Feb, 2. 2013 3:11PM = The Health Law Firm — No. 4604. P14 STATE OF FLORIDA» AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No,; 2012010592 Ve. ARCADIA ENTERPRISES INC, d/b/a PINE ACRES GOLDEN AGE CENTRE, Respondent, / ADMINISTRATIVE COMPLAINT The Agency for Health Care Administration (hereinafter “Agency”, by and through the undersigned counsel, files this Administrative Complaint against Arcadia Enterprises Inc, d/b/a Pine Acres Golden Age Centre (hereinafter “Respondent” or “facility”), pursuant to Section 120.569, and 120.57, Florida Statutes, (2012), and alleges: , NATURE OF THE ACTION . This is an action for revocation of the facility's Extended Congregate Care (“ECC”) license and to impose an administrative fine in the amount of four thousand dollars ($4,000.00) based. upon three (3) State Class IT deficiencies pursuant to §429, 19(2)b), Florida Statutes (2012), JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to §§ 20,42, 120,60 and Chapters 408, Part IY, and 429, Part I, Florida Statutes (2012). | 2. Venue lies pursuant to Fla. Admin. Code 8. 28-106.207, Feb, 7 2013 3:11PM . The Health Law Firm . Mo 4604 PL 15. 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 facilides pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4, Respondent operates a 17-bed assisted living facility located at 3030 Cub Lake Drive, Apopka, Florida 32703, and is licensed as an assisted living facility, license number 6106, with extended. congregate care (“ECC") services specialty licensure. 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- A0077 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 1 Pursuant to Florida law: Staffing Standards (1) ADMINISTRATORS. Every facility shall be under the supervision of an adrninistrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required. by Part I of Chapter 429, F.5., and this rule chapter. Fla, Admin, R, 584-5.019 wee License reqnized; fee (1) The requirements of part IL of chapter 408 apply to the provision of services that require licensure pursuant to this part and part IT of chapter 408 and to entities licensed. by or applying for such licenstire from the agency pursuant to this part, A license issued by the agency is required in order to operate an assisted living facility in this state. 2 Feb, 7, 2013 3:12PM = The Health Law Firm - . , No 4604 . (2) Separate licenses shall be required for facilities maintained in separate prernises, even though operated under the same management, A separate license shall not be required for separate buildings on the same grounds, (3) In addition to the requirements of s. 408,806, each license granted by the agency must state the type of care for which the license is granted, Licenses shall be issued. for one o more of the following categories of care: standard, extended congregate care, limited nursing services, or limited mental health. (a) A standard license shall be issued to facilities providing one of more of the personal services identified in s, 429,02, Such facilities may also employ or contract with a person licensed under part I of chapter 464 to administer medications and perform other tasks as specified in 8,429,255. (b) An extended. congregate care license shall be issued to facilities providing, directly or through contract, services beyond those authorized in paragraph (a), including services performed by persons licensed under part I of chapter 464 and. supportive services, as defined by rule, to persons who would otherwise be disqualified from continued residence in a facility Licensed under this part. 1. In order for extended. congregate care services to be provided, the agency must first determine that all requirements established in law and rule are met and must specifically designate, on the facility's license, that such services may be provided and whether the designation applies to all or part of the facility. Such designation may be made at the time of initial licensure or relicensure, or upon request in writing by a licensee under this part and part II of chapter 408. The notification of approval or the denial of the request shall be made in accordance with part II of chapter 408. Existing facilities qualifying to provide extended congtegate care services must have maintained a standard license and may not have been subject to administrative sanctions during the previous 2 years, or since initial licensure if the facility has been licensed for less than 2 years, for any of the following reasons: a. A class I o class TI violation; b, Three or more repeat or recurring class III violations of identical or similar resident care standards from which a pattern of noncompliance 1s found by the agency; 16 Feb. 7, 2013. 3:12PM The Health Law Firm No. 4604 ¢. Three or more class Til violations that were not corrected in accordance with the corrective action plan approved by the agency; d. Violation of resident care standards which results in requiring the facility to employ the services of a consultant pharmacist or consultant dietitian; e, Denial, suspension, or revocation of a license for another facility Licensed under this part in which the applicant for an extended congregate care license has at least 25 percent ownership interest; of f. Imposition of a moratorium pursuant to this part or part II of chapter 408 or initiation of injunctive proceedings.. 2. A facility that is licensed to provide extended congregate care services shail maintain a written progress report on each person who receives services which describes the type, amount, duration, scope, and outcome of services that are rendered and the general status of the resident's health. A registered nurse, or appropriate designee, representing the agency shall visit the facility at least quarterly to monitor residents who are receiving extended congregate care services and to determine if the facility is in compliance with this part, part IT of chapter 408, and relevant rules. One of the visits may be in conjunction with the regular survey. The monitoring visits may be provided through contractual arrangements with appropriate community agencies, A registered nurse shall serve as part of the team that inspects the facility. The agency may waive one of the required yeatly monitoring visits for a facility that has been licensed for at least 24 months to provide extended congregate care services, if, during the inspection, the registered nurse determines that extended congregate care services are being provided appropriately, and if the facility has no class I or class Il violations and no uncorrected class TI violations. The agency must first consult with the long-term care ombudsman council for the area in which the facility is located to determine if any complaints have been made and substantiated about the quality of services or care. The agency may not waive one of the required yearly monitoring visits if complaints have been made and substantiated, Feb, 2 2013 3:12PM = The Health Law Firm, . No. 4604 3. A facility that is licensed to provide extended congregate care services must: a, Demonstrate the capability to meet unanticipated resident service needs. b, Offer a physical environment that promotes a homelike setting, provides for resident privacy, promotes resident independence, and allows sufficient congregate space as defined by rule, c. Have sufficient staff available, taking into account the physical plant and fixe safety features of the building, to assist with the evacuation of residents in an emergency. d, Adopt and follow policies and procedures that maximize tesident independence, dignity, choice, and decision making to permit residents to age in place, so that moves due to changes in fictional statis are minimized or avoided. e, Allow residents or, if applicable, a resident's representative, designee, surrogate, guardian, or attorney in fact to make a variety of personal choices, participate in developing service plans, and share responsibility in decision making. f, Implement the concept of managed risk, g. Provide, directly or through contract, the services.of a person licensed under part I ofchapter 464, h. In addition to the training mandated in s, 429.52, provide specialized training as defined by rule for facility staff. 4. A facility that is licensed to provide extended congregate care services is exempt from the criteria for continued residency set forth in rules adopted under s. 429.41, A licensed facility must adopt its own requirements within guidelines for continued residency set forth by rule. However, the facility may not serve residents who require 24-hour nursing supervision. A licensed facility that provides extended congregate care services must also provide each resident with a written copy of facility policies governing admission and retention. Feb, 7. 2013) 3:13PM The Health Law Firm mo, No. 4604 5. The primary purpose of extended congregate care services is to allow residents, as they become more impaired, the option of remaining in a familiar setting from which they would otherwise be disqualified for continued residency, A facility licensed to provide extended congregate care services may also admit an individual who exceeds the admission criteria for a facility with a standard license, if the individual is determined appropriate for admission to the extended congregate cate facility. ‘ 6. Before the admission of an individual to a facility licensed to provide extended congregate care services, the individual must undergo a medical examination as provided in s. 429.26(4) and the facility must develop a preliminary service plan for the individual. 7, When a facility can no longer provide or arrange for services in accordance with the resident's service plan and needs and the facility's policy, the facility shall make arrangements for relocating the person in accordance with 8, 429.28(1)(k). 8. Failure to provide extended congregate care services may result in denial of extended congregate care license renewal. Section 429.07, Fla, Stat. (2012) wee Extended Congregate Care Services (1) LICENSING. .. (a) Any facility intending to establish an extended congregate care program must meet the license requirements specified in Section 429.07, F.S., and obtain a license from the agency in accordance with Rule 58A-5.014, F.A.C, (b) Only that portion of a facility which meets the physical requirements of subsection (3) and which is staffed in accordance with subsection (4) shail be considered licensed to provide ECC services to residents which meet the admission and continued residency requirements of this rule. (5) ADMISSION AND CONTINUED RESIDENCY. (a) An individual must meet the following minimum criteria in order to be admitted to an extended congregate care program. 6 Feb. 7. 2013. 3:13PM The Health Law Firm - No. 4604 1. Be at least 18 years of age. 2. Be free from signs and symptoms of a communicable disease which is likely to be transmitted to other residents or staff; however, @ person who has human immunodeficiency virus (ATV) infection may be admitted to a facility, provided that he would otherwise be eligible for admission according to this rule, 3. Be able to transfer, with assistance if necessary, The assistance of more than one person js permitted. 4, Not be a danger to self or others as determined by a health care provider, ot mental health practitioner licensed under Chapter 490 or 491, FS, 5. Not be bedridden. 6. Not have any stage 3 or 4 pressure sores. 7. Not require any of the following nursing services: a. Oral or nasopharyngeal suctioning; - b, Nasogastric tube feeding; c. Monitoring of blood gases; d, Intermittent positive pressure breathing therapy; é. Skilled rehabilitative services as described in Rule 59G-4,290, FAC, or oO f, Treatment of a surgical incision, untess the surgical incision and the condition which caused it have been stabilized and a plan of care developed, 8. Not require 24 hour nursing supervision. 9, Have been determined to be appropriate for admission to the facility by the facility administrator. The administrator shall base his/her decision on: a. An assessment of the strengths, needs, and preferences of the individual, the health assessment required by subsection (6) of this rule, and the preliminary service plan developed under subsection (7); 7 . 0 Feb, 1 2013) 3:13PM: The Health Law Firm. No. 4604 b, The facility's residency criteria, and services offered or arranged for by the facility to meet resident needs; and. c, The ability of the facility to meet the uniform fire safety standards for assisted living facilities established under Section 429.41, F.S., and Rule Chapter 694-40, FAC. (b) Criteria for continued residency in an ECC program shall be the same as the criterla for admission, except a8, follows: 1, A resident may be bedridden for up to 14 consecutive days. 2. A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: a, The resident qualifies for, is admitted to, and consents to the services of a licensed hospice which coordinates and ensures the provision of any additional care and services that may be needed; b, Continued residency is agreeable to the resident and the facility; ¢, An interdisclplinary care plan is developed. and implemented by a licensed hospice in consultation with the facility. Facility staff may provide any nursing ' service within the scope of their license including 24- hour nursing supervision, and total help with the activities of daily living; and d, Documentation of the requitements of this subparagraph is maintained in the resident's file, (6) HEALTH ASSESSMENT. Prior to admission to an ECC program, all persons, including residents transferring within the same facility to that portion of the facility licensed to provide extended congregate care services, must be examined by a physician or advanced registered nurse practitioner pursuant to Rule 58A-5,0181, F.A.C. A health assessment conducted within 60 days prior to admission to the ECC program shall meet this requirement, Once admitted, a new health assessment must be obtained at least annually. Fla. Admin. R. 58A-5.030 P, 2 Feb. 7, 2013 A 13PM The Health Law Firm No. 4604 8. On August 28, 2012, the Agency completed biennial re-licensure survey of the Respondent facility and found the facility out of compliance with the above Rule, 9, Based upon record review and interviews, the administrator failed to assure the appropriate operation and maintenance of the facility, including proper Extended Congregate Care services (ECC) admission of a resident who needed ECC services, Findings included: During the entrance conference, the administrator, who was also the ECC nurse, said there were no residents receiving ECC services. But during an interview, a direct-care staff member said Resident #4, who had been admitted. on July 18, 2012, had a feeding tube and was receiving assistance from the ECC nurse with tube feedings and site management. During an interview, the administrator/ECC nurse admitted that she administered the resident's tube feedings 4 times a day, However, physician’s ofders regarding the PEG tube! and tube feedings were lacking, She said she was not aware that the resident needed to be on ECC. She further admitted that no admission documents for the ECC program had been completed, A July 18, 2012, resident transfer summary from a Skilled Nursing Facility (SNF) to the ALF stated that the reason for transfer was the resident did not need the SNF if the ALF was able to provide the tube feeding. This was the only documentation that the facility had regarding the feeding tube, No documentation was found showing that the facility had admitted the resident to'the ECC program, The administrator could not locate the resident's Form 1823 but said that she “previously had a copy.” The guardian had requested. copies and might have taken the 1823 from the facility, She cafled the resident's pharniacy and requested that they fax a copy of page 4 which listed the resident's medications, Page 4 of the 1823 was dated July 19, 2012. Pages 1, 2 and 3 were unavailable, Page 4 of the 1823 revealed a physician's order dated July 18, 2012 as follows: ° Nutren (ibe feeding) 2 cans 250. milliliters via gastric tube 4 times a day for nutrition ‘Florida Administrative Rule 5,0185(8) makes all nutraceuticals, including Nutren (the tube feeding product being used for this resident) “over-the-counter products” (“OTCs”) that must bs treated like medloations and must be labeled with the resident's name and the manufacturer's label with directions for use or the licensed health care provider's directions for use, ee Feb, 7. 