STATE OF FLORIDA : AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, - Petitioner, vs. Case No. 2015010763 SWOF LLC d/b/a GULF WINDS, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, SWOF LLC d/b/a GULF WINDS (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2015), and states: | NATURE OF THE ACTION This is an action to impose an administrative fine against an assisted living facility in the sum of SIXTY FOUR THOUSAND FIVE HUNDRED DOLLARS ($64,500.00) based upon twelve (12) Class II violations pursuant to Section 429.19(2)(b), Florida Statutes (2015), one (1) unclassified background screening violation and to REVOKE the license pursuant to Sections 429.14(1)(e) 2 and 3, and 408.815, Florida Statutes (2015). JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 - and 120.57, Florida Statutes (2015). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2015). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state regulations, statutes and rules governing such facilities. Chapters 408, Part II, and 429, Part I, Florida Statutes (2015); Chapter 58A-5, Florida Administrative Code. The Agency may deny, revoke, or suspend any license issued to an assisted living facility, or impose an administrative fine in the manner provided in Chapter 120, Florida Statutes (2015). Sections 408.815 and 429.14, Florida Statutes (2015). 5. The Respondent was issued a license by the Agency (License Number 7804) to operate a 50-bed assisted living facility located at 2745 Venice Avenue East, Venice, Florida 34292, and was at all times material required to comply with the applicable state regulations, statutes and rules governing assisted living facilities. COUNTI The Respondent Failed To Ensure Adequate Supervision Of Residents In Violation Of Section 429.26(7), Florida Statutes (2015) And Rule 58A-5.0182(1), Florida Administrative 6. The Agency re-alleges and incomporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, the facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and services to treat the condition. Section 429.26(7), Florida Statutes (2015). Pursuant to Florida law, an assisted living facility must provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) Facilities must offer personal supervision, as appropriate for each resident, including the following: (a) Monitoring of the quantity and quality of resident diets in accordance with ‘Rule 58A-5.020, Florida Administrative Code. (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 resident. (c) Maintaining a 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) Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services. Rule 58A-5.0182(1), Florida Administrative Code. 8. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 9. Based on resident records reviewed and staff interviews, the Respondent failed to notify the responsible parties when a significant weight loss occurred for 1 of 5 resident records reviewed, specifically Resident #4. The facility failed to document a significant incident for 2 of 2 residents, specifically Resident #14 and Resident #20, involved in an altercation. The facility 3 failed to provide adequate assistance with transfers for 1 of 29 residents, specifically Resident . #25, resulting in an injury. 10. A review of Resident #4's record showed the following weights: On 9/25/14 resident weighed 103 Ibs. (pounds); on 11/16/14 resident weighed 101 lbs.; on 4/14/15 the health assessment showed a weight of 96 lbs.; on 5/5/15 resident weighed 95 lbs.; on 7/31/15 resident weighed 93 Ibs. 11. This was a 10 pound weight loss in 10 months. A further review of Resident #4's record showed no documentation that the physician, hospice, and the resident's responsible party were notified of this significant weight loss. 12. An interview about the lack of notification was conducted with the Administrator on 9/24/15 at 1:10 p.m. She stated, "Resident #4 is on hospice." 13. On 9/23/15 at 11:53 a.m., Resident #14 stated, Resident #20 punched me "in the mouth about 2 weeks ago and broke one of my teeth. I called the police on a violent resident, and I've been black balled by staff and some of the residents, about two weeks ago. I never went to the hospital or the dentist after that. The Administrator didn't want me to report it to the police." 14. On 9/24/15 at 1:15 p.m., the Administrator said Staff F witnessed this incident and to spoke with the resident. 15. On 9/24/15 at 1:30 p.m., Staff F said approximately 3 weeks ago this incident happened. Staff F said Resident #14 was taunting Resident #20. Staff F was bringing a tray from a resident room back to the kitchen. Staff F told Resident #14 to stop taunting Resident #20. Staff F saw Resident #20 get up from the table where the resident was sitting and Staff F told the resident to sit back down and ignore Resident #14. Staff F said she turned around and Resident #20 leaped over to Resident #14 and hit the resident in the jaw. Staff F grabbed Resident #20’s arm too late. Resident #14 told Staff F he/she was going to call the police. Staff F said there were no injuries. When asked about Resident #14's missing lower tooth, Staff F confirmed Resident , 4 #14 had all teeth before the incident. 16. A review of the incident report showed this altercation occurred on 8/28/15 between Resident #14 and Resident #20. Staff F was the witness to the altercation. She wrote she had to "...pull them apart and everything was fine." The incident report failed to show the physician, law enforcement, the abuse registry, and residents’ representatives were notified. The incident report failed to show any steps taken to prevent this from reoccurring. 17. A review of Resident #14's record showed no documentation of this incident or a tooth missing. 18. On 9/16/15 at 3:30 p.m. and again on 9/23/15 at 2:15 p.m., a family member of Resident #25’s said the resident used a walker when he/she moved in the facility, but now the resident is in a wheelchair and is incontinent. The family member said Resident #25 was dropped from a recliner to a wheelchair on 8/19/15 when transferring with the assistance of one staff. Resident #25's knee was swollen and painful. The resident had a mobile x-ray done after the injury. Due to continued pain, Resident #25 was sent to an acute care hospital for further evaluation. 19. On 9/16/15 at 3:45 p.m., the Administrator verified Resident #25's fall with injury occurred while under the care of a facility caregiver. The Administrator admitted she had not completed any reports about the incident. 20. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 408.813(2)(b), Florida Statutes (2015). 21. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine 5 shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b) Florida Statutes (2015). COUNT II The Respondent Failed To Provide A Safe, Decent Living Environment, Free From Abuse And Neglect In Violation Of Section 429.28(1), Florida Statutes (2015) And Rule 58A- 5.0182(6), Florida Administrative Code 22. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 23. Pursuant to Florida law, no resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, 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 ina 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. (c) 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 9 a.m. and 9 p.m. at a minimum. 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 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 Section 429.27, Florida Statutes. (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. @ 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. G) Access to adequate and appropriate health care consistent with established and recognized standards within the community. 5 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. ()_ Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, 7 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(1), Florida Statutes (2014). Pursuant to Florida law, (a) A copy of the Resident Bill of Rights as described in ' Section 429.28, Florida Statutes, or a summary provided by the Long-Term Care Ombudsman Program must be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, Florida Administrative Code. (b) In accordance with Section 429.28, Florida Statutes, the facility must have a written grievance procedure for receiving and responding to resident complaints, and for residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The telephone number for lodging complaints against a facility or facility staff must be posted in full view in a common area accessible to all residents. The telephone numbers are: the Long-Term Care Ombudsman Program, 1(888) 831-0404; Disability Rights Florida, 1(800) 342- 0823; the Agency Consumer Hotline 1(888) 419-3456, and the statewide toll-free telephone number of the Florida Abuse Hotline, 1(800) 96-ABUSE or 1(800) 962-2873. The telephone numbers must be posted in close proximity to a telephone accessible by residents and must be a minimum of 14-point font. . (d) The facility must have a written statement of its house rules and procedures that must be included in the admission package provided pursuant to Rule 58A-5.0181, Florida Administrative Code. The rules and procedures must at a minimum address the facility’s policies regarding: 1. Resident responsibilities; 2. Alcohol and tobacco; 3. Medication storage; 4. Resident elopement; 5. Reporting resident abuse, neglect, and exploitation; 6. Administrative and housekeeping schedules and requirements; 7. Infection control, sanitation, and universal precautions; and 8. The requirements for coordinating the delivery of services to residents by third party providers. (e) Residents may not be required to perform any work in the facility without compensation, unless the facility rules or the facility contract includes a requirement that residents be responsible for cleaning their own sleeping areas or apartments. If a resident is employed by the facility, the resident must be compensated in compliance with state and federal wage laws. (f) The facility must provide residents with convenient access to a telephone to facilitate the resident’s right to unrestricted and private communication, pursuant to Section 429.28(1)(d), Florida Statutes. The facility must not prohibit unidentified telephone calls to residents. For facilities with a licensed capacity of 17 or more residents in which residents do not have private telephones, there must be, at a minimum, a readily accessible telephone on each floor of each building where residents reside. (g) In addition to the requirements of Section 429.41(1)(k), Florida Statutes, the use of physical restraints by a facility must be reviewed by the resident’s physician annually. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance, is not considered a physical restraint. Rule 58A-5.0182(6), Florida Administrative Code. 24. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 25. - Based on interviews and record reviews, the Respondent failed to ensure a safe 9 environment for 3 of 29 residents, specifically Resident #14, Resident #22, and Resident #25. The Respondent failed to protect Resident #14 from Resident #20 resulting in Resident #14 being hit in the mouth and losing a tooth; failed to protect Resident #22 from verbal abuse; failed to prevent injury for Resident #25 and failed to train staff as required. 26. On-9/23/15 at 11:53 a.m., Resident #14 stated that Resident #20 punched the resident in the mouth about 2 weeks ago and broke one of my teeth. Resident #14 stated, "I called the police on a violent resident, and I've been black balled by staff and some of the residents, about two weeks ago. I never went to the hospital or the dentist after that. The Administrator didn't want me to report it to the police." 27. On 9/24/15 at 1:15 p.m., the Administrator said Staff F witnessed this incident and spoke with her. 28: On 9/24/15 at 1:30 p.m., Staff F said approximately 3 weeks ago this incident happened. Staff F said Resident #14 was taunting Resident #20. Staff F was bringing a tray from a resident room back to the kitchen. Staff F toid Resident #14 to stop taunting Resident #20 and~ saw Resident #20 get up from the table where the resident was sitting and Staff F told Resident #20 to sit back down and ignore Resident #14. Staff F said she turned around and Resident #20 leaped over to Resident #14 and hit the resident in the jaw and Staff F grabbed Resident #20’s arm too late. Resident #14 told Staff F he/she was going to call the police. Staff F also stated there were no injuries. When asked about Resident #14's missing lower tooth, Staff F confirmed Resident #14 had all teeth before the incident. 