STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Noy STATE OF FLORIDA, . AGENCY FOR HEALTH CARE ay ADMINISTRATION, Petitioner, a “| . 5 | O s v. Case Nos. 2007010324 GOLD KEY DEVELOPMENT, INC., D/b/a CARRIAGE INN, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration, (hereinafter “thé Agency”), by and through the undersigned counsel, and files this administrative complaint against the Respondent, GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to revoke the license of an assisted living facility pursuant to Subsection 429.14(1)(e)2, Florida Statutes (2006), Subsection 408.815(1)(c), Florida Statutes (2006), and Subsection 408.815(1)(d), Florida Statutes (2006), or alternatively, to impose an administrative fine in the amount of twelve thousand dollars ($12,000.00), pursuant to Subsections 429.19(2)(b)-(c), Florida Statutes (2006), based upon the facility committing one Class I violation and seven Class II violations. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to sections 120.569 and 120.57, Florida Statutes (2006). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2006). 3. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable federal and state regulations, statutes and rules, governing assisted living facilities. Ch. 408, Part II, and Ch. 429, Part I, Fla. Stat. (2006); Ch. 58A-5, Fla. Admin. 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. $§ 408.813, 408.815, 429.14, Fla. Stat. (2006). 5. The Respondent was issued a license by the Agency (License Number 10146) to operate a 35-bed assisted living facility located at 3409 W. 19" Street, Panama City, Florida 32405, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules governing assisted living facilities. COUNTI REVOCATION OF LICENSE The Respondent Was Cited For One Class I Deficiency and Seven Class II Deficiencies In Violation Of F.S. 429.14(1)(e)1 and 2 6. The Agency re-alleges and incorporates by reference paragraphs 1] through 5. 7. Under Florida law, the Agency may deny, revoke, or suspend license issued under Chapter 429, Part I, Florida Statues, or impose an administrative fine in the manner provided under Chapter 120, Florida Statutes, for any action enumerated in Subsection 429.14(1)(a)-(n), Florida Statutes. The Respondent is being cited for one Class I and seven Class II deficiencies. § 429.14(1)(e), Fla. Stat. (2006). 8. The Agency re-alleges and incorporates by reference the allegations in Counts IT through IX. . 9. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. 10. As a result of this complaint survey, the Agency cited the Respondent for one Class I and seven Class deficiencies in violation of Section 429.14(1)(e)1 and 2, Florida Statutes (2006). 11. The Respondent was cited for and committed one Class J and three or more Class II deficiencies in violation of Section 429.14(1)(e)1 and 2, Florida Statutes (2006). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to revoke the license of the Respondent to operate the above- referenced assisted living facility. COUNT I The Respondent Failed To Ensure Proper Assistance With Self-Administration of Medication In Violation Of Section 429.256(3){a), Florida Statutes (2006) Isolated Class I Violation 12. The Agency re-alleges and incorporates paragraphs | through 5. 13. Under Florida law, all staff of an assisted living facility must assist residents in self-administer medications in the follwing manner: Medication, in its dispensed, properly labeled container, shall be taken from where it is stored and brought to the resident. Section 429.256(3)(a), Florida Statutes (2006). . 14. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. 15. Based upon record review and interview, the Respondent failed to comply with the above-referenced provision. 16. Based on record review and interview, the Respondent failed to ensure that when staff provided assistance with self-administration of medication, it did not assist in the following manner: Medication, in its dispended, properly labeled container, shall be taken from where it is stored and brought to the resident which was not done for one of fifteen sampled residents (Resident #2). The surveyor’s findings were: 1. A tour of the facility was conducted on 04/06/2007. During the tour it was observed that sampled resident #2 had 8 Insulin (pre-filled by a Licensed Practical Nurse/LPN no longer at the facility or employed by. the facility) syringes filled with a clear liquid stored in the facility's medication room. There was no name (who they were for), date drawn up/filled, type insulin, amount of insulin to be in each syringe, or any other identification to the 8 prefilled syringes. During the observation of the 8 syringes it was revealed by review of the Medication Observation Record (MOR) for sampled resident #2 that the physician's order was for 16 units of the Insulin to be given every day and it was also observed that 3 of the 8 syringes had between 17 & 18 units of the clear liquid in them. The facility supervisor stated, "They belong to sampled resident #2." 