STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA Ne.: 2015007558 v. Return Receipt Requested: 7002 2410 0001 4240 3015 MANULY’S ADULT CARE, INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Manuly’s Adult Care, Inc: (hereinafter “Manuly’s Adult Care”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes, (2014), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $10,500.00 pursuant to Section 429.19(2)(b), Florida Statutes (2014), for the protection of the public health, safety and welfare and $199.87 survey fee pursuant to Section 429.19(7), Florida Statutes (2014). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 429, Part I, Florida Statutes (2014), and Chapter 58A-5, Florida Administrative Code. 5. Manuly’s Adult Care operates a 6-bed assisted living facility located at 12710 NW 8" Lane, Miami, Florida 33182. Manuly’s Adult Care is licensed as an assisted living facility license number AL9279 with an expiration of 8/2015/2016. Manuly’s Adult Care was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNTI MANULY’S ADULT CARE FAILED COORDINATE THE DELIVERY OF SERVICES WITH HOSPICE FOR FOUR SAMPLED RESIDENTS Section 429.28, Florida Statutes, and Rule 58A-5.0182(6), Florida Administrative Code (RESIDENT CARE-RIGHTS & FACILITY PROCEDURES) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 6/18/2015 and based on observation, record review, and interview, it was determined that the facility failed to coordinate the delivery of services with hospice for 4 out of 7 (#'s 1, 4, 5, and 7) sampled residents, The facility failed to limit physical restraints to half bed rails with a doctor's order for usage for 2 out of 7 (#'s 4 and 5) residents, the facility used furniture and multiple bed rails as forms of restraints to prevent residents from getting out of the bed. The facility also endangered residents and violated their rights by allowing a non-resident/staff who did not have a Level II background screening to sleep in the facility and to perform personal hygiene and store clothing in resident rooms. 2 8. On 6/18/2015 at 5:30 a.m., Resident #4 was observed being restrained in bed by the use of a recliner placed against the bed alongside of a half bed rail. This prevented the resident from being able to get out of bed without staff assistance. 9. On 6/18/2015 at 5:30 a.m., Resident #5 was observed in bed with two sets of half bed rails on the right side of the bed. This prevented the resident from being able to get out of bed without staff assistance. The resident was repeatedly shouting, "Let me out! Get me up!" The staff did not respond to these requests. 10. On 6/18/2015 at 5:35 a.m., Resident #3 was observed using a portable toilet in his bedroom while Resident #2 was present. 11. On 6/18/2015, at 5:30 am., Residents #'s 1, 4, 5, and 7 were observed in the facility, bed-bound and unable to assist with activities of daily living (ADLs). Residents # 4 and 5 were observed to be unable to use their hands. 12. Record review revealed that Residents #'s 1, 4, 5, and 7 were receiving hospice services. Record review revealed that the facility did not have interdisciplinary plans of care for four of four residents under hospice care (Residents #'s 1, 4, 5, and 7). The facility failed to coordinate with hospice services to have staff perform administration of medications to the four hospice residents. 13. On 6/18/2015 at 8:20 a.m., Staff C, who arrived at work at 7:25 a.m., was observed taking a crushed substance that had been left in the medicine cabinet area and pouring it into a hot cup of coffee. Staff C then poured the mixture into Resident #4's mouth. When asked how she knew what she was giving the resident, Staff C stated that Staff B had told her what it was. 14. On 6/18/2015, Staff #C stated, regarding Resident #4, "This is the only way this resident can take her medication because she can't do it herself. She can't even hold the cup, and it is hard for her to swallow. She likes coffee so someone figured out to put the meds in there." 15. Record review on 6/18/2015 revealed, that the Agency for Health Care Administration (AHCA) Form 1823 Health Assessment for Residents #4 and 5 stated that the residents were able to self-administer their medications. The Health Assessments were not updated to reflect that the residents needed administration of medications. A review of Resident #4's record revealed that there was no doctor's order for the resident's medications to be crushed before they were administered. 16. On 6/18/2015 at 5:47 a.m., a woman who identified herself as the "sister" of Staff B was observed brushing her teeth and using the restroom in a resident bedroom. She also was observed going into a portable closet inside Residents #6 and 7's bedroom. The portable closet in the resident's room was filled with the "sister's" clothing. 17. On 6/18/2015 record review revealed that the woman observed in the facility was living with a census of seven residents and having access to the resident area and sharing space with residents and did not have a record at the facility and did not have level II background screening or any documentation of training regarding abuse or neglect of the elderly. 