29. A review of the incident report showed this altercation occurred on 8/28/15 between Resident #14 and Resident #20. Staff F was the witness of this altercation. Staff F wrote she had to "...pull them apart and everything was fine." A review of the incident report showed physician, law enforcement, abuse registry, and residents’ representatives were not notified. Also no steps were taken to prevent this from reoccurring. 10 30. A review of Resident #14's record showed no documentation of this incident or a tooth missing. 31. A review of facility records showed Staff F was hired on 6/18/15 as a direct care staff. Staff F had no documentation of training in resident behaviors, resident rights, abuse, neglect and exploitation, elopement, emergencies, incident reports or safe food handling. Staff F did have a certificate for 75 hour Home Health Aide training. The certificate lacked the course content, so it could not be determined which of the required training may have been met. 32. On 9/24/15 at 11:00 a.m. Resident #22 stated, "They told me I had to go to bed when I did not want to. I hate it here. A night staff female yells at me. I've had things stolen, a brand new pair of shoes. I told the Administrator about the shoes being stolen and nothing happened." 33. On 9/24/15 at 2:35 p.m. Staff F said Resident: #22 is concerned about "the girls" who provide care (Staff B and Staff C). Staff F said Resident #22 thinks they are not doing anything for him/her. Staff F said Resident #22 said staff talks nasty to him/her. 34. On 9/16/15 at 3:30 p.m. and again on 9/23/15 at 2:15 p.m., a family member of Resident #25 said the resident used a walker when he/she moved in here, but now Resident #25 is in a wheelchair, and is incontinent. The family member said Resident #25 was dropped on 8/19/15 when transferring from a recliner to a wheelchair with the assistance of one staff. Resident #25's knee was swollen and painful. The resident had a mobile x-ray done after the injury. Due to continued pain, Resident #25 was sent to an acute care hospital for further evaluation. 35. On 9/16/15 at 3:45 p.m. the Administrator, verified Resident #25's fall with injury occurred while under the care of a caregiver. The Administrator verified she had not completed any reports about the incident. 36. Personnel record reviews revealed 12 of 13 persons hired, specifically Staff A, B, 11 C, D, E, F, G, H, J, K, L, and N, as direct care staff or employed over 30 days lacked documentation of required trainings. Staff lacked training in infection control, activities of daily living and resident behaviors, resident rights, abuse, neglect and exploitation, elopement, emergencies, incident reports, or safe food handling. A culture where staff are not trained as required to perform their job duties from October 2014 through September 2015 is a direct threat to the health and well-being of the residents. 37. | The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class J violation. Section 408.813(2)(b), Florida Statutes (2015). 38. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b) Florida Statutes (2015). COUNT Ill The Respondent Failed To Ensure Prescription Drugs Were Properly Labeled And Dispensed In Violation Of Rule 58A-5.0185(3), Florida Administrative Code 39. The Agency re-alleges and incorporates by reference paragraphs one (1) through _ five (5). 40. Pursuant to Sections 429.255 and 429.256, Florida Statutes, and Rule 58A- 5.0185, licensed facilities may assist with the self-administration or administration of medications to residents in a facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule. Any unlicensed person providing assistance with 12 self administration of medication must be 18 years of age or older, trained to assist with self administered medication pursuant to the training requirements of Rule 58A-5.0191, Florida Administrative Code, and must be available to assist residents with self-administered medications in accordance with procedures described in Section 429.256, Florida Statutes and this rule. (b) In addition to the specifications of Section 429.256(3), Florida Statutes, assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed. (c) In order to facilitate assistance with self-administration, trained staff may prepare and make available such items as water, juice, cups, and spoons. Trained staff may also return unused doses to the medication container. Medication, which appears to have been contaminated, must not be returned to the container. (d) Trained staff must observe the resident take the medication. Any concerns about the resident’s reaction to the medication or suspected noncompliance must be reported to the resident’s health care provider and documented in the resident’s record. (e) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to enable the resident to take medication as prescribed: 1. The health care provider may prescribe a medication schedule that coincides with the resident’s presence in the facility; 2. The medication container may be given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record; 3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection (2), and given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record; or 13 4. Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose packaging; (f) Assistance with self-administration of medication does not include the activities detailed in Section 429.256(4), Florida Statutes. 1. As used in Section 429.256(4)(h), F.S., the term “competent resident” means that the resident is cognizant of when a medication is required and understands the purpose for taking the medication. 2. As used in Section 429.256(4)(i), Florida Statutes, the terms “judgment” and “discretion” mean interpreting vital signs and evaluating or assessing a resident’s condition. Rule 58A- 5.0185(3), Florida Administrative Code. 41. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 42. __ Based on observation and interview, the Respondent failed to ensure unlicensed staff assisted 4 of 7 residents, specifically Resident #4, Resident #5, Resident #7, and Resident #9, with self-administration of medication within the scope of their duties and training required under Florida Statutes. The Respondent failed to provide prescribed medications to 2 of 4 residents reviewed, specifically Resident #5 and Resident #18, for medications. 43, Unlicensed and untrained staff drawing insulin into a syringe has the potential to directly affect the safety and well-being of the resident. Unlicensed staff are required to have 4 hours of medication training which does not include insulin dosing. Unlicensed and untrained staff does not have training in oxygen titration which can affect the safety and well-being of the resident by over or under oxygenation. 44. At the time of the survey, training for assisting with self-administration of medications by unlicensed staff did not address blood sugar testing, insulin, and oxygen 14 administration. The minimum requirements for this additional training had not been established. 45. On 9/23/15 at 12:00 p.m., observations included Staff D gave Resident #18 medications. The Clonazepam (an antianxiety medication) card showed there was one pill left. A review of the Medication Observation Record revealed the resident was going to receive this medication at 4:00 p.m. that day. 46. On 9/24/15 at 12:00 p.m., the Clonazepam was still in the medication card for Resident #18. An interview was conducted with Staff F and she stated she did not give this medication to Resident #18 in the morning. 47. On 9/24/15 at 2:15 p.m., Staff C said she gave the Clonazepam to Resident #18 last night. However, observation at 12:00 p.m. showed this pill was still available. 48. A review of the Medication Observation Record showed Resident #18 is to receive this medication three times a day. Resident #18 did not receive the third pill on 9/23/15. 49. A review of Resident #5's physician order on the health assessment form dated 5/23/15 showed, "wound care - rt [right] great toe and rt leg ulcer - clean w/[with] ns [normal saline] apply prisma [a collagen dressing], cover w/mepilex border [a foam dressing with adhesive]. Change mwf [Monday, Wednesday, Friday]. Apply lac-hydrin [a lactic acid formulated] lotion to legs and feet (not between toes) q [every] shift." 50. A review of Resident #5's Medication Observation Records for May through September 2015 showed the resident was not receiving the Lac-hydrin lotion. 51. A review of Resident #5's home health agency notes showed there was no documentation they were providing the Lac-hydrin lotion. 52. On 9/24/15 at 11:50 a.m., the Administrator reviewed the physician order on the health assessment form and stated she was not aware of the Lac-hydrin order. 53. On 9/24/5 at 12:00 p.m., the home health agency Director of Nursing said the nurse comes to the facility every day to do wound care with Viscopaste [a zinc paste bandage] 15 and stretch guard and paper tape for Resident #5. She was not aware of the order for the Lac- hydrin lotion and they are not putting this lotion on the resident’s legs. 54. On 9/24/15 at 2:30 p.m., Staff F said she assisted Resident #5 and #9 with their blood sugar testing and insulin. She said she gives Resident #5 the stick (lancet) and the resident pokes him/herself. Staff F places the tape into the device and hands it to Resident #5. She then takes it back and notes the blood sugar test result and writes it down. She then dials the insulin dose amount on the insulin pen. Resident #5 then gives him/herself insulin. 55. For Resident #9, Staff F said she does the same for the blood sugar, but the insulin is in a bottle. Staff F draws the amount needed up and hands the syringe to Resident #9. She said she knew how to draw up the bottled insulin into the syringe. 56. On 9/23/15 at 10:00 am., Resident #7 said staff assists with medications. Resident #7 said he/she will wake up and find pills on the floor or water spilled on the floor. Resident #7 will be sleeping, and the staff will place pills on the night table and not wake him/her up. 57. An observation of Resident #4 on 9/16/15 revealed Resident #4 was returning to bed after supper. The resident was stood up by Staff C grasping the resident under the arms and lifting the resident to his/her feet. The resident was able to bear weight and was pivoted by Staff C and lowered onto the bed. Staff C then handed Resident #4 oxygen tubing and clasped Resident #4's hands and fingers and attempted to manipulate the residents’ fingers to put the oxygen tubing in the residents nostrils. The resident was unable to do this and Staff C stopped after it became obvious the resident had fallen asleep. Staff C continued to stand beside the bed and look at the resident. The Administrator, who was present, said the resident usually assisted with the oxygen, yet admitted when the resident could not assist, the staff applied the oxygen and turned on and set the concentrator. 58. Observations on 9/16/15 included a nebulizer beside the Resident #4's bed. The 16 Administrator verified the unlicensed staff administers the nebulizer treatments to the resident. The Administrator stated, "Well we will be able to do these things soon." The Administrator was referring to the anticipated changes in assisted living facility regulations resulting from changes in the Florida statutes. The Administrator said Resident #4 was under hospice care and was ordered to have 2 liters of oxygen on when in bed. She verified hospice staff were not providing this service when it is needed. The Administrator verified the facility has no licensed staff. 59. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 408.813(2)(b), Florida Statutes (2015). 60. | The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b) Florida Statutes (2015). COUNT IV The Respondent Failed To Provide Appropriate Care By Maintaining A Safe Living Environment In Violation Of Section 429.176, Florida Statutes (2015) And Rule 58A- 5.019(1), Florida Administrative Code 61. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 62. Pursuant to Florida law, if, during the period for which a license is issued, the owner changes administrators, the owner must notify the agency of the change within 10 days and provide documentation within 90 days that the new administrator has completed the 17 applicable core educational requirements under Section 429.52, Florida Statutes. Section 429.176, Florida Statutes (2015). Pursuant to Florida law, every facility must be 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 provision of appropriate care to all residents as required by Chapters 408, Part II, 429, Part I, Florida Statutes and Rule Chapter 59A-35, Florida Administrative Code, and this rule chapter. (a) An administrator must: 1. Be at least 21 years of age; 2. If employed on or after October 30, 1995, have, at a minimum, a high school diploma or G.E.D.; 3. Be in compliance with Level 2 background screening requirements pursuant to Sections 408.809 and 429.174, Florida Statutes; and 4. Complete the core training and core competency test requirements pursuant to Rule 58A- 5.0191, Florida Administrative Code, no later than 90 days after becoming employed as a facility administrator. Individuals who have successfully completed these requirements before December ‘1, 2014, are not required to take either the 40 hour core training or test unless specified elsewhere in this rule. Administrators who attended core training prior to July 1, 1997, are not required to take the competency test unless specified elsewhere in this rule. 5. Satisfy the continuing education requirements pursuant to Rule 58A-5.0191, Florida Administrative Code. Administrators who are not in compliance with these requirements must retake the core training and core competency test requirements in effect on the date the non- compliance is discovered by the agency or the department. (b) In the event of extenuating circumstances, such as the death of a facility administrator, the agency may permit an individual who otherwise has not satisfied the training requirements of 18 subparagraphs (1)(a)4. of this rule to temporarily serve as the facility administrator for a period not to exceed 90 days. During the 90 day period, the individual temporarily serving as facility administrator must: 1. Complete the core training and core competency test requirements pursuant to Rule 58A- 5.0191, Florida Administrative Code; and 2. Complete all additional training requirements if the facility maintains licensure as an extended congregate care or limited mental health facility. (c) Administrators may supervise a maximum of either three assisted living facilities or a group of facilities on a single campus providing housing and health care Administrators who supervise more than one facility must appoint in writing a separate manager for each facility. However, an administrator supervising a maximum of three assisted living facilities, each licensed for 16 or fewer beds and all within a 15 mile radius of each other, is only required to appoint two managers to assist in the operation and maintenance of those facilities. (d) An individual serving as a manager must satisfy the same qualifications, background screening, core training and competency test requirements, and continuing education requirements of an administrator pursuant to paragraph (1)(a) of this rule. Managers who attended the core training program prior to July 1, 1997, are not required to take the competency test unless specified elsewhere in this rule. In addition, a manager may not serve as a manager of more than a single facility, except as provided in paragraph (1)(c) of this rule, and may not simultaneously serve as an administrator of any other facility. (e) Pursuant to Section 429.176, Florida Statutes, facility owners must notify the Agency Central Office within 10 days of a change in facility administrator on the Notification of Change of Administrator form, AHCA Form 3180-1006, May 2013, which is incorporated by reference and available online at: http://www-flrules.org/Gateway/reference.asp?No=Ref-04002. Rule 58A-5.019(1), Florida Administrative Code. 19 63. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 64. Based on observation, resident and staff interviews, the court appointed receiver . (as a financial manager), subcontracted management company, and Administrator failed to ensure enough staff to provide care and services to meet resident needs for 6 of 29 current residents, specifically Residents #2, #6, #13, #23 #25, and #29 . The managers and Administrator failed to prevent abuse and ensure a safe environment for 3 of 29 residents, specifically Resident #14, #22, and #25. The managers and Administrator failed to provide all residents scheduled activities. The managers and Administrator failed to schedule the facility for 24 hour First Aid and cardiopulmonary resuscitation (CPR) coverage. The managers and Administrator failed to ensure all staff had training necessary to do their jobs and failed to audit the daily financial operations of the facility, ensure the properly executed contracts for each resident were honored and failed to ensure resident personal income was provided to them for 6 of 35 residents reviewed, specifically Residents #2, #14, #18, #19, #22 and #30, for financial information. These failures directly threaten the residents and resulted in Residents #14 and #25 being injured, Resident #2 waiting hours for meals, and Resident #22 being verbally abused. 65. On 9/23/15 at 11:53 a.m., Resident #14 stated that Resident #20 punched him/her in the mouth about 2 weeks ago and broke one of my teeth. Resident #14 stated, "I called the police on a violent resident, and I've been black balled by staff and some of the residents, I never went to the hospital or the dentist after that. The Administrator didn't want me to report it to the police." 66. On 9/23/15 at 11:53 am., Resident #14 stated that Resident #20 punched the resident in the mouth about 2 weeks ago and broke one of my teeth. Resident #14 stated, "I called the police on a violent resident, and I've been black balled by staff and some of the residents, about two weeks ago. I never went to the hospital or the dentist after that. The 20 Administrator didn't want me to report it to the police." 67. On 9/24/15 at 1:15 p.m., the Administrator said Staff F witnessed this incident and spoke with her. 68. On 9/24/15 at 1:30 p.m., Staff F said approximately 3 weeks ago this incident happened. Staff F said Resident #14 was taunting Resident #20. Staff F was bringing a tray from a resident room back to the kitchen. Staff F told Resident #14 to stop taunting Resident #20 and saw Resident #20 get up from the table where the resident was sitting and Staff F told Resident #20 to sit back down and ignore Resident #14. Staff F said she turned around and Resident #20 leaped over to Resident. #14 and hit the resident in the jaw and Staff F grabbed Resident #20’s arm too late. Resident #14 told Staff F he/she was going to call the police. Staff F also stated there were no injuries. When asked about Resident #14's missing lower tooth, Staff F confirmed Resident #14 had all teeth before the incident. 69. A review of the incident report showed this altercation occurred on 8/28/15 between Resident #14 and Resident #20. Staff F was the witness of this altercation. Staff F wrote she had to "...pull them apart and everything was fine." A review of the incident report showed physician, law enforcement, abuse registry, and residents’ representatives were not notified. Also no steps were taken to prevent this from reoccurring. 70. A review of Resident #14's record showed no documentation of this incident or a tooth missing. 71. A review of facility records showed Staff F was hired on 6/18/15 as a direct care staff. Staff F had no documentation of training in resident behaviors, resident rights, abuse, neglect and exploitation, elopement, emergencies, incident reports or safe food handling. Staff F did have a certificate for 75 hour Home Health Aide training. The certificate lacked the course content, so it could not be determined which of the required training may have been met. 72. On 9/24/15 at 11:00 a.m. Resident #22 stated, "They told me I had to go to bed 21 when I did not want to. I hate it here. A night staff female yells at me. I've had things stolen, a brand new pair of shoes. I told the Administrator about the shoes being stolen and nothing happened." 73. On 9/24/15 at 2:35 p.m. Staff F said Resident #22 is concerned about "the girls" | who provide care (Staff B and Staff C). Staff F said Resident #22 thinks they are not doing anything for him/her. Staff F said Resident #22 said staff talks nasty to him/her. 74. On 9/16/15 at 3:30 p.m. and again on 9/23/15 at 2:15 p.m., a family member of Resident #25 said the resident used a walker when he/she moved in here, but now Resident #25 is in a wheelchair, and is incontinent. The family member said Resident #25 was dropped on 8/19/15 when transferring from a recliner to a wheelchair with the assistance of one staff. Resident #25's knee was swollen and painful. The resident had a mobile x-ray done after the injury. Due to continued pain, Resident #25 was sent to an acute care hospital for further evaluation. 75. On 9/16/15 at 3:45 p.m. the Administrator, verified Resident #25's fall with injury occurred while under the care of a caregiver. The Administrator verified she had not completed any reports about the incident. 76. An observation of the noon meal on 9/16/15 revealed the cook called off and the Administrator said she could not get anyone else to come in. The meal was being served by a housekeeper. The facility served all the residents in the dining room their meals, special requests and re-orders. After all residents in the dining room were served at 2:00 p.m., the staff began to serve the residents in their rooms. Observation of the food preparation found staff did not know how to puree a meal. The ground hot dog was put into a blender and blended into small chucks. The housekeeper put the baked beans in the blender and made a soupy paste. The second time she was prompted by another staff to add water to the hot dogs and got a more puree consistency. She added water to both the beans and corn. The beans were very runny. The corn became a 22 watery corn-flavored liquid. This was served to Residents #2 and #13. 77. Observation on 9/16/16 revealed the supper meal began at 5:15 p.m. Since the housekeeper was gone, only two staff were scheduled on the second shift. One staff became the cook and the second staff waited tables. Food service and resident care continued until 6:45 p.m. At 7:00 p.m. Resident #2, who is bedbound, had still not been assisted to eat. 78. Observation during lunch on 9/23/15 at 12:20 p.m. showed there are two staff serving lunch to the residents and one cook preparing meals. There is a table of six residents sitting together. Five residents were served their lunch by 12:23 p.m. Resident #6 was not served until 12:50 p.m. Four of these residents finished eating by 12:40 p.m. Resident #23 (who is sitting at this table) requested a sandwich at 12:35 p.m. Resident #23 received the sandwich at 1:15 p.m. 79. Residents #2 and #13 are on hospice care and remain in their beds at all times. On 9/23/16 at 12:55 p.m., Staff D stated that these two residents eat. in their rooms. Observation on 9/23/16 at 1:43 p.m. showed Residents #2 and #13's pureed foods were prepared by the cook. The cook placed them in bowls on the kitchen counter waiting for the staff to serve the two residents. 80. The surveyor notified Staff A at 1:45 p.m. that the food was ready for the two residents to be served. She put the food bowls onto plates and walked away. 81. Observation at 2:30 p.m. showed the food was sitting on the kitchen counter. After surveyor intervention at 2:30 p.m., Residents #2 and #13 were both served their lunch by 2:55 p.m. 82. On 9/23/16 at 2:30 p.m., Staff D and Staff A both said they were taking care of Resident #22 who requires two people to assist with incontinent needs. They were also taking care of other residents' toileting needs. Staff D also had to take care of the medication pass. They both stated they need one staff for medication pass and two staff for resident care needs. There 23 are only two staff on this shift. As a result, they can't take care of all the resident needs timely. 83. Observations on 9/23/15 throughout the course of the day showed no activities being offered. A review of the activity calendar located in the dining room showed: "AM: daily news, brain games and puzzles, music" are scheduled in the morning. 