2. An interview with sampled resident #2 was conducted on 04/06/2007. During this interview the resident acknowledged that the facility did not allow him to draw up his own insulin or have his medication (insulin and oral medications) in his room to self administer but that the facility staff (Aid & Supervisor) would bring the pre-filled (see item #1 above) medication (insulin) to his/her room when the scheduled time for administration was each day and was not allowing him/her to draw up the medication from the medication (insulin) vial. 3. An interview with the facility's supervisor was conducted on 04/06/2007. During this interview the supervisor acknowledged that the previous employee (an LPN), no longer working at the facility, had pre-drawn insulin in syringes for sampled resident #2 and they were stored in the facility's medication room (Note: Syringes were unlabeled with any name, date or substance in them). The supervisor also acknowledged that there had been no licensed (physician, nurse, physician's assistant, registered nurse practitioner) person in the facility to assist in or administer medications to residents since the LPN left the facility on 03/22/2007. The supervisor also acknowledged that the staffs Aids were taking the pre-filled insulin syringes to sampled resident #2 every evening at the scheduled time and that the resident was not drawing up his/her own medication as per the self administration process. 17. The Respondent’s deficient practice constituted a Class I violation, pursuant to Chapter 429.256(3)(a), Florida Statutes (2006). 18. The Agency shall impose an administrative fine for a cited Class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation as set forth in Section 429.19(2)(a), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five thousand dollars ($5,000). COUNT Ill The Respondent Failed To Ensure Each Resident Was Determined To Be Appropriate For Admission To The Facility Based On The Medical Examination Report In Violation Of F.A.C. 58A-5.0181(n)1-3 Isolated Class II Violation 19. The Agency re-alleges and incorporates paragraphs 1 through 5. 20. Under Florida law, an assisted living facility is required to ensure that each resident is appropriate for admission to the facility based on the medical examination report. Fla. Admin Code R. 58A-5.0181(1)(n)1-3. 21. On or about April 6, 2006, the Agency conducted a complaint survey of the Respondent and its Facility. 22. Based on observation, record review and interview the facility's administrator failed to ensure each resident was determined to be appropriate for admission to the facility based on the medical examination report for 5 of 15 (#4, #5, #6, #7, & #8) sampled residents. The surveyors’ findings were: 1. During a tour of the facility it was noted that there was no licensed nursing personnel/staff at the facility. The administrator and the Supervisor stated, "The Licensed Practical Nurse (LPN) walked out on 03/22/2007 and we have not had any nurses since." The administrator also stated, "and we won't hire any more after this." The facility did not have a licensed nurse working at the facility between 03/22/2007 and the day of the complaint survey. 2. A review of the resident's records was conducted on 04/06/2007. During these record reviews it was revealed that the following residents were documented on the DOEFA Form 1823 in the questioning statement - Does the individual need help with their medications (Yes/No)?, and if Yes please describe; to require "Nursing" Staff to "Administer" medications in lieu of unlicensed staff "Assisting" with medications: Sampled resident Description when question answered - "Yes" Sampled resident #4 ("Nursing Staff needs to dispense medications") Sampled resident #5 ("Nursing Staff needs to administer medications") Sampled resident #6 (Left Blank) Sampled resident #7 ("Needs to be given medications" Note: additional hand written in other ink than the original - “Error, Yes box checked and after the above statement, "Needs to be given medications," "self administers," was written in. There was no new or updated DOEA 1823 for this resident. There was no documentation for this alteration of the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this." Sampled resident #8 ("Licensed Nurse to Administer" Note: the word "Administer was scratched out using a different ink and the words “assist if needed later with medications" was written in. There was no documentation in the resident's chart to show there had been a change in the resident's status. There was no documentation for this alteration of the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.") , 3. An interview with the facility's administrator was conducted on 04/06/2007. The administrator could not show any documentation where any of the above resident's were re-evaluated by the physician (Physician's Assistant/Advanced Registered Nurse Practioner) and not longer needed to have their medications administered instead of assisted with. The administrator also stated, "After today they all will be assist only residents." The administrator also could no show where the resident had been assessed/evaluated for further residency continuance at the facility. 