2013: 3:14PM = The Health Law Firm: - No 4604 P ’ The resident is to receive nothing by mouth e Flush gastric tube with 200 ml of water twice a day , Gastric tube site care daily, cleanse with normal saline, pat dry, apply triple antibiotic ointment, cover with (unable to read) sponge, secure with tape every shift and as needed. 10. The facility's failure to require its administrator to comply with the requirements in Chapter 429 and the above Rule regarding services provided to Resident #4, including appropriately admitting the resident to BCC and having accurate written physician orders for the tube feedings and site care, is unacceptable and a violation of Florida law. 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 Class IT offense as defined at Section § 429,19(2)(b), Florida Statutes (2012). | WHEREFORE, the Agency intends to impose an administrative fine in the amount of two thousand dollars ($2,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section § 429.19(2)(b), Florida Statutes (2012), COUNT II ~ AE206 13. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 14. Pursuant to Florida law: (7) SERVICE PLANS. (a) Prior to admission the extended congregate care supervisor shall develop a preliminary service plan which includes an assessment of 10 2B Feb, 7 2013 3:14PM = The Health Law Firm ; : No. 4604° P. 24 whether the resident meets the facility's residency criteria, an appraisal of the resident's unique physical and peycho social needs and preferences, and an evaluation of the facility's ability to meet the tesident's needs. (b) Within 14 days of admission the congregate care supervisor shall coordinate the development of a written service plan which takes into account the resident's health assessment obtained pursuant to subsection (6); the resident's unique physical and. psycho social needs and preferences; and how the facility will meet the resident's needs including the following if required: 1. Health monitoring; . 2. Assistance with personal cate services; 3, Nursing services; 4, Supervision; 5, Special diets; 6. Ancillary services; 7, The provision of other services such as transportation and supportive services; and 8, The manner of service provision, and. identification of service providers, including family and friends, in keeping with resident preferences, (c) Pursuant to the definitions of “shated responsibility” and “managed risk” as provided in Section 429,02, F.S., the service plan shall be developed and agreed upon by the resident or the resident's Tepresentative or designee, surrogate, guardian, or attomey-in-fact, the facility designee, and shall reflect the responsibility and right of the resident to consider options and assume risks when making choices pertaining to the resident's service needs and preferences. (d) The service plan shail be reviewed and updated quarterly to reflect any changes in the manner of service provision, accommodate any changes in the resident's physical or mental status, or pursuant to recommendations for modifications in the resident's care as documented. in the nursing assessment. (9) RECORDS. Feb, 7 2013 3:14PM ~The Health Law Firm 15. {a} In addition to the records required under Rule $84-5.024, F.A.C., an extended congregate care progrdm shall maintain the following: 1. The service plans for each resident receiving extended congregate care services; Fla, Admin, R, 58A-5.030 On August 28, 2012, the Agency completed biennial re-licensure’survey of the Respondent facility and found the facility out of compliance with the above Rule. - 16, service plan for the resident who was receiving PEG tube feedings and medications through Based on observation, record Teview and interviews, the facility lacked. a pieliminary the PEG tube. Findings included: 17. During the entrance conference, the administrator, whe was also the ECC nurse, said there were no residents receiving ECC services. But dusing an interview, a ditect-care staff member said Resident #4 had a feeding tube, The direct care staff member took the surveyor to the kitchen to show her cases of Nutren (gastric tube feeding), 250 ml, botiles in a closet, She explained that the administrator/EHCC nurse administers tube feedings to Resident #4. Resident #4 was admitted on July 18, 2012, but there was no AHCA, Form 1823 in the file, The July 18, 2012, resident transfer summary from the Skilled Nursing Facility (SNF) to the ALF stated that the reason for transfer was the resident did not need the SNF ifthe ALF was able to provide the tube feeding, This ‘was the only documentation the facility had that indicated the resident had a | feeding tube. During an interview, the adrainistrator/ECC nurse admitted that there was no documentation completed for services in the ECC program. There was no documentation found to indicate that the facility had or developed a preliminary ECC service plan to address how the facility would meet the resident's physical and psychosocial needs with attention to the care necessary for the PEG tube site, for administering PEG tube feedings or medications via the PEG tube. The facility's failure to develop and keep a preliminary service plan in the files for the resident who was receiving PEG tube feedings is a violation of Florida law. 12 No. 4604 P05 Feb, 7, 2013 3:15PM The Health Law Firm’ . No. 4604 P 18, 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, ot security of the clients, other than class I violations, 19, The same constitutes a Class II offense as defined at Section § 429.19(2)(b), Florida Statutes (2012), ) 26 WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars (61,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section § 429,19(2)(b), Florida Statutes (2012). COUNT 20. The Agency re-alleges and incorporates paragraphs (1) through (8) and paragraph (9) in Count I as if fully set forth herein. 21, Pursuant to Florida law: (8) EXTENDED CONGREGATE CARE SERVICES. All services shall be provided. in the least restrictive environment, and in a manner which respects the resident's independence, privacy, and dignity, (a) An extended congregate care program may provide supportive services including social service needs, counseling, emotional support, networking, assistance with securing social and leisure services, shopping service, escort service, companionship, family support, information and referral, assistance in developing and implementing selfdirected activities, and volunteer services, Family or friends shall be encouraged to provide supportive services for residents. The facility shall provide training for family or friends to enable them to provide supportive services in accordance with the resident's service plan, (b) An extended congregate care program shall make available the following additional services if required by the resident's service plan: 1. Total help with bathing, dressing, stooming and toileting; 2, Nursing assessments conducted more frequently than monthly; 13 Feb. 7. 2013 3:15PM = The Health Law Firm No. 4604 3, Measurement and recording of basic vital functions and weight; 4, Dietary management including provision of special diets, monitoring nutrition, and observing the resident's food and fluid intake and output; | 5, Assistance with self-administered medications, or the administration of medications and treatments pursuant to a health care provider's order, Ifthe individual needs assistance with self-adininistration the facility must inform the resident of. the qualifications of staff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain _ the resident's or the resident's surrogate, guardian, or attorney- in-fact's informed consent to provide such assistance as required under Section 429.256, F.S.; 6. Supervision of residents with dementia and cognitive impairments; 7. Health education and counseling and the implementation of health-promoting programs and preventive regimes; 8. Provision or atrangement for rehabilitative services; and 9. Provision of escort services to health-related appointments, (c) Licensed nursing staff in an extended congregate care program may provide any nursing service permitted within the scope of their license consistent, with the residency requirements of this rule and the facility's written policies and procedures, and the nursing services are: 1, Authorized by a health care provider's order and pursuant to a plan of care; 2. Medically necessary and appropriate for treatment of the resident's condition; 3, In accordance with the prevailing standard of practice in the nursing community; 4, Aservice that can be safely, effectively, and efficiently provided in the facility; 5. Recorded in nursing progress notes; and 4 Feb, 7 2013 3:15PM The Health Law Firm No. 4604 =P 22. 6, In accordance with the resident's service plan, (d) At least monthly, or more frequently if required by the resident's service plan, a nursing assessment of the resident shall be conducted. (9) RECORDS. (a) In addition to the records required under Rule 58A-5.024, F.A.C., an extended congregate care program shall maintain the following: 2. The nursing progress notes for each resident receiving nursing services: [and] 3. Nursing assessments Fla. Admin, R, 58A-5.030 On August 28, 2012, the Agency completed biennial re-licensure survey of the Respondent facility and found the facility out of compliance with the above Rule, 23, Based. on observation, record review and interviews, the facility was not providing the required monthly nursing assessment; nor did it have nursing progress notes for each time the services were delivered. Findings included: During the entrance conference, the administrator, who was also the ECC nurse, said there were no residents receiving ECC services. But during an interview, a direct-care staff member said Resident #4 had a feeding tube. The direct care staff member took the surveyor to the kitchen to show her cases.of . Nutren (gastric tube feeding), 250 ml, bottles in a closet. She explained that the administrator/ECC nurse administers tube feedings to Resident #4, The July 18, 2012, resident transfer summary from the Skilled Nursing Facility (SNF) to the ALF stated that the reason for transfer was the resident did not need the SNF if the ALF was able to provide the tube feeding, This was the only current documentation the facility had that indicated the resident had a feeding tube. Nursing notes documenting the tube feedings and site management were lacking. Also there were no written monthly nursing assessments in the files. At 12:20 PM, the surveyor observed the ECC nurse (Administrator) administer the Nutren, The schedule, she said, was 8:30 AM, 12 PM, 5PM and 8:30 PM. Each time she administered two (250 ml) cans of the Nutren 15 . 28 Feb, 7. 2013 3:15PM = The Health Law Firm ; No. 4604 =P. 29 liquid through the resident's PEG tube, using a syringe. She said she flushed the tube each time with 8 oz. or 240 ml, water. , She crushed the resident's medications and administered them through the tube with water. As the Nutren was very thick, she added water during the feeding. She had obtained a verbal order from the resident's physician, she said, but she did not document the order. She explained that the resident did not speak ‘Ee acknowledged thatthe understood the tube feeding process and tried to assist, "He was later observed ambulating about the facility. During a phone interview, the resident's physician confirmed the Nutren order and. that 8 oz. water was to bé given at éach of the four feedings. He said he did not sign the AHCA form 1823 for the resident, However, he would send written orders for the facility’s files. The PEG tube had a gauze dressing at the site, The ECC nurse/ Administrator explained that she washed the PEG tube site with soap and water and applied a dry 4x 4 dressing, She explained that there was no infection and, thus, “wound cate” as it is usually understood was unnecessary. The only order she had, she said, was for wound care 3x/day and as needed. No nursing progress notes had been cornpleted for the procedure, 24, — The facility's failure to keep written documentation of physician orders for the tesident with PEG tube feedings and site care; to keep nursing notes documenting services delivered; and to perform and keep records of the required monthly nursing assessment is a violation of Florida law. . 25. 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. 26. The same constitutes a Class II offense as defined at Section § 429.19(2)(b), Florida Statutes (2012). WHEREFORE, the Agency intends to impose an administrative fine in the amount 16 Fed, 7. 2013 3:16PM The Health Law Firm - No. 4604, P | 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), Florida Statutes (2012). NOTICE OF RIGHTS 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 Cave Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32508; Telephone (850) 412-3630, RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE — ENTRY OF A FINAL ORDER BY THE AGENCY. . CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S, Certified Mail, Delivery Confirmation Receipt No. 7011 0470 0000 7951 2985 to Theresa E, Morris, Registered Agent for Arcadia Enterprises Inc., 9748 Cub Cove, Apopka, FL 32703-1942 and to Theresa E. Morris, Administrator, Pine Acres Golden Age Centre, 5030 Cub Lake Drive, Apopka, FL 32703, this Whe January; 2013. FLORIDA AGENCY FOR HEALTH ARE ADMINISTRATION 525 Mittor Lake Drive, 330K. St. Petersburg, FL 33701 Office: (727) 552-1945 Fax: (727) 552-1440 Copies furnished to: Lorraine Henry | . 