84. On 9/23/15 at 2:45 p.m., Staff D and Staff G both stated they do not have any time to run these activities. It takes most of their time to provide activities of daily living for the residents and provide assistance for two meals. When they had three staff working on this shift "everything ran much easier" and they were able to provide the scheduled activities. 85. Observation on 9/24/15 from 9:00 a.m. through 2:30 p.m. showed the scheduled activities on the calendar were not offered. On 9/24/15 the facility had added a pool staff person on the day and evening shifts. This additional help still did not allow staff to have time to provide activities. 86. In an interview on 9/23/15 at 10:22 a.m., Resident #8 said he/she needs assistance with showers. Staff told the resident not to shower without assistance. Resident #8 wants a shower every other day but only gets two a week. "There are only 2 people working each night and has to wait and wait and wait." 87. On 9/23/15 at 11:10 am., Resident #24 said staff helps with showers, dressing, and sometimes the bathroom. Sometimes they are "slow." The resident has to wait a little longer "maybe about 1/2 hour." 88. On 9/23/15 at 12:25 p.m., Resident #6 said he always has to wait a long time to get food (ordered a puree diet). Resident #6 is the last to eat. There are not enough staff in the dining room. For every meal everyone has to wait a long time to be served. 89. On 9/23/15 at 10:20 a.m. Resident #29 said he/she had been here about 15 months. The night shift staff fall asleep on the couch. They (the administration) know about it. 90. On 9/16/15 at 3:30 p.m. and again on 9/23/15 at 2:15 p.m., a family member of 24 Resident #25 said the resident used a walker when he/she moved in here, but now the resident is in a wheelchair, and is incontinent. She said Resident #25 was dropped on 8/19/15 when transferring from a recliner to a wheelchair. Resident #25's knee was swollen and painful. The resident had a mobile x-ray done after the injury. Due to continued pain, Resident #25 was sent to an acute care hospital for further evaluation. 91. . On 9/16/15 at 3:45 p.m., the Administrator verified Resident #25's fall with injury occurred while under the care of a caregiver. She verified she had not completed any reports about the incident. 92. On 9/24/15 at 2:30 p.m., Staff I said there are not enough staff to take care of laundry. Sometimes there is no cook and one of the direct care people has to cook leaving one person on the floor through dinner. 93. On 9/24/15 at 2:35 p.m. Staff F said there are not enough staff. "We need 3 not 2. Two staff is a rush and we have to focus on medications, dining room, laundry and people." 94. A review of the staff schedule on 9/16/15 revealed two direct care staff are scheduled for each shift. A cook is scheduled from 7:00 a.m. to 7:00 p.m., anda housekeeper is scheduled from 7:00 a.m. to 3:00 p.m. Monday through Friday. No additional staff are scheduled to replace the housekeeper on the weekends; thereby adding to the work load of the direct care staff. The Administrator does not appear on the schedule. 95. The staffing schedule was reviewed with the Administrator on 9/16/15 and again on 9/23/15. On 9/23/15 the Cook was present for the noon meal, but not the supper meal. The lack of care and food service was discussed with the administrator at 7:30 p.m. on 9/16/15 and again at 2:30 p.m. on 9/23/15. The administrator said 4 current residents required two-person assistance with activities of daily living and transferring. She then said it would take another 2 - staff to evacuate the remaining 25 residents in 13 minutes. She was told she must staff to meet the needs of the residents including unplanned emergency needs. 25 96. On 9/24/15, one agency staff person was placed on the day and evening shift. The services went quicker, but still no activities were provided to residents and Resident #2 was not assisted to eat until after all the other residents had eaten. 97. 12 (Staff A, B, C, D, E, F, G, H, J, K, L, and N) of 13 persons employed as direct care staff or employed over 30 days lacked documentation of required trainings. Staff lacked training in infection control, activities of daily living and resident behaviors, resident rights, abuse, neglect, and exploitation, elopement, emergencies, incident reports or safe food handling. 98. 9 (Staff B, C, D, E, F, G, H, K, and M) of 10 direct care staff employed over 30 days failed to receive the training in the facility's policy and procedures for Do Not Resuscitate Orders (DNRO) within 30 days of employment. 99. 2 (Staff D and G) of 6 unlicensed staff assisting with medications failed to obtain the required 4 hours of initial training. Unlicensed untrained staff assisting with medications has the potential to affect the health and well-being of the residents. 100. The Administrator failed to ensure at least one staff member per shift, who had completed courses in First Aid and CPR and holds a current valid card documenting completion of such courses, was in the facility at all times for 13 (Staff A, B, C, D, E, F, G, 1, J, K, L, N, and O) of 15 staff employed and 3 of 3 shifts, except 5 days a week when Staff H worked the 6:00 a.m. to 2:00 p.m. shift, or when the Administrator was in the building. 101. On 9/16/15 at 7:30 p.m. the Administrator said the information in the staff files was ail she had. She verified everything was filed in the folders. She stated she knew Staff H had First Aid and CPR recently and she was current also. 102. A review of the staff schedule showed 5 of 7 days when Staff H worked the 6:00 a.m. to 2:00 p.m. shift, so the facility had coverage for that shift. The remaining scheduled shifts did not provide First Aid/CPR coverage. The Administrator did not appear on the schedule and the facility maintained no time sheets. 26 103. She verified the schedule only has 5 of 21 shifts weekly where there is First Aid and CPR coverage. She said she did not know if anyone else had the training and admitted she had not planned the schedule for coverage. 104. On 9/16/15 at 11:30 a.m. the Administrator said she had become the administrator about two weeks ago. She had taken and passed the Assisted Living Facility (ALF) Core training and had recently had an ALF Core up-date. A record review revealed a receiver was appointed by the Court on 2/24/15. The Administrator said the Receiver subcontracted with a Management Company, closer to the facility, to assist with the operations of the facility. The administrator said the manager acted as the administrator until they asked her if she wanted to be the administrator and she was promoted. The Administrator said she was not given any instructions on the financial or business aspect of running the facility. She said the Management Company does all of that. She said she only knew how much to collect from the residents because she was given a list of residents and amounts owed. She said there was no accounting in the facility. She accepted checks and deposited them in the facility business account. She did not keep a separate account for resident funds, but co-mingled all funds in the business account. 105. She showed the surveyor a binder she was recording the resident funds kept by the facility. For 2 of 3 (Residents #22 and #14) resident fund accounts reviewed, neither account had been credited for personal funds not contractually owed to the facility. 106. The administrator said she logs the monthly payment checks into a receipt book by check number only and occasionally makes a copy of the checks. 107. The administrator verified the facility was a representative payee for 2 residents (Residents #20 and #22). The administrator said the facility had been the payee for these two residents since their respective admissions. The administrator verified the social security check for Resident #14 is stamped before deposit, like the other two Social Security checks and deposited in the facility account. She verified the check is not made out to the facility as 27 representative payee, but it is treated like it is. She said these checks are deposited in the one facility account from which all transactions are paid out. 108. The administrator verified there is no surety bond as required. 109. Attempts were made to get payment records and bills for each resident. Spread sheets were finally obtained on 9/18/15, but only showed partial money collections by month from March 2015 to August 2015. 110. The administrator and Consultant verified the facility has no ongoing accounting for each resident since their admission, or through September 2015. 111. A review of the safekeeping documentation revealed Resident #22 had no money deposited in the safekeeping accounting since admission on s/s except for $24.00. The resident was charged for haircuts and nail trimming and owed the facility a balance of $26. 112. Resident #22 receives $1057.00 a month from Social Security. A review of the contract revealed Resident #22 was to pay the facility $700.00 a month with an additional $1100.00 from the Health Maintenance Organization. This amount would leave a balance of $357 each month for the resident. Which leaves $1785.00 unaccounted for. 113. On 9/16/15, the administrator stated she just deposits the whole check. She had not realized the entire amount was not owed to the facility and should be credited to the resident for spending money. She was observed to immediately write "$1785" at the top of the safekeeping form for Resident #22. 114. She further said the facility pays for Resident #22's medications monthly. A review of the pharmacy statement for 8/31/15 revealed the resident's year to date medication expense totaled $266.83, leaving $1518.17 unaccounted for. 115. A review of safekeeping documentation showed Resident #14 debits for hair care. As of 8/18/15 the account shows a negative balance of $20.00 and no money. 116. A review of the contract signed 3/16/14 revealed Resident #14 was to pay 28 $600.00 to the facility and the Health Maintenance Organization would pay $1200.00 a month. A rate change notification revealed the contracted amount was lowered from $1800.00 a month to $1200.00 a month for a semi-private room on 7/20/15. 117. . On 9/18/15, Financial Spread sheets from March 2015 through August 2015 show the facility was collecting $1724.00 a month and documenting a debit of $76.00 a month for lack of payment. 118. As of 7/20/15, the facility should have refunded $185.90 for the decrease in July rent due to living in a semi-private room. Also the facility should not have collected the $524.00 for August or September. The safekeeping documentation showed a debit of $20.00 and no deposit of the funds from July to September, leaving $1233.90 unaccounted for and due to Resident #14. 119. Staff M, Administrator, said she did not realize the money was not due the facility. She stated she deposits the checks and the facility pays for the resident's medications monthly ($24.66 a month). 120. - A review of the pharmacy invoice obtained on 9/ 16/15 revealed the resident's year to date medication expense was $206.42. That amount plus the $20.00 for beauty salon services would leave a credit of $1007.48 unaccounted for. 121. A review of Resident #18's contract dated 5/4/15 revealed the amount contracted for was $1600.00. A review of the financial spread sheets from May 2015 to August 2015 revealed the resident is being charged $2200.00 a month. This would constitute an overpayment of $600.00 a month. 122. A review of Resident #2's contract dated 3/4/09 and 10/9/12 revealed the amount contracted for was 2500.00. A review of the financial spread sheets from March 2015 to August 2015 revealed the facility is charging Resident #2 $3400.00 a month. This is an overcharge of $900.00 a month without contractual right or $5400.00 overpayment. 29 123. On 9/21/15 the facility submitted a statement from Resident #2's Bank trust showing the $3400.00 has been paid monthly since 10/22/12. These 35 overpayments would amount to $31,500.00. 124. A review of Resident #19's contract revealed the contract was executed on 2/9/13. The contract amount was $1950.00 a month. A review of the facility accounting spread sheets from March 2015 to August 2015 revealed the resident is being charged $2000.00 a month. No rate increase notice was present in the resident's record. This amounts to a $50.00 a month rate increase without contractual right. 