4. Also during the tour it was observed that sampled resident #2 had 8 Insulin (pre-filled by a Licensed Practical Nurse/LPN no longer at the facility or employed by the facility) syringes filled with a clear liquid stored in the facility's medication room. There was no name (who they were for), date drawn up/filled, type insulin, amount of insulin to be in each syringe, or any other identification to the 8 prefilled syringes. The facility supervisor stated, They belong to sampled resident #2." 5. An interview with sampled resident #2 was conducted on 04/06/2007. During this interview the resident acknowledged that the facility did not allow him to draw up his own insulin or have his medication (insulin and oral medications) in his room to self administer but that the facility staff (Aid & Supervisor) would bring the pre-filled (see item #1 above) medication (insulin) to his/her room when the scheduled time for administration was. 6. An interview with the facility's supervisor was conducted on 04/06/2007. During this interview the supervisor acknowledged that the previous employee (an LPN), no longer working at the facility, had pre-drawn insulin in syringes for sampled resident #2 and they were stored in the facility's medication room (Note: Syringes were unlabeled with any name, date or substance in them). The supervisor also acknowledged that there had been no licensed (physician, nurse, physician's assistant, registered nurse Practioner) person in the facility to assist in or administer medications to residents since the LPN left the facility on 03/22/2007. The supervisor also acknowledged that the staff Aids were taking the pre-filled insulin syringes to sampled resident #2 every evening at the scheduled time and that the resident was not drawing up his/her own medication as per the self administration process and there was no one to verify that the correct amount of insulin was in each syringe. 23. The Respondent was given a mandatory correction date of May 6, 2007. 24. The Respondent's deficient practice constituted a Class II violation, pursuant to Florida Administrative Code Rule 58A-5.0181(1)(n)1-3. 25. | The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000). COUNTIV The Respondent Failed To Have At Least One Staff Member Who Is Trained In First Aid And CPR At All Times When Residents Are In The Facility In Violation Of F.A.C. 58A-5.019(4)(a)4 Isolated Class II deficiency 26. The Agency re-alleges and incorporates paragraphs | through 5. 27, Under Florida law, an assisted living facility is required to have at least one staff member who is trained in First Aid and CPR in the facility at all times when residents are in the facility. Fla, Admin. Code R. 58A-5.019(4)(a)4. 28. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. . 29. Based upon record review and/or interview, the Respondent failed to comply with the above-referenced provision. 30. Based on observation and interview the facility failed to have at least one staff member who is trained in First Aid and CPR, as provided under Rule 58A-5.0191, in the facility at all times when residents are in the facility. The surveyors’ findings were: 1. An initial tour of the facility was conducted on 04/06/2007. During this tour it was noted that there were 3 staff members in the facility upon the survey team arrival (Supervisor, Cook, & Aid). During the process of the tour the administrator arrived at the facility. No other staff members arrived at the facility until after the AHCA main office was notified of the deficient practice at approximately 5:45 PM Central Standard Time. 2. A review of the facility's personnel records was conducted on 04/06/2007. During this review it was revealed that there was no staff member in the facility certified in Ist Aid or CPR at or during any portion of the survey until after the notification of the AHCA Field Office was conducted. 3. Interviews were conducted on 04/06/2007 during the survey of the 3 staff members and administrator. During these interviews the Administrator, Supervisor, & Cook acknowledged they did not have a Ist Aid or CPR certification. The resident Aid at the facility was the only individual that thought he/she may have a Ist Aid and CPR certification but did not produce documentation to show this during or after the survey. A call from the administrator to the resident Aid (who had left the facility) at the end of the survey (after notification to the Field Office was completed) was conducted to see if documentation could be produced and to have the Aid return to the facility. The call was not returned by the Aid and the Aid did not return to the facility and no documentation was produced to verify that the Aid had current CPR/1st Aid certifications. 