18. Based on the foregoing facts Manuly’s Adult Care violated Section 429.28, Florida Statutes, and Rule 58A-5.0182(6), Florida Administrative Code, herein classified as a Class II deficiency, which warrants on this case an assessed fine of $5,000.00. COUNT IE MANULY’S ADULT CARE FAILED TO ENSURE THAT IN THE ABSENCE OF THE ADMINISTRATOR A QUALIFIED STAFF WAS RESPONSIBLE FOR THE OPERATION AND MAINTENANCE OF THE FACILITY Rule 58A-5.019(3), Florida Administrative Code (STAFFING STANDARDS -— LEVELS) CLASS IT VIOLATION 19. | AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 20. During a complaint investigation conducted on 6/18/2015, and based on observation, record review, and interview, it was determined that the facility failed to ensure that in the absence of the Administrator, a qualified staff was responsible for the operation and maintenance of the facility including the management of all staff and the provision of appropriate care to all residents. The facility had 7 residents living at the facility. The facility also did not have a staff member designated in writing to be in charge of the facility when the facility administrator and/or manager were absent. 21. Upon arrival at the facility on 06/18/2015 at 5:15 a.m., and knocking and calling for at least 5 minutes, without being able to reach anyone inside of the facility, furniture was heard moving inside the facility. A staff member finally came to the door and asked for a moment before she opened the door. 22. On 06/18/2015 at 5:25 a.m., it was observed Staff B and another woman in the facility with 7 residents. On 6/18/2015, at 5:30 a.m., Residents #'s 1, 4, 5, and 7 were observed in the facility, bed-bound and unable to assist with activities of daily living (ADL's). Residents #4 and 5 were observed to be unable to use their hands. Staff C arrived on 06/18/2015 at 7:25 a.m., but did not stay for the survey. 23. Review of the staff schedule for June 2015 (third week) documented the following for Thursday, 06/18/2015: 7 am to 4 pm, Staff B (present during the survey) 7 am to 3 pm, Staff C (arrived at 7:30 am and left during the survey) 12 pm to 8 pm, Staff A (not present during the survey) 8 pm to 7 am, Administrator (not present during the survey) 24. The facility is required to have 212 hours per week for a census of seven residents. During the monitoring survey on 06/18/2015 it was revealed that the facility did not have a person in charge in the absence of the Administrator. The designated Manager was unable to communicate with the surveyors during the survey because she had an unlicensed investigation in progress at another location. Record review showed that the facility did not have a staff member designated in writing to be in charge of facility during the absence of the Administrator and Manager's absence. 25. On 06/18/2015 at 7:25 a.m., Staff B stated that the facility's Administrator was out of the country and the facility's Manager was taking care of another facility and this was the reason she could not come to the facility. 26. On 6/18/2015 at 6:30 a.m., unidentified medications were observed in cups in the medicine cabinet area. Staff B stated, she prepared the medications during the night and signs the medication observation records (MOR's) in advance because she does not have time to do these tasks in the morning. 27. | MORs were reviewed on 06/18/2015 at 5:50 a.m., they showed 6 out of 7 residents G's 1, #2, #4, #5, #6, #7) medications were signed as given on 06/18/2015 for 7:00 am. (scheduled dosage time). 28. Medication pass observations on 06/18/2015 at 6:35 a.m. found the following: Staff B took the medications that were already placed in a cup from the medication cabinet for 6 Resident #1. She dropped the medications on a spoon then gave the medications to Resident #1. 29. On 06/18/2015 at 7:20 a.m. Staff B took the medications already placed in a cup from the medication cabinet. Staff B dropped the medications in a napkin that was on the table, she asked Resident #2 if he was going to'take the medications. Resident #2 answered, "I will take it later," while eating breakfast. Staff B left the residents and did not observe or ensure that Resident #2 took his medications. 30. On 06/18/2015 at 7:35 a.m., Staff B took medications already placed in a cup from the cabinet where day care participant medications were stored. Staff B dropped Resident #3's medications on a spoon then gave thé medications to the resident. 31. Staff B stated, this was a day care resident and the facility did not have the MOR's for Resident #3. 32. On 6/18/2015 at 8:20 a.m. Staff C, who arrived at work at 7:25 a.m., was observed taking a crushed substance that had been left in the medicine cabinet area and pouring it into a hot cup of coffee. Staff C then poured the mixture into Resident #4's mouth. When asked how she knew what she was giving the resident, Staff C stated that Staff B had told her what it was. On 6/18/2015, Staff #C stated regarding Resident #4, "This is the only way this resident can take her medication because she can't do it herself. She can't even hold the cup, and it is hard for her to swallow. She likes coffee so someone figured out to put the meds in there." 33. Record review on 6/18/2015 revealed that Agency for Health Care Administration (AHCA) Form 1823 Health Assessment for Residents #4 stated that the resident was able to self- administer their medications. The Health Assessment was not updated to reflect that the resident needed administration of medications. A review of Resident #4's record revealed, there was no doctor's order for the resident's medications to be crushed before they were administered. 