Assisted living facility again facing licensure fight
By JIM ROSS, Times Staff Writer
CRYSTAL RIVER -- The River Oaks Assisted Living facility is in hot water again.
Less than two years ago, River Oaks paid a $1,500 fine after the state alleged several problems. In response, the state stopped trying to pull the facility's operating license.
Now, a new challenge is in the works. After delivering two negative report cards to River Oaks this year, regulators in late April announced they won't renew the facility's license.
River Oaks also could face more fines, the Agency for Health Care Administration said.
River Oaks is objecting to the state action, and so are many people who are pleased with the care their loved ones receive at the facility just east of U.S. 19 and north of Crystal River.
Those people defend River Oaks and its owner-operator, Dan Ward, whom they credit with helping elderly people who otherwise would languish in other facilities.
"The people (staff) here, I call them angels," said Bob Newton, 77, whose wife, Isabelle, is a longtime resident of the facility at 10845 Gem St.
Residents will stay put, and the facility will carry on with day-to-day activities while the formal challenge plays out.
Ward said the state agency is doing the same thing it did during the last licensure flap: Unfairly punishing him for administrative matters that don't affect patient care; misinterpreting state requirements; inaccurately reporting what was happening at River Oaks; refusing to recognize the quality care the facility delivers; and ignoring the overwhelmingly positive response he receives from residents and their families.
The state inspection team visited River Oaks on Jan. 24 to conduct a standard review and to investigate a complaint. Inspectors reported finding a host of problems, most of which concerned administrative matters, records showed.
For example, they said River Oaks failed to maintain an updated record of "major incidents" that had occurred at the home, and also failed to notify the Agency for Health Care Administration immediately of adverse incidents, according to the inspection report.
Both reporting requirements are spelled out in state law and/or state administrative code.
Ward, in an informal written response to the state, said the incidents in question were noted in the residents' charts, which is a legally sufficient method of reporting. He also said some of the incidents in question didn't qualify as major.
River Oaks also was cited for failing to post the state's latest inspection report, as is required by law, and for changing two residents' diets without record of physician orders.
Ward, in his written response, said previous state inspectors had said River Oaks' practice -- posting a notice telling people that the inspection report was available in the office -- was acceptable.
As for the diet changes, Ward said a physician had approved the change and prepared a written order to that effect.
The complaint that inspectors investigated concerned the use of restraints and treatment of residents.
Inspectors wound up scolding River Oaks for restraining three residents to their chairs during meals, saying such actions were violations of the Resident Bill of Rights and served to deny patients' dignity.
"I told Denise (Godfrey, one of the inspectors) that the restraints were medically necessary to protect the residents from injurious falls, and that they were used only with the consent of the residents' family and a physician's order," Ward wrote in his response to the state.
"I further explained that our willingness to use the restraints in response to the family's request and physician order was motivated by our desire to protect the rights of these residents to remain in the least restrictive setting of their choice as guaranteed by the Americans with Disabilities Act, which was reaffirmed by the 1997 U.S. Supreme Court's Olmstead decision," he wrote.
But Ward doesn't want the state, or the public, to take his word for it. He asks them to talk to people like David Watson.
Watson, a former Citrus County School Board member, brought his mother, Gladys, to live at River Oaks almost two years ago. She had Alzheimer's disease. River Oaks secured her in her seat to make certain she didn't fall and injure herself.
Watson said punishing River Oaks for proper use of safety devices is wrong. "You're just throwing common sense out the window," he said.
In fact, "I think you're violating rights in the other direction" by disallowing a home to provide proper safety, he said.
In the state report, inspectors reported finding residents' rooms locked, which they said was a violation of their right to privacy.
In his written response, Ward wrote that Godfrey refused to tell him which residents were locked out of their rooms.
"I told her only two residents did not have keys to their room in the unsecured station of the building, their names, that they shared the same room and have advanced dementia, and that their spouse and daughter, respectively, explicitly requested we not provide their loved ones unescorted access to their bedrooms during normal waking hours to prevent the life threatening physical and mental decline both residents previously experienced when they had their own keys," Ward wrote.
After the Jan. 24 inspection, state workers prepared their report and sent it to River Oaks. Ward said the state didn't give him and his staff nearly enough time to review the report and prepare a plan of correction.