125. A review of Resident #30's contract revealed the signatures were not dated. The contract showed Resident #30 was to pay $800.00 a month and the Health Maintenance Organization (HMO) was to pay $1100.00 a month. A review of the financial spread sheets revealed the facility had been collecting $1900.00 from the resident and $1100.00 from the HMO since March 2015 at least. This would be an overpayment of $1100.00 a month. 126. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class J violation. Section 408.813(2)(b), Florida Statutes (2015). 127. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2015). 30 COUNT V The Respondent Failed To Provide Appropriate Care By Maintaining Minimum Staff In Violation Of Rule 58A-5.019(3), Florida Administrative Code 128. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 129. Pursuant to Florida law, minimum staffing: Facilities must maintain the following minimum staff hours per week: Number of Residents Staff Hours/Week 0-5 168 6-15 212 16- 25 253 26-35 294 36-45 335 46-55 375 56- 65 416 66-75 . 457 76-85 498 86-95 539 For every 20 residents over 95 add 42 staff hours per week. 2. Independent living residents as referenced in subsection 58A-5.024(3), Florida Administrative Code, who occupy beds included within the licensed capacity of an assisted living facility and who receive no personal, limited nursing, or extended congregate care services, are not counted as a resident for purposes of computing minimum staff hours. 3. At least one staff member who has access to facility and resident records in case of an emergency must be in the facility at all times when residents are in the facility. Residents serving as paid or volunteer staff may not be left solely in charge of other residents while the facility 31 administrator, manager or other staff are absent from the facility. 4. In facilities with 17 or more residents, there must be at least one staff member awake at all hours of the day and night. 5. A staff member who has completed courses in First Aid and Cardiopulmonary Resuscitation (CPR) and holds a currently valid card documenting completion of such courses must be in the facility at all times. a. Documentation of attendance at First Aid or CPR courses offered by an accredited college, university or vocational school; a licensed hospital; the American Red Cross, American Heart Association, or National Safety Council; or a provider approved by the Department of Health, satisfies this requirement. b. A nurse is considered as having met the course requirements for both First Aid and CPR. In addition, an emergency medical technician or paramedic currently certified under Chapter 401, Part III, Florida Statutes, is considered as having met the course requirements for both First Aid and CPR. 6. During periods of temporary absence of the administrator or manager of more than 48 hours when residents are on the premises, a staff member who is at least 21 years of age must be physically present and designated in writing to be in charge of the facility. No staff member shall be in charge of a facility for a consecutive period of 21 days or more, or for a total of 60 days within a calendar year, without being an administrator or manager. 7. Staff whose duties are exclusively building or grounds maintenance, clerical, or food preparation do not count towards meeting the minimum staffing hours requirement. 8. The administrator or manager’s time may be counted for the purpose of meeting the required staffing hours, provided the administrator or manager is actively involved in the day-to- day operation of the facility, including making decisions and providing supervision for all aspects of resident care, and is listed on the facility’s staffing schedule. 32 9. Only on-the-job staff may be counted in meeting the minimum staffing hours. Vacant positions or absent staff may not be counted. (b) Notwithstanding the minimum staffing requirements specified in paragraph (a), all facilities, including those composed of apartments, must have enough qualified staff to provide resident supervision, and to provide or arrange for resident services in accordance with the residents’ scheduled and unscheduled service needs, resident contracts, and resident care standards.as described in Rule 5 8A-5.0182, Florida Administrative Code. (c) The facility must maintain a written work schedule that reflects its 24-hour staffing pattern for a given time period. Upon request, the facility must make the daily work schedules of direct care staff available to residents or representatives, for that resident’s care. (d) The facility must provide staff immediately when the agency determines that the requirements of paragraph (a) are not met. The facility must immediately increase staff above the minimum levels established in paragraph (a) if the agency determines that adequate supervision and care are not being provided to residents, resident care standards described in Rule 58A- 5.0182, Florida Administrative Code, are not being met, or that the facility is failing to meet the terms of residents’ contracts. The agency will consult with the facility administrator and residents regarding any determination that additional staff is required. Based on the recommendations of the local fire safety authority, the agency may require additional staff when the facility fails to meet the fire safety standards described in Section 429.41(1)(a), Florida Statutes, and Rule Chapter 69A-40, Florida Administrative Code, until such time as the local fire safety authority informs the agency that fire safety requirements are being met. 1. When additional staff is required above the minimum, the agency will require the submission of a corrective action plan within the time specified in the notification indicating how the increased staffing is to be achieved to meet resident service needs. The plan will be reviewed by the agency to determine if the plan increases the staff to needed levels to meet resident needs. 33 2. When the facility can demonstrate to the agency that resident needs are being met, or that resident needs can be met without increased staffing, modifications may be made in staffing requirements for the facility and the facility will no longer be required to maintain a plan with the agency. (e) Facilities that are co-located with a nursing home may use shared staffing provided that staff hours are only counted once for the purpose of meeting either assisted living facility or nursing home minimum staffing ratios. (f) Facilities holding a limited mental health, extended congregate care, or limited nursing services license must also comply with the staffing requirements of Rules 58A-5.029, 58A-5.030 or. 58A-5.031, Florida Administrative Code, respectively. Rule 58A-5.019(3), Florida Administrative Code. 130. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 131. Based on observations, resident, family, and staff interviews, and review of facility records, the Respondent failed to ensure there are enough staff to provide care and services to meet resident needs for 6 of 29 residents, specifically Residents #2, #6, #13, #23 #25, and #29, and to provide all residents scheduled activities. Failure of staff to meet the needs of the residents directly threatens the residents, resulted in injury to Resident #14, and resulted in Resident #2 waiting hours for meals. 132. On 9/23/15 at 11:53 a.m., Resident #14 said that Resident #20 punched the resident in the mouth about 2 weeks ago and broke a tooth. Resident #14 never went to the hospital or the dentist. Resident #14 told the Administrator and the Administrator didn't want the resident to call the police. 133. On 9/24/15 at 1:30 p.m., Staff F said approximately 3 weeks ago this incident happened. Staff F said Resident #14 was taunting Resident #20. Staff F was bringing a tray from 34 a resident room back to the kitchen. Staff F told Resident #14 to stop taunting Resident #20 and saw Resident #20 get up from the table where the resident was sitting and Staff F told Resident #20 to sit back down and ignore Resident #14. Staff F said she turned around and Resident #20 leaped over to Resident #14 and hit the resident in the jaw and Staff F grabbed Resident #20’s arm too late. Resident #14 told Staff F he/she was going to call the police. Staff F also stated there were no injuries. When asked about Resident #14's missing lower tooth, Staff F confirmed Resident #14 had all teeth before the incident. 134. An observation of the noon meal on 9/16/15 revealed the cook called off and the Administrator said she could not get anyone else to come in. The meal was being served by a housekeeper. The facility served all the residents in the dining room their meals, special requests and re-orders. After all residents in the dining room were served at 2:00 p.m., the staff began to serve the residents in their rooms. Observation of the food preparation found staff did not know how to puree a meal. The ground hot dog was put into a blender and blended into small chucks. The housekeeper put the baked beans in the blender and made a soupy paste. The second time she was prompted by another staff to add water to the hot dogs and got a more puree consistency. She added water to both the beans and corn. The beans were very runny. The corn became a watery corn-flavored liquid. This was served to Residents #2 and #13. 135. Observation on 9/16/16 revealed the supper meal began at 5:15 p.m. Since the housekeeper was gone, only two staff were scheduled on the second shift. One staff became the cook and the second staff waited tables. Food service and resident care continued until 6:45 p.m. At 7:00 p.m. Resident #2, who is bedbound, had still not been assisted to eat. 136. Observation during lunch on 9/23/15 at 12:20 p.m. showed there are two staff serving lunch to the residents and one cook preparing meals. There is a table of six residents sitting together. Five residents were served their lunch by 12:23 p.m. Resident #6 was not served until 12:50 p.m. Four of these residents finished eating by 12:40 p.m. Resident #23 (who is 35 sitting at this table) requested a sandwich at 12:35 p.m. Resident #23 received the sandwich at 1:15 p.m. 137. Residents #2 and #13 are on hospice care and remain in their beds at all times. On 9/23/16 at 12:55 p.m., Staff D stated that these two residents eat in their rooms. Observation on 9/23/16 at 1:43 p.m. showed Residents #2 and #13's pureed foods were prepared by the cook. The cook placed them in bowls on the kitchen counter waiting for the staff to serve the two residents. 138. The surveyor notified Staff A at 1:45 p.m. that the food was ready for the two residents to be served. She put the food bowls onto plates and walked away. 139. Observation at 2:30 p.m. showed the food was sitting on the kitchen counter. After surveyor intervention at 2:30 p.m., Residents #2 and #13 were both served their lunch by 2:55 p.m. 140. “On 9/23/16 at 2:30 p.m., Staff D and Staff A both said they were taking care of Resident #22 who requires two people to assist with incontinent needs. They were also taking care of other residents' toileting needs. Staff D also had to take care of the medication pass. They both stated they need one staff for medication pass and two staff for resident care needs. There are only two staff on this shift. As a result, they can't take care of all the resident needs timely. 141. Observations on 9/23/15 throughout the course of the day showed no activities being offered. A review of the activity calendar located in the dining room showed: "AM: daily news, brain games and puzzles, music" are scheduled in the morning. 142. On 9/23/15 at 2:45 p.m., Staff D and Staff G both said they do not have any time to run these activities. It takes most of their time to provide activities of daily living for the residents and provide assistance for two meals. When they had three staff working on this shift, “everything ran much easier" and they were able to provide the scheduled activities. 143. Observation on 9/24/15 from 9:00 a.m. through 2:30 p.m. showed the scheduled 36 activities on the calendar were not offered. On 9/24/15 the facility had added an agency pool staff person on the day and evening shifts. This additional help still did not allow staff to have time to provide activities. 