30 Feb, 7, 2013 3:16PM = The Health Law Firm No. 4604 P31 PRINTED: Gayt3/2012 FORMAPPROVED (TEMENT OF DEFICIENCIES TA S) PROVIDERISUPPLIERGLIA RAT OE DEriClENG Ot) PROVDERVBUPRLIERVOLY 0X2) MULTIPLE CONSTRUCTION A BUILDING ALI911910 5. WING NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODER PING ACRES GOLDEN AGE GENTRE eee (41D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION of PREFIX (EACH DEFIGIENGY MUST BE PRECEDED BY FULL PREFIA {BACH CORRECTIVE ACTION SHOULD BE GOMPLETE TAG REGULATORY OR L8G IDENTIFYING INFORMATION) TAG ileal tA ahi DATE Initial Comments AN00 Ablannial re-lieansura survey was conducted on 08/28/12. The Assisted Living Facillly had deficlencies fourid at the time of the visit. A008) 8BA-8.0484 (2) FAG Admissions - Health Assessment @ HEALTH ASSESSMENT. As part of the {admission criteria, an individual must undergo a face-to-face medical examination completed by a licensed health care provider, as specified in elther paragraph (a) or (b) of this subsection. (a) Amadical examination completed within 80 calendar days prior to the individual's admission to a facility pursuant to Section 429,28(4), F.8, ‘The examination must address the following: 1, The physical and mentat status of the resident, Including the Identification of any health-related problems and functional limitations; 2. An evaluation of whether the individual will require supervision or assistance with the activities of daily living; 3. Any nursing or therapy services required by the Individual; 4. Any spacial diet required by the individuat 5. Alist of current medications presoribed, and whether the individual will require any assistanee | with the administration of medication; 6, Whether the individual has signs or symptoms of a communicable disease which Is likely fo ba tranamllted to other residents or staff; 7. Astatement on the day of the examination that, in the opinion of the examining Isensed health care provider, the individual's needs can be met in an assisted living facility; and §, The date of tha examination, and the name, ' signature, address, phone number, and llkense umber of the examining licensed health care provider, The medical examination may be ARCA Form 3020-0001 a ‘ LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIEN REPRESENTATIVE'S BIGNATURE Feb, 7, 2013 3:16PM = The Health Law Firm No. 4604 =P. 3? PRINTED: 08/19/0012 FORM APPROVED Agency for Health Cara Administration STATEMENT OF DEFICIENGIES AND PLAN OF CORRECTION O41) PROVIDER/SUPPLIER/CLIA (IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUOTION ALt1911910 NAME OF PROVIDER OR SUPPLIER PINE ACRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, 2)F CODE 5030 CUB LAKE DRIVE APOPKA, FL $2703 ID SUMMARY STATEMENT OF DEFICIENCIES io | PROVIDER'S PLAN OF CORRECTION pi EACH DEFICIENCY MUST SE PRECEDED BY FULL PREFIX EAGH CORRECTIVE ACTION SHOULD BB TAG EGULATORY OR L8G IDENTIFYING INFORMATION} TAG O8S-REFERENGED 10 THR APPRGPRIATE A008 | Continued From page 1 condueted by a currently lleensed health care provider from another state. ’ (b} Amedical examination completed aftar the resident's admission to the facllity within 30 calendar days of the admission date, The examination must be tacordad on AHCA Form 1828, Resident Health Assessment for Assiatad Living Facilities, October 2010, The form is hereby incorporated by reference. A faxed copy ofthe complated form is acceptable, A copy of AHCA Form 1823 may be obtatned from the Aganay Central Office or its website at www. fdho, state. fl. uwMCHQ/Long_Term_Care/ shitpi/Avww. dhe, state f.us/MCHG/Long_Term_C aral> Assisted_jiving/pdffAHCA_Form, 1823%.paf, The form must be cornpleted as follows: 1. The resident! 5 licensed health care provider must complete all of (he required Information in Sections 1, Health Assessment, and 2, Self-Care and General Oversight Assessment, @. Items on the form that may have been omitted by the licensed health care provider during the examination do not necessarily require ari additional face-to-face examination for completion, b, The facility may abtain the omitted information elther verbally or in writing from the licensed health care provider, ©, Omitted information reselved verbally must be documented In the resident's record, including the name of the llcansed health care provider, the name of the facility staff recording thé information and the date the information was provided, 2. The facility administrator, or designee, must complete Section 3 of the form, Services Offered or Arranged by the Facllity, or may use electronic documentation, which at a minimum includes the élements in Section 3, This requirement does hot apply for residents receiving: AHCA Form 3020-0001 STATE FORM an FEUSIE ifoontnuation shaat 2 of 44 Feb, 7, 2013 3:17PM = The Health Law Firm No. 4604 P. 33 Se Agency for Hes iatrati OVED STATEMENT OF DEFICIENCIES AND PLAN OF GORRECTION 4) PROVIDERIGUPPLIER/GLIA IDENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION ALI1941310 NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE PINE AGRES GOLDEN AGE CENTRE Fccaeree are Ka) ID ‘SUMMARY STATEMENT OF DEFIGIENGIES PROVIDER'S FLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (BAGH GORREOTIVE AOTION SHOULD BE Gi TAG REGULATORY OR L80 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROP! RIATE DEFICIENCY) Ei 4.008) Continued From page 2 a. Extended congregate care (ECC) services in facilities holding an ECC license; b. Services under community living support plans in facilities holding limited mental health licenses; o, Medicaid assistive care services; and d, Medical waiver services, , (c) Any Information required by paragraph (a) that is not contained in the madical examination report conducted prior to the individual's admission to the facility must ba obtained by the admintstrator witin 30 days after admission using AHCA Form (4) Medical examinations of residents placed by the department, by the Department of Children and Family Services, or by an agency under contract with elther department must be conducted within $0 days before placement in the facility and recorded on AHCA Form 1823 deserlbad in paragraph (h), (2) An assessment that has been conducted through the Comprehensive, Assessment, Review and Evaluation for Lang-Term Gare Services (CARES) program may be substituted for the medical examination requirements of Sentlon 429.426, F.S., afd this rule, (f) Any orders for medications, nursing, therapeutic diets, or other services fo he provided or supervieed by the facility tesued by the ‘ licengad health care provider conducting the medical examination may be attached to the health assessment. A licensed health care provider may attach a do-nobresuscitate order for residents who do not wish cardiopulmonary resuscitation to be administered in the case of cardiac or respiratory arrest, (g) Areatdent placed on @ temporary emergency basis by the Department of Children and Family Services pursuant fo Section 415.105 or 415.1051, F.8., shall be exempt from the examination requirements of this subsection for ARCA Form 3020-0001 STATE FORM ae FEUSit "——Heontinuation sheet Sof 44 Feb, 7, 2013 3:17PM = The Health Law Firm No, 4604 =P. 34 PRINTED: 08/43/2012 FORM APPROVED (X2) MULTIPLE CONSTRUGTION A. BUILDING ALMI841340 BANG NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE Fra ae le (X4) 1 SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF GORRECTION RB) PREFIX (EACH DEFIOJENGY MUST BE PRECEDED QY FULL PRERX (BAGH GORREGTIVEAGTION SHOULD BE COMPLETH TAG REGULATORY OR L6G IDENTIFYING INFORMATION) TAG CROSS-REFERENGED Toe APPROPRIATE DATE A008 A008) Continued From page 3 up to 30 days. However, a resident accepted for temporary emergenay placement shall be entered on the facility's admission and discharge log and counted In the fadility cenaus; a facility may not exeaad Iis licensed capacity in order to accept a suoh a resident, Amedical examination must be conductad on any temporary emergency placement resident accepted for reguiar admiaeton. IDENTIFIGATION NUMBER: ‘This Statute or Rule is not met as evidenced by: Based on record raviaw and interview the facili fallad to ensure the AHCA Form 1823, Residant Health Assessment for Assisted Living Facilities, October 2010 was completed for 1 of 4 sampled residents (#2) and falled to have @ completed 1823 for 1 of 4 sampled residents (#4), Findings; 41, Record review for resident #4 revealed she was admitted on 7/18/12 and thare was no documentation to review to indicate an AHCA Form 1823 was completed, Interview with the administrator on 8/26/12 at approximately 1/16'PM who stated she could not |: locate the 1823 and previouly had a copy, She further stated the guardian had requested copies and possibly had taken the 1823, She stated she had faxed page 4 of the 1823 to the pharmacy to onder medications, called the pharmacy at that time and raquested that thay fax a copy of page 4, Page 4 was faxed by the pharmacy fo the faollity at approximately 1:30 PM. Page 4 of the 1629 was dated 7/49/12, She was unable to locate pages 1, 2 and 3. ARCA Form s020-0001 STATE FORM ata FEUS1E Weontinuation sheet 4 of 44 Feb, 7. 2013. 3:17PM = The Health Law Firm No. 4604 =P, 35 PRINTED: 097492012 FORMAPPROVED Agency for Health Cara A ion, : STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (41) PROVIDERVSUPPLIER/CLIA. Xe) MULTIPLE GONSTRUOTION IDENTIFICATION NUMBER: A BUILDING , ALAt9t1910 mid NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE soy Cus LAKE Ne 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION REFIX {BAGH DEFICIENCY MUST BE PREGEOED BY FULL PREFIX (BAGH GORRECTIVE AOTION SHOULD BE TAS REGULATORY OR LSC IDENTIFYING INFORMATION) TAS GROSS RE EREN DED OA APPROPRIATE A008} Continued From page 4 2, Record review for resident #2 revealed an 1823 dated 2/26/10 completed upon admission. There was no documentation to review to indicate an 1823 had bean completed since the time of, admission onthe ANCA Form 182%, October ~ Interview with the administratey on 8/28/12 at approximately 3:30 PM who etated she was not aware the 1823's were to be updated on the October 2010 revised form. Claas Ill ! B6A-6.0%82(6) FAC; 429.28 FS Resident Care - Rights & Facility Procedures (8) RESIDENT RIGHTS AND PACILITY PROCEDURES, (a) Acopy of the Resident Bill of Rights as described in Section 429,28, F.8., or a summary provided by the Long-Term Cate Ombudsman Couneil shai! be posted In full view in a freely accessible resident area, and included In the admission package provided pursuant to Rule 68A-6,0181, F.A.C, (b) in accordance with Section 429.28, F.8., the facility ahall have.a written grievance procedure - . for recaiving and responding to resident complaints, and for residents to recommend changes to facllity policies and procedures, The facility must he able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in a common area accessible {o all residents. The addresses and telaphone numbers ate: the District Long-Term Care Ombudsman Counsii, 1(886)831-0404; the RHIGA Font 5020-0001 STATE FORM oo” FEU314 {feantnuation sheet 5 of44 Feb, 7 2013 3:18PM The Health Law Firm : No. 4604 =P. 36 PRINTED: 09/13/2012 FORMAPPROVED Agency for Health Care Admintetratio: STATEMENT OF DEFIGIENCIES AND PLAN OF CORRECTION (Al) PROVIDERISUPPLIER/G! LA MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: a) A BUILDING 8. WiNG AL41941310 NAME OF PROVIDER OF SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5030 CUB LAKE DRIVE ’ PINE AGRES GOLDEN AGE CENTRE APOPKA FL 32703 J SUMMARY STATEMENT OF DEFICIENCIES Db PROVIDER'S PLAN OF CORRECTION Ke) Bis Pix (EACH DEFICIENCY MUST BE PRECEDED BY FULL paar EACH GORREQTIVE AOTION SHOULD GE COMPLETE TAG REGULATORY OR LEG IDENTIFYING INFORMATION) TAS LY ORE ER SE CIENGY APPROPRIATE DATE 30) Continued From page 5 Advocacy Center for Persons with Disahilitiss, 4(800)342-0822; the Florida Local Advocacy Council, 1(800)842-0825; and the Agency Consumer Hotline 1(888}419-3466. (d) The statewide toll-free telephone number of the Florida Abuse Hotina " 1(800)96-ABUSE or 1(800)982-2873 " shail be posted In full view fh a common area accessible to all residents, (6) The facility shall have a written statement of {ts house rules atid procedures which shall be inoluded In the admission package provided pursuant to Rule $8A-8.0184, F.A.C, The mules and procedures shall address the facility's policies with respect to such issues, for example, 43 ragident responsibilities, the facility's alcohol and tobacco poliey, medication storage, the dalivery of services to residents by third party providers, resident elopement, and other administrative and housekeeping praotices, schedules, and requirements, (i) Residents may not be required to perform any wark in the facility withaut compensation, excapt that facility rules or the facility contract may include a requirement that residents he rasponsible for cleaning thelr own sleeping areas orepartments, If a resident is employed by the facility, the resident shall be compensated, ata minimum, atan hourly wage consistent with the federal minimum wage law. (g) The facility shall provide rasidents with convenient access to a telephone to facilitate the . resident‘ ¢ right to unrestricted and private communication, pursuant fo Section 429.26(1)(d), FS. The facility shall not prohibit unidentified telephone calls to residents. For facilites with a licensed capacity of 17 or more residents in which residents do not have private telephones, there shall be, at a minimum, an accessible telephone on each floor of each building where residents realde, HCA 020-0001 erars FORA hala FEUSII Ifcontinualign sheet 8 0144 Feb, 7 2013 3:18PM The Health Law Firm No. 4604 P. 37 PRINTED: 08/13/2012 FORM APPROVED STATEMENT OF DEFICIENCIES: AND PLAN OF CORREGTION (Xt) PROVIDER/SUPPLIERICLIA } MULTIPLE GONSTRUOTION IDENTIFICATION NUMBER: ie 6 A, BUILDING AL11911310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGH CENTRE Posner ta me) is SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORREGTION 5) BRONX | (GAGHDBFICIENGY MUST BE PRECEDED BY FULL PREFIX EAGHGORREGTIVEAGTION SHOULD BE | coMpume TAG REGULATORY OR LBG IDENTIFYING INFORMATION) TAG cl OSSRRPERENCED TOE APPROPRIATE A.030| Continued From page 6 (h) Pursuant to Section 429.44, F.S., the use of physioal restraints shalt be Iimited to half-bed falls, and only upon the written order of the resident's physician, who shall review tha order biannually, and the consent of the resident or the realdent' s representative, Any davice, including | hatt-bed rails, whioh the resident chooses to use and can remove or avoid without assistance shail not be considered a physical restraint 429.28 Resident bil of rights.- (4) No resident of a facliily shall be deprived of any civil or legal rights, benefita, or privileges guaranteed by law, the Constitution of the State of Florida, or the Gonstitution of the United States as a tasident of a facility. Every residentof a facility shall have the right to: e) Liva In @ safe and decent living environment, ¢ from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and tha need for privacy. (¢) Retatn and use his or her own clothes and other persottal property in his or her Immediate (ving quarters, so as to maintain Individuality and personal dignity, except when the fanility can | demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents, ° : : (d) Unrestricted private communication, Including aceiving and sanding unopened correapondence, access to a telephone, and visiting with any person of his or her choloa, at any time between the hours of @ a.m. and 9 p.m, ata minirqum, Upon request, the facility shall make provisions to extend visiting hours for caregivers and out-of-town guests, and In other similar situations. {e} Freedom to participate In and benefit from community services and activities and to achieve ARCA Form 3020-000 STATE FORM oa FEUSTI {feontinuston sheel 7 of 44 Feb. 7. 2013 3:18PM = The Health Law Firm No. 4604 P38 PRINTED: 09/13/2012 FORM APPROVED CES ANO PLAN GF CORRECTION (kt) PROMIDEREUPPLIERUCLIA 0X2) MULTIPLE CONSTRUOTION AL11919310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, cl? CODE PING ACRES GOLDEN AGE CENTRE Pee (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORREOTION Ais) PREFIX (BAGH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX (EACH CORRECTIVE ACTION SHOULD Bi COMPLETE TAG REGULATORY OR LG IDENTIFYING INFORMATION) TAG CAO ETRE RIENaY) APPROPRIATE. DATE A030) Continued From page 7 the highest possible level of Independence, autonomy, and interaction within the community, (f) Manage his or har financial affairs unless the resident or, if applicable, tha resident" 6, representative, designee, surrogate, guardian, or attomey ft fact authorizes the administrator of the facility te provide safekeeping far funds as provided in 5, 429.27, (g) Share a room with his or her spouse If both are residents of the facility, (h) Reasonable opportunity for regular exeralse several times a week and to be outdoors at regular and frequent intervals except wher preventad by inolement weather, (i) Exercise etvil and religious tlberties, including the right to independent personal decisions. No religious baliefs or practices, nor any attendance at religious services, shall be imposed upon any realdent (j) Access to adequate and appropriate health care conslstent with established and recognized standards withtn the community. (k) At least 45 days' notice of relacation or termination of residency from the facility unless, for medicat reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages In a pattem of conduct thatis harmful or offensive to other residents, In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 46 days' notice ofa nonermergency relocation of residency termination. Reasons for relocation shall be set forth in writing, In order for a facility te terminate the residency of an individual without notice as provided herein, the facility shall show good cause in a court of competent jurisdiction. ()) Present grievances and resommend changes in policles, proceduras, and services to the staff A030 STATE FOR Lid FEUSI1 itcontinyation sheet 8 of 44 eb, 7 2013 3:19PM = The Health Law Firm No, 4604 PL 39 PRINTED: 08/13/2012 . FORM APPROVED (Kt) PROVIDER/SUPPLIERIGHA STATEMENT OF DEFICIENCIES CTON IDENTIFICATION NUMBER: AND PLAN OF CORRE (2) MULTIPLE CONSTRUCTION A BUILDING. B, WING ALt1811310 NAME OF PROVIDER OR SUPPLIER STREET ADDRES, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE S40 CUB LAKE DRE map SUMMARY SIATENENT OF DEFICIENCIES D PROVIDERS PLAN OF OORREOTION 7 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX IEAQH CORREOTIVE AOTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG BE-REFERENGED 70 THE APPROPRIATE Date Continued From page & of the facility, gevemtng officials, or any other person without restraint, interference, coercion, discriminatin, or reprisal, Each facility shall establish a grievance procedure to facilitate the tesidents' exerolde of this right, This right: Includes access te drrbudsman volunteers and advocates and the right to be a member of, to ba active in, and to associate with advosacy or special interest groups. This Statute or Rule Is not mat as evidenced by: Based on observation and interview the facliity failed to ensure the use of physical restraints was linited to half-rails for one Random sampled resident (RSW), Findings: Observation of R