31. | The Respondent was given a mandatory correction date of May 6, 2007. 32. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than a class I violations. 33. . The Respondent’s deficient practice constituted a Class II violation. 34. | The Agency shall impose an administrative fine for a cited class IT violation in an amount not less than $1,000 and not exceeding $5,000 for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. 35. | The Respondent was given a mandatory correction date of May 6, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000). COUNT V The Respondent Failed To Encourage And Allow Residents Who Are Capable Of Self- Administering Their Medications Without Assistance To Do So In Violation Of F.A.C. 58A-5.0185(1)(a) Isolated Class Ii Violation 36. | The Agency re-alleges and incorporates paragraphs 1 through 5. 37. Under Florida law, an assisted living facility is required to encourage and allow residents who are capable of self-administering their medications without assistance to do so. Fla, Admin. Code R. 58A-5.0185(1){a). 38. | Based upon record review and/or interview, the Respondent failed to comply with the above-referenced provision. 39. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. 40. Based on observation and interview the facility failed to ensure residents who are capable of self-administering their medications without assistance must be encouraged and allowed to do so for 1 of 15 (#2) sampled residents. The surveyors’ findings were: 1, A tour of the facility was conducted on 04/06/2007. During the tour it was observed that sampled resident #2 had 8 Insulin (pre-filled by a Licensed Practical Nurse/LPN no longer at the facility or employed by the facility) syringes filled with a clear liquid stored in the facility's medication room. There was no name (who they were for), date drawn up/filled, type insulin, amount of insulin to be in each syringe, or any other identification to the 8 prefilled syringes. During the observation of the 8 syringes it was revealed by review of the Medication Observation Record (MOR) for sampled resident #2 that the physician's order was for 16 units of the Insulin to be given every day and it was also observed that 3 of the 8 syringes had between 17 & 18 units of the clear liquid in them. The facility supervisor stated, "They belong to sampled resident #2." 2. An interview with sampled resident #2 was conducted on 04/06/2007. During this interview the resident acknowledged that the facility did not allow him to draw up his own insulin or have his medication (insulin and oral medications) in his room to self administer but that the facility staff (Aid & Supervisor) would 10 bring the pre-filled (see item #1 above) medication (insulin) to his/her room when the scheduled time for administration was. 3. An interview with the facility's supervisor was conducted on 04/06/2007. During this interview the supervisor acknowledged that the previous employee (an LPN), no longer working at the facility, had pre-drawn insulin in syringes for sampled resident #2 and they were stored in the facility's medication room (Note: Syringes were unlabled with any name, date or substance in them). The supervisor also acknowledged that there had been no licensed (physician, nurse, physician's assistant, registered nurse practioner) person in the facility to assist in or administer medications to residents since the LPN left the facility on 03/22/2007. The supervisor also acknowledged that the staff Aids were taking the pre-filled insulin syringes to sampled resident #2 every evening at the scheduled time and that the resident was not drawing up his/her own medication as per the self administration process. 41. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than a class I violations. 42. -The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. 43. The Respondent was given a mandatory correction date of May 6, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000.00). 11 COUNT VI The Respondent Failed To Ensure Each Resident Admitted Or Assessed For Continued Residency At The Facility Was Capable Of Taking His/Her Own Medication With Assistance From Staff If Necessary To Meet Residency Criteria In Violation Of F.A.C. 58A-5.0185(4)(a) Isolated Class II Violation 44, The Agency re-alleges and incorporates paragraphs 1 through 5. 45. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. 