page 1 of'1 Register / Sign ia Search USPS.com of Track Packages Shop Business Solutions Locanon FEATURES PALM HARBOR, Fi, 84684 Certified MuiI™ TAMPA, FL 33630 ‘OTHER USPS STS ‘Business Customer Gateway » Postal Inspectors » Inspector General » Postal Explorer > 07/06/2012

Docket for Case No: 12-002335

Orders for Case No: 12-002335