STATE OF FLORIDA % 4 AGENCY FOR HEALTH CARE ADMINISTRATION Ln &y STATE OF FLORIDA, AGENCY FOR aos 4p, ty de, HEALTH CARE ADMINISTRATION, Bessey Op 45 any Petitioner, . ST Case No. 2006008274 VS. MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE, (D (ot 14 54 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against MANJO INVESTMENTS, INC., d/b/a PALMETTO PLACE (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to impose administrative fines in the amount of five hundred ($500.00) pursuant to Section 429,.19(2)(c), Florida Statutes (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429.07, Florida Statutes (2006). . 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable statutes, rules, and regulations governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. The Respondent operates a 16-bed assisted living facility (hereinafter “Facility”) located at 5341 Palmetto Road, New Port Richey, Pasco County, Florida 34652, and, at all times material hereto, was licensed by the Agency to operate such Facility (License Number 5 630). 5. At all times material hereto, the Respondent was 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 One (1) through Five (5) as if fully set forth herein. 7. That pursuant to Florida law, the facility shall maintain a daily observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration... The MOR must include, inter alia, the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR maintained by an assisted living facility must be immediately updated each time the medication is offered or administered. Rule 58A-5.0185(5)(b), Florida Administrative Code 8. That on or about October 12, 2005, the Agency conducted a complaint survey (CCR#200600863 5) at Respondent’s assisted living facility (hereinafter “Facility”). 9. That based upon the review of records and interview, the Respondent failed to maintain an up-to-date medication observation record (MOR) for one (1) of three (3) residents reviewed in violation of Rule 58A-5.0185(5)(b), Florida Administrative Code. 10. That the Petitioner’s representative reviewed the Respondent’s records regarding and medications maintained for resident number one (1) on October 12, 2005 and noted the following: a. That the resident’s MOR indicated that the resident was receiving Seroquel 100 mg. tablet two times daily; b. That the prescription required that the Seroquel be administered two times daily and one tablet at bedtime. 11. That the Petitioner’s representative interviewed the Respondent’s administrator on October 12, 2005 who indicated that the Seroqeul 100 mg. tablets were provided to resident number one (1) in accord with the prescriptive dosages despite the error on the resident’s MOR. 12. That the above reflects that the Respondent failed to maintain an accurate and up-to-date MOR for resident number one (1), the same being in violation of law. 13. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility, or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents. | 14. That the Agency cited the Respondent for a Class III violation in accordance with Section 400.419(2)(c), Florida Statutes (2005).' 15. That the Agency provided a mandated correction date of November 15, 2005. 16. That during a re-visit survey conducted November 16, 2005 the Agency determined that the Respondent had corrected the deficiency. 17. That on or about August 16, 2006, the Agency conducted a Complaint Survey (CCR#2006007256) of Respondent’s Facility. ' Chapter 400, Part IIT, Florida Statutes (2005) was recodified at Part I, Chapter 429, Florida Statutes (2006) effective July 1, 2006. Section 400.419, Florida Statutes (2005) was in effect on October 12, 2005, and is the identical statutory provision now codified at Section 429.19, Florida Statutes (2006). 18. That based upon the review of records, observation, and interview, the Respondent failed to maintain an up-to-date medication observation record (MOR) for three (3) of three (3) sampled residents. 19. That the Petitioner’s represéntative reviewed the Respondent’s records and medications maintained for three residents on August 16, 2006, and noted the following: a. Resident number one (1): That the resident’s MOR reflected that orders for medications included Cogentin Img twice a day and Effexor 150mg twice a day; That the pharmacy label for the resident’s Cogentin prescription directed use of “take 1 at bedtime;” That the pharmacy Jabel for the resident’s Effexor directed use of 100mg twice a day. b. Resident number two (2): That the resident’s MORs reflected that orders for medications included Bactrim DS 800mg/160mg to be taken twice a day for 7 days; That the resident’s MOR had been annotated to reflect that the Bactrim had been administered and taken from August 1 through 16, 2006; That a supply of Bactrim for the