46. Based on observation, record review and interview the facility failed to ensure each resident admitted or assessed for continued residency at the facility was capable of taking his/her own medication with assistance from staff if necessary to meet residency criteria for 5 of 15 (#4, #5, #6, #7, & #8) sampled residents. The surveyors’ findings were: 1. A review of the resident’s records was conducted on 04/06/2007. During these record reviews it was revealed that the following residents were documented on the DOEA Form 1823 in questioning statement - Does the individual need help with their medications (Yes/No)?, and if Yes please describe; to require "Nursing" Staff to "Administer" medications in lieu of unlicensed staff "Assisting" with medications: Sampled resident Description when question answered yes Sampled resident #4 ("Nursing Staff needs to dispense medications") Sampled resident #5 ("Nursing Staff needs to administer medications") Sampled resident #6 (Left Blank) Sampled resident #7 ("Needs to be given medications" Note: additional hand written in other ink than the original - "Error, Yes box checked and after the above statement, "Needs to be given medications," "self administers," was written in. There was no new or updated DOEA 1823 for this resident. There was no documentation for this alteration the the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any 12 47. 48. 49, documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.") Sampled resident #8 ("Licensed Nurse to Administer" Note: the word "Administer was scratched out using a different ink and the words "assist if needed later with medications" was written in. There was no documentation in the resident's chart to show there had been a change in the resident's status. There was no documentation for this alteration on the orginal DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.") 2. An interview with the facility's administrator was conducted on 04/06/2007. The administrator could not show any documentation where any of the above residents were re-evaluated by the physician (Physician's Assistant/Advanced Registered Nurse Practioner) and no longer needed to have their medications administered instead of assisted with. The administrator also stated, "After today they all will be assist only residents." The administrator also could no show where the resident had been assessed/evaluated for further residency continuance at the facility. The Respondent was given a mandatory correction date of May 6, 2007. The Respondent’s deficiency constituted a Class I deficiency. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000). COUNT VII The Respondent Failed To Provide Care And Services Appropriate To The Needs Of 50. Residents Accepted for Admission To The Facility In Violation Of F.A.C. 58A-5.0182 Pattern Class II Violation The Agency re-alleges and incorporates paragraphs 1 through 5. 51. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. 52. Based on observation and record review the facility failed to provide care and services appropriate to the needs of residents accepted for admission to the facility for 6 of 15 (#2, #4, #5, #6, #7, & #8) sampled residents. The surveyors’ findings were: 1. During a tour of the facility it was noted that there was no licensed nursing personnel/staff at the facility. The administrator and the Supervisor stated, "The Licensed Practical Nurse (LPN) walked out on 03/22/2007 and we have not had any nurses since." The administrator also stated, "and we won't hire any more after this." The facility did not have a licensed nurse working at the facility between 03/22/2007 and the day of the complaint survey. 2. A review of the resident's records was conducted on 04/06/2007. During these record reviews it was revealed that the following residents were documented on the DOEA Form 1823 in the questioning statement - Does the individual need help with their medications (Yes/No)?, and if Yes please describe; to require "Nursing" Staff to "Administer" medications in lieu of unlicensed staff "Assisting" with medications: Sampled resident Description when question answered - "Yes" Sampled resident #4 ("Nursing Staff needs to. dispense medications") Sampled resident #5 ("Nursing Staff needs to administer medications") Sampled resident #6 (Left Blank) Sampled resident #7 ("Needs to be given medications" Note: additional hand written in other ink that the original - "Error, Yes box checked and after the above statement, “Needs to be given medications," "self administers," was written in. There was no new or updated DOEA 1823 for this resident. There was no documentation for this alteration of the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.") Sampled resident #8 ("Licensed Nurse to Administer” Note: the word "Administer was scratched out using a different ink and the words "assist if needed later with medications" was written in. There was no documentation in the resident's chart to show there had been a change in the resident's status. There was no documentation for this alteration of the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any 14 documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.") 