on 6/28/12 at approximately 9:30 AM revealed sha was reclined in a chair with herlegs up. The resident was unable to get up from the chalrindependantly. The resident was observed at 10:15 AM and she continued to be taclined in tha chair. The resident was not Intervieweble due to her cognitive aaltua, oo Interview with staff on said date at approximately 40:18 AM who stated the resident was unable to gat up without the staff pressing the lever on the recliner to put the footrest dawn, providing her walker atid standing by to ensure the resident stood up and grasped the walker, Interview with the administrator on sald date at approximately 3:30 PM who was not aware the resident had her legs up In the recliner, was restrained, and unable to put the faot rest down STATE FORM bad FEUS1I Weontinuaton sheet 9 oF 44 Feb, 7. 2013 3:19PM © The Health Law Firm No. 4604 | P, 40 PRA Agency for Health Care Administratio STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDSR/SUPPLIEROLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B, WING ALI1919310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE PINE. AGRES GOLDEN AGE CENTRE eh ae (44) 1D SUMMARY STATEMENT OF DEFICIENCIES —j ib PROVIDER'S PLAN OF CORRECTION 5) PREFIX (BAGH DEFICIENGY MUST BE PREGEOED BY FULL PREFIX {EACH CORREGTIVE ACTION SHOULD BE COMPLETE TAS REGULATORY OR LSC IDENTIFYING INFORMATION) TAG OROSE-RBFERENCED Rae APPROPRIATE DATE A030! Continued From page 9 on the chair, Class Ill A030 68A-5.0188(3) FAC Medication - Assistance with Self-Admin y (3) ASSIBTANCE WITH SELF-ADMINISTRATION, (a) For facilities which provide assistance with self-adminiatarad medication, either: a nurse; or an unlicensed staff member, who Ja at least 18 years old, trained fo assist with salf-administered medivation in accordance with Rule 66A-5.0194, F.A.C., and abla to demonstrate fo the administrator the ability to accurately read and interpret a presoription label, must be available to assist realdents with self-administered medications in accordance with provadures described in Section 429.258, F.8. (b) Assistance with self-administration of medication Includes verbally prompting a resident to take medications as preserbed, retrieving and opening. properly labeled medication container, and providing assistance as specified in Section 429,266(3), F.S, In order to facilitate assistance with self-administration, staff may prepare and make available such items as water, juice, cups, and spoons. Staff may also return unused doses to the medication container. Medication, which appears to hava been contaminated, shall not be tatumed to the container, _ | (¢) Staff shall observe the resident take the medication, Any conearns about the resident's reaction to the medication shall be reported to the resident's health care provider and documented in the resident’ s record, (d) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to AHIGA Form 5020-0001 STATE FORM cave FES Hcontnuation sheet 70 of 44 Feb, 7, 2013 3:19PM The Health Law Firm No. 4604 PL 44 PRINTED: 08/13/2012 FORMAPPROVED (1) PROVIDER/SUPPLIERICLIA ES nN IDENTIFICATION NUMBER: AND PLAN OF CORRECTION (x2) MULTIPLE CONSTRUCTION AL BUILDING sige pennennenenneonssnonne ALtt914310 SWING ogi2812012 -NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE AGRES GOLDEN AGE CENTRE petra rae a (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORREGTION we) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX AGH CORRECTIVE ACTION SHOULD BE PLEVE: TAG REGULATORY OR L8G IDENTIFYING INFORMATION) TAG q BS-REFERENDED 10 THE APPROPRIATE DATE ) DATE SURVEY a COMPLETED A082) Continued From page 10 enable the resident to take medication as presoribed: 4. The health care provider may presoribe a medication achedule which coincides with the resident's prasence in the faollity; 2, Tie medication container may be given to the rasident or a friend or family member upan leaving the facility, with this fact noted In the resident’ s medication record; 3. Tha medication may be transferred to a pill organizer pursuant (6 the requirements of subseation (2), and given to the resident, a friend, ar family member upon leaving the facility, with this fact noted In the resident's medication Techrd; oF 4, Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose packaging; (8) Pursuant to Section 428.266(4)(h), F.S., the term " compatent resident" means that the resident Is cognizant of when @ medication is required and understands the purpose for taking the medication. (f) Pursuant to Seotion 429,256(4)(i), F.S., the terms "Judgment" and “discretion” mean Interpreting vital signe and evaluating or assessing a resident's condition. | (4) Assistance with seff-administration dees not Include; (a) Mixing, compounding, converting, or cafculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scared tablet or crushing a tablet as prescribed. (b) The preparation of syringes for Injection or the administration of medications by any Injectable route, (c) Administration of medloations through intermittent positive pressure breathing machines ora nebulizer, ABCA Form 3020-000 STATE FORM on FEUStI ‘ ifcontinuation sheet 11 of 44 Feb, 7. 2013 3:49PM = The Health Law Firm No. 4604 =P. 42 : SR ROS Agency for Health Care Administratio: i STATEMENT OF OEFICIENCIES AND PLAN OF CORRECTION (M1) PROVIDER/SUPPLIERICLIA MULTIPLE CONS! IDENTIFICATION NUMBER: oa TRUSTION ALII911310 | NAME OF PROMIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE AGRES GOLDEN AGE CRNTRE APOPKATEL an70e Fee i") ’ SUMMARY STATEMENT OF DEFICIENCIES lp PROVIDER'S PLAN OF CORRECTION i} (EAGH DEFICIENCY MUST BE PREOEDED BY FULL PREFIX (FAOH CORREGTIVE ACTION SHOULD BE G TAG REGULATORY OR L&C IDENTIFYING INFORMATION) TAG cediakeiar tit APPROPRIATE oxte BEFICIEN! 2| Continued From page: 11 (d) Administration af medications by way of a {ube Inaerted In a cavity of the body, (8) Administration of parenteral preparations, (f) Irrigations or debriding agents used in the treatment of a akin condition, (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or ‘health care professional with prescriptive authority fo be given “as needed,” unless the order Is written with epecific paramaters that prealude independent judgment on the part of the unlicensed pergon, and at the request of a competent resident (i) Medications for which the time of administration, the arrount, the strength of dosage, the method of administration, ar the reason for administration requires Judgment or discretion on the part of the unlicensed person, ‘This Statute or Rula is not metas evidenced by: Based on observations and interview the facility failed to engura when unlicensed staff provided assistance with the self-administratian of medications, the staff followed the appropriate procedure at all tines and did not take 4. Medication, in ite dispensed, properly labelad container, from where it was atored and brought to the resident. 2, 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 and ensure tha resident was capable of giving crushed madications on a spoon indepandently for 1 of 4 sampled residents (#1), Findings: Observation on 8/28/12 at approximately 11:68 AM revealed resident #1 was asleep in her high back wheelchair at the dining table. The med AHCA Form 3020-0001 STATE FORM wre FEUST1 \foontinuation sheet’ 12 of 44 Feb, 7, 2013 3:20PM = The Health Law Firm No. 4604 =P. 43 PRINTED: 08/13/2012 FORMAPPROVED STATEMENT OF DEFICIENCIES DATE SURVEY AND PLAN OF CORRECTION elites pre enn GONETRUGTION Oe COMPLETED ALNgHTat0 3. WING NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, OITY, STATE, ZIP CODE PINE AGRES GOLDEN AGE GENTRE — (#4) ID SUMMARY STATEMENT OF CEE ULL PROVIDER'S PLAN OF CORREGTION, PREFIX (EAGH DEFIGIENGY MUST BE PREG! Patra CORRECTING ACTION TAG REGULATORY OF L8G IDENTIFYING INFORMATION) Nal THE, AS PROPRIATE AO82| Continued From page 12 tech had the resident's medication crushed in a medicine cup in applesauce and tried to awaken tha resident te take her medications, The resident was not easily awakened, and opened her mouth, when cued, and the med tach . spooned the crushed medioations In applesauce into her mouth, The resident was not interviewable due to her cognitive Impairment and was unable to use her hands fo take the spaon and feed herself the medications. The unlicensed staff did not In the presence of the resident, read the label, open the contalner, remove a presoribed amount of medication from the container, closes tha container and administered the crushed medications on a spoon to the resident. Resident record review ravealed an ALF health ageaesment form (1623) dated 8/12/12 indicated diagnoses of dementia, nonverbal and hypertension. The resident needed assistance with self-adininistration of medications. The resident was admitted to hospices on 4/27/12, Interview with the administrator on satd date at approximately 3:30 PM who was not aware the med tach was not following the proper procedure when administering crushed medications tod ’ cognitively impalred resident, who was unabla to assist with self-administration of medications. She also stated she previoualy had a furse who administered medicationa, but she was no longer employed at the facility, Class Itt AOS! 88A-5.0186(5) FAC Medication - Storage and Disposal ARICA Form 8020-0004 STATE FORM on Feust4 Hoontnuation sheet 13 0f44 ae eb 7 2083) 3:20PM = The Health Law Firm No, 4604 PL 44 PRINTED: 09/792012 FORM APPROVED rare OF DEFICIENCIES ID PLAN OF CORRECTION (8) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 0X2) MULTIPLE CONSTRUCTION A, BUILDING ALAIO1Ig4 B. WG a11310 NAME OF PROVIDER OR SUPPLIER STRERT ADDREES, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE pone etat tade 84) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORREOTION ia PREFIX (BAGH DEFICIENCY MUST BE PRECEDED RY FULL PREFIX BAGH CORRECTIVEACTION SHOULD EE TAG * REGULATORY OR L6G IDENTIFYING INFORMATION) TAG ediakele ty APPROPRIATE. “RAYE Continued From page 13 (6) MEDICATION STORAGE AND DISPOSAL, (8) tn order to necommoadate the needs and preferences of residents and to encourage residents to remain as Independent as possible, residents may kaep thelr medications, both prescription and over-the-counter, in thelr. possession both on or off the facitity premises: or tn their rooms or apartments, which must be kept locked when residents are absent, unless the Medication is ih a secure place within the rooms oF apartments or In some other secure place which {5 out of sight of other residents, However, both prescription and over-the-counter medications for residents shall be centrally stored if 4. The facility administers the medication; 2, Tha resident requests cantral storage. The facility shall maintain a list of all medications heing stored pursuant to such @ request; 3. The medication is determined and documented by the health cara provider to be hazardous If kept in the personal possession of the parson for whom It ls prescribed; 4, The resident falls to maintain the medication in @ safe manney as described In this paragraph; oh The facility determines that because of phys sloal arrangements and the conditions or its of residents, tha personal posseacion of maaaleation by a resident poses a safely hazard fe ather residents; of 6, The facility 's rules and regulations require central storage of medication and that policy has been provided fo tha resident prior to admission as required under Rule 58A-5.0181, F.AC. (b) Centrally stored medications must be: 1. Kept in a locked cabinet, locked cart, or other looked storage receptacle, room, or area at all times; 2, Located in an area free of dampness and abnormal temperature, except that a medication STATE FORM cave FEWStt Ieontinuation sheet 14 of 44 Feb, 7, 203 3:20PM = The Health Law Firm No. 4604 =P. 45 PRINTED: 00/43/2012 FORMAPPROVED (81) PROVIDERISYPPLIERCLIA IDENTIFICATION NUMBER: AND PLAN OF CORREGTION (X92) MULTIPLE CONSTRUCTION A BUILDING ALSi9t1340 RWInG 20 NAME OF PROVIDER OR SUPPLIER , STREET ADDRESS, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE ce teens ayia | ‘SUMMARY STATEMENT OF DEFICIENGIES 1D PROVIDERS PLAN OF CORRECTION PREFIX (EA0H DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (BACH CORRECTIVE AOTION SHOULD BE TAG REGULATORY OR L8G IDENTIFYING INFORMATION) TAG CROBE-REFERENOED Mi ‘THE APPROPRIATE A055) Continued From page 14 fequiring refrigeration shall be refrigerated. Refrigerated medications shall be secured by being kept in a locked container within the reftigerator, by keeping the refrigerator locked, or by keeping the area In which refrigerator Is located looked; A055 3, Accessible to staff responsible for filling pilkorganizers, assisting with setf-administration, or administering medication, Such staff must have ready access to keys fo the medication storage areas at all {imas; and 4, Kept separately from the medications of other residents and properly closed or sealed. - (0) Medication which has been discontinued but which has not expired shall be returned to the resident or the resident's repregentative, as appropriate, or may be centrally stored by the facility for future resident use by the resident at the resident's request, if centrally stored by the facility, it shall be stored separately fram medication in current use, and tha area in whieh it is stored shall be marked " discontinued medication," Such mediation may be raused if re-prescribed by the resident’ s health care provider, (d) When a resident's stay Inv the facility has ended, the administrator shail return all medications to the reeident, the resident's family, or the resident’ 5 guardian unless otherwise prohibited by faw. If, after notification and walting at least 15 days, the residant's medications are still at the faoility, the medisations shall be considered abandoned and may disposed of in accordance with paragraph (8). (a) Medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented i the resident! s racord, The medication may be taken STATE FORM on Feustt Ifcontnuaton sheet 46.0844 Feb, 7. 