144. Inan interview on 9/23/15 at 10:22 a.m., Resident #8 said he/she needs assistance with showers. Staff told the resident not to shower without assistance. Resident #8 wants a shower every other day but only gets two a week. "There are only 2 people working each night and has to wait and wait and wait." 145. On 9/23/15 at 11:10 a.m., Resident #24 said staff helps with showers, dressing, and sometimes the bathroom. Sometimes they are "slow." The resident has to wait a little longer "maybe about 1/2 hour." 146. On 9/23/15 at 12:25 p.m., Resident #6 said he always has to wait a long time to get food (ordered a puree diet). Resident #6 is the last to eat. There are not enough staff in the ’ dining room. For every meal everyone has to wait a long time to be served. | 147. On 9/23/15 at 10:20 a.m. Resident #29 said he/she had been here about 15 months. The night shift staff fall asleep on the couch. They (the administration) know about it. 148. On 9/16/15 at 3:30 p.m. and again on 9/23/15 at 2:15 p.m., a family member of Resident #25 said the resident used a walker when he/she moved in here, but now the resident is in a wheelchair, and is incontinent. She said Resident #25 was dropped on 8/ 19/ 15 when transferring from a recliner to a wheelchair. Resident #25's knee was swollen and painful. The resident had a mobile x-ray done after the injury. Due to continued pain, Resident #25 was sent to an acute care hospital for further evaluation. 149. On 9/16/15 at 3:45 p.m., the Administrator verified Resident #25's fall with injury occurred while under the care of facility staff. The Administrator verified she had not completed any reports about the incident. 150. On 9/24/15 at 2:30 p.m., Staff 1 stated there is not enough staff to take care of 37 laundry. Sometimes there is no cook and one of the direct care people has to cook leaving one person on the floor through dinner. 151. On 9/24/15 at 2:35 p.m. Staff F stated there is not enough staff. We need 3 not 2. Two staff is a rush and we have to focus on medications, dining room, laundry, and people. 152. A review of the staff schedule on 9/16/15 revealed two direct care staff were scheduled for each shift. A cook is scheduled from 7:00 a.m. to 7:00 p.m. and a housekeeper was scheduled from 7:00 a.m. to 3:00 p.m. Monday through Friday. No-additional staff were scheduled to replace the housekeeper on the weekends; thereby adding to the work load of the direct care staff. The Administrator did not appear on the schedule. 153. The staffing schedule was reviewed with the Administrator on 9/16/15 and again on 9/23/15. On 9/23/15 the cook was present for the noon meal, but not the supper meal.. The surveyor discussed the lack of care and food service with the Administrator at 7:30 p.m. on 9/16/15 and again at 2:30 p.m. on 9/23/15. The Administrator said 4 current residents required two-person assistance with activities of daily living and transferring. She admitted it would take another 2 staff to evacuate the remaining 25 residents in 13 minutes. The surveyor told the Administrator she must staff to meet the needs of the residents, including unplanned emergency needs. 154. On 9/24/15 one agency pool staff person was placed on the day and evening shift. The services went quicker, but still no activities were provided to residents and Resident #2 was not assisted to eat until after all the other residents had eaten. 155. Personnel record reviews revealed 12 (Staff A, B, C, D, E, F, G, H, J, K, L, and N) of 13 persons employed as direct care staff or employed over 30 days lacked documentation of required training. Staff lacked training in infection control, activities of daily living and resident behaviors, resident rights, abuse, neglect, and exploitation, elopement, emergencies, incident reports, or safe food handling. 38 156. 9 (Staff B, C, D, E, F, G, H, K, and M) of 10 direct care staff employed over 30 . days failed to receive the training in the facility's policy and procedures for Do Not Resuscitate Orders (DNRO) within 30 days of employment. 157. 2 (Staff D and G) of 6 unlicensed staff assisting with medications had failed to obtain the initial required 4 hours of training. Unlicensed untrained staff assisting with medications has the potential to affect the health and well-being of the residents. 158. The facility failed to ensure at least one staff member per shift in the facility at all times who had completed courses in First Aid and cardiopulmonary resuscitation (CPR) and holds a currently valid card documenting completion of such courses. A review of personnel records revealed 13 (Staff A, B, C, D, E, F, G, I, J, K, L, N, and O) of 15 staff employed did not have First Aid and/or CPR. 159. On 9/16/15 at 7:30 p.m. the administrator stated the information in the staff files was all she had. She verified everything was filed in the folders. The Administrator said she knew Staff H had First Aid and CPR recently and she was current also. 160. A review of the staff schedule showed 5 of 7 days when Staff H worked the 6:00 a.m. to 2:00 p.m. shift, the facility had coverage for that shift. All other scheduled shifts had no First Aid and CPR coverage. The Administrator did appear on the staff schedule and the facility maintained no time sheets. 161. The Administrator verified the schedule had only 5 of the 21 shifts weekly where there was First Aid and CPR coverage. She said she did not know if anyone else had the training. She admitted she had not planned the schedule for coverage. 162. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 408.813(2)(b), Florida Statutes (2015). 39 163. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2015). COUNT VI The Respondent Failed To Provide One Staff Member Per Shift Who Had Completed Training In First Aid And Cardiopulmonary Resuscitation In Violation Of Rule 58A- 5.0191(4), Florida Administrative Code 164. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 165. Pursuant to Florida law, a staff member who has completed courses in First Aid and CPR and holds a currently valid card documenting completion of such courses must be in the facility at all times. (a) Documentation of attendance at First Aid or CPR course offered by an accredited college, university or vocational school; a licensed hospital; the American Red Cross, American Heart Association, or National Safety Council; or a provider approved by the Department of Health, shall satisfy this requirement. (b) A nurse shall be considered as having met the training requirement for First Aid. An emergency medical technician or paramedic currently certified under Chapter 401, Part III, Florida Statutes, shall be considered as having met the training requirements for both First Aid and CPR. Rule 58A-5.0191(4), Florida Administrative Code. 166. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 40 167. Based on schedules and personnel record reviews and staff interviews, the Respondent failed to ensure at least one staff member per shift, who had completed courses in. First Aid and cardiopulmonary resuscitation (CPR) and holds a current valid card documenting completion of such courses, was in the facility at all times for 3 of 3 shifis, except 5 days a week when Staff H worked the 6:00 a.m. to 2:00 p.m. shift, or when the Administrator was in the building. Records show 13 (Staff A, B, C, D, E, F, G, J, J, K, L, N, and O) of 15 staff employed did not have current First Aid and/or CPR. 168. A culture which does not ensure at least one staff 24 hours/seven days a week are trained in First Aid and CPR is a direct threat to the health and well-being of the residents. The staff are trained to call 911, but were not trained to provide care in the interim while waiting for Emergency Medical Services (EMS) to arrive. 169. On 9/16/15 at 7:30 p.m., the Administrator said the information in the staff files was all she had. She verified everything was filed in the folders. The Administrator stated she knew Staff H had First Aid and CPR recently and she was current also. 170. A review of the staff schedule showed 5 of 7 days when Staff H worked the 6:00 a.m. to 2:00 p.m. shift, so the facility had coverage for that shift. All other scheduled shifts did not provide First Aid/CPR coverage. The Administrator did not show on the staff schedule and the facility maintained no time sheets. 171. The Administrator verified the schedule only has 5 of 21 shifts weekly where there is First Aid and CPR coverage. The Administrator said she did not know if anyone else had the training and admitted she had not planned the schedule for coverage. 172. On 9/24/15 at 2:15 p.m. Staff C stated she would call 911 ifthe emergency was "bad enough." She would call the manager and family member, "we don't have a nurse." She said DNR (do not resuscitate) is "when you can't do chest compressions and stuff like that on them." 41 173. On 9/24/ 15 at 2:10 p.m. Staff D said he would call 911 in an emergency or hospice if necessary. 174. On 9/24/15 at 2:35 p.m. Staff F said she would call 911 in and emergency and then family members. She would make copies of information needed and have it ready for (EMS). 175. On 9/24/15 at 2:28 p.m. Staff I said in an emergency, such as a tornado, she would keep residents safe and away from windows. 176. Staff personnel record reviews on 9/16/15 and 9/23/15 revealed the following: Staff A was hired on 9/10/14 as a direct care staff. Staff A had no documentation of training in First Aid and CPR. Staff B was hired on 10/23/14 as a direct care staff. Staff B had no documentation of training in First Aid and CPR. Staff C was hired on 11/10/14 as a direct care staff. Staff C had no documentation of training in First Aid. Staff D was hired on 4/7/15 as a direct care staff. Staff D had no documentation of training in First Aid and CPR. Staff E was hired on 7/9/15 as a direct care staff. Staff E had no documentation of training in First Aid and CPR. Staff F was hired on 6/18/15 as a direct care staff. Staff F had no documentation of training in First Aid and CPR. Staff G was hired on 2/15/15 as a direct care staff. Staff G had no documentation of training in First Aid and CPR. Staff 1 was hired on 3/9/09 as a direct care staff. Staff I had no documentation of training in First Aid and CPR. Staff J was hired on 7/9/15 as a housekeeper. Staff J had no documentation of training in First Aid and CPR. Staff K was hired on 10/2/14 as a direct care staff. Staff K had no documentation of training in First Aid and CPR. Staff L was hired on 3/7/15 as a cook. Staff L had no documentation of training in First Aid and CPR. Staff N was hired on 8/19/15 as a cook. Staff N had no documentation of training in First Aid and CPR. Staff O was hired on 9/21/15 as a cook. Staff O had no documentation of training in First Aid and CPR. 177. The Respondent’s deficient practice constituted a Class II violation in that it 42 related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class [ violation. Section 408.813(2)(b), Florida Statutes (2015). 178. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2015). COUNT VIL The Respondent Failed To Provide Adequately Trained Staff In Food Services In Violation Of Rule 58A-5.020(1), Florida Administrative Code 179. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 180. Pursuant to Florida law, when food service is provided by the facility, the administrator, or an individual designated in writing by the administrator, must be responsible for total food services and the day-to-day supervision of food services staff. In addition, the following requirements apply: (a) If the designee is an individual who has not completed an approved assisted living facility core training course, such individual must complete the food and nutrition services module of the core training course before assuming responsibility for the facility’s food service. The designee is not subject to the 1 hour in-service training in safe food handling practices. (b) If the designee is a certified food manager, certified dietary manager, registered or licensed dietitian, dietetic registered technician, or health department sanitarian, the designee is exempt from the requirement to complete the food and nutrition services module of 43 the core training course before assuming responsibility for the facility’s food service as required in paragraph (1)(a) of this rule. (c) An administrator or designee must perform his or her duties in a safe and sanitary manner. (d) An administrator or designee must provide regular meals that meet the nutritional needs of residents, and therapeutic diets as ordered by the resident’s health care provider for residents who require special diets. (e) An administrator or designee must comply with the food service continuing education requirements specified in Rule 58A-5.0191, Florida Administrative Code. Rule 58A- 5.020(1), Florida Administrative Code. 181. On or about September 16, 2015 through September 25, 2015, the. Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 182. Based on observations, resident record reviews and staff interview, the administrator was responsible for total food service and failed to ensure the staff preparing and/or serving the meals served 3 (Residents #2, #6, and #13) of 3 residents their therapeutic diets which met the nutritional requirements. 183. An observation of the noon meal on 9/16/15 revealed the meal being served was a hot dog with bun, baked beans, corn and jello. The approved menu showed BBQ pork, baked beans, coleslaw, and tapioca pudding with chocolate chips was to be served. The Administrator said they did not serve the BBQ pork because it was not thawed out, and they did not have coleslaw as the food shipment did not come in time. The Administrator said the cook called off today and she could not get anyone else to come in. 184. The Administrator said there are 3 people on a puree diet. The meal was observed to be served by the housekeeper. She provided one plate at a time as two caregivers asked for plates. The facility served all the residents in the dining room their meals plus the special 44 requests and re-orders. At 2:00 p.m., after the dining room residents were served, the staff began to serve the residents in their rooms. The facility ran out of cooked vegetables for the last two people with regular diets. No substitutions were made. 185. An observation of the food preparation revealed the housekeeper did not know how to puree foods. A hot dog was put into a blender and blended into small chunks. The housekeeper put the baked beans in the blender and made a soupy paste. For the second plate, she was prompted by another staff to add water. She got a more puree consistence for the hot dog, but it still had lumps. She added water to both the beans and corn. The beans were very runny and the corn was a watery corn-flavored liquid. This was served to Residents #2 and #13. 186. An observation of the food service on 9/16/15 revealed Staff D and Staff F had gloves on during the noon meal. They handled the resident plates and touched their thumbs to the eating surface when delivering the plates to each resident. They were observed picking up the empty plates to return to the kitchen and delivering the next person's plate, without washing their hands. They were observed picking up glasses by placing their hand over the top of the glass and gripping the drinking surface of the glass. Observations were made of the lack of sanitary food service from 12:00 p.m. to 1:30 p.m. Staff continued going from soiled plates to clean plates, re- filling drinking glasses and serving drinks to residents, all with the same pair of gloves on and no hand washing. This continued until surveyor intervention. Then staff were observed changing gloves between deliveries, still without washing their hands. 187. An observation of the supper meal on 9/16/16 revealed the meal began at 5:15 p.m. and was a biscuit with chipped beef, mash potatoes, asparagus and cake. Since the housekeeper was off duty, only two staff were scheduled on the second shift. One staff became the cook and the second staff waited tables. Food service and resident care continued until 6:45 p.m. At 7:00 p.m. Resident #2, who is bedbound, had not been assisted to eat. The caregivers believed Resident #2 and #13 were on pureed diets. The caregiver/cook had prepared a tray for 45 Resident #2. It contained mash potatoes and non-pureed chipped beef and ice cream. No substitution was made for the bread or vegetable. The food delivery was stopped while the chipped beef was pureed. Resident #2 was not served until 7:00 p.m. 188. A review of the Cycle 4 menu revealed the noon meal on 9/23/15 was to be a cabbage roll, scalloped potatoes, marinated tomatoes and sherbet. The meal served was breaded pork, stuffing and green beans. An observation of the meal service revealed the cook was wearing gloves while preparing the plates for each resident. The cook touched the stove, pots and ladles, refrigerator, cabinet doors and door handles and the handles on the kitchen sink. The cook then proceeded to make 3 lunch meat sandwiches. The cook handled the sandwiches with the same gloves he had been wearing since the meal service began. He left deep finger impressions in all 3 sandwiches. The food production was stopped by the surveyor. After washing his hands and changing gloves, the cook made new sandwiches. 189. An observation on 9/23/15 at 2:55 p.m. showed staff serving Residents #2 and #13 lunch. At this time the facility was out of prepared food. An interview was conducted with Staff A at 2:55 p.m. on 9/23/15. She stated she is serving Residents #2 and #13 a dish of butterscotch pudding, a four ounce glass of tomato juice and two other four ounces glasses of different juices. No substitutions were made for the protein or starch. 190. A review of the Cycle 4 menu revealed the noon meal on 9/24/15 was to be Parmesan chicken, garlic mash potatoes, broccoli and cauliflower. The meal served was pepperoni pizza and cake. No substitution was made for 3 ounces of chicken or the vegetable. 191. An observation on 9/24/15 during lunch showed staff serving Residents #2 and #13 a cup of pureed chicken noodle soup, a cup of pudding and a glass of juice. 192. An observation on 9/23/15 at 2:55 p.m. and on 9/24/15 showed Resident #2 being served a pureed diet for lunch. A review of the resident’s health assessment form dated 4/30/15 showed there was no diet order on this assessment. 46 193. On 9/23/15 at 3:30 p.m., the administrator reviewed Resident #2's record. She reported the hospice paperwork showed the resident was supposed to be on a cardiac diet. 194. A review of Resident #6's health assessment form dated 5/6/13 showed a mechanical soft diet was prescribed. A further review of the record showed there were no other diet orders written in the record. Observations of the 9/16/15, 9/23/15, and 9/24/15 meals showed the resident was served a pureed diet. 195. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 408.813(2)(b), Florida Statutes (2015). 196. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2015). COUNT VII The Respondent Failed To Follow A Standard Menu, Failed To Provide Substitutions Of Menu Items And Failed To Have An Adequate Supply Of Non-Perishable Food In Violation Of Rule 58A-5.020(2), Florida Administrative Code 197. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 198. Pursuant to Florida law, the meals provided by the assisted living facility must be planned based on the current USDA Dietary Guidelines for Americans, 2010, which are incorporated by reference and available for review at: http://www.firules.org/Gateway/reference.asp?No=Ref- 47 04003, and the current summary of Dietary Reference Intakes established by the Food and Nutrition Board of the Institute of Medicine of the National Academies, 2010, which are incorporated by reference and available for review at: http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DR. Is/New%20Material/SDRI%20Values%20SummaryTables%2014.pdf. Therapeutic diets must meet these nutritional standards to the extent possible. . (b) The residents’ nutritional needs must be met by offering a variety of meals adapted to the food habits, preferences, and physical abilities of the residents, and must be prepared through the use of standardized recipes. For facilities with a licensed capacity of 16 or fewer residents, standardized recipes are not required. Unless a resident chooses to eat less, the facility must serve the standard minimum portions of food according to the Dietary Reference Intakes. (c) All regular and therapeutic menus to be used by the facility must be reviewed annually by a licensed or registered dietitian, a licensed nutritionist, or a registered dietetic technician supervised by a licensed or registered dietitian, or a licensed nutritionist to ensure the meals meet the nutritional standards established in this rule. The annual review must be documented in the facility files and include the original signature of the reviewer, registration or license number, and date reviewed. Portion sizes must be indicated on the menus or on a separate sheet. 1. Daily food servings may be divided among three or more meals per day, including snacks, as necessary to accommodate resident needs and preferences. 2. Menu items may be substituted with items of comparable nutritional value based on the seasonal availability of fresh produce or the preferences of the residents. (d) Menus must be dated and planned at least 1 week in advance for both regular and therapeutic diets. Residents must be encouraged to participate in menu planning. Planned menus must be conspicuously posted or easily available to residents. Regular and therapeutic menus as 48 served, with substitutions noted before or when the meal is served, must be kept on file in the facility for 6 months. (e) Therapeutic diets must be prepared and served as ordered by the health care provider. 1. Facilities that offer residents a variety of food choices through a select menu, buffet style dining, or family style dining are not required to document what is eaten unless a health care provider’s order indicates that such monitoring is necessary. However, the food items that enable residents to comply with the therapeutic diet must be identified on the menus developed for use in the facility. 2. The facility must document a resident’s refusal to comply with a therapeutic diet and provide notification to the resident’s health care provider of such refusal. (f) For facilities serving three or more meals a day, no more than 14 hours must elapse between the end of an evening meal containing a protein food and the beginning of a morning meal. Intervals between meals must be evenly distributed throughout the day with not less than 2 hours nor more than 6 hours between the end of one meal and the beginning of the next. For residents without access to kitchen facilities, snacks must be offered at least once per day. Snacks are not considered to be meals for the purposes of calculating the time between meals. (g) Food must be served attractively at safe and palatable temperatures. All residents must be encouraged to eat at tables in the dining areas. A supply of eating ware sufficient for all residents, including adaptive equipment if needed by any resident, must be on hand. (h) A 3-day supply of nonperishable food, based on the number of weekly meals the facility has contracted with residents to serve, must be on hand at all times. The quantity must be based on the resident census and not on licensed capacity. The supply must consist of foods that can be stored safely without refrigeration. Water sufficient for drinking and food preparation must also be stored, or the facility must have a plan for obtaining water in an emergency, with the plan coordinated with and reviewed by the local disaster preparedness authority. Rule 58A- 49 5.020(2), Florida Administrative Code. 199. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 200. Based on observations, facility menu review, and resident and staff interviews, the Respondent failed to serve food that was palatable, failed to serve food on the menu, failed to make appropriate substitutions, failed to updated menus annually, and failed to have enough non- perishable food on hand according to their census. 201. An observation of the noon meal on 9/16/15 revealed the meal being served was a hot dog with bun, baked beans, corn and jello. The menu showed BBQ pork, baked beans, coleslaw, and tapioca pudding with chocolate chips was to be served. The Administrator said they did not serve the BBQ pork because it was not thawed out, and they did not have coleslaw as the food shipment did not come in time. The Administrator said the cook. called off today, and she could not get anyone else to come in. The facility served jello instead of pudding. The Administrator said there are 3 people on a puree diet. The meal was served by the housekeeper. She provided one plate at a time as two caregivers asked for plates. The facility served all the residents in the dining room their meals plus the special requests and re-orders. At 2:00 p.m., after the residents in the dining room (except Resident #6's puree diet) were served, the staff began to serve the residents in their rooms. The facility ran out of cooked vegetables for the last two people having regular diets. 