on geet peep Pe _. FILED . STATE OF FLORIDA, oe oui. AGENCY FOR HEALTH CAREWDMEINISTRATRONEP | 3° PH 4: 32 yo : . ms "ot . eink STATE OF FLORIDA AGENCY FOR ADU ON IVE HEALTH CARE ADMINISTRATION, any VALS HEARINGS Petitioner, ) Case No. — 2006005704 vs. . ar ne . DOS OF CRYSTAL RIVER ALF, LLC, meme d/b/a CRYSTAL GEM ALF, . Respondent. . . i) lo - 4% Cf 7 u/ / ADMINISTRATIVE COMPLAINT. COMES NOW the Agency For Health Care Administration (hereinafter Agency), by and. through the undersigned counsel, and files this Administrative Complaint against DOS OF CRYSTAL RIVER ALF, LLC, d/b/a CRYSTAL GEM ALF, (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of three thousand dollars ($3,000.00) based upon three cited State Class II uncorrected deficiencies pursuant to §400,419(2)(c) Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3, The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing Received Time Aug.16. 10:20AM assisted living facilities pursuant to the Chapter 400, Part Ii, Florida Statutes, and Chapter 58A- 5 Fla. Admin. Code, respectively. 4, Respondent operates a 40-bed assisted living facility located at 10845 West Gem Street, Crystal River, Florida 34428, and is licensed as an assisted living facility, license number 10687. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. " The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. vA That pursuant to Florida law, an individual must be capable of taking his/her own medication with assistance from staff if necessary. If the individual needs assistance with self- administration the facility must inform. the resident of the professional qualifications of facility staff who will be providing this assistance, and if unlicensed staff will be providing such, assistance, obtain the resident’s or the resident’s surrogate, guardian, or attorney-in-fact’s written jnformed consent to provide such assistance as required under Section 400.4256, F.S., R. 58A- 5.0181(1)(e)(1), Fla. Admin. Code. 8. That on February 28, 2006, the Agency conducted acomplaint survey of Respondent. _ 9. That based upon the review of records and interview, the Respondent facility failed to engure that one (1) of two (2) residents were capable of taking his/her own medications with just assistance from staff, the same being an inappropriate placement and in violation of law. 10, That the Petitioner's representative reviewed the Respondent’s records regarding resident number two (2) on February 28, 2006, and noted the resident's health assessment (form 1823) dated November 4, 2005 which indicated that the resident required medication administration and that the resident’s blood sugar levels must be monitored. }1. That the Petitioner’s representative interviewed the Respondent’s administrator on February 28, 2006 who indicated that Respondent had no licensed personnel on staff to administer medications to residents or to tale blood sugat readings necessary to monitor blood sugar levels, though a nurse conducts resident assessments monthly. 12, That the resident was incapable of self administering medications and monitoring blood ) glucose levels and thus inappropriate for residence at the facility. 13. That the Agency provided Respondent with a mandatory correction date of March 28, 2006. 14. That on April 13, 2006, the Petitioner Agency conducted a follow-up to the complaint survey of Respondent. 15. That based upon observation, ‘the review of records, and interview, the Respondent facility failed to ensure that one (1) of seven (7) residents who require assistance with medication . was receiving assistance with his/her medication. Failure to ensure residents are receiving assistance with medication instead of medication administration may mean that the resident does not meet residency criteria and is in violation of law. 16, That the Petitioner’s representative noted upon review of the Respondent facility on April 13, 2006 that the medication refrigerator contained two unit dose vials of insulin for resident number six (6). 17. That the Petitioner’s representative interviewed the Respondent’s assistant administrator on April 13, 2006 who indicated as follows: a) That resident number six (6) is capable of assisting with self administration of his/her insulin; Received Time Avg.18. 1:36PM b) That the facility had been utilizing pre-filled pharmacy 30 unit dose syringes; c) That the last syringe had been utilized the prior evening and that the facility was awaiting a refill; ) d) That the pharmacy visits the facility every evening. 18. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number six (6) on April 13, 2006 and noted the following: a) b) °) qd) ¢) That the resident’s health assessment (form - 1823) was dated January 10, 2006; That the health assessment indicated that the resident requires assistance with self administration of medication; That the resident’s medication observation record reflected that the resident receives, since April 6, 2006, Lantus 30 units subcutancously at bedtime; That a ourse’s note dated March 22, 2006 provided “Resident [#6] able to self administer own insulin see home health notes; That a review of the resident’s home health notes memorialize the following: * 03/08/06 - Admitted for insulin instruction. We are to instruct patient on insulin administration after staff prepares syringe. Patient is confused times three, * 03/11/06 - Patient is confused and disoriented.,.Staff drew up 6 units regular insulin, Instructed patient to grab up abdominal skin between fingers and inject needle. Patient did well, She will not be able to do this without assist. * 03/12/06 - ...Attempted to have patient draw up own insulin but [patient] almost stabbed self and [patient] contaminated the needle on bottle. [Patient] did do accu check and injection with coaching. 