2013 3:21PM The Health Law (41) PROVIDER/SUPPLIER/OLIA IDENT! AND PLAN OF CORRECTION FICATION NUMBER: ALI1941810 NAME OF PROVIDER OR SUPPLIER PINE ACRES GOLDEN AGE CENTRE x4) 10 SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH GEFICIENCY MUST BE PRECEDED BY FULL, REGULATORY OR L8G IDENTIFYING INFORMATION} A085! Continued From page 15 aan under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the ANCA Form 3020-0001 STATE FORM provision of adequate care to all ' STREET ADDARSS, CIty, STATE, ZIP CODE 5030 CUB LAKE DRIVE APOPKA, FL 32708 A to a pharmacist for disposal or may be destroyed by the administrator or designee with one witness, (f) Facilities that hold a Special-ALF permit issued by the Board of Pharmacy may tetum dispensed medicinal drugs to the diapensing pharmacy pursuant fo Rule 64816-28,870, F.A.C. This Statute or Rule is not met as evidenced by: Based on observation and Interview the facliity failed to ensure centrally stored medications for 1 of 4 sampled residents (#1) were kept in a locked storage area at all times, Findings: Observation on 8/28/12 at approximately 4PM revealed there was a bottie of Iiquid Valporio Acid (for sefgures) 1.25 roilligrams thrae times a day for resident #1 unattended on top of the medication cart, ‘The medication was not kept secure at all tines, Interview with the administrator on said date at approximately 3:30 PM who stated the medication should be locked lin the medication cart at all times and was not aware the med tach ; left the medication unattended, Class tll 58A-5,018(1) FAC Staffing Standards - Administrators Staffing Standards, (1) ADMINISTRATORS. Every facility shall be f Firm No, 4604 PL 46 PRINTED: 09/43/2012 FORM APPROVED (Xa) MULTIPLE CONBTRUGTION (8) BATE BURNEY A BUILDING 8. WING PROVIDER'S PLAN OF CORRECTION (Xs) PREFIX {EAGH GORREGTIVR ACTION SHOULD BE COMPLETE. TAG CROBE-REPERENGED TO i APPR PATE BATE, 055 AOT? a FeUSt4 Weantinuation sheet 16.0144 Feb, 7, 2013 3:21PM = The Health Law Firm No, 4604 P47 PRINTED: oata/2012 FORM APPROVED IENCIES AND PLAN OF CORRECTION (Ki) PROVIDER/SUPPLIER/OLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUOTION AL11911310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP GORE PINE ACRES GOLDEN AGE CENTRE 5030 CUB LAKE DRIVE APOPKA, FL $2703 ; {x4)1D SUMMARY STATEMENT OF DEFICIENCIES (6 PROVIDER'S PLAN OF CORRECTION 1x8) PREFIX (BAGH DEFIGIENGY MUST BE PRECEDED BY FULL PREFIX EAQH CORREOTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OF LSG IDENTIFYING INFORMATION) TAG Gq aided APPROPRIATE DATE Continued From page 16 tealdents as required by Part | of Chapter 429, F.S., and this rule chapter, (a) The administrators shail: 1. Be atleast 21 years of age; 2. {femployed on or after August 15, 1990, have a high school diploma or gansral equivalency diploma (G.E.D,), or have been an operator or administrator of a licensed assisted living facility in the State of Florida for at lsast oné of the past $ years in which the facility has met minimum standards, Administrators employed on or after October $0, 1995, must have a high school diploma or G.E.0.; ” 3, Be In compliance with Level 2 baekground screening standards purauant to Seation 429.174, F.8,; and 4. Gamplete the care training requirement pursvant to Rula SBA-5,0194, FAG. (b) Administrators may supervige a maximum of either three assisted living facilities or a combination of housing and health care facilities or agencies on a single campus, However, administrators who supervise more than one facility shall appoint in writing @ separate ” Manager" for each facility who must 1, Be at least 21 years old; and 2. Complate the core training requirement pursuant to Rule 68A-5.0191, F.A.C, (c) Purauant to Section 429,176, F.S,, facility owners shall notify both the Agency Field Office and Agency Central Office within ten (10) days of a change in a facility administrator on the Notification of Change of Administrator, AHCA Form 3180-1006, January 2006, which Is Incorporated by reference and may be obtained from the Agency Cantal Offices. The Agency Central Office shall conduct a background sereaning on the new adiministrater In accordance with Section 429.174, F.S., and Rule 58A-5,014, F.AC. AHGA Form 3020-0001 : STATE FORM sae FEUSII {teontinustion sheat 17 of 44 | Feb, 7. 2013 3:21PM = The Health Law Firm No. 4604. PL 48 PRINTED; cav1g/2012 FORM APP! ROVED Ott) PROVIDERISYPPLIERCLIA IDENTIFICATION NUMBER: (Ke) MULTIPLE CONSTRUCTION 4. BHILDING oN AL(1911510 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP GODE PINE ACRES GOLDEN AGE CENTRE eee ea (44) 10 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX AcAGH CORRECTIVE AOTION SHOULD BE TAG REGULATORY OR LSG IDENTIFYING INFORMATION) TAG Gl alien TO THE APPROPRIATE Continued From page 17 This Statute or Rule fs not met as evidenced by: Based on record review and interview the administrator failed to ensure oparation and maintenance of the facility including the provision of adequate care to all residents was completed for 1 of 4 eampled residents (#4), who received a peg tube feading and falled to ensure accurate written physician orders for gastric tube feeding and gastric site cane, completed nursing progress notes each time the service was delivered and @ nursing assessment completed monthly for 1 of 4 sampled residents (a) whe received Extended Congragate Care services (EGC). Findings; During the entrance conference on 6/28/12 at approximately 0:18 AM with the administrator, the FCC nurse, stated thera were no residents recelving ECO services. Intarview with the direct care staff on eald date at approximately 11 AM who stated resident #4 had 4 feeding tube. ‘The direct care staff went to the kitchen with the surveyor and there Were cases of Nutren (gastric tube feeding) 250 millifets bottles, in a closet, that she stated the administrator/ECG nurse used to administer the tube feedings to tesldent #4. Record review for resident #4 revealed she was admitted on 7/18/12 and thare was no documentation to review to indicate an AHGA Form 1823 was completed, ARGA Foin 8020-0001 STATE FORM wae FrUatH Weoontnuation shear 16 of 44 Feb, 7, 2013 3:22PM = The Health Law Firm No. 4604 =P. 49 PRINTED: et S012 Avency for Health Care Adminjatration —— STATEMENT OF DEFICIENCIES AND PLAN OF GORREOTION (41) PROVIDER/SUPFLIERCLIA (X2) MULTIPLE CONSTRUGTION IDENTIFICATION NUMBER: A SULDING 8, WING. ALA4911310 NAME OF PROVIDER OR SUPPLIER PINE AGRES GOLDEN AGE CENTRE TREET ADDRESS, CITY, STATE, Z1P CODE 8090 CUB LAKE DRIVE APOPKA, FL 82703 { ‘BUNMARY STATEMENT OF DEFICIENGIES 0 PROVIDER'S PLAN OF GORRECTION em EFI (EAGH DEFICIENCY MUST BE PREGEDED SY FULL, PREFIX H CORRECTIVEACTION SHOULD BE COMPLETE TAS REGULATORY OR 1.86 IDENTIFYING INFORMATION) TAG GROSS-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY) A077| Continued From paga 18 Review of the resident tranafer summary dated 78/12 from the Skilled Nurging Facility (BNF) to the ALF stated the reason for transfer was the resident did hotneed the SNF ifthe ALF was able to provide the tube faeding, which was the only current documentation the fanillty had available to review that Indicated the resident had a feading eB. Interview with the administrate/ZGC nurse on 8/28/12 at approximately 11:15 AM who stated she administered the resident's tube feadings 4 times a day and was not aware the resident needed to be on ECG, She further stated: thera was no documentation completed for admission and services in tha ECG program. Record review revealed there was no documentation the facility had admitted the resident to the ECC program or developed a preliminary ECC service plan Further interview with the administrator on 8/28/12 at approximately 1:15 PM who stated she could not locate the 1823 and previously had a copy. She further atated the guardian had requested copies and possibly had teken the 1823, She, stated she had faxed page 4 ofthe 4823 to the’ pharmacy fo order medications, called the pharmacy at that time and requested that they fax a copy of page 4. Page 4 was faxed by the pharmacy to the facility at approximately 4:30 PM, Page 4 of the 1824 was dated THON, She was unable to locate pages 1, 2 and 3. Review of page 4 of the 1823 revealed a physician's order dated 7/18/12 for: 4, Nutren (tube feeding) 2 cane 260 millers via gastric tube 4 times a day for nutrition 9, The resident Is to receive nothing by mouth AHIOA Form 30a0-0001 STATE FORM wa FEUSIt iteontinuation sheet 19 of 44 Feb, 7. 2013 3:22PM = The Health Law Firm No. 4604 PL 50 PRINTED; 08/18/2012 FORMAPPROVED (Xt) PROVIDER/BLPPLIERICLIA 1) IDENTIFICATION RUMBER: GA) MULTPLE GOSTRUOTIO AND PLAN OF CORRECTION ALI1911340 NAME OF PROVIDER OR SUPPLIER | PINE AGRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, ZIP CODER §030 CUB LAKE DRIVE APOPKA, FL. 32708 yi SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION . ro) ROS. {BACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX BAGH CORRECTIVEAGTION SHOULD BE COMPLETE TAG REGULATORY O8 L&C IDENTIFYING INFORMATION) TAG OROSE-REPERENGED TO THE APPROPRIATE DATE DEFICIENCY) AQT ‘ A077} Continued From page 19 3. Flush gastric tube with 200 milliters of water twice a day 4. Gastric tube site care dally, cleanse with normal saline, pat dry, apply triple antiblotio ointment, cover with (unable to read) sponge, secure with tape every shift and as needed, Record review revealed there was no documentation the facility had admitted the resident to the ECG program or developed a preliminary ECC service plan to addrass how the facility would meet the resident's physical and psychosocial needs, with attention to care to ba provided for the peg tube site, administering peg tube feedings and administaring medications via the pag tube, Class I 5BA-8,019(2) FAG Staffing Standards - Staff (2) STAFF. (a) Newly hired staff shall have 30 days to submit a statement from a health cara provider, based on a examination conducted within the last six months, that the person does not have any signs of symptoms of a communicable disease Including tuberculosis, Freedom from tuberculosis must b¢ documented on an annual baste, A person with a positive tuberoulosis test must submit @ health eare provider’ s statement that the person does not constitute a nek of communicating tuberculosis, Newly hited staff does not include an employee transferring fram one facility to another that is under the same Management or ownership, without a break In service. If any staff member Is later found to fave, or is suspected of having, a communicable disease, he/she shall be removed from duties until the administrator datermines that such ARCA Form 3020-0001 STATE FORM tee EUS fenntinuation sheet 20 at 44 Feb. 7. 2013 3:22PM The Health Law Firm No. 4604 =P. 51 PRINTED: 08/12/2012 FORMAPPROVED STATEMENT OF DEFIIENCIES RECTION AND PLAN OF GORI (K2) MULTIPLE CONSTRUCTION (Xt) PROVIDER/SUPPLIERICLIA IDENTIFIGATION NUMBER: a AL41911310 NAME OF PROVIDER OR SUPPLIER PINE ACRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, ZIP CODE 5030 CUB LAKE DRIVE APOPKA, FL 82703 & ip ‘SUMMARY STATEMENT OF DEFICIENCIES iD PROVIOER'S PLAN OF CORRECTION ] a a hie (EACH DEFIGIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAS « OBE-REFERENGED TO APPROPRIATE DATE A078| Continued From page 20 condition no longer exists. (b) All staff shall be assigned dutles consistent with his/her level of education, training, preparation, and experiance. Staff providing services requiring lloansing pr certification must be appropriately icensed‘or certified. All staff shall exarciae thelr responsibiliiies, consistent with thelr qualifications, to observe residents, to document observations on the appropriate rasident' s record, and to report the observations to the residant' s health care provider in accordance with this rule chapter. (0) All staff must amply with the training requirements of Rule 68A-8.0194, FAG. (d) Staff provided by a staffing agenoy or employed by a business entity contraotin; to provide direct or indirect services to residents must be qualified for the position In accordance with this rule chapter, The cantract between the facility and the staffing agency or contractor shall specifically describe the services the staffing agency or contractor will be providing to residents. (e) For facilities with a licensed capacity of 17 or more residents, the facility shall: 4. Davelop @ written job description for each staff position and pravide a copy of the job description to wach staffmeniber; and 2, Maintain time sheets for all staff, This Statute or Rule (s not met aa evidenced by: Based on observation and interview the faollity failed fo engure unlicensed staff were aasignad duties consistent with their level of education, training and preparation and experience and did not ensure a nurse sdministered medications to 4 of 4 sampled residents (#4), a cognitively impalred resident, who was unable to assist with selt-administeation of medications. B Hi hy STATE FORM wate Feuat1 itcantinuatton sheet 24 of 44 Feb, 7. 2013 3:22PM STATEMENT OF DEFKHENCIES SN OF ConRECTION (Xt) PROVIDERISUPPLIERICLIA, IDENTIFICATION NUMBER: AL41911310 NAME OF PROVIDER OR SUPPHIER | PINE ACRES GOLDEN AGE CENTRE SUMMARY STATEMENT OF OEFICIENCIES eat DEFICIENCY MUST SE PREGEDED BY FUN, EGULATORY OR LSC IDENTIFYING INFORMATION) A078! Continued From page 21 Findings; Observations on 6/28/12 at approximately 11:85 AM revealed realdent #1 was asleep in her high back wheelchalr at the dining table, The med fach had the resident's medication crushed In a cup in applesauce and tried to awaken the resident to take her medications. The reaident was not easily awakened, opened har mouth when cued and thie med tech speoned the crushed medications into her mouth, The rasident was not interviewable due to her cognitive Impairment and was unable fo use her hatids to aesist with the Spoon, Resident record review revealed an ALF health asgesament form (1823) dated 3/12/12 Indicated diagnoses of dementia, nonverbal and hypertension. The resident needed assistance with seltadministration of medications. ‘The resident was admitted to hosploe on 4/27/12, ‘Tha facility did not have & nurse available to administer medications to residents who were unable to assist with self-administration of medications, Interview with the administrator on said date at approximately 3:30 PM who was not aware the med fach could not administer madications crushed In food to a cognitively impaired resident, who wag unable to assist with self-administration |. of medications. She also stated she previously had a nurse who administared medications, but she was no longer employed at the facility. Class Il A083) 5BA-6.020(2) FAC Food Service - Dietaty Standards ARCA Farin 020-0001 STATE FORM The Health Law Firm No, 4604 PL 52 PRINTED: 09/15/2012 FORMAPPROVED (02) MULTIPLE GONSTRUOTION 8030 CUB LAKE DRIVE APOPKA, FL 32703 PROVIDER'S PLAN OF CORRECTION ( CORRECTIVE AGTION SHOULD BE ROPRIATE (EACH QROSS-REFERENGED TO THE APP! DEFICI PEUS($ HBNEY) Hteontinuation sheet 22 Of 44 Feb, 7. 