resident was not available at the facility; That the physician’s orders for the medication reflected that the medication was prescribed to commence on July 28, 2006 at the rate of two times daily for a period of seven (7) days; That no further orders for the administration of Bactrim to the resident was located. c. Resident number three (3): That the resident’s MORs reflected that orders for medications included orders for Lorazepam 1mg to be taken three times a day at 8 AM, 5 PM and 8 PM, and Ibuprofen 600mg every 8 hours as needed for pain; That medications maintained by the Respondent for the resident reflected on the pharmacy label on the Lorazepam to read twice a day at 8AM and 2PM.; That medications maintained by the Respondent for the resident reflected on the pharmacy label on the Ibuprofen read three times a day routinely with another card available that read every 6 hours as needed for pain; That medications maintained by the Respondent for the resident reflected a bottle for Effexor 75mg, two tablets twice a day; That the resident’s Effexor prescription and medication was not listed on the MORs. 20. That each of the above resident’s MORs did not accurately reflect the medications, directions for use, and accurate recording of when the medication was taken and as such were not up-to-date and maintained as required by law. 21. That the Petitioner’s representative interviewed the Respondent’s administrator and the Respondent’s assistant on August 16, 2006 who indicated the following: a. That the Bactrim prescribed for resident number two (2) had been continued as the resident suffered from a severe infection; b. That the three resident’s received their medications from the FACT team; c. That the facility suffered from multiple problems in getting medications and administration orders correctly from the FACT team: d. That the FACT team had caused the medication errors suffered by the Respondent; e. That they do not know if they were administering medications correct . medications as ordered to these three residents. 22. That based upon the above, the Agency determined that the Respondent failed to maintain an up-to-date medication observation record for the three sampled resident’s and as such failed to meet the requirements of law. 23, That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents. 24, That the Agency cited the Respondent for a repeat Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2006). 25. That this constitutes a repeat violation as provided by law. 26. That the Respondent has been cited for violation of this regulation at least three (3) times prior to the survey of October 12, 2005. 27. That the Agency provided a mandated correction date of September 16, 2006. 28. That Respondent's failure to maintain an up-to-date medication observation record is in violation of Rule 58A-5.0185(5)(b), Florida Administrative Code, as set forth in this count, and constitutes grounds for the imposition of an administrative fine in the amount of five hundred dollars ($500.00), pursuant to Section 429, 19(2)(c), Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). Respectfully submitted this on day of October, 2006. Thdmas J. Walsh, IT Fla. Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 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: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS' #3, Tallahassee, Florida 32308. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8108 on October "% ¢/ , 2006 to: Amanda N. Mark, Admin., Registered Agent, Palmetto Place, 5341 Palmetto Road, New Port Richey, Florida 34652 and by U.S. Mail to: John F. Gilroy, III, Esq., 1435 East Piedmont Dr., #102, Tallahassee, Florida 32308. / splaghean IL, Esq. ‘ Copies furnished to: Amanda N. Mark, Admin. John F.Gilroy If, Esq. Thomas J. Walsh, I, Esq. Registered Agent John F. Gilroy II, P.A. Agency for Health Care Admin. Palmetto Place 1435 East Piedmont Dr., #102 525 Mirror Lake Drive, 330G 5341 Palmetto Road Tallahassee, FL 32308 St. Petersburg, FL 33701 New Port Richey, FL 34652 (U.S. Mail) (Interoffice) (U.S. Certified Mail) SENDER: COMPLEgg m@ Complete Items +s7 and 3. Also complete...” item 4 If Restricted Delivery Is desired, ™ Print your name and address on the reverse so that we can retum the card to you. @ Attach this card to the back of the mallplece, or on the front if space permits. 1. Article Addressed to: aon ; \ Wo a D. Is delivery address diffe If YES, enter delivery adi CT Registered C1 Insured Mall CE conten aI a i Shag eal (1 Return Receipt for Merchandise); . C.D. { wine FALS@,| 4. Restrcted Delivery? (Extra Fee) 1 Yes 2. Artiola Numb \ stk i 7005 LibO 0002 2254 aLoa PRL COR AY Gr ety PS Fom 3611, Febnay abe Daneatsaaummenit Samm) ES a Ee, in * eG 7, : Ble B&O Bho. & ease Nae Ep cn

Docket for Case No: 06-004929