STATE OF FLORIDA uF AGENCY FOR HEALTH CARE ADMINISTRATION FER Ie Py 5 é 435g AGENCY FOR HEALTH CARE awl A ADMINISTRATION, MOMINIST Rg jos HEAR IMAG ETL AQ Petitioner, AHCA No.: 2004011090 Vv. Return Receipt Requested: 7002 2410 0001 4234 3670 CREST MANOR ASSISTED LIVING, 7002 2410 0001 4234 3687 L.C., d/b/a CREST MANOR, Respondent. OS-OS | b / ADMINISTRATIVE COMPLAINT eS EN COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Crest Manor Assisted Living, L.c. d/b/a Crest Manor (hereinafter Crest Manor”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $3,000.00 pursuant to Section 400.419, Florida Statutes (2004), for the protection of the public health, safety and welfare and $500.00 survey fee pursuant to Section 400.419(10), and 400.428(3) (c), Fla. Stat. (2004) JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Palm Beach County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code. 5. Crest Manor operates a 52-bed assisted living facility located at 504 Third Avenue South, Lake Worth, Plorida 33460, Florida 33460. Crest Manor is licensed as an assisted living facility license number AL10028, with an expiration date of November 30, 2006. Crest Manor was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I CREST MANOR FAILED TO PROVIDE PROPER ASSISTANCE WITH THE ADMINISTRATION OF MEDICATIONS TO ENSURE A RESIDENT RECEIVED HIS/HER MEDICATIONS PER THE PHYSICIAN’S ORDERS Rule 58A-5.0185(3) (b), Florida Administrative Code (MEDICATION STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates Paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 11/04/04 and based on observation, review of the Medication Observation Records, resident records and interview with the Administrator and nurse, the facility did not provide proper assistance with the administration of medication to ensure a resident received his/her medications per the physician's orders. 8. On 8/02/02, Dr. Kapila D/C Resident #1's Lexapro 20mg. The resident, as per the MOR, continued to be assisted with this medication until 8/13/04. The facility also received a D/C order for this medication on 8/25/04 when Levoxyl 100mcg, 1 daily was prescribed by Dr. Alikon. 9. On 8/16/04 Dr. Kapila prescribed Zyprexa 5mg, 1/2 po 6 PM for one week and then to be D/C. The facility assisted Resident #1 with this medication as stated on the MOR for only four days, 8/16/04 to 8/19/04, not the prescribed seven days. On 8/16/04 the MOR for this resident also reveals that the resident was assisted with Zyprexa 5 mg 1 tab PM, which was D/C on 8/16/04 when the new dose was prescribed and the 5mg dose was discontinued. The resident according to the MOR received both doses on 8/16/04. 10. Based on the foregoing, Crest Manor violated 58a- 5.0185(3) (b), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. COUNT II CREST MANOR FAILED TO MAKE EVERY REASONABLE EFFORT TO PROVIDE MEDICATIONS THAT WERE PRESCRIBED TO RESIDENTS BY A PHYSICIAN RULE 58a-5.0185(7) (£), Florida Administrative Code (MEDICATION STANDARDS) Class II Violation 11. AHCA re-alleges and incorporates Paragraphs (1) through (5) as if fully set forth herein. 12. During the complaint investigation conducted on 11/04/04 and based on record review and interviews with staff and residents, the facility failed to make every reasonable effort to provide medications that were prescribed to residents by a physician. 13. The following prescribed medications were not available to be assisted with by facility staff for Resident #1 from 8/20/04 to 8/27/04 when the resident became ill and required immediate hospitalization: a) Ativan 1 mg QD at 3 PM b) Lasix 40mg 1 QD c) Klor-con 10meq 2 tabs (20 meq) OD da) Temazepam 30mg 1 tab HS e) Paxil 20mg 1 QD at 6 PM f£) Aricept 10mg 1 QD at 6 PM g) Restoril 15mg 1 HS; PRN for sleep 14. The following prescribed medication was not available from 8/25/04 to 8/27/04: a) On 8/25/04, the resident was taken to another physician, who prescribed Levoxyl 100mcg. oD. This prescription was never filled according the resident's records and the MOR and the resident was never assisted with this medication. 15. This absence of medications for this resident was noted in the resident's observation notes. The facility dia not notify the resident's primary physician or the prescribing physician that the resident was not taking his/her medication. The facility did call the resident's niece to find out why the pharmacy bill was not being paid but took no actions to obtain an emergency supply of these medications. 16. A review of the 8/04 MOR, resident record and the facility records for Resident #1 reveals that the MOR was left blank without any explanation by the staff member as to why this resident was not assisted with these medications or why it these medications were not obtained and available. The facility did not have any record or knowledge of any of the resident's physicians being notified that the resident did not have these medications or the facility not being able to assist the resident in taking or obtaining these medications. The resident became ill on 8/27/04 and required emergency hospitalization. 17. Based on the foregoing, Crest Manor violated 58A- 5.0185(7) (£), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. COUNT III CREST MANOR FAILED TO ENSURE THAT RESIDENT’S HEALTH CARE PROVIDER IS ADVISED OF SIGNIFICANT CHANGES Section 58A-5.0182(1)(d), Florida Administrative Code (RESIDENT CARE STANDARDS) Class II VIOLATION 18. AHCA re-alleges and incorporate Paragraphs (1) through (5) as if fully set forth herein. 19. During the complaint investigation conducted on 11/04/04 and based upon record review and interview it was revealed that the facility did not ensure that resident's health care provider is advised of significant changes. 20. Resident #1 over the last six months became more agitated and anxious. According to the Administrator, the resident was referred to see the psychiatrist. The psychiatrist prescribed many psychotropic medications that appeared to adversely affect or have no effect on the resident. The resident's family requested the resident see another psychiatrist for further evaluation. The facility did not apprise the resident's primary care physician of these multiple visits and medications that were prescribed as a result. The resident according to the observation notes became increasingly ill, and when the medications were not available, from 8/20/04 to 8/27/04, he/she required emergency hospitalization. There was no documentation available to ensure that these changes in the resident's condition and medication regime were brought to the attention of the resident's primary physician by the facility. 21. Based on the foregoing, Crest Manor violated 58A- 5.0182(1) (d), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida Statutes, AHCA May assess a survey fee of $500.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I, II, and III. B. Assess an administrative fine of $3,000.00 against Crest Manor on Count I for one uncorrected Class III violation. Cc. Assess a survey fee of $500.00 against Crest Manor, pursuant to Sections 400.419(10), and 400.428(3) (ac), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. son E. Rodney istant General} Counsel Agency for Health Care Administration 8350 N. W. 52™ Terrace Suite 103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE al EA I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Bonita A. Brody, Administrator, Crest Manor, 504 Third Avenue South, Lake Worth, Florida 33460, and to David B. Thomas, Registered Agent, 2151 N.E. Coachman Road, Clearwater, Florida 33765 ony (inary 7) , 2005. Lklon Nelson E. Rodney

Docket for Case No: 05-000576