2013 3:23PM = The Health Law Firm No. 4604 =P. 53 PRINTED; 08/13/2012 FORMAPPROVED (61) PROVIDERSUPPLIERIGLIA WENTIFICATION NUMBER: (42) MULTIPLE CONSTRUCTION A BUILDING A LONER RA NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP GORE 5030 CUB LAKE DRIVE PINE ACRES GOLDEN AGE CENTRE APOPKA, FL 32708 gxayD SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF GORREOTION Xs) PREFIX (each DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EAGH CORRECTIVE ACTION SHOULD BE GOMPLETE TAG EGULATORY OR LSC IDENTIFYING INFORMATION) TAG aliens APPROPRIATE GATE A.093| Continued From page 22 (2) DIETARY STANDARDS. {a) The Tenth Edition Recommended Dietary Allowatees established by the Food and Nutrition Board - National Research Council, adjusted for age, sex and aotivity, shall be the nutritional standard used fo evaluate meals, Therapeutic diets shall meat these nutritional standatds to the extent possible, A summary of the Tenth Editon Recommended Dietary Allowances, Interpreted by @ dally food guide, Is available from the DORA Assisted Living Program. (b) The recommended dietary allowances shall be met by offering a varlaly of foods adapted to the food habits, preferences and physleal abilities of tha residents and prepared by the use of standardized reolpes. For facilites with a lleensed capanity of 16 or fawer realdents, standardized recipes are not required. Unies a resident chooses to eat less, the recommended dietary allowances to be made available to eaoh resident dally by the facility are as follow 4. Protein: 6 ounces or 2 or more satvings; 2. Vegetables: 3 5 eervings, 3, Fruit 2 4 or more servings; 4, Bread and starches: 6 11 or more servings; 6, Milk or milk equivalent; 2 servings; 6, Fats, alle, and sweets: use sparingly; and 7. Water, ' (c) All reguiar and therapeutic manus to be used by the facility shall be reviewed annually by a ragistered dietitian, licansed dietittan/nutritionist, or by a dietetic technician supervised by 4 registered dietitian or ficansed dietitan‘nutritionist, to ensura the meals are commensurate with the nutritional standards established In this rule, Portion sizes shall be indicated on the menus or on # separate sheet, Daily feed servings may he divided among three or more meals per day, including snacks, as P a STATE FORM beat Fevati Heontinuation sheet 23 at 44 Feb, 7 2043 3:23PM = The Health Law Firm No. 4604 =P. 54 oe Agency for Healt Care Administration ‘ (X41) PROVIDER/SUPPLIERIGLIA IDENTIFICATION NUMBER: (42) MULTIPLE CONSTRUCTION ALI1911310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP GQDE PINE ACRES GOLDEN AGE CENTRE me UE AE (44) 10 SUMMARY STATEMENT OF DEFIGIENGIES 1) PROVIDER'S PLAN OF CORRECTION (5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EAGH CORRECTIVE ACTION SHOULA BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CRORE-NEFERENGSD TO THE APPROPRIATE ra A093} Continued From page 23 necessary to accommodate rasident needs and preferances. This review shail be documented in the facility files and inchide the signature of the reviewer, registration or license number, and date reviewed, Menu items may be substituted with items of comparable nutritional value based on the seasonal availability of fresh produce or the prafarences of the residents, (d) Menus to be served shall be dated and planned at least one week In advance for both regular and therapeutic diets, Resldents shall be encouraged to participate In menu planning, Planned menus shall be conspicuously posted or easily avaliable to residents, Regular and therapeutic menus as served, with substitutions noted before of when the meal is served, shall be kept on file in the facility for @ months, (e) Therapautle diets shall be prepared and served a6 ordered by the health cata provider. 4. Paallitles that offer residents a varialy of food choleas through a select menu, buffet style dining of family style dining are net required to docurnent what is eaten unless a health care provider's ordar Indicates that such monitoring Is necessary. However, the food items which enable residents to camply with the therapeutle diet shall be identified on the menus developed for use in the facility. 2, The facility shall document a resident’ s refusal to comply with a therapeutic diet and nolification te the resident ' s health care provider of such refueal. Ifa resident refuses to follow a therapeutic diet after the benefits are explained, @ signed statement from the resident or the resident ' s responsible party refusing the dlet is acceptable desumentation of a resident’ s preferences. In such instances dally documentation is not necessary. (f For facilities eurving three or more meals a day, no more than 14 hours shall elapse between 20) : TATE FORM an FEUSTI iteantinuation sheet 24 of 44 Feb. 7. 2043 3:23PM The Health Law Firm No. 4604 =P. 55 PRINTED: 09/13/2012 FORM APPROVED (X41) PROVIDEFVEUPPLIERJCUA MULTIPLE GONSTRUOTION {DENTIFIGATION NUMBERt oan « one) AL11911340 NAME OF PROVIDEE OR SUPPLIER _ PINE ACRES GOLDEN AGE GENTRE STREET ADDRESS, 5030 CUB LAKE DRIVE APOPKA, FL 32703 \D PROVIDER'S PLAN OF CORRECTION O19 PREFIX (PAGH CORRECTIVE ACTION SHOULD BE. COMPAL TAS OROSS-REPERENCED TO THE APPROPRIATE DATE DEFICIENCY) (44) 1D BUMMARY STATEMENT OF DEFICIENCIES EACH DEFICIENCY MUST BE PREGEDED BY FULL, EGULATORY GR LSG IDENTIFYING INFORMATION) 4.083} Continued From page 24 the end of an evening meal containing @ protein food and the beginning of a maming meal. Intervals betwaan meals shall be evenly distributed throughout the day with not less than fwo hours ner mora than six hours between the end of ohe meal and the beginning of the next. For residents without access to kitohen facilitias, snacks shall be offered at least ono par day. Snacks are not considered to be meals for the purposes of catoulating the tma between meals. (g) Food shall be served attractively at safe and palatable tamperatures, All residents shall be encouraged to eat at tables In the dining areas. A supply of eating wate suffiatant for all Tesidents, Including adaptive equipment if needed by any resident, shall be on hand, (h) AS-day supply of non perlahabla food, based on the number of waakly meals the facility has contracted with residents to serve, and shall be on hand at all times. The quantity ehell ba based on the resident census and not on licensed capacity, The supply shall consist of dry or carinad foods that do not require refrigeration and shall be kept in sealad containers which ate labeled and dated, The food shail be rotated In accordance with shelf life to ansure safety and palatability, Water sufficient for drinking and food preparation shall also ba stored, or the facility shall have a plan for obtaining water in an emergency, with the pian coordinated with and reviewed by the local disaster preparedness autherly, This Statute or Rute is not met as evidenced by: Based on observation and Intarview the facility failed to provide a 3-day supply of nonperishable food, calculated an the number of weekly meals i007 STATE FORM Lig FEUSII ifeontnuatian sheer 25 of 44 Feb, 7, 2013 3:24PM = The Health Law Firm No, 4604 P56 PRINTED: 09/43/2042 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECT! or (Xf) PROVIDER/SUPPLIERICLIA MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: ”) " AL14991310 STREET ADORESS, CITY, STATE, ZIP CODE . NAME OF PROVIDER OR SUPPLIER PINE AGRES GOLDEN AGE CENTRE se A x4) 10 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORREGTION fr) PREFIX eet DEFICIENGY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG ULATORY OR LSC IDENTIFYING INFORMATION) TAG OROSS-REFERENCED TO THE APPROPRIATE DATE A083 A093] Continued From page 25 the faciily has contracted with residents to serve, which shail be on hand at all mes. Water guifiotent for drinking and food preparation shall also be stored, or the facility shall have a plant for obtaining water in an emergency, with the plan coordinated with and reviewed by the local disaster preparedness authority. On 8/28/12 at approximately 2:00 PM, inspection of the facility's 3-clay supply of nonparishabie food and water revealed that the facility did nat have any water for drinking and for food preparation. Also there was no dry-powdered or condensed | milk for cooking. On 9/28/12 at approximately 2:18 PM, interview with administrator revealed she has 4 gas generator for the facility, She believe that this was sufficient because It would keep the electricity on. Clase Il 5BA-8,023(9) FAG Physical Plant~ Safe Living Environ/Other , (3) OTHER REQUIREMENTS. (a) All facilities musti 4. Provide a safe living environment pursuant to Section 429.28(1)(a), F.8.; and 2, Must be nvaintalned free of hazards; and 3, Must ensure that all existing architectural, mechanieal, aleotrical and structural syetems and appurtenances are Maintained In good working order, (b) Purauant to Section 420,27, F.S., residents shail be given the option of using their own belongings as epave permits, When the facility supplies the furnishings, each resident bedroom ~ AREA Form 5020-0001 “STATE FORM aa FEU3t1 tleontinuation sheat 28 of 44 Feb, 7, 2013 3:24PM The Health Law Firm No. 4604 =P. 57 PRINTED: 09/13/2012 FORMAPPROVED KA) eadnietter ccm 063} DATE SURVEY ENTIFICATION NUMBER: (#2) MULTIPLE CONSTRUCTION GOUPLETED A. BUILDING er AL1911340 NAME OF PROVIDER OR SUPPLIER PINE ACRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, 5080 CUB LAKE DRIVE APOPKA, FL 32708 BUNMARY STATEMENT OF DEPIGHENGIES PROVIDER'S PLAN OF CORRECTION (FACH DEFIGIENCY MUST BE PRECEOEO BY FULL Ea CORRECTIVEAOTION SHOULD BE REGULATORY OR L8G IDENTIFYING INFORMATION) al FRE ENE Oy APPROPRIATE A182| Continued From page 26 or sleeping area must have at least the following - furnishings: ‘ 4. Aglean, corifortable bad with @ maitrass no legs than 36 inches wide and 72 Inches tong, with the top surface of the mattress a comfortable. height to ensure aasy access by the resident 2. Aciosat or wardrobe apace for hanging clothes: 3, Adresser, chest or other fumiture designed far storage of personal effects; , 4. Atable, bedside Jamp or ficar lamp, and waste basket and 8, Acomfortable chair, if requested. (a) The facility must rieintain master of duplionte keys fo resident bedrooms to be waed in the event of an emergency, (d) Residents who use portable bedaide commodes must be provided with privacy during Use, (e) Facilities must make avallable linens and personal laundry services for residents who require such services. Unens provided by @ facility shall be free of tears, staing and nat be threadbare, This Statute or Rule fs not met as evidenced by: Based on observation and interview the facility failed to ensure the wallpaper on the weet wing was maintained, Finding: During the tour of the facility on 9/29/2012 at approximately 9:00 AM a tour of the west wing revealed wallpaper peeling in two places In the canter of the upper side wail. RF TATE FORM ont Feuatt {teontnuaton sheet 27 of 44 Feb. 7, 2013 3:24PM Th ron : e Health L i aw Firm Ho. 4604 P. 58 mae a Agency for Health Care Administration . STATEMENT OF DEFICIENGIES DATE SURVEY 2ND PLAN OF CORRECTION FO TERE (42) MULTIPLE CONBTRUGTION Pe OONRLETEO ALI911310 - og/zpi2042 NAME OF PROVIDER OR SUPPLIER | pINE AGRES GOLDEN AGE CENTRE S10 Ca A (Rap 1D | SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN UF CORRECTION PREFIX {BACH DEFICIENCY MUBT BE PRECEDED BY FULL EAN oR SSS Tne SHOULD BE TAG RECULATORY OR L&C IDENTIFYING INFORMATION) a BFERENGED [O 1H APPROPRIATE, A.182| Conthued From page 27 On 8/26/2012 at approximately 3:30 PM, an interview with the administrator ravealad she | thought her maintenance peraon was aware ofit, However, she could not produce any documentation regarding repair requests forthe - wail paper. Class Wl A162] 884-5.024(3) FAC Revords - Resident (3) RESIDENT RECORDS. Resident records shall be maintained on the premises and include: (a) Resident demographic data as follows: 41. Name; 2, Sex; 3, Race; 4, Date of birth; 5. Place of birth, if known; 6, Social security number, 7, Medicaid and/or Medicare number, or name of other health Insurancs carer, 8, Name, address, and telephone number of next of kin, fesponsible party, or other person the resident would like to have notified In case ofan emergency, and relationghip to resident; and 9, Name, address, and phone number of health care provider, and case manager Happlicable. (b) Acopy ofthe medical examination describad in Rule 68A-8,0181, F.A.C, {c) Any health care provider’ s orders for medications, nursing services, therapeutic diets, do not resusoltate order, or other services to be provided, supervised, of Implemented by the tacitly that require a health care provider’ 5 order. (d) Asigned statement from a resident refusing a therapeutic diet pursuant ta Rule §8A-6,020, FAC. ARCA Femm 3020-0001 ; STATE FORM ang FEUBM Heontinuation shpat 26 of 44 Feb, 7. 2043 3:25PM = The Health Law Firm No. 4604 PL 59 PRINTED: 00/43/2012 FORMAPPROVED Avanoy for Health Gare Administratio) STATEMENY OF DEFIGIENCIES AND PLAN OF GQRRECTION (Ki) PROVIDERISUPPLIFROLIA is INSTRUCTION IDENTIFICATION NUMBER: Oe) MULTIPLE CO on " ALt1941340 _ NAME OF PROVIDER OR SUPPLIER PINE AGRES GOLDEN AGE CENTRE STRERT ADDRESS, CITY, STATE, ZIP CODE $030 GUB LAKE DRIVE APOPKA, Fl. 32708 084) 1D SUMMARY STATEMENT OF QEFIGIENGIES i) PROVIDERS PLAN OF CORRECTION Ke) PREFIX (EACH DEFICIENCY MUST BE PRAGEOED Y FULL PREFIX (BAGH CORREOTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR USO IDENTIFYING INFORMATION} TAG CROSSREF RRND APPROPRIATE DATE Continued From page 28 (6) The resident record described in paragraph BBA-B.0182(1}(e), FAC. (A Aweight record which fs Initiated on adtnission. Information may be taken from the resident's health assessment, Residents receiving assistance with the aotivities of dally living shall have their waight recorded semi-annually, : (9) For facilities which will have unlicensed staff assisting the realdent with the self-administration of medication, a copy of the written Informed consent described In Rule 58A-6.0181, F.A.C., if auch consents not inoluded In the resident’ s contract. (h) For facilities which manage a pill organizer, assist with self-administration of medieations or administer medications for a resident, the required medication records maintained pursuant to Rule 58A-5.0188, F.A.C. () Acopy of the resident ' s contract with the facility, including any addendums to the contract, as desoribad in Rule 68A-5.026, P.A.C. (i) For a facility whose awner, administrator, or staff, or representative thereof serves a6 ai attomey in fact for a resident, a copy of the monthly written statement of any transaction made on behalf of the resident as required under Section 429.27, FS, . (k) For any facility which maintains a separate {rust fund to receive funds or other praperty belonging to or due a resident, a copy of the quarterly written statement of funds or other property disbursed as required undar Section 429.27, F.8, (\) Acopy ofAltemate Care Certification for Optional State Supplementation (QS8) Form, GF-E8 1008, March 1998, if the resident is an O85 reeiplent, The absence of this form shall net be considered a deficiency if the facility can demonstrate that it has made @ good faith effort ARGA Form 3020-0001 STATE FORM oon FEUST! Wtonntinuaton sheer 26 of 44 Feb. 7, 2043 3:25PM The Health Law Firm No. 4604 =P. 60 PRINTED: 09/18/2012 FORM APPROVED (02) MULTIPLE CONSTRUCTION AL11991970 NAME OF PROVIDER OR SUPPLIER PINE AGRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, AP COOE 6030 CUB LAKE DRIVE APOPKA, FL 32703 SUMMARY STATEMENT OF DEFICIENCIES 1D | PROVIDER'S PLAN OF CURREOTION Rove (BACH DEFICIENCY MUST SE PRECEDED BY FULL PREFIX {EAR GORRECTIVE ACTION SHOULD BE co! REGULATORY OR L8G IDENTIFYING INFORMATION) TAR ¢ SS REFERENCED 10 TE APPROPRIATE DATE Continued From page 29 to obtaln the required documentation from the Deparbnent of Children and Family Services, (m) Documentation of the appointment of a health care surrogate, quardian, or the existence of a power of attomey where applicable. (n) For hospice patients, the interdisciplinary care plan and other documentation that the resident i a hospice patient as required under Rule 68A-5,0181, FAC. (0) For apartments, duplexes, quadruplexes, or single family homes that are designated for independent living but which are