Inspectors were back again March 14, records showed. They said they found some problems corrected but found 14 not corrected.
At 9:30 a.m. that day, for example, inspectors found five residents restrained to their dining room chairs and a sixth resident restrained to a gerichair. Three hours later, the inspectors saw six residents restrained to dining room chairs.
Once again, the state said such restraining was beyond limits allowed in state law and the Resident Bill of Rights. And once again, Ward said the facility's care was appropriate and in keeping with state law and the desires of the residents and/or their families.
In fact, he noted in a separate letter that River Oaks staff has helped restore the walking ability of residents the agency had said shouldn't be restrained.
"The families of these residents feel certain that, had their loved ones been forced into nursing homes, they would not be walking today, as no nursing home even approaches the 1:4 average restorative aide-to-patient ratio at River Oaks that enables us to provide one-on-one gait reconditioning and learning as a part of every personal care interaction," Ward wrote in that letter.
Roy Southerland will attest to that. His mother-in-law, Ruth Cox, is 95. She is mobile today but needed to be restrained for safety earlier in her stay at River Oaks. "It was a necessary thing we had to do," Southerland said.
The state alleged more procedural and paperwork problems. It also cited River Oaks again for failing to develop a grievance policy for residents, family and visitors. Ward told inspectors the procedure is for the resident or his/her nurse or nursing aide to tell him about any problems.
The state said it found 22 serious deficiencies during the first inspection and that 14 of them weren't corrected on re-inspection. It argued that such performance indicated a failure to meet minimum licensure standards, which in turn was grounds for denial of license renewal.
Ward, who this week will request a formal hearing on the agency's decision, said the agency is "uniformly misclassifying" alleged paperwork problems as patient care problems. State law says such problems are not grounds to deny licensure renewal unless the troubles collectively affect the health, safety and welfare of residents, he said.
"The detailed evidence for each citation clearly did not, and could not, honestly claim" such harm, Ward wrote.
Ward said the state did the same thing a few years ago before realizing its errors and agreeing to stop challenging River Oaks' license.
Back then, the state cited many alleged paperwork problems at River Oaks. It also said the facility kept serving five residents whose required care exceeded what the home was authorized to provide.
Ward said the main problem was that the state wanted him to pass some residents along to nursing homes but he, the residents and their families wanted them to stay in a less-restrictive setting.
He said the state backed off its claims and in fact revised its regulations to recognize the propriety of feeding assistance River Oaks was providing. Ward said he paid the fine and cleared the case because it had dragged on too long.
This time, he said he will mount a fast fight.
Helping him will be testimonials from relatives who have seen their loved ones improve and flourish after even a short time at River Oaks.
Libby Buckley's husband, Tom, lived in five facilities during a six-week stretch before she found River Oaks' phone number in the phone book. He has Alzheimer's disease and was becoming violent, in part because of the heavy medication he was taking.
"He is not easy," Mrs. Buckley said of her husband. They both are 80.
But the River Oaks staff has worked wonders, she said. Thomas Buckley is walking better now and behaves better. Mrs. Buckley wonders what would happen to residents if River Oaks closed, since many facilities have waiting lists.
Ward said River Oaks succeeds because its staff is properly trained and given the time to work on restorative care. They don't restrain residents for convenience or encourage use of tranquilizers.
They don't give up on residents. Just because a resident can't stand or walk or talk today doesn't mean he won't be able to do so tomorrow.
Ward said all long-term care facilities should be doing the same thing, but they don't. The irony of the state's aggressive action, he said, is that a quality facility that provides restorative care like it should is being punished for alleged paperwork problems.
Maria Huebbers' mother, Maria Marsh, has been at River Oaks about 15 months. Mrs. Marsh, 76, has Alzheimer's disease and couldn't recognize her daughter.
"Now when I call her she knows who I am," she said.
Michelle Smentek's father, Herb Liddon, suffers from dementia and has been at River Oaks the past 10 months. "These are the best days of my life," he now tells his daughter and her husband, Scott.
Charlene Walker's mother, Marie Froh, is 78. "She's a totally different woman" since coming to River Oaks seven months ago, Walker said.
"I don't worry about her here."
-- Jim Ross writes about medical issues and social services in Citrus County. Reach him at 860-7302 or firstname.lastname@example.org.
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