19. That Florida law provides that assistance with self-administration of medications does not include the preparation of syringes for injections or administration of medications by any injectable route. Section 400.4256(4)(b), Fla. Stat. (2006). Received Time Aug.16. 10:20AM 20. That the Petitioner’s representative interviewed the Respondent's administrator on April 13, 2006 who indicated as follows: a) That there are no licensed personnel on staff to administer medications; b) That there are no licensed personnel on staff to monitor blood sugar levels; c) That she was under the impression that either the pharmacy had forwarded pre- filled syringes for the resident to utilize or the resident’s family prepared the insulin syringes for the resident to self inject. 21. That the Petitioner's representative interviewed the Respondent’s family member and power of attorney on April 13, 2006 who indicated that the family member typically visits on Wednesdays and Sundays and does not assist with resident's insulin. 22. That the Petitioner’s representative interviewed Respondent's staff members numbered one (1) and two (2) on April 13, 2006 who both indicated that the resident's insulin sometimes is pre-drawn by another facility staff member or the staff member will prepare and draw the | syringe for the resident to inject. . 23, That the resident was incapable of self administering medications and monitoring blood glucose levels and thus inappropriate for residence at the facility. 24. The Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class [il deficiency. 25, Thatthe Agency provided Respondent with a mandatory correction date of May 13, 2006. 26. That the same constitutes an uncorrected deficiency. Received Time Aug. 18. 10:20AM WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2005). COUNT Tt 27. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 28. That pursuant to Florida law, every facility shall 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 adequate care to all residents as required by Part II of Chapter 400, F.S. Fla. Admin. Code R. 58A-5.019(1). 29. That on February 28, 2006, the Agency conducted a complaint survey of Respondent. 30. That based upon the review of records and interview, the Respondent’s administrator who is responsible for the overall provision of care for the residents, failed to ensure that two (2) of two (2) residents were appropriate for admission to the facility. . 31. That the Petitioner’s representative reviewed the Respondent's records on February 28, 2006 and noted the following regarding resident number two (2): a) That the health assessment was not accurately completed; b) That the resident required administration of medications and the monitoring of blood glucose levels. 32. That the resident was not appropriate for placement in the Respondent facility as the facility does not employ nurses who are required for medication administration and blood sugar level checks which the administrator, who is responsible for evaluating and assessing a resident Received Time Aug. 16. 10:20AM" to be appropriate for the facility did not note nor did the administrator note that the assessment was not accurately completed. 33. That the Petitioner’s representative reviewed the Respondent’s records on February 28, 2006 and noted the health assessment of resident number one (1) contained another facility name and the address and phone number were incorrect. 34. . That the Petitioner's representative interviewed the Respondent's administrator on. February 28, 2006 who indicated the following: a) That there are no licensed personnel on Respondent's staff to administer medications or monitor blood glucose levels; b) That resident number one (1) resided at another assisted living facility with _ his/her spouse and just recently the spouse had been taken to the hospital; c) That resident number one (1) was discovered on highway 19 trying to find the spouse; . . d) That the other facility asked this facility if they would place the resident in their . secured area; é) That "[the resident] hasn't been here that long, just a few days." The resident was listed on the log as being admitted on 1/13/06, approximately one month and 15 days ago. 35. That resident number one (1) was listed on the log as being admitted on January 13, 2006, approximately one month and 15 days ago. 36. That the health assessment for resident number one (1) did not reflect that the resident was appropriate for placement in the Respondent facility in light of the resident's wandering activity, there was no physician’s indication that the resident was in need of a secure placement, Received Time Aug.J6. 10:20AM and no annotations or record of the resident’s wandering behaviors. 37. That there was no indication that the Respondent facility took staffing or other measures to provide adequate care and monitoring. for the wandering behavior of resident number one (1). 38. That the Respondent's administrator failed to ensure adequate staff and care was available to meet resident needs, the same being in violation of law. 39. That the Agency provided Respondent with a mandatory correction date of March 28, 2006. ; 40. That on April 13, 2006, the Petitioner Agency conducted a follow-up to the complaint survey of Respondent. 41, That based upon observation, the review of records, and interview, the Respondent facility failed to ensure that one (1) of seven (7) residents who require assistance with medication was receiving assistance with his/her medication. Failure to ensure residents are receiving assistance with medication instead of medication administration may mean that the resident does not meet residency criteria and is in violation of law. 42, That the Petitioner’s representative noted upon review of the Respondent facility on April 13, 2006 that the medication refrigerator contained two unit dase vials of insulin for resident number six (6). . 