licensed es assisted living faciitties solely for the purpose of delivating personal services to reeidents in their homes, when and if such services are needed, record keeping on residents who may receive meals but who do not receive any personal, imied nuraing, or extended congragate care service shall ba limited ta the following: 4, Alog listing the names of residents participating in this arrangement, 2, The resident demographic data required under this subsection; 4, The medical examination described in Rule §8A-5.0181, FAC; 4, ‘The resident’ s contract desctibed in Rule 5BA-5.026, F.A.C,; and 5, Ahealth care provider's order for a therapeutic diet if such diet ls prescribed and the resident participates in the meal plan offered by the facillly, (p) Except for resident contracts which must be retained for 8 year, all resident records shall he retained for 2 years following the departure ofa resident from the facility unless it is required by contract to retain the records for a longer period of time, Upon request, residents shall be provided a copy of their resident records upon departure from the factlity. (4) Additional resident records requirements for AHGA Form 3020-0007 STATE FORM eae FRUSIt : Iteontinuation aheet 20 of 44 Feb. 7, 2013 3:25PM The Health Law Firm No. 4604 PF. 61 PRINTED: 08/49/2012 FORM APPROVED om) PROVIDER SUP rueucua (82) MULTIPLE CONSTRUCTION AND PLAN OF CORREQTION . abst testy DENTIFIGATION NUMBER: A BUILDING ALII911910 Bw qei28i204 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE ‘ PINE ACRES GOLDEN AGE CENTRE TRC ons (%4) 1D SUMMARY STATEMENT OF DEFICIENCIES. . io PROVIDER'S PLAN OF GORREOTION but) PREFIX BACH DEFICIENGY MUST BE PRECEOED BY FULL, PREPIX {EACH CORRECTIVE AOTION SHOULD BE SOMPLETE TAG EGULATORY OR L8G IDENTIFYING INFORMATION) TAG GROBS REFERENCED 1 tie APPROPRIATE bate A.162| Continued From page 30 A162 facilities holding 4 limited mental health, extended congregate care, or limited nursing servicas license are provided in Rules 6BA-6.029, 56A-5.030 and 56Ar8.031, F.A.C., respectively. This Statute of Rule is not mat as evidenced by: Based on record review and interview the facility failed to ensure the residant record contained a copy of the documentation of the appointment of a guardian for { of 4 sampled residents (#4), Findings: Record review and review of the resident's demographic information revealed resident #4 had a guardian appointed. There was no documentation to review to indicate the facility obtained a copy of the guardianship papers, Phone interview with the guardian on 8/28/12 at approximately 1 PM stated she had been the rasident’s guardian for several months, Interview with the administrator on 8/28/12 at approximately 3 PM who etated the resident had aguerdian. She alsa stated she did not have a copy of the quardianship papers. | Glass I A 167) 68A-5,026(1) FAC Resident Contracts Resident Contracts. (4) Pursuant to Section 429.24, F.S., prior to or at {he time of admission, each resident or legal representative stall exeoute a contract with the facillly which contains the following provisions: (a) Allet of the specific services, supplies and accommodations to be provided by the facility to AHGA Form 392040001 . STATE FORM oF FeUaH \eontinvation sheet 37 of 44 Feb, 7, 2013 3:26PM The Health Law Firm No. 4604 P. 62 PRINTED: 08/19/2012 FORMAPPROVED Agency for Health Care A STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (M1) PROVIDER/EUPPHIERICLIA MULTIPLE UOTION IDENTIFICATION NUMBER: =) SONSTRUGTIO ALA1914310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 217 QODE PINE ACRES GOLDEN AGE CENTRE posta ae Ra iD SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION REFIK (EACH DEFIGIENGY MUST BE PRECEDED BY FULL PREFIX (BAGH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSO IDENTIFYING INFORMATION} TAG CROSS-REFGRENGED TO THE APPROPRIATE DEFICIENCY) A 187 | Continued From page 31 the resident, including limited nursing and extended congregate care services if the facility is licensed to provide such services. (b) The dally, weekly, or monthly rate, (6) Alist of any additional services and charges to be provided that are not Included In the daily, weekly, or monthly rates, ora reference to a separate fee schedule which ehall be attached ta the contract, (8) A provision giving at least 30 days written notice prior to any rate increase, (8) Any tights, dutles, or obligations of residents, other than thoge specified In Seotion 420,28, F.S. (f) The purpose of any advance payments of deposit payments and the refund policy for such advance or deposit paymerits. (3) Arefund policy which shall conform fo Section 420.24(3), F. (h) Awritten bed hold policy and provisions for terminating a bed hold agreement if a facility agrees in writlng to reserve a bed for a resident who Ig admitted to a nursing home, health care facility, or psychlatrio facility, The resident or responsible party shall notify the facility in writing of any change in status that would prevent the resident from returning to the facility, Unt euch written notice Is received, the agreed upon daily, weekly, or monthly rate may be charged by the facility unless the resident’ s medical condition, such as the resident's hetng comatose, prevents the resident from giving wriiten notification and the resident does not have a responsible party to act in the resident's behalf, (i) Apravision stating whether the organization is affiliated with any religious organization, and, if so, which organization and its relationship to the facility. ()) A provision that, upon determination by tha administrator or health care provider that the ragident needs services beyond thoes the facllily ACA Fort 3020000 STATE FORM aw FeUS{{ ifountinuation shact 32 of 44 Feb. 7, 2013 3:26PM The Health Law Firm No. 4604 PL 63 PRINTED: 09/19/2012 FORM APPROVED Ageney for Health Care Administration STATEMENT GF DEFICIENCIES SEAN OF CORRECTION mt) PROVIDERSUPPLIERGUA K2) MULTIPLE GONSTRUCTION AL41944340 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZF CODE 5030 CUB LAKE DRIVE PINE ACRES GOLDEN AGE CENTRE SOOPKA, FL. $2703 x4) ID BUMMARY STATEMENT OF DEFICIENGIES PROVIDER'S PLAN OF CORRECTION PREFIX (PACH DBFICIENGY MUBT BE PRECEDED BY FULL (GACH CORRECTIVE AGTION SHOULD bE , | TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Ri OROBS-REFERENGED TO THE APPROPRIATE, DEFICIENCY) A167} Continued From page 32 js lleanaed to provide, the resident or the reaident * representative, or agency acting on the resident! 6 behalf, shall be notified In writing that the resident must make arrangements for transfer to a care setting that has services neaded by the resident In the evant the resident has no person to represent him, the facility shall refer the resident to the sovial aarvice agency for placement. \f there Is disagreement regarding the appropriateness of placement, provisions as outlined In Section 429.26(6), F.S,, shall take affect. (k) A provision that residents must be assessed upon admission pursuant to eubseotion 8GA-4,0181(2), F.AC., and every 3 years thereafter, or alter a significant change, pursuant to subsection (4) of thet rule, (i) The facility 's policies and procedures for seltadministration, assistance with sel-administration and administration of medications, if sepia pursuant fo Rule 6GA-5.0186, F.A.G. This also Includes provisions regarding over-the-counter (OTC) products pursuant {o subsection (8) of that rule. (tn) The facility's policies and procedures related to a properly executed Do Not Resuscitate Order, This Statute or Rule is not met as evidenced by: Based on record review and Interview the facility failed to provide @ provision in the contract that rasidents must ba assessed upoh admission pursuant to subsection 584/5.0181(2), F.AC., and evety 3 yeara thereafter, or after a significant change, pursuant to subsection (4) of that rule for 2 of 2 sampled residents (#4 G4), Findings: AHGA Form 020-0001 STATE FORM cr) FEUST Hreontauation sheet 85 of 44 Feb, 7. 2013 3:26PM = The Health Law Firm No. 4604 =P. 64 PRINTED: 08/4 8/2012 FORM APPROVED | STATEMENT OF DEFIGIENGIES | AND PLAN OF CORREGTION M1) PROVIDER/GUPPLIER/OLIA IDENTIFIGATION NUMBER: DATE SURVEY 6X2) MULTIPLG GONSTRUGTION Oe) Dare SUR AL11911316 NAME OF PROVIDER OR SUPPLIER PINE AGRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, ZIP CODE 5080 CUB LAKE DRIVE APOPKA, FL 52703 4} 1 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORREGTION mr?) PREFIX (EAGH DEFICIENCY MUST BE PREGEOED BY FULL PREFIX Apacs CORRECTIVE AGTION SHOULO BE COMPLETE TAG REGULATORY OR LEC IDENTIFYING INFORMATION) TAG cl OBE REFERENGED 19 THRAPEROPRIATE DATE A167} Continued From page 33 Review of facility contracts revealed residents #4 and #4, revealed did not have a statement of the facliity policy conceming completion af a new Form 1823 at least avery 3 years after the initial assessment or after a significant change as defined in rule 88A-5,0134, F.A.C. During the Interview with the facility Administrator on 08/28/12 at approximately 2:10pm, she stated that she was unaware of any changes with the contract requirements, Class 1V rea 58/-5.030(6) FAC ECC - Health Assessment (6) HEALTH ASSESSMENT, Prior to admission to an ECC program, all persons. Including residents transferring within the same facility to that portion of the facility licensed to provide extended congragate care services, must be examined by a physivian or advanced registered nurse praotitioner pursuant to Rule 5BA-5,0181, F.A.C. A health assessment conducted within 60 days prior to admlasion to the ECC program shall meet this requirement. Once admitted, a new health aasessment must be obtained at least annually. This Statute of Rule is not met as evidenced by: Based on record review and interview the faalilty failed to ensure for 4 of 4 sampled rasidents (#4) who recelved ECG services, a completed health assessment (1823) was in the residant's record, Findings: Entrarice conference on 8/28/12 at approximately AYIGA Form S020-0008 STATE FORM an FEUS11 Ifcontinuation shat 34 of 44 Feb. 7. 2013 3:26PM The Health Law Firm No. 4604 =P, 65 PRINTED: 08/13/2012 FORMAPPROVED Ag STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION ency for Health Care Administration (1) PROVIDERJSUPPLIER/CLIA ULTIPLE, TR IDENTIFICATION NUMBER: mae CONSTRUCTION BATE SURVEY PE OMPLETED AL11941310 STREET ADDRESS, CITY, STATE, ZIP CODE 8030 CUB LAKE BRIVE APOPKA, FL 92703 SUMMARY STATEMENT OF DEFIGIENCIES 1D PROVIDER'S PLAN OF GORREGTION sy (GAGH DEFICIENCY MUST BE PRECEDED BY FULL, PREFIX (EACH CORRECTIVE ACTION SHOULD BE. PLETE REGULATORY OR L8G IDENTIFYING INFORMATION) TAG OROBE-REFERENCER TO APPROPRIATE nare AE205| Continued From page 34 9:18 AM with the administrator, the EGG purse, who stated thera were no residents receiving ECC services, NAME OF PROVIDER OR SUPPLIER PINE AGRES GOLDEN AGE CENTRE i) Rede TAG Interview with direct care staff on sald date at approximataly 11 AM who stated resident #4 had a feeding tube. The direct care ataff went to the kitohen with the surveyor and there were cases of Nutren (gastric tube feeding) 280 miliiters bottles, Ina oloset, that she stated the administrator/EGC nurse used to administer the tube feedings to resident #4, Record review for resident #4 revealed she was adinitted on 7/18/12 and there was no doournentation to review to Indloata an AHCA For 1823 was completed, Review of the resident transfer summary dated 7/18/12 from the Skilled Nureing Facility (SNF) te the ALF stated the reason for transfer was the resident did not need the SNF ifthe ALF was able to provide the tube feeding, which was the anly current documentetion the facility had available to review that indicated the resident had a feeding tube. Interview with the administrator on 8/28/12 at approximately 1:16 PM who stated she could not locate the 1823 and previously had a copy, She further stated the guardian had requested copies and possibly had taken the 1823. She stated she had faxed page 4 of the 1823 to the pharmacy to ofder medi¢ations, called the pharmacy at that time ahd requested that they fax a copy of pags 4, Page 4 was faxed by the pharmacy to the faollty at approximately 1:30PM. Page 4 ofthe 4823 was dated 7/19/12, She was unable to iogate pages 1, 2 and, She alzo Stated she administered the resident's tube feedings 4 times AHGA Forts 3020-0001 STATE FORM ane FRUS11 {reantinuaton shret 99 of 44 Feb, 7. 2013 3:27PM The Health Law Firm No. 4604. 66 PRINTED: 09/12/2012 FORMAPPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORREGTION {X1) PROVIDER/SUPPLIERIGLIA IDENTIFICATION NUMBER: R2} MULTIPLE CONSTRUCTION ALA1911310 COMPLETED oiz#i2012 NAME OF PROVIDER OR SUPPLER STREET ADDRESS, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE fed ad iy tl (X4) 1D SUMMARY STATEMENT OF PEN PROVIDERS PLAN OF CORRECTION 5} PREFIX (EAGH DEFIGIENGY MUST BE PRECEDED 8) pre ICTIVE ACTION SHOULD BR GOMPLETE TAG EGULATORY OR LSG IDENTIFYING INFORMATION) The ql DO NEFERENGED Toe APPROPRIATE DATE AE2Z08| Continued From page 35 a day and was not aware the resident needed to he on ECG, Class fil 8 68A-5.030(7) FAC ECC ~ Service Plans (7) SERVICE PLANS, (a) Prior to adinission the extanded congragate care supervigor shall develop a preliminary service plan which includes an assessment of whether the resident meets the facility 's residency criteria, ary appraisal of the residant's unique physical and psycho social neads and preferences, and an evaluation of the facility's ability to meet the resident's needs, (b) Within 14 days of admission the congregate care supervisor shall cnardinate the development of a written service plan which takes Into account the resident's health assessment obtained pursuant to subsection (6); the resident's unique physical and psyoho social neads and preferences; and how the facility will meet the resident's neads Including the following If required: 1. Health monitoring; 2. Assistance with personal care services; %, Nursing services; 4. Supervision; 6. Special diets, 6. Anclilary services; 7. The provision of ather services such a5 transportation and supportive services; and 8, The manner of service provision, and identification of serviss providers, including family and friands, In keeping with resident preferences. (c) Pursuant fo the definitions of " shared Fesponsibility” and ° managed risk" as provided in Section 429.02, F.S., the service pian shall be developed and agreed upon by the AGA Form 320-000" STATE FORM on FEUSTi IFeantinuation sheet $5 of 44 Feb, 7. 