7 34. On 06/18/2015, the Agency for Health Care Administrator requested a directed plan } of correction from the facility. The directed corrective actions included: a). The Assisted Living Facility is required to submit a plan to the Agency by 5:00 PM on June 19, 2015, indicating how the facility will come into compliance with the facility's licensed capacity of six beds b) The Assisted Living Facility is required to submit a staffing schedule by 5:00 PM on June 19, 2015 detailing which qualified staff will be available to provide care and services through July 6, 2015. c) The Assisted Living Facility is required to provide written documentation of a qualified manager or designee providing oversight to the field office in the absence of the administrator to the Area 11 field office by 5:00 PM June 19, 2015. d) The Assisted Living Facility is required to provide a written plan outlining the facility's actions to ensure the provision of three meals a days plus a snack with less than 14 hours between dinner and breakfast. 35. . As of 06/22/2015, AHCA has not received any documentation from the facility. 36. Based on the foregoing, Manuly’s Adult Care violated Rule 58A-5.019(3), Florida _ Administrative Code, a Class II deficiency, which carries, in this case a fine in the amount of $5,000.00. COUNT III MANULY’S ADULT CARE FAILED TO OBTAIN A LICENSURE CAPACITY INCREASE PRIOR TO PROVIDING PERSONAL CARE, MEALS, AND ASSISTANCE WITH MEDICATIONS TO SEVEN RESIDENTS, AND THE LICENSED CAPACITY IS THE SIX Section 408.812, Florida Statutes (UNLICENSED ACTIVITY) UNCLASSIFIED VIOLATION 37. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully forth herein. 38. During the complaint investigation conducted on 6/18/2015, and based on observations, record review, and interview, it was determined that the facility failed to obtain a licensure capacity increase prior to providing personal care, meals, and assistance with medications to seven residents. The facility provided services to residents outside the current license capacity of six. 39. Upon arrival to the facility on 06/18/2015 at 5:15 am. and after knocking and calling for at least 5 minutes without being able to reach anyone inside of the facility, furniture was heard moving inside the facility. The staff member finally came to the door and asked for a moment before she opened the door. 40. On 06/18/2015 at 5:25 a.m., it was observed observed Staff B and another woman in the facility with 7 residents. On 6/18/2015, at 5:30 a.m., Residents #s 1, 4, 5, and 7 were observed in the facility, bed-bound and unable to assist with activities of daily living (ADLs). Residents #4 and 5 were observed to be unable to use their hands. 41. Facility tour on 06/18/2015 at 5:25 a.m. with Staff B found the following: Room #1, Residents #4 and #5 Room #2, Resident #1 Room #3, Resident #3 and #2 Room #4, Resident #6 and #7 42. Record review of the facility's admission and discharge log documented the following residents were admitted to facility: Resident #1, Admitted: 05/01/2015 Resident #2, Admitted: 02/01/2013 Resident #4, Admitted: 01/15/2008 Resident #5, Admitted: 07/10/2014 Resident #6, Admitted: 09/01/2013 Resident #7, Admitted: 09/20/2014 43. Record review also showed Residents #s 1, 2, 4, 5, 6, and 7 had resident agreements executed between the residents and the facility. Resident #3 (admitted on 04/22/2013) had a day care agreement with the facility from 7 a.m. to 8 p.m. The day care agreement showed Resident #3 would receive three meals per day and would not réceive housing and a resting area. 44. On 06/18/2015 at 5:25 a.m. Staff B stated that the facility had 6 residents and Resident #3 was a day care that slept in the facility when her son could not take care of the resident. 45. On 06/18/2015 at 6:50 am. Resident #3 stated that she was living in facility for several months. 46. Based on the foregoing, Manuly’s Adult Care violated Section 408.812, Florida Statutes, an unclassified deficiency, which carries, in this case a fine in the amount of $500.00. SURVEY FEE Pursuant to Section 429.19(7), Florida Statutes, AHCA may assess a survey fee of $199.87 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and II. B. Assess an administrative fine of $10,500.00 against Manuly’s Adult Care on Counts I, I and III, for the violations cited above. 10 C. Assess a survey fee of $199.87 against Manuly’s Adult Care, pursuant to Sections 429.19(7), Florida Statutes (2014). D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2014). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. Nelson E. Rodney Assistant General Counsel Agency for Health Care Administration 8333 NW 53” Street, Suite 300 Miami, Florida 33166 (305) 718-5908 Copies furnished to: Field Office Manager Agency for Health Care Administration 8333 N.W. 53" Street, Suite 300 Miami, Florida 33166 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Manuel Gonzalez, Administrator Manuly’s Adult Care, 12710 NW 8” Lane, Miami, Florida 33182 on Apa L | > 2015. Ale E. Rodney STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: MANULY’S ADULT CARE, INC. AHCA No: 2015007558 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2008) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Administrative Complaint and I waive my right-to object and to have a hearing. J understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4, A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC eas AOE a Sesion Sivssete st SENDER: COMPLETE THIS.SECTION ON DELIVERY eke s Mai ETT Domes

Docket for Case No: 15-006530