43, That the Petitioner’s representative interviewed the Respondent's assistant administrator on April 13, 2006 who indicated as follows: a) That resident number six (6) is capable of assisting with self administration of his/her insulin, b) That the facility had been utilizing pre-filled pharmacy 30 unit dose syringes; c) That the last syringe had been utilized the prior evening and that the facility was Received Time Aug. 16. 10:20AM awaiting a refill; d) That the pharmacy visits the facility every evening. 44, —‘ That the Petitioner's representative reviewed the Respondent’s records regarding resident number six (6) on April 13, 2006 and noted the following: | a) | That the resident’s health assessment (form - 1823) was dated January 10, 2006; b) That the health assessment indicated that the resident requires assistance with self administration of medication; ¢) That the resident’s medication observation record reflected that the resident receives, since April 6, 2006, Lantus 30 units euboutaneously at bedtime, d) That a nurse’s note dated March 22, 2006 provided “Resident [#6] able to self administer own insulin see home health notes; e) That a review of the resident’s home health notes memorialize the following: * 03/08/06 - Admitted for insulin instruction. We are to instruct patient on insulin administration after staff prepares syringe. Patient is confused times three. * 03/11/06 - Patient is confused and disoriented...Staff drew up 6 units regular insulin. Instructed patient to grab up abdominal skin between fingers and inject needle. Patient did well. She will not be able to do this without assist. * 03/12/06 - ,..Attempted to have patient draw up own insulin but [patient] almost stabbed self and [patient] contaminated the needle on bottle. [Patient] did do accu check and injection with coaching. 45, That Florida law provides that assistance with self-administration of medications does not include the preparation of syringes for injections or administration of medications by any injectable route. Section 400.4256(4)(b), Fla. Stat. (2006), 46. That the Petitioner's representative interviewed the Respondent’s administrator on April 13, 2006 who indicated as follows: a) That there are no licensed personnel on staff to administer medications; Received Time Aug. 16. 10:20AM b) That there are no licensed personnel on staff to monitor ‘blood sugar levels; c) That she was under the impression that either the pharmacy had forwarded pre- filled syringes for the resident to utilize or the resident’s family prepared the insulin syringes for the resident to self inject. J 47, That the Petitioner’s representative interviewed the Respondent’s family member and power of attorney on April 13, 2006 who indicated that the family member typically visits on Wednesdays and Sundays and does not assist with resident's insulin. 48. That the Petitioner’s representative interviewed Respondent's staff members numbered one (1) and two (2) on April 13, 2006 who both indicated that the resident's insulin sometimes is pre-drawn by another facility staff member or r the staff member will prepare and draw the syringe for the resident to inject. 49, That the Respondent’s administrator failed to ensure adequate staff and care was available to meet resident needs, the same being in violation of law. 50. The Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class II deficiency. . 51, That the Agency provided Respondent with a mandatory correction date of May 13, 2006. 52. ‘That the same constitutes an uncorrected deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2005). 10 Received Time Aug-16. 10:20AM COUNT DL 53. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. . 54. That pursuant to Florida law, for facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider's order or prescription label. R. 58A- 5.0185(4)(a) Fla. Admin. Code. i 55. That on February 28, 2006, the Agency conducted a complaint survey of Respondent. 56. That based upon the review of records and interview, the Respondent facility failed to ensure that a licensed staff member was available to provide medications to two (2) of three (3) residents that were identified as requiring medication administration. 57. That the Petitioner’s representative reviewed Respondent's records for residents numbered one (1) and two (2) on February 28, 2006 and noted the following: a) That the health assessment of resident number one (1) indicated that the “‘Patient js severely impaired intellectually by dementia,” b) That the health assessment of resident number two (2) indicated that the resident required medication administration and monitoring of blood sugar levels. 58. That the Petitioner’s representative interviewed the Respondent's staff aide on February 28, 2006 who indicated that she does administer medications to residents that are cognitively impaired. 59. That the Petitioner's representative interviewed the Respondent’s administrator on February 28, 2006 who indicated as follows: a) That aides can adrainister Tylenol if they have orders PRN (as needed) for a fever li Received Time Aug. 16. 