STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. . Case No.; 2013003684 SUMMERVILLE 3 LLC d/b/a EMERITUS AT LAKE MARY, Respondent. : / _ ADMINISTRATIVE COMPLAINT The State of Florida Agency for Health Caré Administration (hereinafter “Petitioner” or “A gency”), by and through the undersigned counsel, files this Administrative Complaint against Sunimerville 3 LLC d/b/a Emeritus at Lake Mary (hereinafter “Respondent”, pursuant to Section § 120.569 and Section § 120.57 , Florida Statutes (2012), and alleges: a NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $1,500.00 based upon one State Class II deficiency pursuant to Section § 429.19(2)(b), Florida Statutes (2012). ~ JURISDICTION AND VENUE i. The Agenéy has jurisdiction pursuant to Section § 20.42, Section § 120.60 and Chapters 408, Part II, and 429, Part I, Fla. Stat: (2012). 2. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 3, The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforceinent of all applicable regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida . Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 92-bed assisted living facility (hereafter “ALF”) with Limited Nursing Services and located at 150 Middle Street, Lake Mary, Florida 32746. It is licensed as an ALF, license nuinber 10162. . 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 - tag A0025 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully . set forth herein. 7. Pursuant to Florida law: Resident Care Standards: An assisted living facility shall provide care and nati appropriate to the needs of residents accepted for admission to the SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: : (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. ~ 77 7 > ~(b) Daily observation by designated staff of the activities‘of the resident--"* - -- ~ while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident's whereabouts. The resident may travel independently in the community. (d) Contacting the resident's health care provider and other appropriate . party such as the resident's family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services.. Fla. Admin. Code R. 58A-5.0182(1) REE Resident bill of rights (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by Jaw, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. ’ (©) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. . (d) Unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar situations. “Oa m. and 9 pm’ at 4 niiiimivm. Upon réquest, the facility shall make ~~~ (e) Freedom to participate in and benefit from community services and activities and to achieve the highest possible level of independence, autonomy, and interaction within the community. (f) Manage his or her financial affairs unless the resident or, if applicable, the resident's representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide safekeeping for funds as provided in s. 429.27. (g) Share a room with his or her spouse if both are residents of the facility: (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. (i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any resident. (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. - (k) At least 45 days' notice of relocation or termination of residency from the facility unless, for medical 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 pattern of conduct that is 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 45 days’ notice of a nonemergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show . good cause in a court of competent jurisdiction. (I) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other “-—~—“érson Without restraint, interference, coercion, discrimination; or ~~ *- reprisal. Each facility shall establish a grievance procedure to facilitate the residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. Section 429.28, Fla. Stat. (2012) 8. On July 19, 2012, the Agency conducted a biennial re-licensure survey in tandem with a Limited Nursing Services biennial re-licensure survey, of Respondent's assisted living facility, and found it out of compliance with the above statute and rule. . 9. Based on observation, record review and interviews, among other things, the facility failed to provide care and services to prevent the development of pressure ulcers and failed to follow a healthcare provider's order for the administration of oxygen. Findings included: | Resident #3 Resident #3’s May 15, 2012, Resident Health Assessment form 1823, filled ‘out on the day of admission, listed the following diagnoses: toxic metabolic encephalopathy, diabetes mellitus and senile dementia. She was independent with eating but required assistance with ambulation and transfer, grooming, bathing and dressing. She did not have a pressure ulcer upon admission. Documented in a service note from June 21, 2012, was the following: “notified by staff of the Stage 2 wound at right buttock, MD [was] notified and orders for Home Health received." This was the only note found about a Stage Il pressure ulcer. The home health agency (“HFLA”) notes revealed: . 