3. An interview with the facility's administrator was conducted on 04/06/2007. The administrator could not show any documentation where any of the above resident's were re-evaluated by the physician (Physician's Assistant/Advanced Registered Nurse Practitioner) and no longer needed to have their medications administered instead of assisted with. The administrator also stated, "After today they all will be assist only residents." The administrator also could no show where the resident had been assessed/evaluated for further residency continuance at the facility. 4. Also during the tour it was observed that sampled resident #2 had 8 Insulin (pre-filled by a Licensed Practical Nurse/LPN no longer at the facility or employed by the facility) syringes filled with a clear liquid stored in the facility's medication room. There was no name (who they were for), date drawn up/filled, type insulin, amount of insulin to be in each syringe, or any other identification to the 8 prefilled syringes. The facility supervisor stated, "They belong to sampled resident #2." ; 5.. An interview with sampled resident #2 was conducted on 04/06/2007. During this interview the resident acknowledged that the facility did not allow him to draw up his own insulin or have his medication (insulin and oral medications) in his room to self administer but that the facility staff (Aid & Supervisor) would bring the pre-filled (see item #1 above) medication (insulin) to his/her room when the scheduled time for administration was. 6. An interview with the facility's supervisor was conducted on 04/06/2007. During this interview the supervisor acknowledged that the previous employee (an LPN), no longer working at the facility, had pre-drawn insulin in syringes for sampled resident #2 and they were stored in the facility's medication room (Note: Syringes were unlabeled with any name, date or substance in them). The supervisor also acknowledged that there had been no licensed (physician, nurse, physician's assistant, registered nurse Practitioner) person in the facility to assist in or administer medications to residents since the LPN left the facility on 03/22/2007. The supervisor also acknowledged that the staff Aids were taking the pre-filled insulin syringes to sampled resident #2 every evening at the scheduled time and that the resident was not drawing up his/her own medication as per the self administration process and there was no one to verify that the correct amount of insulin was in each syringe. 53. | The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a class III 15 deficiency as provided for in Subsection 429.19(2)(c), Florida Statutes (2006). 54. The Respondent was given a mandatory correction date of May 6, 2007. 55. The Respondent’s deficiency constituted a repeated class III deficiency. 56. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. WHEREFORE, the Petitioner, State of Flonda, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000). COUNT VIM The Respondent Failed To Have A Master Or Duplicate Key For All Resident Rooms At The Facility To Be Used In The Event Of An Emergency In Violation Of F.A.C. 58A-5.023(4)(g) Isolated Class II Deficiency 57. The Agency re-alleges and incorporates paragraphs 1 through 5. 58. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility. 59, Based on observation and interview the facility failed to have a master or duplicate key for all resident rooms at the facility to be used in the event of an emergency. The surveyors’ findings were: 1. A tour of the facility was conducted on 04/06/2007. During this tour it was observed that the suite 39/40 resident room (sampled resident #1) was locked and was not accessible to the survey team. An attempt for the staff to open another door was unsuccessful due to furniture against the door. An interview with the administrator was conducted on 04/06/2007. During this interview the administrator acknowledged that the resident's room (suite 39/40) was locked and stated, "Since he is a “part owner" in the facility this surveyor could not enter that room for survey purposes and also stated, "I don't have a key for that room." 16 (Note: the staff later tried to find a way into the room for the purposes of conducting the survey but were unsuccessful.) When the staff and the administrator were asked the general where about of sampled resident #1 the administrator stated, "We don't have to keep track of him as he is part owner.” 60. The Respondent was given a mandatory correction date of May 6, 2007. 61. The Respondent’s deficiency constituted a Class II deficiency.. 62. | The Agency shal! impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1,000). COUNT IX The Respondent Failed To Have Documentation Of Current Certification In An Approved First Aid And CPR Course In At Least One Personnel Record For Staff On Duty At The Facility In Violation of F.S. 429.275(2) And F.A.C. 58A-5.024(2)(a)1 And F.A.C. 58A-5.0191(4) Widespread Class II Deficiency 63. The Agency re-alleges and incorporates paragraphs 1 through 5. 64. On or about April 6, 2007, the Agency conducted a complaint survey of the Respondent and its facility. 