10:20AM or pain; b) That such administration does not require the aide to make a judgment calls c) That the administrator and the Advanced Registered Nurse Practitioner felt that the elderly are going to have pains and fever and they don't need to “...g0 and sit - inthe Emergency Room (ER) for 6 hours and then be given Tylenol and sent back here." 60. That the administration of medications and the monitoring of blood ghucose levels require training and skills of licensed personnel and such activity being conducted by individuals without the requisite training, including but not limited to the assessment of patients, puts the ‘resident at great risk. 61. That the Respondent failed to provide licensed staff to administer medications, the same being a violation of law. 62, That the Agency provided Respondent with a mandatory correction date of March 28, — 2006. . ) | 63. ° That on April 13, 2006, the Petitioner Agency conducted a follow-up to the complaint survey of Respondent. | 64. That based upon observation, the review of records, and interview, the Respondent facility failed to ensure that one (1) of seven (7) residents who require assistance with medication was receiving assistance with his/her medication. Failure to ensure residents are receiving assistance with medication instead of medication administration may mean that the resident does not meet residency criteria and is in violation of law. | , 65. That the Petitioner's representative noted upon review of the Respondent facility on April 13, 2006 that the medication refrigerator contained two unit dose vials of insulin for resident 12 Received Time Aug. 16. 10:20AM number six (6). 66. That the Petitioner’s representative interviewed the Respondent's assistant administrator on April 13, 2006 who indicated as follows: 67. a) That resident number six (6) is capable of assisting with self administration of his/her insulin; b) That the facility had been utilizing pre-filled pharmacy 30 unit dose syringes; c) That the last syringe had been utilized the prior evening and that the facility was awaiting a refill; , , d) That the pharmacy visits the facility every evening. That the Petitioner's representative reviewed the Respondent's records regarding resident number six (6) on April 43, 2006 and noted the following: a) That the resident’s health assessment (form - 1823) was dated January 10, 2006; b) That the health assessment indicated that the resident requires assistance with self administration of medication; c) That the resident’s medication observation record reflected that the resident receives, since April 6, 2006, Lantus 30 units subcutaneously at bedtime; d) That a nurse’s note dated March 22, 2006 provided “Resident [#6] able to self administer own insulin see homie health notes, e) That a review of the resident’s home heaith notes memorialize the following: # 93/08/06 - Admitted for insulin instruction. We are to.instruct patient on insulin administration after staff prepares syringe. Patient is confused times three. * 03/11/06 - Patient is confused and disoriented.,..Staff drew up 6 units regular insulin, Instructed patient to grab up abdominal skin between fingers and inject needle. Patient did well. She ‘will not be able:to do this without assist. * 03/12/06 - ... Attempted to have patient draw up own insulin but [patient] Received Time Aug. 16. 10:20AM almost stabbed self and [patient] contaminated the needle on bottle. [Patient] did do accu check and injection with coaching. 68. That Florida law provides that assistance with self-administration of medications does not include the preparation of syringes for injections or administration of medications by any injectable route. Section 400.4256(4\b), Fla. Stat. (2006). 69. That the Petitioner's representative interviewed the Respondent’s administrator on April 13, 2006 who indicated as follows: a) That there are no licensed personnel on staff to adruinister medications; b) That there are no licensed personnel on staff to monitor blood sugar levels; c) That she was under the impression that either the pharmacy had forwarded pre- filled syringes for the resident to utilize or the resident’s family prepared the insulin syringes for the resident to self inject. 710, That the Petitioner’s representative interviewed the Respondent’s family member and power of attorney on April 13, 2006 who indicated that the family member typically visits on Wednesdays and Sundays and does not assist with resident's insulin. | 71. That the Petitioner's representative interviewed Respondent’s staff members numbered one (1) and two (2) on April 13, 2006 who both indicated that the resident's insulin sometimes is pre-drawn by another facility staff member or the staff member will prepare and draw the syringe for the resident to inject. 92° ‘ That the Respondent failed to provide licensed staff to administer medications, the same being a violation of law. 73, The Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 14 Received Time Aug. 16. 10:20AM TA. That the Agency provided Respondent with a mandatory correction date of May 13, 2006. 73. That the same constitutes an uncorrected deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2005). Respectfully submitted this f day of August, 2006. Céunsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 72°7.552.1440 (fax). Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120,569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to 4gency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (8 50) 922-5873. : RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 15 Received Time Aug.16. 10:20AM CERTIFICATE OF SERVICE L HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7004 2510 0005 4049 1451 on August g , 2006 to AGI Registered Agents, Inc., 1200 Brickell Avenue, Suite 900, Miami, FL 33131 and by regular US. Mail to Laurene Holder, Administrator, Crystal Gem ALF, 10845 West Gem St., Crystal River, FL 34428. . Walsh I, Esquire Copies furnished to: Laurene Holder, Administrator Crystal Gen, ALF Thomas J. Walsh, IL Agency for Health Care Admin. AGI Registered Agents, Inc. 1200 Brickell Avenue, Suite 900 Miami, FL 33131 10845 West Gem St. 525 Mirror Luke Drive, 330G (U.S. Certified Mail) Crystal Rivet, FL 34428 St. Petersburg, FL 33701 (U.S. Mail) Cinteroffice) 16 Received Time Ave. 16. 10:20AM

Docket for Case No: 06-003474