6/22/12 - Patient admitted for wound care for Stage If pressure ulcer right : . buttock. Nurse cleansed the wound and gauze applied. Skin prep to peri-wound; wound covered with hydrocolloid and transparent dressing. Wound size: 1 x 1 x 0.10 cm deep. Lesion pink with no drainage. 6/26/12 There was no dressing in place when nurse arrived. Wound and periwound were cleansed with normal saline by the nurse, then dried. Prep applied to periwound. Hydrocolloid dressing applied to wound. Dressing secured with Tegaderm. Wound size: 0.7x0.7x 0.1 cm. 6/29/12 - Wound care to right buttocks. Cleansed and patted dry. Skin _prep applied to periwound. Covered with duoderm; secured with Tegaderm. (There were no measurements.) 1/3/12 No prior dressing found at site of wound. Buttocks cleansed with SNS. Gauze applied. Skin prep to peri- wound. Covered with hydrocolloid. Secured with transparent dressing. Wound size: 0.6 x 0.6 cm. Healing well. Wound pink with pin point red open center. Resident #3 was lying in bed during a tour of the facility. She resided in the secured unit. During lunch she was seen sitting at the table eating. By 1:30 pm, she was seen in her wheelchair. On being asked about special instructions. to relieve pressure, the staff said there were none. The staff said the resident could not ambulate without assistance. They had to assist her from the wheelchair to a chair located in the common area. Notably, there was no cushion in her wheelchair and no specialty mattress on her bed. Other than the above, there was no documentation found in the record regarding the pressure ulcer. It was unclear whether the wound had healed and unclear whether any interventions had been put in place to prevent pressure ulcers. During an interview, the Resident care director said the resident was diabetic and admitted that she was at risk to develop pressure ulcers. She said they were going to order a gel cushion for the wheelchair and follow the recommendations of the home health nurses. A HHA note dated July 18, 2012, recommended gel overlay and possible vitamin therapy. The HHA nurse had assessed the wound as “resolved,” “will make one more visit to assess stability and skin integrity.” Resident #1 Resident #1 resides in the secure memory care unit. He had an ALF assessment form 1823 that listed diagnoses of dementia, coronary obstructive pulmonary disease (COPD), asthma, congestive heart failure (CHF), gastro- intestinal bleed, enlarged prostate, osteoporosis, arthritis and GERD along with a-history of pneumonia and debilitation. A physician’s order dated May li, 2012 required: 2 liters 02, continuous by nasal cannula. He was observed with an oxygen concentrator and four oxygen tanks in his room. The OQ, was not turned on. An unlicensed staff member who worked in the memory care unit regularly said sometimes the resident puts the oxygen on himself. Sometimes the nurse does it. When the facility administrator was present, Resident #1 was asked to demonstrate how he puts the oxygen on. He put the nasal tube under his chin. - He was unable and did not know how to turn the oxygen concentrator on. During an interview, the administrator said she did not know that the resident had an Order for oxygen 2 liters, continuous. She thought the resident was independent with his oxygen. : The facility did not have licensed staff who could properly administer the oxygen to Resident #1. , 10. The Respondent's failure to be aware of the residents’ general health and physical | well-being, to keep proper documentation of health changes which resulted in the provision of additional services and to assure proper care and supervision by having licensed staff on duty when needed is unacceptable and violation of law. . 11. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility, or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents. 12, The Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2012). WHEREFORE, the Agency intends to impose an administrative fine in the amount * of one thousand, five hundred dollars ($1,500.00), against Respondent, an ALF in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2012). NOTICE OF RIGHTS - _ Respondent is notified of its right to request an administrative hearing pursuant to § 120.569, Florida Statutes. Respondent has thé riglit to tetain, and be represented by an ~~~ attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg. #3, MS #3, Tallahassee, FL 32308; Telephone (850) 412-3630. The Respondent is farther 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. andthe entry of a final order by the Agency. : CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of thé foregoing Administrative Complaint has been served by U.S. Certified Mail, Return Receipt No. 7011 0470 0000 7951 3319, to Corporation Service Company, 1201 Hays Street, Tallahassee, FL 32301- 2525 and, by regular U.S. Mail to Tammy Cain, Adminision Emeritus at Lake Mary, 150 Middle Street, Lake Mary, FL 32746, this | BN day of June, 2013. STATE OF FLORIDA, AGENCY FOR HEALTHCARE ADMINISTRATION 525. Mirror Lake Dr. N., Suite 330H St. Petersburg, Florida 33701 (727) 552-1945; Fax: (727) 552-1440 suzanne.hurley@ahca.myflorida.com Copy to Lorraine Henry, AHCA Area 7

Docket for Case No: 13-004397