65. _ Based’on record review and interview the facility failed to have documentation of current certification in an approved First Aid and CPR course in at least 1 personnel record for staff on duty at the facility, as provided under Rule 58A-5.0191 at all times when residents are in the facility. The surveyors’ findings were: 1. An initial tour of the facility was conducted on 04/06/2007. During this tour it was noted that there was 3 staff members in the facility upon the survey team arrival (Supervisor, Cook, & Aid). During the process of the tour the administrator arrived at the facility. 2. A review of the facility's personnel records was conducted on 04/06/2007. During this review it was revealed that there was no staff member in the facility certified in Ist Aid or CPR at or during any portion of the survey. 3. Interviews were conducted during the survey on 04/06/2007 of the 3 staff members and administrator. During these interviews the Administrator, Supervisor, & Cook acknowledged they did not have 1st Aid or CPR certification. The resident Aid was the only individual that thought he/she may have a 1st Aid and CPR certification but did not produce documentation to show this during or after the survey. 4. A call from the administrator to the resident Aid at the end of the survey was conducted to see if documentation could be produced and to have the Aid return to the facility. The call was not retuned by the Aid and the Aid did not return to the facility. 66. The Respondent was given a mandatory correction date of May 6, 2007. 67. The Respondent’s deficiency constituted a Cass IT deficiency. 68. | The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of one thousand dollars ($1000). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1, Make findings of fact and conclusions of law in favor of the Agency as set forth above. 18 2. Revoke the license of the Respondent to operate the above-referenced assisted living facility. 3. Secondarily, in the altemative to license revocation, impose an administrative fine against the Respondent in the total amount of twelve thousand dollars ($12,000). 4. Enter any other relief that this Court deems just and appropriate. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. . fob | Respectfully submitted 7p } § day of September, 2007. Florida Bar # 0768715 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the Administrative Complaint and Election of Rights form 19 have been served to: Administrator and Registered Agent, Jane A. Jones, 3409 West 19” Street, Panama City, Florida 32405, by U.S. Certified Mail, Return Receipt Requested (7004 2890 0000 5527 1275), and to Owner Gold Key Development, Inc., 3409 West 19" Street, Panama City, Florida 32405, by U.S. Certified Mail, Retum Receipt Requested (7004 2890 0000 5527 1282), on this _[$ a day of September, 2007. (\ a fi Ly f a Lf PAAA : “Ub 5 oore Copy furnished to: Barbara Alford, FOM 20 US. Postal Service: CERTIFIED MAIL, RECEIPT (Domestic Mail Only; No:tnsurance Coveragé Provided) 004 e490 0000 Sse? Las For delivery information visit our website at WWW.USDS:cOMms OFFICIAL USE Return Receipt Fee (Endorsement Required) Restricted Del Fee (Endorsement ey Fee Sent To | eee: togeh Bh Total Postage & Fees See Reverse for Instructions ; = SENDER: COMPLETE THIS SECTION = Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ® Print your name and address on the reverse so that we can return the card to you. ® Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: nw w AD AO, cs aN B. Received by ( Printed Nene D. Is delivery address different from item 1? 1 Yes If YES, enter delivery address below: .No CSA rate + Ke -_ 3. we Type ‘Certified Mail ‘ [1 Express Mall O Registered CD Return Receipt for Merchandise 1D Insured Mail 0 c.0.b. 4. Restricted Delivery? (Extra Fee) BD Yes Fete LVMH SaArcip ray AL Baas ae aye 7004 2890 0000 5527 127s & PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 US. Postal Servicer: CERTIFIED MAIL. RECEIPT (Domestic Mail Only; No insurancé Coverage Provided) For delivery information visit our website-at wwW.USpS.coma L USE a Return Receipt Fee {Endorsement Required} Restricted Delivery Fee (Endorsement Required) Shou 2890 0000 SSe7 l2ae & ‘Bireat, Ape or PO Box No. PS-Forin.3800, June. 2002 See Reverse for Instructions 8, SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY & Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery ts desired. @ Print your name and address on the reverse so that we can return the card to you. “1 iw attach this card to the back of the mailpiece, wane o Rate “7 an | ‘or on the front if space permits. Yes - D. ts delivery address}different from item 17 1. Article Addressed to: it YES, enter delivery address below: [1 No Gocdch Urey Pe EASQ IAN, SH OM eek AR Nair ° Cs nn On henry aa HE Ck SA RLS D Retum Receipt for Merchandise. O insured Mail §=§0 C..0,,D. 4, Restricted Delivery? (Extra Fee) 7004 2690 OO000 S52? lLese PS Form 3811, February 2004 Domestic Retum Recelpt 2. 102595-02-M-1540 a

Docket for Case No: 07-005105