2013 3:27PM = The Health Law Firm No. 4604 =P. 67 mare Agency for Health Care Administration ° STATEMENT OF DEFICIENCIES = 1X1) PROVIDERIGUPPLIERIOLIA AND PLAN OF CORRECTION Y IDENTIFICATION NUMBER: (42) MULTIPLE OONSTRUGTION AL11911910 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, Lily, STATE, IP CODE PINE AGREG GOLDEN AGH CENTRE G99 CUB LANE DANE (x4) 1D SUMMARY STATEMENT OF OEFICIENGIES 1D PROVIDER'S PLAN OF CORRECTION 5) PREFIX (BAGH DEFICIENCY MuST BE PRECEDED SY FULL PREFIX jen GORRECTIVEAGTION SHOULD BE COMPLETE TAG REGULATORY OR L8G IDENTIFYING INFORMATION) TAG CROSE-REFERENGED TO THE APPROPRIATE DATE . DEFICIENGY) ' A206) Continued From page 36 AB206 resident or the resident’ s representative or designee, surrogate, guardian, or attomey-in-fact, the facility designee, and shall raflect the responsiblity and right of the resident to consider options and assume risks when making choices pertalning to the resident's service needs and preferences, (4) Tha service plan shall ba reviewed and Updated quarterly to reflect any changes in the tanner of service provision, acopmmodate any changes in the resident’ s physical or mental status, or pursuant to recommendations for modifications In the resident’ § care as dooumented in the nursing asseesment. This Statute or Rule is not met as evidenced by. Based on record review and Interview the facility failed to ensure a preliminary service plan was completed for 4 of 4 sampled residents (#4), who received a peg tube feeding, Findings: Entrance conference on 8/28/12 at approximately 0:15 AM with the administrator, the EOC nurse, who stated there were no residents teceiving ECCsenices, Interview with direct care staff on sald date at approximately 11 AM who stated residant#4 had a feeding tube. The direct cara staff went fo the kitchen with the surveyor and there were cases of Nutren (gastric tube feeding) 250 milliters hattiss, ina closet, that she stated the administrator/ECC nurse used to administer the tube feedings to resident #4, Record review for resident #4 revealed she wae ARCA Form 2020-0001 STATE FORM outa FEUSTI ieonknualion sheet 87 of 4d Feb, 7 2013 3:27PM = The Health Law Firm No. 4604 =P. 68 PRINTED: 09/19/2012 : FORM APPROVED Agency for Health Care Administatio: STATEMENT OF Pa eaaaiee (Ki) PROVIDERUSUPPLUIERICLIA (42) MULTIPLE CONSTRUGTION IDENTIFIGATION NUMBER: AL11911340 NAME OF PROVIDER OR SUPPLIER . RINE ACRES GOLDEN AGE CENTRE STREET ADDRESS, CITY, STATE, ZIPCODE 6080 CUB LAKE DRIVE APOPKA, FL 32703 (4) ID | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORREGTION PREFIX (EACH ORFIGIENCY MUST BE PRECEDED BY FULL Ack CORREOTIVE AOTION SHOULD BE $0 by REGULATORY OR L6G IDENTIFYING INFORMATION) ql OSS-REFERENG TROT APPROPRIATE DATE AE208| Continued From page 37 admitted on 7/16/12 and there was no documentation to review to indicate an AHCA Form 1623 was completed, Review of resident transfer summaty dated , 7842 from the Skilled Nursing Facility (SNF) to the ALF stated the reason for transfer was the reaidant did not need the SNF ifthe ALF was able to provide the tube feeding, which was the only current documentation the facility had available to | review that Indicated the reatdent had a feading tube. Interview with tha administrator/ECC nurse on 8/28/12 at approximately 11:18 AM who stated she administered the resident's tube feedings 4 times a day, wae not aware the reeldent needed to be on ECG and did not complete any documentation for admission and services In the ECG program. Record review revealed there was no dosumentation the faoility had admitted the resident fo the ECC program or developed a praliminary ECC service plan Further interview with the administrator on 9/26/42 at approximately 1:18 PM who stated she could not locate the 1823 and previously had a copy, She further stated the guardian had requested coples and possibly had taken the 4823, She stated she had faxed page 4 of the 4823 to the pharmacy to order medications, called the pharmacy at that time and requested that they faxa copy of page 4, Page 4 was faxed by the fi artnacy to the facility at approximately 4:30 PM, Page 4 of the 1823 was dated 792, She was unable to locate pages 4, 2 and 3, AHCA Form 3020-000 STATE FORM att FEUSII {Foontnustion shewt 36 of 44 Feb, 7, 2013 3:28PM The Health Law Firm No. 4604 =P. 69 PRINTED: 09/13/2012 FORMAPPROVED (41) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: HES AND PLAN OF GORREOTION (08) DATE SURVEY (X2} MULTIPLE CONSTRUOTION COMPLETED ALI1911310 08/28/2042 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, OITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE got0 CUB LAKE QVE SUMMARY STATEMENT OF DEFICIENCIES 1p PROVIDER'S PLAN OF CORRECTION (XS) (EACH DEFIGIENDY MUST BE PRECEDED BY FULL PREFIX (FACH GORRECTIVEAGTION SHOULD BE COMPLETE, REGULATORY OR L8G IDENTIFYING INFORMATION) TAG CROGE-REPERENCED NOY APPROPRIATE DATE A206) Continued From page 38 Review of page 4 of the 1823 reveslad a physician's order dated 7/18/12 for, 1, Nutren (tube feeding) 2 cans 280 milliters via gastric tube 4 times a day for nutrition 2, The residantis to receive nothing by mouth 3, Flush gastric tube with 200 millitars of water twice a day ; 4, Gastric tube site care dally, cleanse with normal saline, pat dry, apply triple antibiotic ointment, cover with (unable to read) sponge, seoure with taps every shift and as needed, Record review revealed there was no documentation the facility had admitted the tesldent to the ECC program ar developed a preliminary ECC service plan to address how the facilily would meet the resident's physical and psychosocial needs, with attention to care to be provided for the peg tube site, administering peg tube feedings and administering medications via the peg tube. Class Il AE207| §8A-5.030(8) FAC ECC - Services (8) EXTENDED CONGREGATE CARE SERVICES, All services shall be provided in the feast reatrictive environment, and inatwanner . |. which respects the resident's independence, privacy, and dignity. (a) An extended congregate care program may provide supportive services including social servioa needs, counseling, emotional support, networking, assistance with sequring social and leisure services, shopping service, escort service, companionship, family support, information and referral, assistance in developing and Implementing seff directed activities, and volunteer services, Family or friends shall be STATE FORM sve FEUBI : Wcomtinuatlon shpat 29 of 44 Feb. 7. 2013 3:28PM The Health Law Firm No. 4604 P70 PRINTED: 09/43/2012 FORMAPPROVED O81) PROVIDERISUPPLIEAYCLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (42) MULTIPLE CONSTRUCTION A. BUILDING ALI1944340 8. WING WAM OF PROVIDER OR SUPPER STREET ADDRESS, CITY, STATE, EP CONE PINE AGRES GOLDEN AGE CENTRE APOMKA PL S270 UMMARY STATEMENT OF DEFICIENCIES par ebene PLAN OF CORRES TION Park ac DEFICIENGY MUST BE PREQEDED SY FULL Page ECTIVE ACTION BHOULD BE REGULATORY OR LSG IDENTIFYING INFORMATION) cADREREPERENGED rahe, THE APPROPRIATE i 7| Continued From page 39 encouraged to provide supportive services for residents, The facility shall provide training for family or friends to enable them to provide supportive services in aecordance with the resident’ s service plant, 7 (b) An extended congregate care program shall make available the following additional services If required by the resident's service plan: 4. Total help with bathing, dressing, grooming and follating; 2, Nursing assessments conducted mora frequently than-snonthly; 3. Measurement and recording of basic vital funotions and weight; 4, Dietary management including provision of spactal diets, monitoring nutrition, and observing the resident’ s food and fuld Intake and output; 5, Assistance with selfadministered medications, or the administration of medications and treatments pursuant to a health care provider’ s order, {f the individual needs aselstance with selfeadministration the facility must Inform the resident of the qualifications of ataff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain the resident’ s or the resident's surrogate, guardian, or attomey-in-fact ' s informed consent to provide such seatatence as required under Section 429,258, F. 6. ee aen of residents with dementia and cognitive impairments; 7. Health education and counseling and the implementation of health-promoting programs and pravantive regimes; 8, Proviston or arrangement for rehabilitative services; and 9. Provision of escort services to health related appointments, (c) Licensed nursing staff in an extended congregate care program may provide any AIGA Fotm 8020-000 STATE FORM ene SURVEY 7 POHPLETED 08/28/2042 FRUSI Ireantinuation seat 40 of 44 Feb, 7 2013 3:28PM = The Health Law Firm No. 4604 PF. 71 PRINTED: 09/73/2012. FORMAPPROVE! Age for Health Care Administration ° SYATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION Kay Pade a hal (M2) MULTIPLE CONSTRUGTION ABIDING Wi ALs4911310 & WANG NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 21? CODE PINE ACRES GOLDEN AGE GENTRE 8080 CUB LAKE DRIVE APOPKA, FL 32703 (4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORREGTION en PREFIX AgAGH DEFICIENCY MUST BE PRECEDED BY FULL PRERK fest CORRECTIVE ACTION SHOULD BE COMPLETE TAG EGULATORY Of LSC IDENTIFYING INFORMATION) TAS i REFBRENGED TO THE APPROPRIATE DATE AE207| Continued From page 40 AB207 nursing serviea permitied within the scope of thelr \icanse conelstent with the residency requiremente of this rule and the facility ' s written policies and procedures, and the nurelng services are: re 4, Authorized by a health care provider's order and pursuant to a plan of care; 2, Medically necassary and appropriate for treatment of the resident ' s condition; 3, In accordance with the prevailing standard of practice in the nursing community; 4. Aservice that can be safely, effectively, and efficlantly provided in the facility; 6, Reoorded in nursing progress notes; and 6. In acoardance with the resident's service plan. (d) Atleast monthly, or mora frequently if required by the resident's service plan, a nursing assessment of the resident shall be conducted. This Statute or Rule Is not met as evidenced by: Based on record review and Interview the facility falled to eneure they had accurate written physician orders for gastric tube feeding and gastric site care, completed nursing pragrass notes each time the service was delivered and a nursing assessment completed monthly for 1 of 4: sampled residents (#2) who recelved Extended Congregate Care services. Findings: Entrance conference on 6/28/12 at approximately 9:15 AM with the administrator, the ECC nurse, who stated there were no residents receiving EGC services. AGA Form 3020-0001 : STATE FORM Cr) Faust Woontnuation shoot 44 of 44 Feb, 7. 2013 3:29PM = The Health Law Firm No. 4604 =P, 72 PRINTED: 09/19/2012 FORM APPROVED Agenoy for Health Gare Administration : STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X41) PROVIDERIBUPPLIERICLIA MULTIPLE CONSTRUCTION IRENTIFICATION NUMBER: 7) oN N ALtI91340 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE. AGRES GOLDEN AGE GENTRE pang aera ae SUMMARY STATEMENT OF DEFICIENCIES iP) PROVIDER'S PLAN OF CORREOTION Pe) REFIX (BAGH DEFICIENGY MUST BE PRECEDED BY FULL PREFIX EACH CORRECTIVE AOTION SHOULO BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAS ceetialaa APPROPRIATE BATE AE207| Continued From paga 41 Interview with direct care etaff on sald date at approximately 11 AM who stated resident#4 had a feeding tuba. ‘The direct care staff went to the kitchen with the surveyor and there were cases of Nutran (gastric tube feeding) 250 millitars bottles, in a closet, that she stated the administrator/ECO nurse used to administer the tuba feedings to fesident #4, Record feview for resident #4 revealed she was admitted on 7/18/12 and there was no donumentation to review to indicate an AHCA Form 1823 was completed, Review of resident transfer summary dated 71812 from the Skilled Nursing Facility (SNF) to the ALF stated the reason for tranafer was the rasident did not heed SNF If ALF was able to provide the tuba feeding, which was the only current documentation the faollity had avaliable to review that Indicated the resident had a feeding tube. Intarview with the administrator/ECC nuree on 8/28/12 at approximately 11:15 AM who stated she administered the resident's tube feedings 4 times a day, was not aware the resident needed to be on ECC and did not complete any documentation for admission and services In the - ECC program. Further interview with the administrator on 8/28/12 at approximately 7:15 PM who stated she could not fppate the 1623 and previously had a copy. She further stated the guardian had requested copies and possibly had taken the 4823. She stated she had faxed page 4 of the 4823 to tha pharmagy to order medications, called the pharmacy at that time and requested thet they fax a copy of page4. Page 4 was faxed AMIGA Form 3020-0001 STATE FORM an FEUSTI ifcontinuallon ahoet 42 of 44 Feb. 7. 2013 3:29PM The Health Law Firm No. 4604 =P. 73 PRINTED: 08/43/2012 FORM APPROVED (X14) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X24) MULTIPLE CONSTRUOTION A BUILDING 5. WING a semeee f1991310 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE ACRES GOLDEN AGE CENTRE 8020 GUB LAKE DRIVE APOPKA, FL 32703 (4) 10 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION xs) PREFIX (EAGH DEFIGIENGY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR L8G IDENTIFYING INFORMATION) TAG CRORE REPERENGED TO TUSAPTROFRIATE DATE. AE207| Continued From page 42 by the pharmacy to the facility at approximately 4:30PM, Page 4 of the 1823 was dated men. She was unable to locate pages 1, 2 and 3, | Review af page 4 of the 1823 revealed a phyalclan's order dated 7/16/12 for, 4, Nutren (tue feeding) 2 cans 250 milliiters (ml) via gustric tube 4 times a day for nutrition 2, The resident is to reeelve nothing by mouth 3, Flush gastric tube with 200 milliters of water twice a day 4, Gastric tube site care daily, cleanse with normal saline, pat dry, apply triple antibiotic ointment, cover with (unable to read) sponge, secure with tape every shift and as needed, Observation ott aald date at 12:20 PM revealed the ECC nurse administered 2 bottles of Nutran 250 ml via the peg tube and stated she administered the peg tube feeding 4 times a day at 8:30 AM, 12 PM, 5 PM and &:30 PM, The nurse flushed the tube with a little water (she did not measure) and stated the glass of watar she was using was & ounces (240 ml) and she flushed {he tube 4 times a day with 8 ounces of water, She poured the Nutren in the syringe, then crushed the residents medications, poured water | . Into the tube end stated the Nutren-was very thick and she added water during the feeding. She gtated at that time that she apoke to the physician regarding Ineeasing the daily water, as the resident was dehydrated, and did not have documentation of the verbal order. The nurse did not have documentation to indicate the physician incveased the daily amount of water. The nurse stated the resident was nonverbal, The STATE FORM we FEUSTI Meantinuation sheet 43 of 44 Feb, 7, 2013 3:29PM The Health Law Firm No. 4604 P74 PRINTED; 08/43/2012 FORM APPROVED Agency for Health Care Administratio . STATEMENT OF DEAIGIENCIES AND PLAN OF GORRECTION 41) PROVIDER/SUPPLIERICUA Ml iN 93) DATE SURVEY a IDENTIFICATION NUMBER: Oh) MULTIPLE CONSTRUCTION COMPLETED AL11911310 NAME OF PROVIRER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8990 CUB LAKE DRIVE PINE ACRES GOLDEN AGH CENTRE APOPKALFL 32703 Ip SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION Seer Ect DEFICIENCY MUST 8& PRECEDED BY FULL PREFIK ae CORREOTIVE ACTION SHOULD BE coseesTe TAG GULATORY OR L8G IDENTIFYING INFORMATION) TAG q OSB-REFERENEED TG ‘THE APPROPRIATE: DATE AE207| Continued Fram page 43 feading at times. The resident was observed ambulating in the facility during the inspection, wo Phone interview with the fanility physiolan, who was not the physician who signed the 1823, on.) gaid date at approximately 1:36 PM who stated the resident was fo receive Nutren 2 cans, 250 mi vie gastric tube 4 times a day, He also stated the resident was to receive 6 ounces of water with each feeding and stated he would send written orders to the facility. Observation revealed the pag tube had a gauze. dressing at the site, The nurse further stated she washed the peg tube site with soap and water and applied a diy 4 x 4 gauze dressing to the site. She stated there was no Infection at the site and the wound did not need wound care and the only order she had was the order for wound care 3 times a day and as needed, The nuree did not clarify the pag tube site care with the physician and have writen documentation of the changed ~ order, There wera no nursing prograss notes completad gach time the peg tube feeding was administered or peg tube site care was performed or a monthly nursing assesement completed (due 8/18/42). Class I AHGA Farm 3020-000 STATE FORM bid PEUSiS ifeantnuation sheet 44 nf 44

Docket for Case No: 13-001557

Orders for Case No: 13-001557