202. An observation of food preparation found staff did not know how to puree.a meal. The hot dog was put into a blender and blended into small chunks. The housekeeper put the baked beans in the blender and made a soupy paste. The second time she was prompted by another staff to add water and got a more puree consistency for hot dogs. She added water to both the beans and corn. The beans were very runny and the corn was a watery corn-flavored liquid. This was served to Residents #2 and #13. 50 203. An observation of the supper meal on 9/16/16 revealed the meal began at 5:15 p.m. and was a biscuit with chipped beef, mashed potatoes, asparagus, and cake. When the housekeeper left, only two staff remained scheduled on the second shift. One staff became the cook and the second staff waited tables. Food service and resident care continued until 6:45 p.m. At 7:00 p.m. Resident #2, who is bedbound, still had not been assisted to eat. The staff believed the resident was on a pureed diet. The caregiver/cook had prepared a tray with mashed potatoes and non-pureed chipped beef and ice cream. No substitution was made for the bread or vegetable. The food delivery was stopped until the chipped beef was pureed. Resident #2 was not served until 7:00 p.m. 204. A review of the Cycle 4 menu revealed the noon meal on 9/23/15 was to be a 6 ounce cabbage roll, 1/2 cup of scalloped potatoes, 1/2 cup marinated tomatoes and 1/2 cup sherbet. The meal served was breaded pork, stuffing, and green beans. 205. An observation during the lunch meal on 9/23/15 showed about 10 residents remaining in the dining room at approximately 1:00 p.m. One resident asked for ice cream. The rest of the residents asked if they could have ice cream also. Staff served them ice cream. A review of the menu showed they were to be served sherbet. However, most of the residents left the dining room and were not offered any dessert. 206. An observation on 9/23/15 at 2:55 p.m. showed staff served Residents #2 and #13 lunch. An interview was conducted with Staff A on 9/23/15 at 2:55 p.m. Staff A said she was serving Residents #2 and #13 a dish of butterscotch pudding, a 4 ounce glass of tomato juice and two other 4 ounce glasses of different juices. No substitution was made for the protein or starch. 207. An observation on 9/24/15 during lunch showed residents were served pizza and cake. A review of the menu showed: Parmesan chicken, mashed potatoes, broccoli and cauliflower. Residents #2 and #13 were served pureed chicken noodle soup, pudding, and a glass of juice. Pizza and chicken noodle soup were not on the menu board showing there was a 51 substitution for this lunch. No substitution was made for the 3 ounces of chicken or the vegetable. 208. Interviews were conducted with residents throughout the course of the survey. Resident #1 was interviewed on 9/23/15 at 12:00 p.m. (right before tunch). Resident #1 said the food is not great. The cooks in the kitchen keep changing. Resident #1 does not enjoy it. The staff will make a sandwich if the resident does not like what is being served. Resident #1 eats a lot of sandwiches. Observation during lunch at 1:09 p.m. showed Resident #1 served lunch. Resident #1 stated the meat tasted "like a hard biscuit." The food was hardly warm. Resident #1 requested a sandwich instead of the food being served. 209. Resident #8 was served lunch at 1:18 p.m. on 9/23/15. Resident #8 stated (in reference to the food), "It could be warmer. The food does not taste good." 210. Resident #14 was interviewed during lunch on 9/23/15 and said he/she can't eat it. Resident #14 has an abscessed tooth and said the stuffing was dry and cold and the meat was tough. : 211. Aninterview was conducted with Resident #6 on 9/23/15 at 12:25 p.m. Resident #6 stated, "The food is terrible." Resident #6 always has to wait a long time to get food. Resident #6 is the last to eat and stated, "There are not enough staff in the dining room. For every meal everyone has to wait a long time." 212. Resident #7 was interviewed on 9/23/15 at 10:00 a.m. Resident #7 said a lot of the food was out of cans. The cook has changed many times. Resident #7 did not like the food; the food was not good. Resident #7 would like to have some real meat. 213. -A review of Resident #2's Health Assessment dated 4/30/15 showed there is no diet ordered on this assessment.. Observation during lunch on 9/23/15 at 2:55 p.m. showed the staff gave Resident #2 a pureed diet. 52 214. An interview was conducted with the cook. The cook said he gives Resident #2 a pureed diet. 215. An interview was conducted with the Administrator on 9/23/15 at 3:30 p.m. She reviewed Resident #2's health assessment and confirmed the diet order was not indicated on the assessment. She continued to review Resident #2's record and said she found an order for a cardiac diet from hospice. 216. Areview of Resident #5's health assessment dated 5/23/15 and Resident #25's Health Assessment dated 3/26/14 revealed diet orders for "Calorie Controlled" diet. 217. A review of Resident #6's health assessment dated 5/6/13 showed a mechanical soft diet was prescribed. A further review of the record showed there was no other diet order written. Observations of meals on 9/16/15, 9/23/15 and 9/24/15 showed Resident #6 was served a pureed diet. 218. A review of the menus being used for 9/16, 9/23 and 9/24/15 showed the licensed dietitian reviewed the menu on 7/8/14. An interview was conducted with the Administrator on 9/23/15 at 2:15 p.m. She reviewed the menu and confirmed the date and stated she was not aware the menu was outdated. A review of the 4-cycle menus revealed only a regular menu, with instructions to follow for a low-fat/low cholesterol, no-concentrated-sweets, or no-added-salt diets. The facility had no menu extension for Calorie Controlled, Mechanical Soft, or Puree diets. The administrator stated they have no recipes for any of the therapeutic diets only regular diet recipes. | | 219. An interview was conducted with the Administrator on 9/23/15 at 9:00 a.m. She stated the resident census for this day was 29 residents. A review of the non-perishable emergency supply food shows the facility has powdered milk to make 35 quarts of milk. According to their census the facility need at least 43.5 quarts of milk. The facility had capacity to store 65 gallons of water but needed 87 gallons for the emergency plan. 353 220. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 408.813(2)(b), Florida Statutes (2015). 221. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2015). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2015). COUNT IX The Respondent Failed To Maintain Accurate Business Records That Identify, Summarize, And Classify Funds Received And Expenses Disbursed, Using Written Accounting Procedures And A Recognized Accounting System In Violation Of Sections 429.17(3), 429.275(1), Florida Statutes (2015) And Rule 58A-5.021(1), Florida Administrative Code 222. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 223. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, each facility must report to the agency any adverse court action concerning the facility’s financial viability, within 7 days after its occurrence. The agency shall have access to books, records, and any other financial documents maintained by the facility to the extent necessary to determine the facility’s financial stability. Section 429.17(3), Florida Statutes (2015). Pursuant to Florida law, the assisted living facility shall be administered on a sound financial basis that is consistent with good business practices. The administrator or owner of a facility shall maintain accurate business records that identify, summarize, and classify funds received and expenses disbursed and shall use written accounting procedures and a recognized 34 accounting system. Section 429.275(1), Florida Statutes (2015). | Pursuant to Florida law, the facility must be administered on a sound financial basis in order to ensure adequate resources to meet resident needs pursuant to the requirements of Chapters 408, Part II, Part I, Florida Statutes and Rule Chapter 59A-35, Florida Administrative Code, and this rule chapter. Rule 58A-5.021(1), Florida Administrative Code. 224. On or about September 16, 2015 through September 25, 2015, the Agency conducted a Financial Monitoring Survey of the Respondent’s facility. 225. Based on record reviews and staff and family interviews, the Respondent failed to maintain accurate business records that identify, summarize, and classify funds received and expenses disbursed, using written accounting procedures and a recognized accounting system. The Respondent failed to notify the Agency of a change in financial viability within 7 days after occurrence. The Respondent failed tobe administered. on a sound financial basis, thereby not ensuring adequate resources to meet resident needs for all residents, including incontinence supplies. 226. _The Respondent had a court appointed receiver ordered on 2/24/15. The Respondent failed to notify the Agency until 7/28/15. The change of ownership application filed on 7/28/15 included a financial prospectus which was insufficient and subsequently failed. The omissions re-submission also failed. On 9/16/15 the Agency conducted a financial monitoring visit. 227. On 9/16/15 at 11:30 a.m., the Administrator said she had been the administrator for 2 weeks. She said there was no accounting in the facility. She accepted checks and deposited them into the facility's business account. She did not keep a separate account for resident funds, but co-mingled all funds into the facility's business account. 228. The Administrator presented a binder in which she was recording the resident funds kept by the facility. For 2 (Residents #22 and #14) of 3 resident fund accounts reviewed, 55 neither account had been credited for the personal funds which were not contractually owed to the facility. 229. The Administrator said she logs the monthly payment checks into a receipt book by check number only (without resident names) and occasionally makes a copy of the checks. 230. The Administrator verified the facility was a representative payee for Residents #20 and Resident #22. The Administrator said the facility had been the payee for these two residents since their respective admissions. In addition to these two, the Administrator verified the Social Security check for Resident #14 was also stamped and deposited in the facility account. She confirmed the check was not made out to the facility as representative payee, but it was treated like it was. She said these checks were deposited in the one facility account from which all transactions are paid out. 231. The Administrator verified there was no surety bond as required. 232. Attempts were made to get payment records and bills for each resident. Spread sheets were finally obtained on 9/18/15 from the management company, but only showed partial money collections by month from March 2015 to August 2015. 233. The Administrator and management company consultant verified the facility has no ongoing accounting for each resident since their admission through September 2015. 234. A review of the safekeeping documentation revealed Resident #22 had $24.00 deposited in the safekeeping accounting since admission on 5/1/15. The resident was charged for haircuts and nail trimming and owed the facility a balance of $26.00. 235. Resident #22 receives $1,057.00 a month from Social Security. The check is made out to Gulf Winds ALF as the representative payee. A review of the contract revealed Resident #22 was to pay the facility $700.00 a month with an additional $1,100.00 from the Health Maintenance Organization. This amount would leave a balance of $357 each month for the resident, which leaves $1,785.00 unaccounted for. 56 236. On 9/16/15, the administrator said she just deposits the whole check. She had not realized the entire amount was not owed to the facility and should be credited to the resident for spending money. She was observed to immediately write "$1785" at the top of the safekeeping form for Resident #22. 237. The Administrator further said the facility pays for Resident #22's medications monthly. A review of the pharmacy statement for 8/31/15 revealed the resident's year to date medication expense totaled $266.83, leaving $1518.17 unaccounted for. 238. A review of safekeeping documentation showed Resident #14 debits for hair care. As of 8/18/15 the account shows a negative balance of $20.00 and no money. 239.